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position article Allergo J Int (2020) 29:169–173 https://doi.org/10.1007/s40629-020-00138-2 Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk of anaphylaxis? Position paper of the Food Allergy Working Group of the German Society for Allergology and Clinical Immunology (Deutsche Gesellschaft für Allergologie und klinische Immunologie, DGAKI) Imke Reese · Birgit Ahrens · Barbara Ballmer-Weber · Kirsten Beyer · Katharina Blümchen · Sabine Doelle-Birke · Annice Heratizadeh · Jörg Kleine-Tebbe · Lars Lange · Susanne Lau · Ute Lepp · Vera Mahler · Christiane Schäfer · Sabine Schnadt · Zsolt Szepfalusi · Anja Wassmann-Otto · Thomas Werfel · Margitta Worm Received: 15 June 2020 / Accepted: 25 June 2020 / Published online: 1 September 2020 © The Author(s) 2020 Summary peanut allergy, demands for peanut-free schools are Background Parents of school-age children with food put forward. allergies and potential anaphylactic reactions want Results and discussion The position paper of the their children to have an unburdened and risk-free food allergy working group of the German Society everyday school life. Thus, particularly in the case of for Allergology and Clinical Immunology (Deutsche Dr. A. Heratizadeh · Prof. Dr. T. Werfel Dr.I.Reese Immunodermatology and Experimental Allergology Unit, Nutrition Counseling and Therapy with Special Focus on Allergology, Ansprengerstraße 19, 80803 Munich, Germany Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany Dr.B. Ahrens ·Priv. Doz. Dr. K.Blümchen Department of Pediatric and Adolescent Medicine, Prof. Dr. J. Kleine-Tebbe Allergology, Pulmonology, and Cystic Fibrosis Unit, Westend Allergy and Asthma Center, Berlin, Germany University Hospital Frankfurt, Goethe University, Frankfurt Dr. L. Lange am Main, Germany St. Marien Hospital, Bonn, Germany Dr.B. Ahrens ·Prof. Dr.V.Mahler Dr. U. Lepp Clinical Allergology Section, Paul-Ehrlich Institute, Langen, Pulmonary Medicine, Allergology, Dr. Lepp Practice, Germany Buxtehude, Germany Prof. Dr. B. Ballmer-Weber C. Schäfer Department of Dermatology, University Hospital Zurich, Nutritional Therapy, Schwarzenbek, Germany Zurich, Switzerland S. Schnadt Department of Dermatology and Allergology, Cantonal German Allergy and Asthma Association (DAAB), Hospital St. Gallen, St. Gallen, Switzerland Mönchengladbach, Germany Prof. Dr. K. Beyer · Prof. Dr. S. Lau Prof. Dr. Z. Szepfalusi Department of Pediatric Pulmonology, Immunology, and Department of Pediatrics and Adolescent Medicine, Medical Intensive Care Medicine, Charité—University Hospital University Vienna, Vienna, Austria Berlin, Berlin, Germany Dr. A. Wassmann-Otto Dr.S. Doelle-Birke ·Prof. Dr.M. Worm () Dermatological Outpatient Clinic, Hamburg, Germany Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Charitéplatz 1, 10117 Berlin, Germany email@example.com K Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk. . . 169 position article Gesellschaft für Allergologie und klinische Immunolo- Misjudgment of high-risk situations gie) highlights why the concept of peanut-free schools does not protect peanut allergic children, but rather The perception of supposed safety at a school des- bears potential disadvantages and risks for all those ignated to be “peanut-free” carries the risk for those involved. The focus on peanut as a potential trigger of affected that everyday situations both outside and in- anaphylactic reactions ignores other relevant triggers. side the school are misjudged due to an altered risk Conclusion In order to address the fears and concerns assessment [3, 4]: “handing over responsibility to the of patients, parents, and school staff, it is mandatory school” can lead to greater anxiety in situations out- to develop various coping strategies. These should side the school, especially when the affected child enable and ensure the safety and participation of needs to fend for itself. It carries the risk of depri- food-allergic pupils in classes and other school activi- vation of the allergic child outside the school setting: ties. Therefore, it is important to implement adequate no sports clubs (since these are not peanut-free), no measures for allergen avoidance and emergency treat- children’s choir, and, ultimately, stagnation in their ment for students with conﬁrmed food allergies. development of social interaction, including the abil- ity to take responsibility and develop self-respect for Keywords Peanut allergy · Food allergy · Coping oneself. strategies · Allergen avoidance · Emergency treatment A supposedly safe environment at school can also result in teachers no longer making appropriate risk assessments and, for example, teachers receiving no Introduction training in emergency management, or only inade- The call for “peanut-free schools” is based on the idea quate training. But also on the part of the affected of enabling school-age children with peanut allergy child, the fact that they are in a place deemed to be and either previous anaphylactic reactions or a high safe can result in them not having their emergency risk of experiencing such a reaction to enjoy an un- medication on them at all times. burdened and risk-free school life. The following ar- ticle critically discusses the concept of “peanut-free No reduction in severe reactions at schools in schools” taking into account