She was indignant and didn’t know what she’d done wrong. “They can’t treat me this way,” she said.

Her mother wasn’t pleased to hear of a student disciplining another student, but she had a more immediate concern. Her severely peanut-allergic daughter had been alone while eating.

“Where was your EpiPen?” Cameron asked. The reply: “In my backpack.” And where was that? “In the classroom.”

“If she’d had a reaction in the hall, no one would have been there to help her,” says Cameron. The previous fall, Cameron first learned that adults weren’t supervising the lunch breaks at the Ottawa public school. Instead, pairs of Grade 5 or 6 students oversaw the younger children as they ate at their desks. In case of an emergency, these monitors would have to run and seek out an adult.

Thousands of miles west, in Victoria, B.C., Caroline Posynick can relate. She became a convert to allergy advocacy in 2006 over the issue of student lunch-monitoring.

She had been blissfully unaware that, in a school that ran from kindergarten through Grade 7, lunch for younger grade children was supervised by kids from the eldest grade. She also didn’t realize that the teacher had decided to keep her son Griffin safe by isolating the 7-year-old at the crafts table.

On Valentine’s Day in 2006, “my son was sitting at this special table. A kid who was really, really active got up and put some peanut butter on his finger and then put it on Griffin’s arm,” Posynick says. “He wanted to see what would happen. This occurred with kids watching kids, so they couldn’t stop it.”

There was panic in the room, Griffin froze, and the monitors hustled him off to the teachers’ staff room to get his arm washed.

When Posynick and her husband got to the school they found Griffin with a huge hive on his arm. Benadryl was enough to handle the contact reaction. But the boy’s sense of upset did not go away nearly as quickly.

Incidents with lunch supervision are not hard to find among the parents of food-allergic children. They illustrate that, for all of the advances such as Sabrina’s Law in Ontario (an act to protect anaphylactic pupils) or B.C.’s ministerial framework on anaphylaxis, and for all the allergic community’s advocacy on risk reduction and readiness for emergencies, gaps remain in the protection of food-allergic children.

Within Canada’s public elementary schools, there’s a patchwork of student monitors and adult lunch supervisors, but even with the latter, the person in sight line of the child may not be trained on giving an epinephrine auto-injector. Who’s watching the kids depends on a school board’s policy and then, in turn, on how an individual principal handles (and applies budget to) lunch supervision at his or her school.

For instance, in Vancouver, the norm today is paid lunch assistants, but a ferry ride away in Victoria, students not old enough to babysit frequently patrol lunch in the class.

In 2005, Anaphylaxis Canada did a survey of its online registry about allergy policies in Canadian schools. Of the 678 parents who responded about their child’s public elementary school, 28 per cent said the school relied on student lunch monitors, 43 per cent said school staff supervised (sometimes in combination with students) and 33 per cent had paid lunch supervisors. At some schools, there were also a small percentage of parent volunteers assisting.

Most public elementary students (73 per cent) ate lunch in their class as schools often lacked the space for lunchrooms. “You do have to consider what the principals are dealing with,” notes Laurie Harada, executive director of Anaphylaxis Canada. “They’ve had cutbacks, the best that many principals can do is to have someone to wander the halls and poke their head in and monitor the kids.” That said, she adds: “too much of this is ad hoc, and schools need to think through this.”

U.S. ‘All Over the Map’

In the United States, student lunch volunteers are less the issue, but again – despite a growing number of anaphylaxis laws among the states, there are gaps. Lunch is usually eaten in a cafeteria or lunchroom, making it possible for fewer adult eyes to survey a larger group of kids.

Yet anaphylaxis prevention practices and auto-injector training can vary from district to district, and cafeteria to cafeteria.

Lunch supervision “is an all over the map situation in the U.S.,” says Deb Scherrer, vice president of education for the Virginia-based Food Allergy & Anaphylaxis Network. “Sometimes it’s a teacher, sometimes it’s a food service worker, sometimes it’s a parent – it may be paid staff or volunteer.”

*Name changed by request.

UNITED STATES

FAAN’s Back-to-School Tool Kit
FAAN’s Food Allergy Action Plan
Food Allergy Initiative’s Authorization of Emergency Treatment Form
FAAN/FAI e-learning resource, comprehensive tool for teachers. www.allergyready.com
Federal 504 Plan
AAFA on the Americans with Disabilities Act (ADA)
National Assn of School Nurses’ Anaphylaxis Provision of Care documents

CANADA

Comprehensive resource - Allergy Safe Communities site.

