That Food Makes Me SICK!

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1 HEALTH That Food Makes Me SICK! Managing Food Allergies and Intolerances in Early Childhood Settings T he director of a child care center recalls how her program met the needs of a four-year-old with a severe peanut allergy. The first thing we did was to get a list of the child s forbidden foods from the family s pediatrician and post it in the classroom. We also got a list of the symptoms of a reaction. He starts itching first, so we know to watch for that. Our lunch menus are planned a month in advance, so we give the upcoming menu to the child s mother and she circles anything he is not allowed to eat. The children love cooking activities, but we limit any that involve peanut products to days when he is absent from the center. On days with special menus, such as holidays, his family sends his lunch and snacks with him to the center. The other children are aware of their classmate s food allergies, and the teacher has done a great job of incorporating information naturally while talking about differences and uniquenesses. His younger sibling also has food allergies, so this learning experience prepares us for the future. Marna Holland, EDS, CFCS, is an extension agent with North Carolina Cooperative Extension in Haywood County and a doctoral candidate at North Carolina State University. She conducts training for child care providers on a variety of topics, including nutrition and food safety. See Caring for Our Children, standard 4.010, Care for Children with Food Allergies, and standards 4.008, 4.009, and Marna Holland Young children are particularly susceptible to food allergies and intolerances because their digestive and immune systems are immature. Food sensitivities can be challenging for children, families, and early childhood professionals. It can be difficult for child care program staff to meet the needs of a child with a food allergy or food intolerance while serving snacks and meals to a group of children. The possibility that a child might have a severe reaction to food while at the program can result in stress for both the staff and the family. Collaborating and communicating with families and health professionals, planning menus, keeping complete and thorough records, and planning for emergencies can minimize the potential dangers for children with food allergies or intolerances who attend early childhood programs. Definitions, prevalence, and symptoms Both food allergies and food intolerances are abnormal reactions to food, and their symptoms can be similar. The key difference is that food allergies are triggered by the immune system, while food intolerances are abnormal responses to food that do not involve the immune system. In general, food allergies are more medically serious than food intolerances. People with allergies are often advised to eliminate the food from their diets altogether, while those with food intolerances are sometimes able to manage the condition by lowering intake of the offending food. For example, if a child has a milk allergy, the physician would probably recommend avoiding milk and milk products such as yogurt and ice cream. If a child is lactose intolerant, however, reducing the amount of dairy products might control the condition in some cases; however, it may be necessary to identify an alternative or completely avoid the offending food. Young Children March 2004

2 The most common foods to cause allergies for children are milk, eggs, peanuts, soybeans, tree nuts (such as pecans and walnuts), wheat, fish, and shellfish. The most common foods to cause allergies for children are milk, eggs, peanuts, soybeans, tree nuts (such as pecans and walnuts), wheat, fish, and shellfish (Duyff 2002). In addition, young children might be allergic to oranges, chocolate, legumes, rice, and meats including beef, pork, and chicken (Berman & Fromer 1997). The symptoms of an allergic reaction may include itching and swelling of the lips and mouth, hives, eczema, sneezing, runny nose, difficulty breathing, nausea, vomiting, abdominal cramping, and diarrhea (Bruton 1998). During an anaphylactic response the most severe type of allergic reaction different systems of the body react simultaneously. Symptoms appear and progress quickly and may include severe itching, swelling of the throat, difficulty in breathing, sweating, rapid or irregular heartbeat, low blood pressure, nausea, diarrhea, loss of consciousness, cardiac arrest, and shock (Duyff 2002). Anaphylactic reactions require immediate medical treatment; they can be fatal. The most common anaphylaxis-causing food allergens are tree nuts, eggs, peanuts, and shellfish (Duyff 2002). Casey Sills Food intolerances occur when a person s body has an abnormal, but not allergic, reaction to a food or food additives such as sulfites (used as food preservatives) or food colorings. Possible causes include deficiency of an enzyme or reactions to compounds, additives, or naturally occurring substances in food (Story, Holt, & Sofka 2000; CDE n.d.). Symptoms of food intolerance, which tend to be unpleasant but not as dangerous as food allergies, include nausea, abdominal pain, gas, stomach cramps, bloating, vomiting, diarrhea, headaches, and irritability. Food intolerance is more common than food allergy. Lactose intolerance the inability to digest the milk sugar lactose is the most prevalent. According to the American Dietetic Association (ADA), thirty to fifty million Americans suffer from lactose intolerance (1996, n.p.). A gastrointestinal virus that temporarily destroys the enzyme that breaks down lactose usually causes lactose intolerance in infants. It may take an infant several days to several months to recover completely, depending on the severity of the virus (Bruton 1998). Another common food intolerance is sulfite sensitivity. Persons with asthma can have severe reactions to sulfites (NIAID n.d.). Sulfites are potentially found in fruit juice, dried fruits, gelatin, and instant or frozen potato products (Duyff 2002), all of which may be on the menus in child care facilities. Cultural background appears to be a factor in food intolerances, particularly lactose intolerance. According to the ADA, lactose intolerance affects approximately 90 percent of Asian Americans and 75 percent of African Americans, Native Americans, Jews, and Hispanics in the United States (1996, n.p.). Picture Books about Food Allergies and Intolerances Some books focus on allergies to specific foods, such as nuts or seafood, others on coping with food allergies. Allie the Allergic Elephant Nicole Smith, ages 3 6. No Lobster, Please! Robyn Rogers, ages 4 7. No Nuts for Me Aaron Zevy, ages 4 8. The Peanut Butter Jam Elizabeth S. Nassau, ages 5 8. Taking Food Allergies to School Ellen Weiner, ages 6 8. The Food Allergy and Anaphylaxis Network at org offers a series of picture books about Alexander, a peanutallergic elephant. The books describe how Alexander copes with situations such as birthday parties, eating out, and holidays. Supplementary materials are also available. Young Children March

