Bringing food allergy management and awareness to your community

Food Allergen Exposure in the School Setting: Evidence, challenges, and interventions

Type of Exposure Relevant Facts Practical Challenges Practical Interventions*
Oral Exposure
• There can be “hidden ingredients” in foods.
• Labels and ingredients can change without warning. [1] • Items with advisory labels can contain allergens.[2] • Trace amounts can cause severe allergic reactions.
• Allergens can be detectable in saliva.[3] • All children are protected by law to have a right to a free and appropriate education in the least restrictive environment.
• Cross contact is presence of unintended allergen[1,3]
– Allergen contact with surfaces, food, and saliva are common sources.
– Exposure by mouth or mucus membranes is a common cause of reactions.
• Difficult to monitor outside food, especially if not labeled.
• Reading labels takes training, pre-planning, assigned personnel, and time allowances.
• Celebrations are common source of unlabeled food and cross-contact risk.
• Majority of allergic reactions in school start in classrooms.[4] • Allergic child can be targeted for being cause of potentially unpopular accommodations.
• Risk of bullying/teasing. [5]
Additional consideration for pre-school/early elementary
• Young children can pass saliva to each other via age appropriate exploration.[3, 6] • Some schools children eat in their classrooms/ learning environments.
• Supervision during meal/snack time dependent on resources and staff.


Additional consideration for adolescent/teenage students
• Older students under less supervision and more reliant on self-management.
• Risk-taking, sense of “invincibility”, peer pressure, bullying. [7,8]
• Non-food celebrations, activities, and rewards.
• Limited and pre-screened food projects in classrooms that do not contain the allergen; parent notification of all food projects or activities.
• Scrutiny of chosen foods before use.
• Safe snack stash in classrooms that allow food.
• Fresh fruits and vegetable snack alternatives.
• Adult assistance for food allergic children in selection of safe foods from cafeteria lines.
• No sharing or trading of food, drinks, or personal items.
• Appropriate cleaning of high-touch surfaces and hands.
• Consider encouraging parents of allergic children to send in all foods for child.
• Parent and student community education to create supportive environment.
• Encouragement to report any bullying/harassment.
• No eating on school bus (exception for children medical conditions).

Additional consideration for pre-school/early elementary
• Pre-school and lower elementary: no foods in classroom or selective allergen restriction as needed.

Additional consideration for adolescent/teenage students
• Periodic check-ins to ensure continued self-management.
• Encouragement to report any bullying/harassment.
• Support and continued education by school nurse and staff.
Skin Exposure
• Isolated skin contact on intact skin did not cause severe or systemic reactions when studied, although skin reactions can occur.[9,10] • Soap and water, and commercial hand wipes are effective for cleaning hands or surfaces, eg, table tops.[11] • Hand sanitizers are NOT effective in removing allergen protein residue.[11] • Young children frequently place their hands and objects in their mouth.[6] Age 1-2 yrs.: ~80 times/hr
Age 2-5 yrs.: ~40 times/hr
• Adults touch their eyes, nose, and mouth regularly.[12]
• Limited resources and manpower to clean allergens and prevent cross-contact.
• Some non-edible items contain food allergens; eg, finger paint, play dough, shaving cream, paste, bean bags, furniture, pet food, bird feed.[29] • Skin exposure that can result in mucosal exposure in adults and children (eyes/nose/mouth).

Additional consideration for pre-school/early elementary
• Skin exposure that can quickly turn into mucosal exposure or oral ingestion.[6,12] • Less effective cleaning skills (hands or eating surfaces).
• Same avoidance strategies as oral exposure above.
• Frequent hand washing with soap/water or wipers before and after food handling or whenever hands are dirty.
• Appropriate cleaning of eating areas.

Additional consideration for pre-school/early elementary
• Same avoidance as above.
• Adult supervision of hand cleaning.
• Adult responsibility for cleaning surfaces, toys, bus seats, etc.
Inhalation Exposure
• Volatile organic compounds, not proteins, cause odor. [13] • Proteins cause most allergic reactions.[9] • Inhaling vaporized proteins from active cooking can cause severe allergic reactions and death.[9, 14, 15] • Most inhalation is not fatal.[14] • Projects/experiments involving burning/heating of allergens.
• Field trips, volunteering, or internships in areas where foods are actively cooking or aerosolized if known or at risk for food allergy.
• Activities involve using food powders or grinding/crushing fresh foods.
• No activities that involve cooking foods, or using flours, powders and other small particles of food that can go up in the air.[9,13,14] • No food-related science experiments or classroom activities involving allergen.
• Prior clearance from principal and notification of school nurse for all field trips, especially in classes with known food allergic children.


*Adapted from NSBA, CDC Voluntary Guidelines, and MA state guidelines.

As seen in Pistiner M, Devore C. The Role of Pediatricians in School Food Allergy Management. Pediatric Annals. 2013; 42(8):334-340.

Food Allergy Education TableFood Allergy Education Table

Handy reference table that highlights teaching points tailored for specific groups - elementary school students, adolescents, families with and without food allergies, and school staff. Links are provided to relevant educational materials.

Staff Training: Food Allergies in School – What School Staff Need to KnowStaff Training: Food Allergies in School – What School Staff Need to Know

This 30 minute module is designed to assist the school nurse in staff training and increase food allergy awareness for all school staff including teachers, food service personnel, administrators, aides, specialists, coaches, bus drivers, custodians and others.


1. Muñoz-Furlong A. Daily coping strategies for patients and their families. Pediatrics. 2003;11(3):164-166.

2. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol. 2007;120(1):171-176.

3. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. J Allergy Clin Immunol. 2006;118(3):719-724.

4. McIntyre CL, Sheetz AH, Carroll CR, Young MC. Administration of epinephrine for life-threatening allergic reactions in school settings. Pediatrics. 2005;116(5):1134-1140.

5. Lieberman JA, Weiss C, Furlong TJ, Sicherer M, Sicherer SH. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2010;105(4):282-286.

6. Tulve N, Suggs JC, McCurdy T, Cohen E, Moya J. Frequency of mouthing behavior in young children. J Expo Anal Environ Epidemiol. 2002;12(4):259-264.

7. Sampson, M.A., Munoz-Furlong, A., Sicherer, S.H. Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol. 2006 Jun;117(6): 1440-5. Epub 2006 May 11

8. Monks H, Gowland MH, MacKenzie H, et al. How do teenagers manage their food allergies? Clin Exp Allergy. 2010;40(10):1533-1540.

9. Simonte SJ, Ma S, Mofidi S, Sicherer SH: Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol. 2003;112(1):180-182.

10. Wainstein BK, Yee A, Jelley D, Ziegler M, Ziegler JB: Combining skin prick, immediate skin application and specific-IgE testing in the diagnosis of peanut allergy in children. Pediatr Allergy Immunol. 2007;18:231-239.

11. Perry TT, Conover-Walker MK, Pomés A, Chapman MD, Wood RA. Distribution of peanut allergen in the environment. J Allergy Clin Immunol. 2004;113(5):973-976.

12. Nicas M, Best DJ. A study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract infection. J Occup Environ Hyg. 2008;5(6):347-352.

13. Kim JS, Sicherer SH: Living with food allergy: allergen avoidance. Pediatr Clin North Am. 2011;58(2):459-470.

14. Roberts G, Golder N, Lack G. Bronchial challenges with aerosolized food in asthmatic, food-allergic children. Allergy. 2002;57(8):713-717.


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