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News — By Chief of the Division of Pediatric Allergy and Immunology and Professor of  and Internal Medicine

For many families, going back to school can be a source of anxiety – especially for parents of children with food allergies. Will they be safe in the lunchroom? What if they have a reaction?

Even if your child doesn’t have food allergies, it’s likely that one of their friends does. Food allergies are incredibly common, affecting 32 million Americans. An estimated 8% of children have food allergies, which comes out to about two students per classroom. Allergic reactions occur when the immune system recognizes a naturally occurring foreign substance (such as a food like peanuts) as harmful. Reactions can range from mild to severe.

Every year,  specialists at UT Southwestern and Children's Health Dallas field questions from parents who are worried about whether their older kids will be exposed to allergens or whether younger students will make good choices about swapping foods and snacks at school.

It takes a community to protect kids with food allergies, and providing data-informed education is a big part of our clinical mission:

• I was a member of the , which helped create food safety guidelines for children in Texas schools. Children with food allergies have rights under the Americans with Disabilities Act and Texas law – schools are required to accommodate their dietary needs.
• I also belong to the , which was established by the Texas Department of State Health Services (DSHS) to advise school districts, school nurses, and teachers on maintaining undesignated epinephrine, a lifesaving medication that counteracts a serious allergic reaction.

When we all work together, children with food allergies can focus on learning, and parents can take a deep breath of relief in knowing their children will be safe.

What are some of the common food allergens?

Allergic reactions from foods are typically triggered when the food is ingested. Contact with a food allergen may lead to a local allergic response (e.g., hives at the site of contact), but systemic reactions from contact are rare. Inhalation of an aerosolized food protein could lead to an allergic reaction, but this is uncommon unless an allergic individual is exposed to steam from a food while it is being cooked in a poorly ventilated space (e.g., milk, finned fish, shellfish).

Foods such as peanuts and tree nuts are not easily aerosolized, and airborne reactivity is unlikely for most patients. Common food allergens include:

• Milk is a ubiquitous allergen found in the diets of most cultures. It can be very challenging to avoid milk and milk protein in all forms, including dairy products such as cheese, yogurt, ice cream, and butter.
• Peanut allergies are common, and reactions may be severe. Patients must read labels very closely to avoid accidental ingestion of peanuts, which may be found in a variety of foods, most commonly in candies, snack bars, and in many sauces, such as mole. Patients allergic to peanuts are reactive to peanut protein; therefore, highly refined peanut oil, a fat derived from peanut, is safe – it is often used in fast food restaurants. Other kinds of peanut oil (e.g., cold pressed or expeller pressed peanut oils) do contain peanut protein and should be avoided.
• Shellfish includes crustaceans such as shrimp, lobster, and crab and mollusks such as oysters and clams. Patients must be mindful of cross-contact, since restaurants may use the same fryers to cook shellfish and other foods. We typically advise families to prepare their child’s lunch at home on days when the cafeteria is serving shrimp since it is not uncommon for fried shrimp to end up in other foods being served behind the food counter.
• Finned fish such as catfish, codfish, salmon, or tuna can cause allergies that commonly develop in childhood. Patients should be aware of cross-contamination, since finned fish is commonly prepared in a fryer. Patients should stay out of the kitchen cooking these foods on a stovetop since aerosolization of fish protein may trigger respiratory symptoms that can be severe, particularly in patients with pre-existing asthma.
• Soy protein is an allergen most frequently encountered in plant-based products as a source of protein. Soy is easily recognized in products such as soy milk or soy-based yogurts. It is also important to remember that tofu and edamame are cooked forms of soy. Patients will see soy listed in a number of packaged products. However, the soy derivative used often is soy oil or soy lecithin, which are fat derivatives that do not contain soy protein. Soy protein is often listed as soybean or soy flour.
• Wheat is the most common grain used in breaded products. White bread contains wheat protein, so patients must carefully read the labels of all bread products to make sure wheat is not included as an ingredient.
• Tree nuts, which includes almonds, cashew, pistachios, hazelnuts, pecans, and walnuts, belong to a different botanical family than peanuts, which are legumes. Patients allergic to one tree nut may not be allergic to all; however, it is difficult to differentiate one from another, and families often request schools avoid all tree nuts to minimize the risk of accidental ingestion.
• Egg allergies are common among young children and are often outgrown with age. Most patients can tolerate eggs in baked goods; however, if they are not already eating baked goods at home, it would be recommended to avoid egg in all forms at school.
• Sesame seed has recently been added to the list of allergens required on ingredient labels. Sesame seed may be found in breads as a flour or additive, and it is also commonly found in products like hummus. Tahini is made from ground sesame seed.

What happens when a child is exposed to their food allergen?