3 HEALTH Coping strategies for child care centers Establish written emergency procedures The following strategies can help early childhood educators safely address food allergies and intolerances with sensitivity so that no children feel spotlighted or excluded from any program activity. It will be easier for staff to respond to an emergency if there is a plan that tells everyone what to do. Staff should be trained by medical professionals on how to administer emergency medications, including epinephrine, a treatment for anaphylactic reaction often delivered through an injector called an EpiPen. The content and delivery of training should comply with state regulations about food allergies in child care settings. Develop written policies Lois Main An initial step in addressing a child s food allergies is to request a doctor s statement that gives the specifics of the condition, acplan menus that consider food ceptable food substituallergies and intolerances tions, and instruction Careful menu planning is essenin the event the child tial in managing food allergies and is exposed to the probintolerances. When many foods lem food. A written are eliminated or severely limited, policy should define a child s diet may be deficient in the family s and the nutrients that would normally be teacher s individual supplied by the offending foods. responsibilities regardfor example, a child with a dairy ing the child s food allergy may be at risk for a calcium allergy. deficiency, while a child with a A list of children and wheat allergy may need more iron their reactive foods (Story, Holt, & Sofka 2000). To the should be maintained extent possible, children with food in the center s food allergies and intolerances should preparation and serveat foods similar to those served to ing areas where it the other children to lessen feelis accessible to all ings of difference and isolation. adults involved in Allergy-specific cookbooks feeding children. can be helpful for guiding Other suggesthose preparing meals for tions include allergic children. A wheat-free obtaining parencookbook can aid a center s list of children and their reactive foods tal authorization kitchen staff struggling to and providing should be maintained in the center s food safely feed a wheat-allergic appropriate trainchild. Food label ingredient preparation and serving areas where it ing to administer lists also yield useful informaemergency allergy is accessible to all adults involved tion. (A packaged meat loaf may medication. Barinclude eggs, which would make it in feeding children. ber (2001) advocates off-limits for a child with egg allermaking plans that cover gies.) Allergens are listed in a number of celebrations (such as birthdifferent ways on food labels, but they may days), snacks, and field trips. These plans might call for an allergen-free cupcake to be dropped off by the child s family before the party or for the family to provide extra medication to be sent along for field trips. o the extent possible, children with Thorough documentation is essential to managing a child s allergies in child care. State licensing and health food allergies and intolerances should agencies can recommend what information about allereat foods similar to those served to the gies needs to be maintained in the child s records. These recommendations would also apply to food intolerances. other children. A T Young Children March 2004

4 be hidden. For example, a milk allergy requires not only searching the label for milk but also for whey, nonfat milk solids, and lactose. Make sure snack and mealtimes are safe Provide close supervision during meals and snacks so the child with the food allergy or intolerance does not have contact with offending foods or drinks or touch plates or utensils that might contain traces of the allergen. Using different colored tableware (cups, bowls, plates, utensils) for each child makes it is easier to spot when one child has traded with another (Bruton 1998). Because young children are encouraged to share with each other during other situations, they may need reminders of why they may not trade or give food to each other at mealtimes. Educators face the challenge of watching what the child eats while also encouraging developmentally appropriate self-help skills. It is extremely important to model and teach coping and management skills. Preschool children with life-threatening food allergies must know what foods they can and cannot eat and how and what to tell the teacher when they are having a reaction to food. It is also important for them to understand that, in case of an emergency, their medication is with or near them at all times (BCMCF 1999). Depending on a child s type of food allergy, the center may need to inform all families in the class that a child has a specific condition. In particular, peanut and seafood allergies fall into this category because children can have a reaction just by being near those food products. For a child who is peanut allergic, something as simple as a nearby child eating a snack of peanut butter Review recipes, plans, and labels for activities According to Barber, Counting pumpkin seeds, M&Ms, or sunflower seeds may be a good way to teach number concepts, but to a peanut- or seed-allergic child, even handling these foods may be dangerous (2001, 220). Classroom cooking activities must be monitored closely. Children with food allergies may not be able to eat the finished product after a group cooking activity, but they can participate in other ways, such as gathering bowls and utensils, arranging table settings, pouring drinks, or photographing the activity. Have the child who has the allergy wear plastic gloves so the ingredients don t touch his or her skin (Weiner 1999). Even touching a surface having small amounts of offending food on it may cause some children to develop symptoms. Before reuse for other activities, thoroughly clean food containers, such as egg cartons or yogurt cups, to protect children with severe allergies. Adopt a team approach Successful management of food intolerances and allergies requires a cooperative, team approach. The child who has the allergy, the family, all staff (including substitutes), the physician, other health care providers (nurse or dietitian), and the other children and their families all have roles to play. As children get older, they become increasingly aware of what can happen if they eat forbidden foods and are more able to help regulate their diets. Unfortunately, young children may feel separated and isolated from peers during meals and snack times. It can help to maintain a matter-of-fact approach and encourage the child to take greater responsibility for choosing appropriate foods (Berman & Fromer 1997). Lois Main Educators face the challenge of watching what the child eats while also encouraging developmentally appropriate self-help skills. Young Children March

