EAACI Food Allergy and Anaphylaxis Guidelines: managing patients with food allergy in the community

Food allergy (FA) reactions commonly occur outside the home 1 (Box 1). This section of EAACI Food Allergy and Anaphylaxis Guidelines is intended to provide guidance to all stakeholders in order to reduce the risk of accidental allergic reactions to foods in the community. This guideline is therefore intended to assist those working in school and early-childhood settings (e.g., kindergarten) as well as providers of non-prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast-food outlets). Furthermore, we hope that it will help children with FA, their families, schools, and their specialist and nonspecialist healthcare providers (Table 1). This guideline has been prepared by EAACI's Taskforce on Community and builds on the previous EAACI Position Paper on Management of the Allergic Child at School 2. Details on the production of these guidelines, the approaches used, and the involvement of experts and stakeholders are summarized in the Data S1 and Table S1.

Why the community is important

Food allergy is a common and increasing problem 3, 4 with the main burden occurring in childhood 5. In Europe, at least 25% of school-age children live with allergic disease and FA affects up to 4–7% of primary school children 6. The estimate will vary depending on point or lifetime prevalence and whether this is self-reported, based on oral food challenge, or based on other methods. The pooled lifetime and point prevalence of self-reported food allergy (FA) were 17.3% (95% CI: 17.0–17.6) and 5.9% (95% CI: 5.7–6.1), respectively. The point prevalence of sensitization to ≥1 food as assessed by specific IgE was 10.1% (95% CI: 9.4–10.8) and skin prick test 2.7% (95% CI: 2.4–3.0), food challenge positivity 0.9% (95% CI: 0.8–1.1).

Food allergy, particularly to peanuts, tree nuts, egg, and milk, is the leading cause of anaphylaxis 7, 8, 10, 11. Allergen avoidance education is often targeted at avoidance within the home, with less emphasis on how to avoid community exposure. Anaphylaxis often presents at home, and this is an important situation to manage 1. However, there is also significant risk from community exposure 1. The most common location for anaphylaxis to occur in the community is the school or kindergarten, accounting for 16–22% of reactions 12-16, 16. Between 10% and 18% of FA or anaphylaxis reactions occur at school 1, 17. In a UK survey, 61% of schools had at least one child at risk of anaphylaxis (i.e., had a reported history of anaphylaxis or carried an adrenaline auto-injector (AAI)) 18. Reactions also occur in a wide variety of other community locations including restaurants, sports fields, beaches, and gymnasiums 14. Fatalities due to FA are equally likely to occur at home or in community locations such as a restaurant/takeaway 19, friend's home, school/nursery 21, 24, camp, and work 26, 26.

The management of food-allergic children should therefore aim also to protect against the risk of allergen exposure outside the home. Avoidance of community reactions depends on complex factors and interaction with third parties providing food (e.g., schools) when parents are not present. Anaphylaxis is more common in adolescents and young adults, at an age when they begin to take over responsibility for making food choices outside the home 27 and carrying emergency medication 29-32. Improved education of individuals at risk and their families, peers, school staff, and restaurant and other food service staff about reducing risk can help to prevent fatalities 11. Increased awareness of policymakers may improve care at local and national levels. A harmonized legislation is urgently required for the availability and administration of adrenaline at school as well as for educational multidisciplinary programs aimed at general practitioners and targeting the family as a whole, the restaurant, canteen, and school staff 32.

Families, caregivers, and the allergist

Families of food-allergic children require guidance on managing this potentially long-lasting condition, balancing safety against social and emotional restrictions. Equal weight should be given to protecting children against community and home reactions. Parents and caregivers have primary responsibility for coordinating care for their children. As children reach adolescence, they begin to make food choices by themselves outside the home and take responsibility for carrying their own emergency medication. This coincides with the time of life where severe reactions and deaths due to anaphylaxis become more common. Education should be focused on providing a comprehensive package of age-appropriate avoidance, advice, provision and training in how and when to use emergency medication.