• Allergy Safe Communities’ Emergency Plan for EpiPen
• Allergy Safe Communities’ Emergency Plan for Twinject
• Sample letter from principal
• Sample letter from teacher
• Steps for school anaphylaxis plan
  

Also: Canadian School Boards Association publication:
Anaphylaxis: A Handbook for School Boards (New Edition)

Asthma Action Plans

• Alberta’s Asthma Action Plan (Canada)
  
• The Lung Association’s Action Plan (Canada)
• AAFA’s Student Asthma Action Card (USA)
• American Academy of Family Physicians Asthma Action Plan (USA)

Allergic Living‘s School Articles

• Food in the Classroom – click here
• Allergic Living’s award-winning article – Sabrina’s Law
• Hear Sabrina – Her moving CBC radio documentary – A Nutty Tale
• FAAMA: Inside the U.S. Food Allergy Law here
• Laurie Harada: Talking to School Officials here
  
• Laurie Harada: Off to Kindergarten - here
• Laurie Harada: If Your Child is Bullied - here
• Food Allergy and the Risky Teenage Years - here
• Sabrina’s Law: The Girl Who Inspired Change - here
• Who’s Watching Lunch at School? New excerpt here
  
• Off to College with Allergies - here
• Teens Talk: Life with Allergies - here
• Samantha Yaffe: Grade 1 and Letting Go – click here
• Kids, Anxiety and Anaphylaxis - here
• Backlash Against School Accommodations - here
• Air Quality at School - here
• The September Asthma Spike - here
• Sara Shannon’s Journey with Sabrina’s Law - here
• Reader’s Story: Sabrina’s Law Success - here
• Sabrina’s Law in Context – For a Kid, Dairy Allergy is a Life Changer

State and Provincial anaphylaxis laws, policies and guidelines, click here.

The amount of food the average child comes in contact with at the modern school is several times what his 30- or 40-something parent encountered as a pupil. Today’s staples include the pizza-at-school fundraisers, rich and fatty cafeteria food, and school vending machines brimming with oversized beverages and chocolate bars.

Add to the mix the modern child’s obsession with computers, the hours of instant and text messaging time, and results are a shocker: kids across Canada and the United States are more overweight now than at any other time in history.

Between 1978 and 2004, government statistics show that the proportion of overweight Canadian kids aged 6 to 11 doubled to 26 per cent, while the rate of teenagers who were too heavy also doubled – to a whopping 29 per cent. The rate of obese teens tripled to 9 per cent.

Due to weight issues, the federal government stated that, for the first time, this generation of children might not live as long as their parents. In the United States, over the past three decades there has been a doubling of obesity rates for preschoolers and teens, and a tripling for the 6-to-11-year-old group.

“Kids are drinking more sugary drinks, and you have exercise being designed out of their lives,” says Dr. Brian McCrindle, a cardiologist at The Hospital for Sick Children in Toronto, professor of pediatrics and author of Get a Healthy Weight for Your Child. “Because of safety concerns, they don’t play outside, and you see a proliferation of sedentary pursuits, video and computer.”

As children have grown ever heavier, the concurrent trend, of course, is the skyrocketing of food allergy. A study from Mount Sinai’s School of Medicine in New York, published in 2004, confirmed what allergists knew anecdotally; the incidence of food allergy in the U.S. had doubled, and those statistics are mirrored in Canada. Six to 8 per cent of Canadian school children now have food allergies, which can cause dangerous, even life-threatening reactions. Provinces and states are considering and, in a few cases, passing anaphylaxis-readiness laws in the schools.

But as those bring restrictions on what is appropriate for the lunchbox, simultaneously, the weight issue has grabbed the attention of educators and the media. The result: the pendulum is beginning to swing toward better nutrition in some schools. This means a new focus on fruits and vegetables, which happens to dovetail neatly with concerns about allergens in the class, since those foods are not the top allergenic sources, and they won’t lead to accidental exposures.

The Institute of Medicine, a scientific advisory group based in Washington, produced a report in April, 2007 calling for a dramatic new approach to food in the classroom: no food as rewards; no food for celebrations. Then it ranked foods into tiers. Tier 1 is acceptable: fruits, vegetables, real juice, low-fat dairy, and nothing with trans fat.