the risks and disadvan- the USA with a peanut ban tages, experience with concepts of this kind, as well as data on eliciting doses in order to deﬁnitively arrive A retrospective study of public schools in the USA with at useful recommendations for dealing with (peanut- and without peanut-restrictive policies showed that )allergic children in the school setting. banning peanuts from being brought from home or offered in school, as well as peanut-free classrooms, do not affect the incidence of adrenaline administra- Educational disadvantage due to limited choice tion at school . Only the concept of making peanut- of schools free tables available for affected children in school This type of concept is associated with enormous ex- canteens emerged as beneﬁcial; however, overall, only pectations on the part of parents of affected children a small number of anaphylactic reactions were re- and creates the impression that schools without this ported in schools without peanut-free tables. On the designation are “unprotected places”. As such, the other hand, one must also consider the possible neg- supposed protection offered by attending a “peanut- ative effects of such measures. For example, represen- free school” can have a major inﬂuence on the choice tatives of US patient organizations report that parents of school and result in an educational disadvantage of peanut-allergic children are increasingly requesting for the allergic child; however, an allergic child should physicians to issue certiﬁcates allowing their children also have the freedom to choose a school according to to freely choose where they sit in the canteen, in order his or her abilities (musical, bilingual, teaching focus, to avoid the social isolation of affected children due to etc.). If the label “peanut-free school” is the deciding peanut-free tables or an increased risk of confronta- factor in the choice of school, a child may be disad- tion with other children. vantaged in terms of his or her interests and abilities. Priority must be given to the support and Stigmatization and exclusion of affected protection of all pupils with food allergies individuals Supporting and actively protecting at-risk pupils with In addition, the risk that a peanut-allergic child at chronic diseases, in this case (peanut) allergy, in their a “peanut-free school” (“special school”) will be stig- matized will remain. The ban on peanuts for all stu- The difference between schools with and without peanut-free dents could engender a greater lack of understanding tables was signiﬁcant, but relates only to seven reactions in 196 on the part of unaffected children and increase the schools without peanut-free tables and 19 reactions in 1875 risk of psychological distress and exclusion for aller- schools with peanut-free tables (incidence rate per 10,000 stu- gic children [1, 2]. dents 0.6 versus 0.2; p= 0.009). 170 Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk. . . K position article everyday lives should be a priority . The stringency of between 200 mg and 1 g peanut (around 1/6th of of risk reduction measures can be adjusted to the sen- a whole peanut) to show anaphylactic symptoms. sitivity of the affected child. It is always advisable 40% only experienced an anaphylactic reaction after a dose of between 5 and 20 g peanut (approximately for all children to wash their hands before and after four to seven peanut kernels). These observations eating. highlight the fact that the eliciting dose for severe when using food in lessons, e.g., when a class eats reactions signiﬁcantly differs from individual to in- breakfast together, when cooking, or during hand- dividual and that very small doses are sufﬁcient to icrafts that materials are used that neither exclude elicit anaphylaxis in only a small number of peanut children nor put them at risk of an allergic reaction. allergics. In this context, one should also always consider those children who react to elicitors other than peanut. Al- Fear of severe reactions through inadvertent though peanut is the most frequent elicitor of ana- exposure via inhalation and skin contact phylaxis in childhood, there are a number of other unfounded relevant triggers, such as milk, egg, and various ed- ible nuts, that are relegated to the sidelines due to There are reports that the mere inhalation of peanut the focus on “peanuts”, thereby depriving children af- protein is sufﬁcient to cause severe reactions or even fected by anaphylaxis elicitors other than peanut of anaphylaxis. However, this could not be demonstrated due respect for their allergy [6, 7]. Thus, the desire in targeted investigations [10–12]. It also does not ap- or demand to protect a group of pupils with severe pear that an allergy-relevant quantity of peanut pro- allergic reactions (to peanut) would be at the expense tein capable of triggering severe symptoms can be air- of other pupils with similarly severe reactions to other borne [13, 14]. Fear of severe reactions due to skin allergens and negatively affect their disease manage- contact with contaminated material or door handles ment. is also unfounded. Contact of this kind can at most cause mild skin reactions [15, 16]. On the other hand, expecting an allergic reaction as Eliciting doses differ from individual to individual a result of smelling or seeing peanuts can trigger a fear A major