The first principle is correct diagnosis of the allergy by clinical history, serum-specific IgE and skin prick testing and challenge, if necessary, to identify relevant trigger and tolerated foods 33, 34. The allergist and/or the dietitian should provide comprehensive advice on allergenic foods to be avoided, interpretation of food allergen labeling (including precautionary labeling), and identification of potential sources of cross-contamination. Patients and their families should be advised of the common pitfalls and situations where accidental reactions are particularly frequent or severe, and contingencies for these situations should be discussed. Advice should include guidance for relevant community-specific situations, for example, how to manage FA with reference to school meals, school camps, or social gatherings. Management should also focus on good control of coexisting asthma. Other allergic conditions such as eczema and allergic rhinitis should also be addressed.

The use of comprehensive personalized emergency management plans (PEMPs) is associated with a decreasing frequency of severe reactions following their implementation 27, 36. Regular follow-up is an essential part of any management plan. The ability of parents to assess the risk and manage their child's condition is highly dependent on their own knowledge, attitudes, and beliefs about FA 5. Not surprisingly, misconceptions are held about prevalence and triggers. Also, many families report an adverse effect of the FA on their personal relationships, with some experiencing outright hostility from others when trying to accommodate their child's FA 37.

Provision of AAI devices to those at risk of anaphylaxis is an essential part of the comprehensive PEMP. Indications for provision of AAIs are discussed in detail in the Anaphylaxis guideline 37. Some reports are a warning indication of AAI actual use, in comparison with AAI prescription. According to the Health Council of the Netherlands, 1450–1700 children in the Netherlands are prescribed an AAI device yearly, with 50–75% of children having two devices, one on their person and one stored at day care or school 38. However, an alarming under-prescription of AAI was reported in school-going adolescents: Although the auto-injector was indicated in 3.0%, only 0.09% of the adolescent evaluated owned a device 39. In a study of children from 14 allergy clinics throughout UK, only 16.7% used their prescribed AAI during anaphylaxis 40. These data emphasize the importance of repeated education and assessment of the knowledge on how and when to use of AAI devices 37.

Education is clearly important. Factors associated with greater knowledge are a prior practical demonstration, consultation with an allergy specialist rather than a general physician, and independently seeking additional information from a patient organization 41. Factors correlating with confidence to administer auto-injectors are prior administration, regular training, and empowerment by healthcare professionals to manage a severe allergic reaction 42.

School

Food allergy is a common health issue in the school setting 44, 45. Food-allergic children will be exposed to food ingestion when out of their parents' direct care and require proper management of the adrenaline administration. All schools should therefore have a policy to protect such children. The reality is that many facilities are poorly prepared to protect students. Essential components of policies for the prevention of food allergen exposure are missing 1, 45, teachers have poor knowledge of anaphylaxis triggers, symptoms, and AAIs 17, 47-49, and PEMPs are not currently consistently provided for the majority of students with FA 16.

In one series of food-allergic school children, only 54% had a PEMP, 72% an AAI, and 60% a complete emergency kit 50, 51. Where PEMPs are provided, studies have shown that up to two-thirds of patients and caregivers are unable to administer AAI devices, or even have them available 50.

In a study on a large university campus, only 6.6% of food-allergic students reported always carrying an AAI; in addition, only 39.7% avoided a self-identified food allergen 46.

The goals in school are to create a network of support and a self-sustaining environment of awareness that reduces the likelihood of reactions and enables staff to recognize and treat emergencies. The ideal approach is for schools to develop a formal policy, with the aim of achieving these goals, which is informed by the available expertise.

The school principal should take overall responsibility for provision and delivery of the policy. Early liaison with local expertise such as allergists, pediatricians, allergy nurses, and patient organizations is essential to the implementation of a well-informed, comprehensive policy. There may be significant barriers to be overcome in this regard as ‘education’ and ‘health’ are often governed by different municipal governmental bodies. Therefore, fostering a cooperative partnership between doctors, community nurses, dietitians, parents, and the school community is essential 48.

A named person should be responsible for development of management plans for individual children. This should ideally be a school nurse, but if not available, then another appropriately trained individual (e.g., teacher) could be identified. There may be no such person, in which case the principal is encouraged to seek help in training staff using suitable allergy resources (Box 2). All staff are responsible for implementation of the policy.

Teachers and school staff responsible for student supervision should be properly instructed to recognize the onset of an allergic reaction, including anaphylaxis, and know how and when to get help. In many schools, there is a lack of full-time school nurses, and teachers feel overwhelmed when the responsibility is placed upon them to take care of food-allergic children. It is imperative that teachers receive a comprehensive and practical educational program on food allergies whether a school nurse is available or not.