These are the only snack foods to be allowed for elementary school children and fundraising efforts, while higher-fat and sugary Tier 2 food could be available for after-school activity for teens. No snack, though, should be more than 200 calories.

Next: Banning the cafeteria fryer

IT DOES sound, if not “hysterical,” then at least over the top. One single peanut is noticed on the floor of a school bus and the 10-year-old riders are all told to get out immediately, because of food allergy risks.

The anecdote appears in an opinion article, written by Dr. Nicholas Christakis, a professor of medical sociology at Harvard Medical School, and published last December in the British Medical Journal. Christakis uses the bus incident, which took place at his children’s school in Massachusetts, as a starting point for this thesis: accommodations made for food-allergic students are an unnecessary “charade” based on fears that “represent a gross over-reaction to the magnitude of the threat.”

As an expert on how health conditions affect others in one’s social network, Christakis goes a big step farther, raising the spectre that school responses to food allergies bear “the hallmarks of mass psychogenic illness.” In other words, what used to be called “epidemic hysteria”: the eruptions of fear in towns, schools or hospitals based on the threat of contamination involving, the professor says, “otherwise healthy people in a cascade of anxiety.”

His article quickly grabbed the attention of news outlets around the world. He was interviewed by Time magazine, The New York Times, the Los Angeles Times and Canada’s National Post. Media articles were circulated on websites. The blogosphere had a field day. Suddenly it was fashionable to dismiss food allergy as a made-up phenomenon.

Parents seeking accommodations for kids at school were no longer taking sensible precautions – they were portrayed as hysterical, anxiety-ridden and even needing to “feel special”. Food allergy groups and parents of kids living with the risk of anaphylaxis were put on the defensive, while leading allergists only got to add their brief comments on the media debate as responses to Christakis’s statements.

The fallout from one editorial was remarkable. Yet in writing of needless hysteria, Christakis in fact increased the anxiety within the food allergy community. The widespread attention has had a polarizing effect on those on either side of the school accommodations issue, and now, after many advances have been won to protect students at risk of anaphylaxis, at least one major Canadian newspaper is asking: “Can schools bring back the humble peanut?”

Backlash, however, is not entirely new. “There have always been people who are doubtful that food allergy even exists,” says Anne Muñoz-Furlong, founder of the Food Allergy and Anaphylaxis Network (FAAN), the Virginia-based non-profit that focuses on awareness, education and research.

Of course, the condition is real, it can result in severe and even fatal reactions, and it is more common than ever. The Centers for Disease Control and Prevention in the United States last October reported an 18 per cent increase in the number of children with food allergy from 1997 to 2007. Meantime, a study from the Mayo Clinic in December found that anaphylactic reactions to food are responsible for 50,000 emergency visits each year in the United States, up from a previous estimate of 30,000.

With a rise in food allergies, particularly in children, has come a heightened awareness of the need to keep kids with the condition safe when they are away from their parents. School, of course, is where they spend the bulk of their “away” time, and where foods and snacks are part of daily life. This has led to advocacy, followed by measures to reduce the risk of allergic reactions, mandated by law in places such as Ontario, New Jersey and New York state.

“There are a lot of schools that are dealing well with these allergies,” says Laurie Harada, executive director of Anaphylaxis Canada. “And they’re not all hysterical and living in fear. It has become a part of their norm.” Muñoz-Furlong agrees, pointing out that evacuating a bus due to a peanut is a rare and extreme example. “In the U.S., we have two million school-age children with food allergies. They go to school, they participate in class parties and field trips, they’re on the bus and they are mingling – just like every other child.”

***

ALL THE SAME, the backlash has grown. The current rumblings date back to January 2008, when Harper’s magazine published an article in which writer Meredith Broussard did not mince words. “The rash of fatal food allergies is mostly myth,” she wrote, “a cultural hysteria cooked up with a few ingredients: fearful parents in an age of increased anxiety, sensationalist news coverage and a coterie of well-placed advocates whose dubious science has fed the frenzy.” She slammed FAAN for its fatality statistics that estimate 150 people a year die from food allergies, but neglected to mention that those figures, which emanated from a Mayo Clinic study in Minnesota, were derived using widely accepted methods.