misconception created by the concept of response that sometimes resembles an allergic reac- “peanut-free schools” is the implication that even the tion. Since fear responses are a potential differential tiniest quantities of the allergen need to be avoided diagnosis, it is possible to misjudge the risk status in in order to prevent hazardous reactions. However, both directions (incorrectly assessing an allergic reac- this is not always the case. An international working tion as a fear response and incorrectly assessing a fear group showed that less than 5% of all peanut-allergic response as an allergic reaction). These fears need to children reacted to an eliciting dose of 1.5 mg peanut be combated through targeted education or patient protein (equivalent to around 6 mg peanut = around information and, where necessary, an additional inter- 1/200th of a peanut kernel) with objective symptoms vention in a medical environment (hospital/medical . All these reactions were mild. practice) during which the patient comes into contact According to a recent publication, in which children with the allergen. A recently published study impres- with equivocal peanut allergy underwent oral peanut sively showed that information on the minimal risk challenge, a third (n = 525) of 1634 challenged children of allergic reactions due to mere skin contact as well with suspected peanut allergy (78%) or precautionary as experiencing allergen contact signiﬁcantly reduced avoidance of peanut without suspicion (22%) reacted anxiety in patients and their families and increased positively . While 28% of the reactions were elicited quality of life . by the administration of 25 mg of peanut (equivalent Although severe allergic reactions through inhala- to around 1/50th of a peanut kernel), 38% of the chil- tion or skin contact alone are unlikely, the use of a rel- dren only reacted after a dose of over 1 g of peanut evant allergen should be avoided in the classroom and (equivalent to a whole peanut). Only 10% (n = 55) of other school environments in order to avoid causing the children that tested positive experienced an ana- even mild reactions and fostering anxieties. For exam- phylactic reaction, whereby the age of the tested child ple, it is advisable in cookery or baking clubs not to represented a risk factor, as well as the dose of peanut use ingredients to which a child in the class is allergic. administered. For example, 13- to 18-year-olds had In the case of peanut-allergic pupils, the authors rec- a three-fold higher risk for an anaphylactic reaction ommend avoiding peanut ﬂips, roasted peanuts, and compared to 6- to 12-year-olds. whole peanuts in shells both in the classroom and at If one looks only at the anaphylactic reactions, school events. there are children in whom even small doses of 25–100 mg peanut (around 1/50th to 1/10th of a peanut kernel) elicit anaphylaxis. This was the case in 9% of the mostly older individuals with peanut allergy. A good quarter (27%) of children required a dose K Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk. . . 171 position article Table 1 Fears and concerns of affected individuals when A reliable diagnosis as a basis for effective confronted with food allergens at school, and possible management strategies management strategies using peanut as an example School = dangerous? Above all, a reliable diagnosis is crucial for the ap- What can the school with peanuts trigger in . . . ? propriate management of a food allergy. The diag- Pupils with peanut Parents of Teachers nosis should also facilitate an assessment of the elic- allergy peanut-aller- iting dose and, ideally, be based on double-blinded gic children placebo-controlled challenge testing. One must bear Insecurity Fear of an aller- Fear of administering medica- in mind that, also in peanut allergy, a natural toler- gic reaction in tion/doing something “wrong”/ their child causing “harm” ance can develop and re-evaluation at regular inter- vals is advisable . This is important for all parties Fear of supposed Fear that their Fear of stressful situations due peanut contact (in child will be to conﬂicts with parents and involved: school food, via harassed by students on the subject of: For the parents, to enable them to better judge fellow students, in teachers/fellow “We’ll bring to school and eat the classroom) students what we want” whether (and to what degree) their child is actu- My parents are Fear of being Fear of liability in emergency ally (still) allergic. scared for me “powerless” and situations (duty of supervision, For the physician, so that they can clearly identify “unable to act” liability for accidents, etc.) patients with food allergy and make the diagnosis due to not being not only on the basis of elevated speciﬁc IgE. present For pupils, so that the necessary measures can be Lack of understand- Highly “protec- Fear of outings/excursions, based on a clear diagnosis. ing from teachers/ tive” behavior activities such as cookery fellow students, fear classes, etc. of exclusion and Sound risk assessment needs to be learned and bullying practiced What are the possible management strategies? School as a place for all to learn together and inclusively Optimal disease management includes a realistic as- for life sessment of hazardous situations. This needs to be Accepting the food allergy and