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Free lunch: Managing special diets for children with food allergies and sensitivities

by Heather Pond Lacey

“Peanut free.” “Gluten free.” “Dairy free.” Those labels seem to be everywhere now. A generation ago, peanut butter seemed like the perfect food for children. But today, we are becoming more familiar with the serious risks faced by children with severe allergies to peanuts and other common foods, so schools and child care providers are faced with managing special diets for more and more children.

What do we know about allergies and food sensitivities?
The Centers for Disease Control and Prevention estimate that about 1 in 13 children has a food allergy, an increase of about 50 percent between 1997 and 2011 (CDC 2013; Jackson, Howie, and Akinbami 2013). Most food allergies are triggered by eight common foods:
peanuts
tree nuts
milk
eggs
wheat
soy
fish
shellfish

But other foods can also cause allergies. Allergic reactions can be mild, causing a rash, digestive problems like vomiting or diarrhea, or hay-fever symptoms like sneezing, congestion, or itchy eyes. But they can also cause a life-threatening reaction called anaphylaxis, which causes the airway to swell so much that the child can’t breathe. Anaphylaxis causes approximately 200 deaths a year in the United States.

In addition to food allergies, many children suffer from food sensitivities or food intolerances. For example, celiac disease is a reaction to gluten, a protein in wheat and a few other common grains such as barley and rye, causing severe inflammation in the intestines (Fasano 2005). Children with celiac disease can experience severe belly pain and bloating, chronic digestion problems such as diarrhea or constipation, and even stunted growth because the damaged intestines can’t absorb much nutrition. They also face long-term health problems, like an increased rate of cancer or infertility in adulthood.

Other common food intolerances such as lactose intolerance or non-celiac gluten sensitivity are more likely to show up in the teen years, but they do sometimes affect younger children as well, leading to still more dietary restrictions (Catassi, et al. 2013; Suchy, et al. 2010).

How are children affected emotionally?
Allergies and food sensitivities can cause serious problems with physical health, but they also affect children’s emotional and social well-being. Imagine how a little girl feels watching all her friends gobble up a birthday cake or holiday sweets while she is left out. Imagine how she feels different because she has to eat alone at a separate table every day.

Imagine a little boy being teased because he can’t participate in a class cooking project, or even some science or art projects because they involve allergic materials. Imagine him feeling scared at every mealtime because he remembers getting sick and going to the hospital in the past. Research shows that children with allergies are more likely to feel anxiety and have lower quality of life than other children (Cummings, Knibb, King, and Lucas 2010).

Children with allergies aren’t the only ones suffering from stress and anxiety. Those who care for them struggle too (Cummings, et al. 2010). A number of studies have looked at how parents are affected by their children’s allergies and diet restrictions. They often experience high levels of stress and anxiety about their children’s safety, and even depression. In surveys, these parents describe some ways that their family activities become limited, such as avoiding restaurants, social events, vacations, and even sports or other activities where they aren’t sure their child can be kept safe (Mandell, Curtis, Gold, and Hardie 2005).

They also describe a frustrating lack of support from others, including other family members, friends, and teachers or school administrators. The child’s safety and health depends on the cooperation of all caregivers, but parents often report that other adults can be careless about the foods they offer to the child, sometimes don’t believe how serious the condition is, or may even get angry about having to work around the child’s needs (Muñoz-Furlong 2003).

When parents are overly anxious about the child’s health and safety, the problem can get worse for the child. Allergic children with anxious parents are more likely to feel anxious themselves (Ackerman 2009). The parents are also more likely to be overprotective, so children are less likely to join in with normal childhood activities and they are slower to develop independence in other important ways (Dahlquist, et al. 2014). As allergic children get older, they are also more likely to miss days of school, more likely to get pulled out for homeschooling (Munoz-Furlong 2003), and less likely to participate in other activities like sports (Calsbeek, et al. 2006).

Unfortunately, not much research has been done to look at how others around the child are affected. Just as parents feel burdened and anxious about how to manage a special diet and keep a child safe, teachers and other caregivers share the responsibility and the worry. They must also learn to balance the needs of one child with the needs of others, managing the restricted diet in a busy environment full of active children.

Other children may also be affected. A few studies have looked at how siblings feel; they sometimes feel jealous of the attention that goes to their special sibling, resentful of the restricted family activities and foods, or fearful about their sibling getting sick or dying (Muñoz-Furlong 2003).

Do friends and classmates also experience some of these feelings? Researchers don’t know yet, but it seems likely that they would feel some effects. Unfortunately, some children may also act out with teasing or bullying behaviors when they see a classmate who is different. In some rare cases, allergic children have had allergic reactions when other children smeared them with peanut butter or sprayed them with milk (Muñoz-Furlong 2003).

A personal example
I had to learn quickly about managing special diets when my 4-year-old son, Jonah, was diagnosed with celiac disease. I am grateful that at least there is no risk of anaphylaxis with celiac disease, but to keep him healthy, we have to be just as careful with his food. Even a little bit of gluten cross-contamination (like a bit of flour dust or a few bread crumbs getting onto his food) can make him severely sick for several days.

When he was diagnosed, we suddenly had to re-think everything we knew about feeding our family, learning new recipes and adjusting old ones with new ingredients. We had to learn to read labels more carefully. We had to give up restaurants and take-out food until we could find out which kitchens were truly safe and wouldn’t accidentally spread small amounts of gluten to his food.

But we weren’t the only ones facing a new challenge. Jonah was in a full-time pre-kindergarten program at a large child care center where he ate lunch and two snacks every day in a class with 20 other non-celiac children. We all had some learning to do.