Ideally, school nurses should play a key role in coordinating management of students with food allergies. It is essential that they themselves have received sufficient training in FA. These school nurses can then train the entire school staff. A train-the-trainer anaphylaxis education program providing school nurses with curriculum, lesson plans, teaching-learning activities, and resources for anaphylaxis education of all school staff has been suggested in Europe (and the US) through patient organizations 51, 52. http://www.anaphylaxis.org.uk/.

The nominated individual should adapt the PEMP for each student. Parents need to be included in discussions on school management (including PEMPs) as they are well practiced in managing their child's FA by the time they reach school age. When school staff and parents cannot agree on an important issue, it can be taken to the specialist.

Another important component of the policy is to have systems in place to identify food-allergic children to school staff, especially catering or new/temporary staff. Any food provided by the school should have clear allergen labeling; menus including allergen information should be available to the families in advance. Appropriate food handling procedures should be put in place to minimize the risk of cross-contamination. A general ‘allergen-ban’ in isolation is inadequate, falling short of a ‘whole school management’ approach to instill allergy awareness throughout the school. Measures in line with these approach include: making sure that the child cannot be in contact with other children having allergenic foods, for example by having a teacher sitting in between the child and the other children; cleaning faces, hands, and the floor after meals; making sure that the allergic child has his/her own treats.

Bullying, teasing, and harassment of children with FA together with denial of their condition is also be frequently encountered 53, 54. Policies should be structured around ethical principles of confidentiality (where appropriate), fairness, avoiding stigmatization, and empowerment of those affected 55.

Primary and secondary/tertiary school policies should differ in order to reflect the needs and developmental level of their students. Primary school children tend to be in a more protective environment. In secondary schools, pupils should be supported in becoming more responsible for their allergies. During the teenage years, adolescents should be positively encouraged to self-manage their condition while still in a ‘semi-protected’ environment, in preparation for adulthood 56, 57. An ‘adolescent-centered’ approach empowers secondary pupils in a process that is meaningful and relevant to their lives 58.

Secondary schools should educate the peers of students with FA in good practice, risk awareness, and management of emergencies. This may help counteract the ignorance, stigma, and bullying associated with allergies.

Prompt administration of adrenaline is the first-line treatment for anaphylaxis. Scheduled checks for the availability of AAIs are essential, to identify AAI expiry and ensure timely replacement, in liaison with the family 59. Quick and easy access to adrenaline is also an issue since in many cases the device is stored in a remote office causing a delay. School policy should specify a protocol to bring the device to the student promptly during an emergency. Storage in the class or cafeteria or other unlocked and easily accessible locations is recommended for primary school students. As soon as the student achieves a proper level of maturity, they can be encouraged to self-carry the device.

Adrenaline auto-injectors are not always subsidized by public health insurance, limiting their availability 60. In such cases, government support for reimbursement of AAIs in low-income households is desirable. Some US and Australian, though not European, legislatures are now permitting the patient nonspecific availability of AAIs in schools, which may address this issue of children and adolescents having to always carry their own AAIs. However, students will still need to carry their own AAI to protect them from the effects of food sharing and food accidents on the way to and from school (Box 3).

Providers of non-prepacked foods

Restaurants and other food establishments, such as bakeries, takeaways, deli counters, and fast-food outlets, pose a number of potential dangers for individuals with FA, particularly due to cross-contamination and unexpected ingredients.

A telephone survey of US patients who suffered reactions to peanut and tree nut in restaurants, bakeries, and shops showed that only 45% with previously diagnosed FA notified the establishment of their allergy. In the remainder of cases, reported reactions resulted from ingestion of food not intended for them, ingestion of food selected from buffet/food bars, or skin or inhalational contact (e.g., residual food on tables; peanut shells covering floors; being within a meter of the cooking of the food). For 78% of all reported reactions, someone in the establishment knew that the food contained the allergen as an ingredient. In 50% of these incidents, the food item was ‘hidden’ (e.g., in sauces and dressings). In 22% cases, exposures were reported from contamination caused primarily by shared cooking or serving supplies 61.