5 HEALTH and crackers from home can result in a medical emergency. The program or the family of the child with the allergy can send a letter to the other families detailing the child s allergies and what foods need to be eliminated from the environment (Barber 2001). Taking a positive, proactive approach in informing families who need to know about the allergy should make the situation less stressful. It is also important to teach the rest of the children in the class not to share Print Resources for Early Childhood Educators Barber, M The parent s guide to food allergies. New York: Henry Holt. Breault, J Special foods for special kids: A training tool for child care providers on feeding children with special needs. Topeka: National Food Service Management Institute and Kansas State University. Bruton, S., ed Every little bite counts: Supporting young children with special needs at mealtime. Sacramento: California Department of Education. A guide to feeding young children with special needs: For early childhood programs, families, and anyone responsible for the feeding of young children Phoenix: Arizona Department of Health Services. NFSMI/UM (National Food Service Management Institute/University of Mississippi) From the trainer s tablet: Lessons for family/home child care providers: Food intolerance and allergies. University, MS: Authors. Online: www. nfsmi.org/ Information/cclessons/allergies.pdf USDA (United States Department of Agriculture) Building blocks for fun and healthy meals: A menu planner for the Child and Adult Care Food Program. Washington, DC: Author. Web sites Allergies and Food Sensitivities, Food and Nutrition Information Center. American Academy of Allergy Asthma and Immunology. www. aaaai.org Asthma and Allergy Foundation of America. Child Care Nutrition Resource System. childcare/index.html The Food Allergy and Anaphylaxis Network. org Life-Threatening Food Allergies in School and Child Care Settings. food_allergies.pdf National Food Service Management Institute/University of Mississippi. Mary has her own special milk so that she won t get a tummy ache and she can stay healthy. food with the child who has the food allergy or intolerance. Bruton suggests, Explain briefly and simply why a child is not able to share some of the same foods. For example, Mary has her own special milk so that she won t get a tummy ache and she can stay healthy (1998, 95). Conclusion Effective management of food allergies and intolerances in child care settings includes education for staff and families, appropriate written policies, good communication, and thoughtful planning and preparation. Teachers need to be knowledgeable about food allergies; communicate regularly with families, children, and health care providers; plan menus accordingly; and prepare to deal with emergencies. This sound preparation will reduce stress and ensure that the needs of the child and family are met in safe, sensitive, and appropriate ways. References ADA (American Dietetic Association) Lactose intolerance. Chicago: Author. Online: Information/92_nfs43.cfm. Barber, M The parent s guide to food allergies. New York: Henry Holt. BCMCF (British Columbia Ministry for Children and Families) Life threatening food allergies in school and child care settings. British Columbia, CAN: Author. Online: gov. bc.ca/cpa/publications/food_allergies.pdf. Berman, C., & J. Fromer Meals without squeals. Boulder, CO: Bull Publishing. Bruton, S., ed Every little bite counts: Supporting young children with special needs at mealtime. Sacramento: California Department of Education. CDE (California Department of Education). n.d. Food allergies. Sacramento, CA: Author. Online: htm. Duyff, R American Dietetic Association complete food and nutrition guide. 2d ed. Hoboken, NJ: John Wiley. NIAID (National Institute of Allergy and Infectious Diseases). n.d. Food allergy and intolerances. Washington, DC: U.S. Department of Health and Human Services. Online: Story, M., K. Holt, & D. Sofka Bright futures in practice: Nutrition. Arlington, VA: National Center for Education in Maternal and Child Health. Weiner, E Taking food allergies to school. Plainview, NY: JayJo Books. Copyright 2004 by the National Association for the Education of Young Children. See Permissions and Reprints online at org/resources/journal. Young Children March 2004

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