learning to live with it learned and practiced—for each anaphylaxis trigger. Getting background information on food allergies per se, thereby learn- In addition to information provided by the treating pe- ing to identify misinformation, e.g., “inhaling peanut causes death from diatrician and specialist dietician/nutritionist, AGATE anaphylaxis.” (Arbeitsgemeinschaft Anaphylaxie – Training und Ed- Formulate local preventive strategies (e.g., avoiding allergy elicitors when cooking and baking together, voluntary avoidance of, e.g., peanut ﬂips at ucation e.V.) anaphylaxis training and education pro- celebrations and on school trips) grams are suited to this end. These are offered by in- Training to recognize and deal with emergency situations terdisciplinary teams at various locations in Germany (www.anaphylaxieschulung.de). Education programs Respectful dialog and exchange on “being there for one another” are available not only for parents, but also for children, Strengthening at- Making infor- Creating the framework condi- tentiveness and mation on their tions to care for children with adolescents, teachers, and carers. The German Al- (physical) self-aware- child’s disease food allergies and anaphylaxis lergy and Asthma Association (Deutsche Allergie- und ness available risk, learning together Asthmabund, DAAB) also offers advice, information, Self-management Learning to let go Supporting and strengthening an e-learning program, and webinars on the subject the child in their development/ forpatientsaswell asteachersand carers. The aim of self-management these measures is to establish optimal disease man- Assuming responsi- Learning to trust Learning to make sound, par- bility for oneself and their child ticipative decisions (shared agement for those affected and their families, recog- gaining self-respect decision-making) using the nize fears and concerns, and work to counteract these, food allergy as an example thereby ensuring the best possible protection against Learning: to be there for one another allergic reactions in everyday life while achieving good integration in social structures. and training on anaphylaxis and its everyday manage- ment, as provided by reliable sources, are required. Conclusion Funding Open Access funding provided by Projekt DEAL. The concept of “peanut-free schools” is not expedient Conﬂict of interest B. Ahrens and V. Mahler state that the for allergy sufferers and their parents and is poten- content and opinions expressed in this position paper re- tially fraught with risk. What does make sense in the ﬂect the personal expert opinions of the authors and should case of diagnosed food allergy is to implement ap- not be interpreted or cited as if they had been made on propriate measures in schools for allergen avoidance behalf of the relevant higher national federal authorities, and emergency treatment for all food-allergic pupils, the European Medicines Agency, or one of its committees thereby enabling and ensuring pupils’ safety and par- or working groups, or reﬂects their position. K. Beyer de- ticipation in classes and other school activities (Ta- clares having received grants and honoraria from Aimmune, DBV, Infectopharm, and Mylan, outside the present work. ble 1). To this end, sufﬁcient information, education, K. Blümchen declares having received grants and/or hon- 172 Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk. . . K position article oraria from Novartis, HAL Allergy, ThermoFisher, Bencard actions and food-induced anaphylaxis in children. Acta Allergie, Allergopharma, ALK, DBV technologies, Aimmune Paediatr. 2019;108:314–20. Therapeutics, Nestle, and Nutricia, outside the present work. 7. Grabenhenrich LB, Dolle S, Moneret-Vautrin A, Kohli A, A. Heratizadeh declares having received honoraria from LEO Lange L, Spindler T, et al. Anaphylaxis in children and Pharma, Novartis, Pierre Fabre, Sanoﬁ-Genzyme, Beiersdorf, adolescents: the European Anaphylaxis Registry. J Allergy Hans Karrer, Nutricia, Meda, and Lilly, as well as grants from ClinImmunol. 2016;137:1128–1137.e1. Janssen, outside the present work. S. Lau declares having re- 8. Hourihane JO, Allen KJ, Shrefﬂer WG, Dunngalvin G, ceived honoraria from DBV, Sanoﬁ-Aventis, Allergopharma, Nordlee JA, Zurzolo GA, et al. Peanut Allergen Thresh- and ALK, outside the present work. M. Worm declares having old Study (PATS): Novel single-dose oral food challenge received advisory board and lecture honoraria from Aller- study to validate eliciting doses in children with peanut gopharma GmbH & Co. KG, ALK-Abelló Arzneimittel GmbH, allergy. JAllergyClinImmunol. 2017;139:1583–90. Mylan Germany GmbH, Leo Pharma GmbH, Sanoﬁ-Aven- 9. Arkwright PD, MacMahon J, Koplin J, Rajput S, Cross S, tis Deutschland GmbH, Regeneron Pharmaceuticals, DBV Fitzsimons R, et al. Severity and threshold of peanut reac- Technologies S.A, Stallergenes GmbH, HAL Allergie GmbH, tivity during hospital-based open oral food challenges: an Bencard Allergie GmbH, Aimmune Therapeutics UK Limited, international multicenter survey. Pediatr Allergy Immunol. Actelion Pharmaceuticals Deutschland GmbH, Novartis AG, 2018;29:754–61. Biotest AG, AbbVie Deutschland GmbH & Co. KG, and Lilly 10. Leonardi S, Pecoraro R, Filippelli M, Miraglia del Giu- Deutschland GmbH, outside the present work. B. 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