As soon as we heard the diagnosis, my husband and I made an appointment with Jonah’s lead teacher, the school director, and the school nurse. They already had a policy in place for allergies. For example, the entire school was peanut-free and tree-nut free, and other allergies were handled case by case.

But the school had never dealt with celiac before. We needed to start by explaining the condition (with the helpful input of the school nurse and lots of materials from our pediatrician). Then we all brainstormed to develop strategies that would keep our son safe without disrupting the other children too much or overburdening the teachers. We also all agreed that his social and emotional health was as important as his physical health. We wanted to make sure his diet restrictions didn’t make him feel too left out or too different from his friends.

The solutions we developed were not complicated, but they required some planning and some cooperation. We knew it wouldn’t be realistic to ask for a wheat-free classroom, but we could work out a plan to keep unsafe foods away from him. He would no longer eat the snacks supplied by the school; all his food would come from home. At mealtimes, the teachers had always helped open up lunchboxes, heated entrees, and unwrapped foods as needed. Now, they agreed to start with Jonah each time before touching any other children’s food, always wearing fresh gloves, to avoid spreading crumbs to him.

We brought in some of Jonah’s favorite gluten-free sweets to keep on hand for birthdays and other celebrations when the class was enjoying a treat. Children were asked to wash hands after meals, as well as before, to avoid spreading crumbs all over the classroom. With these few changes to the classroom routine, Jonah’s belly troubles finally settled down.

Tips for managing special diets
Though every class and every child will have different needs, our experiences highlighted a few key tips that can make it easier to navigate this tricky issue.
Learn what you can about the child’s condition. No one expects you to become a doctor or a nutritionist, but if you can learn the basics about the child’s condition, you’ll have a lot more confidence about safely managing the child’s food. Ask the parents to explain what they know about it, and ask them to share other resources such as pamphlets or fact sheets they’ve received from the doctor.

You might also find plenty of helpful information online, by searching for organizations linked to that condition, such as Foodallergy.org or celiac.org. The CDC also offers specific advice to help schools and child care providers manage allergies at www.cdc.gov/healthyschools/foodallergies/.
Remember that every child is different, and so is every allergy. General information is a helpful starting place, but symptoms and sensitivities differ from child to child. Some allergic children can’t even be in the same room with their allergen. They can have a life-threatening reaction from touching the food or breathing it in. Others may have only a mild rash even if they eat it directly.

Children with celiac disease or lactose intolerance may have severe stomach pain, but no immediate life-threatening danger. Ask the parents to request a letter from their doctor, who can give more specific information about this child’s needs.
Be prepared for an emergency. Life-threatening reactions can occur quickly when a child is exposed to an allergen. Avoiding an allergic reaction is best, but if a reaction occurs, you need to know what immediate steps to take until medical help arrives, just as in any first-aid situation.
The parents may be able to provide an Emergency Care Plan (ECP), developed by the child’s doctor. You may also need a bit of training to administer an EpiPen^® shot if the child has a severe reaction. Check with your local health department to find out if training is needed and if it’s available near you.
Keep the lines of communication open. If something isn’t working and the child continues to get sick, you may feel worried about the child’s safety, guilty that you can’t keep up, or even defensive if the parents are pointing fingers at you.
On the other hand, even if the child is doing great, you may feel resentful about the extra demands or nervous about confronting the parents if you need to make some changes to help you keep up. If you all go into the situation agreeing that some adjustments may be necessary later, it may be easier to make those adjustments without conflict. Consider setting a date to meet again in a few weeks or months to review how things are working.
Help other children and families learn the safe-food rules. If specific foods have to be banned from your facility, you’ll need to make that clear to all families, and help them understand the seriousness of the rule. Other parents may feel annoyed at the restrictions, but if they understand that another child could suffer a life-threatening attack, you will get more cooperation.

Children also need to know about handwashing rules, no-food-trading rules, and food-safe zones that you may set up where the allergic child eats. Explain the rules in age-appropriate ways. For toddlers, this can go along with other basics rules about handwashing and covering up their coughs to avoid spreading germs. For older children, it may be appropriate to explain that some foods make people sick and we all have to help each other stay healthy. But try to avoid singling out the allergic child if he or she seems self-conscious.
Remember the child’s feelings, as well as their bodies. While safety is the first priority, the child may also be affected emotionally by the condition. The child may feel different and excluded, and will almost certainly feel deprived. Be sensitive to the child’s needs when planning treats and activities. Try to plan foods that all the children can enjoy, or work with the parents to find substitutes that the allergic child will enjoy.

Around holidays and birthdays, encourage other families to bring in non-food goodies, or to come in for a special story or some other special activity that doesn’t focus on food. When you’re planning art or science projects, be aware of allergens that may show up in science or art materials, and try to find alternative materials or choose other activities.

If the allergic child is struggling, talk to the child and to the parents to figure out what kind of support you can offer. A shy child may not want to be singled out, so you might try to downplay the special foods and serving procedures. Other children may feel special because of their unique foods, and may enjoy showing off a bit to their friends.

Food allergies and sensitivities can be intimidating, but they are increasingly a part of life. Staying informed and communicating openly with families can help you make a safe and happy environment for children needing special diets, without feeling overwhelmed by the job.

About the author
Heather Pond Lacey is an associate professor of applied psychology at Bryant University in Smithfield, Rhode Island. Her research and teaching focuses on health, well-being, and decision making. She earned a B.A. in psychology from California State University-East Bay and M.A. and Ph.D. degrees in psychology from the University of Michigan.