Social considerations such as peer pressure, embarrassment, stigma, alcohol ingestion, choice, and spontaneity may hamper a parent or adolescent's ability to apply appropriate avoidance behavior 62. The individual or family should clearly state the allergy (ies) to the provider on each occasion and if possible should preview the menu online. This should be repeated on every visit to take account of change in recipes or staff. The food providers have a responsibility to provide clear, comprehensive information on potential allergenic ingredients so the individual/family can make an informed decision about food consumption. Where the risk is unknown, this should also be stated, and the restaurant should be avoided.

At present, current food allergen legislation requires any of the 14 EU regulatory allergens, where used as ingredient, to be clearly declared within the ingredients list of prepacked foods 63. From December 2014, the Food Information for Consumers Regulation (EU Regulation No. 1169/2011) will also require businesses selling food sold non-prepacked to provide information about allergenic ingredients deliberately used in the food they serve to consumers. The allergens that have to be declared are mentioned in the Annex II of the Regulation. They include most of the major allergens, but not every food allergen. There are examples of voluntary best practice advice for such businesses 64.

Food preparation and handling techniques in catering establishments can increase the risk of a food-allergic reaction due to the possibility of cross-contamination. The frequency of accidental allergic reactions as a result of cross-contamination in food establishments is unknown, although it is frequently encountered in clinical practice. Ignorance of the ingredients in a recipe by serving staff also poses significant risk 65. Good communication between staff preparing food and front-of-house serving staff is essential to prevent this.

Some food-allergic individuals can react to ingestion of trace levels of the offending food, although highly variable ranges of threshold doses exist. The magnitude of the risk depends, among other factors, on the dose of exposure to cross-contaminated foods and the individual's threshold dose 66. Other cofactors at the time of the reaction such as poor asthma control, increasing age, type of food allergen, exercise, infection, menstruation, food additives, NSAIDs, and alcohol use may contribute to severity 66-69. One study showed that for peanut allergy, threshold levels decreased with increasing age and increasing sIgE 70. However, in most fatal reactions, the allergen was an ingredient in the food and not due to cross-contamination, and in most cases, the adrenaline was not available or not administered 11, 71. Insufficient threshold dose information within the food-allergic population restricts the advice on levels of unintended allergenic foods. In two challenge studies, for example, a low threshold did not correlate with severity of reported accidental reactions 67.

The need for more training for restaurant staff and consumer caution on staff knowledge gaps remains high. Studies from the USA and the UK of an assortment of staff from a wide variety of restaurants and fast-food outlets suggest a high degree of confidence, but a low level of knowledge and a desire for further training 72-74.

Traveling abroad may be perceived as potential risky situation for severe food-allergic reactions. Difficulties with airlines or restaurants are frequently quoted 74. The quality of data from studies reporting reactions on airplanes is poor also due to reluctance in survey response 75; however, the data suggest that a small number of reactions occur in this context, some of which are severe. Airline companies show inconsistency, for example, regarding provision of peanuts on board aircraft and requests for special assistance 76-80. Allergic reactions constituted only 2.2% of medical emergencies during commercial passenger flights in the USA 81.

In the survey performed by Greenhawt et al., although 76% of food-allergic patients reported carrying an AAI on a flight, only 10.6% of these individuals used their device, and overall, only 10% received adrenaline (from the auto-injector or via syringe) as treatment. Despite the reaction, 52.4% reported not making any changes in their behavior. However, some protective behavior was reported by the other half: 25.7% reported that they no longer consume food served on board, 23.8% now clean their personal seating area, and 20% request a peanut- or tree-nut-free flight. Twelve percent reported no longer flying commercially as a result of this reaction 78.

The approach to eating on an aircraft should be the same as that for any restaurant, ensuring the cabin staff are aware of the allergy (preferably inform the airline before the flight and the cabin staff on the day), and the contents of any meal served during the flight should be carefully checked. Emergency medication should be carried in the aircraft cabin and not packed into the luggage hold.

At the destination, individuals can use a variety of strategies to remain safe including visiting familiar environments, carrying allergy information cards in the host language, and possibly preparing their own food 82. They should also carry a sufficient supply of emergency medication, bearing in mind it may be difficult to replace, and be prepared to use it.