When Christakis came forward to similarly cast doubt on the wisdom of school accommodations, his words carried considerable weight in the media, since he wrote as a Harvard professor and physician, and did so in the august BMJ. Within the scientific community, however, his views quickly became divisive.

In a letter to the BMJ, Dr. Jonathan Hourihane, a well-regarded Irish pediatric allergist, took issue. Hourihane said, for instance, that the professor had distorted the question of false positive allergy tests: “There is no such thing as ‘meaningless’ allergies to nuts, or else we have to accept the terms ‘meaningless’ asthma and ‘meaningless’ cancer,” he wrote.

It was a lazy afternoon in the residence common room – students were studying for classes, watching TV or simply hanging out with friends. Christine Creese was hungry and grabbed the phone to call a familiar number. Months earlier, the 22-year-old had discovered a local Chinese restaurant that would deliver to her dorm at the University of Toronto. Despite serious allergies to peanuts and nuts, as well shellfish, kiwi and onion – Creese was able to eat the restaurant’s delicious pineapple orange chicken.

On the phone, she went through her usual explanation of her allergies, and got an assurance that her favourite was safe from cross-contamination in that kitchen. “When it arrived, I put a whole piece of chicken in my mouth and suddenly realized that it tasted different,” recalls Creese. She spit it out, and called the restaurant back. The restaurant had accidentally sent the General Tso peanut chicken dish.

A tingling began in her mouth. Soon, Creese’s tongue was itchy and she became hot and flushed. Friends in the common room sprang into action: one called 911 while another had Creese’s EpiPen at the ready. Creese, a third-year student, used her asthma inhaler while others ran out to flag down the ambulance.

She was about to administer her EpiPen, when the paramedics arrived. Creese would end up needing two doses of epinephrine to bring her reaction under control, and spent the rest of the day in hospital.

Creese, now 24, is generally mindful of her medical condition. Before starting her undergraduate degree, she took precautions including asking for, and being given, a single room since it is difficult to enforce a peanut-free shared room, and she feels that “infringes on the autonomy of the other person.”

Food allergic students entering university this fall face a similar need to develop their own safety strategies while adapting to a new, big and autonomous school environment. Of course, any freshman has a lot to adjust to: moving away from home, living in residence, going to class in lecture halls and finding one’s way around campus.

But for those with life-threatening allergies, there is an additional layer of change – there are no parents around to explain to the professors about allergies as they did with the teachers in elementary school, and perhaps high school.

Even the most cautious student with allergies will find an environment of shared accommodations and cafeteria and residence meals an adjustment. And not every allergic student will be careful all the time – science has proven that the late teens and early 20s are a time of the most impulsive decision-making.

Throw into the mix the introduction of campus pub life, new friends and potential romantic interests, and university remains a time of learning inside the class and out. But for the allergic, it is also a time of managing a new level of risk and of learning to speak up for oneself.

With the number of teens entering university with allergies on the rise, many institutions are examining what sort of protective measures they can offer students.

The range of policies among universities and colleges is vast, but there are some encouraging advances. Carleton University in Ottawa has eliminated nuts from the residence dining hall menu and this spring became the third campus in Canada to allow its Student Emergency Response Team – a 24-hour service of volunteers trained in advance lifesaving techniques – to carry EpiPens. The practice began at McMaster University in Hamilton, Ont.

British Columbia’s University of Victoria takes one of the most proactive approaches. Three years ago, a group of students met the UVic administration to ask for improved options for those with allergies and food sensitivities. The university agreed that change was needed.

Of a population of 2,400 students who live in residence, 1,600 eat daily at campus cafeterias and restaurants. The number in residence who informed the university administration of allergies and other dietary restrictions grew to about 24 this year from three in the fall of 2005.

Traditionally, first year students at UVic live in residence, and would only move into cluster housing – a self-contained environment on campus – in second year. “We see it as the next level,” says Gavin Quiney, Director of UVic’s Housing, Food and Conference Services.

“But as we found more and more people presenting allergies, we thought this is too risky to involve them in the large institutional food program.” As a result, first-year students with severe allergies are being allowed to move into cluster housing.

So Eric Champagne, a 17-year-old Calgarian with tree nut, peanut and seafood allergies, is now living in such an apartment with two other young men with severe allergies. “Kudos to them for a great solution that goes a very long way in allaying our fears,” says Eric’s father, Gilles.