When a child is exposed to a food allergen, their body's immune system mistakenly identifies the food as a threat. Allergic antibodies are released, signaling the body to attack. This overreaction can cause symptoms like hives, swelling, or trouble breathing.

Food allergies are different from food intolerances. A food allergy can cause a systemic, sometimes life-threatening immune response, while an intolerance typically causes localized,  that are milder. Signs of an allergic reaction can include:

• Difficulty breathing
• Swelling of the face, tongue, lips, or throat
• Dizziness or lightheadedness
• Hives or rashes
• Watery eyes
• Diarrhea
• Vomiting
• Runny nose and sneezing

Anaphylaxis is a serious, systemic allergic reaction that is usually rapid in onset. In severe cases, it may be fatal due to difficulty breathing or a drop in blood pressure. Fatal reactions to food allergens are rare but can occur. About 11% of schools report at least one anaphylactic reaction a year. Public schools and open-enrollment charter schools in Texas are required to have an anaphylaxis response plan in place for the care of students with diagnosed food allergies, including the use of auto-injectable epinephrine to stabilize a child until medical help arrives. The U.S. Food and Drug Administration recently approved the , the first non-injection anaphylaxis treatment, for adults and children who weigh 66 pounds or more.

What are my child’s rights at school?

According to the , students with food allergies are “considered to have a disability which restricts their diet.” As emphasized by the , this means that schools are required to serve your child food that is safe for them to eat as long as their allergies have been communicated. The school cannot refuse to serve safe and nutritious food alternatives to your child.

Health organizations – including UT Southwestern and Children's – have worked with Texas lawmakers to create guidelines that inform policies and regulations to protect students with allergies:

• Under , parents and guardians must, at the request of the school district, disclose any relevant food allergies.
• , requires that all public schools and open enrollment charter schools in the state create a policy to care for students with food allergies who are at risk of anaphylaxis, based on .
• The , states that each school district, public school, and open enrollment charter school must have a policy in place about distributing and administering epinephrine in the case of anaphylactic shock as well as asthma medication in case of respiratory distress.

How can families help keep kids safer at school?

Individual accountability is key to protecting children with food allergies. Studies show that simply having a peanut-free school policy does not eliminate peanuts or tree nuts from the school environment since these foods are often brought in unregulated lunch or snack foods. Importantly, these policies have not demonstrated a lower incidence of anaphylaxis.

Families, students, and educators must follow the policies and take them seriously. We recommend these strategies to reduce the risk of serious allergic reactions at school:

• Keep open, frequent communication. Do not be afraid to ask for direct communication with school administrators and teachers to discuss policies and precautions.
• Do not trade or share food. Lunch and snack swaps can introduce allergens.
• Read food labels carefully. Allergens legally required to be listed on food labels include milk, egg, fish, crustacean shellfish, tree nuts, peanuts, wheat, sesame seed, and soy. Teach your child where allergens are listed on nutritional labels and what to look for.
• Teach your child to set boundaries. Remind them to ask for allergen information before they accept food. Reassure them that it’s OK to refuse to eat anything that might be unsafe. Teach kids without food allergies that their friends might not be able to eat like them and to never be pushy about food.
• Act quickly at the first sign of a reaction. Teach your kids the signs of an allergic reaction in themselves and in others. Remind them to get an adult to help right away. Make sure supervising adults are aware of the signs and symptoms of an allergic reaction and proper use of self-administered epinephrine. Self-administration of epinephrine is typically reserved for teens, though occasionally older children may be capable in the presence of a supervising adult. When age-appropriate, begin transitioning responsibility to the child to carry epinephrine.

Bridging the gap between food insecurity and allergy safety

One of the best ways to feel in control of your child’s allergies is to pack their lunches at home. You know your child’s allergies best as well as their preferences. Get allergen-free recipes from .

Unfortunately, making food at home is sometimes easier said than done. One in eight Dallas County residents and nearly one in five children face food insecurity at home. Meanwhile, foods that are allergen-free may be more expensive. For example, one 2019 study found that gluten-free foods were 183% more expensive than foods containing gluten.

Food insecurity is often overlooked in the allergy conversation. In 2021, I helped  that showed that most members of the American Academy of Allergy Asthma & Immunology did not routinely screen patients for food insecurity.

UT Southwestern is working to bridge that gap.

Our Pediatric Allergy and Immunology clinic works closely with  to simultaneously  and allergies. Kids with food allergies need nutritious meals to grow, and parents need to know their kids are safe and can be fed without breaking the bank.

It takes a community to keep children with food allergies safe at school. When health care providers, educators, parents, and students all work together, we can reduce accidental ingestion of food allergens and create a comfortable environment for students to thrive.

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