General public

The general public plays a significant role in the well-being of individuals with FA. The emergence of FA as a significant public health problem has been relatively recent and is accompanied by increasing interest from the mass media and the commercial sector, as policymakers respond to the demands of affected individuals 82. Food allergy has become an important issue on the regulatory agenda, particularly in the UK, Canada, the USA, New Zealand, and Australia 83. In order to respond appropriately to the growing prevalence of food allergies, decision-makers must balance protecting the affected population, while accommodating the general public's needs.

Improved FA knowledge among the general public is desirable. A Web-based survey of the general US population showed that familiarity and prior training in FA management were associated with higher knowledge scores. However, respondents tended to minimize the stigma associated with FA and oppose FA policies in schools, such as nut bans or special FA tables 84.

The introduction of public health policies to protect food-allergic individuals should be based on the best available data and expert consensus. Currently, many policies and regulations are being implemented in public spaces (schools, restaurants) despite the lack of scientific consensus 85 (Box 3). Consequently, these policies are often perceived as extreme in the literature, in the media, and by the nonallergic population 86. The inflated perception of risk of severe food allergies in the general population 86-88 has resulted in several debates related to protection vs rights, particularly around the policies developed in response to the disproportionate burden of food allergies in children 88.

In addition, social exclusion (such as parents reluctant to invite a child with allergies, prohibited trips and activities or reduced career options in the longer term) is a growing problem that needs to be addressed at the societal level. In the meantime, careful planning such as training the staff who will be accompanying the allergic child in the trip in allergen avoidance on symptoms recognition and emergency medication should overcome some situations of social exclusion.

Concluding remarks

Food allergy reactions commonly occur outside hospitals and the home environment. Food allergies are now seen as a health risk and there is a growing interest from the general public, mass media, and the commercial sector. Community exposure, traveling abroad, and lack of information from healthcare providers are factors that place food-allergic patients at greater risk of severe or fatal anaphylaxis. In the community, many stakeholders need to work together to reduce the risk of allergic reactions to foods and to manage any that occur.

The ability of the parents of children with food allergies to assess the risk and manage their child's condition is highly dependent on the parental knowledge, attitudes, support of family/friends/others including support organizations and beliefs of FA. School nurses and teachers play a key role in managing young students with food allergies. For older students, self-management should be encouraged. Policies regarding FA management in schools range widely and are often inadequate if not made in conjunction with an informed clinician.

Many retail catering facilities are poorly prepared to handle the advent of anaphylaxis, and the staffs often have poor or truncated knowledge on acute or preventive management of FA. Businesses such as restaurants and takeaways have no legal obligation to warn customers about potential allergen content. The need for more training for restaurant/cafeteria/fast-food/takeaway staff and consumer caution on food allergen content and staff knowledge gaps remains high.

Communication patterns of food-allergic patient within the general community may be hampered by legitimate everyday social considerations such as embarrassment, choice, spontaneity, and discrimination. Increased FA knowledge among the general public is required; nevertheless, the needs and rights of the nonallergic population should be taken into consideration as well. Instead of being blatantly discriminatory, policies should be structured around ethical principles of confidentiality and anonymity, fairness, avoiding stigmatization, and empowerment of the patients.

However, implementing proper risk management strategies should be evidence based. The paucity of randomized–controlled studies on evaluation of effectiveness and cost-effectiveness of such interventions has so far restricted the grade of recommendations, mainly at the level of expert consensus. As a consequence, the adoption of procedures has been limited to very few countries. The time has come to undertake efforts to address properly these issues in order to fulfill adequate safety measures in the community at-large worldwide (Box 4).

Expert panel

We are grateful to the expert panel for providing expert feedback on the final draft of the paper: Magnus Borres (Uppsala University, Uppsala), Anna Bręborowicz (Poznan University of Medical Sciences, Poznan, Poland), Chun-Han Chan (Food Standards Agency, London), M. Hazel Gowland (Anaphylaxis Campaign, Farnborough), Matt Greenhawt (The University of Michigan Medical School, and the University of Michigan Health System, Ann Arbor), Ruchi Gupta (Northwestern University Feinberg School of Medicine, Chicago; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago), Marcia Podestà (Food Allergy Italia).

Author contributions

Antonella Muraro, Chair of the EAACI Food Allergy and Anaphylaxis Guidelines Initiative, has steered and coordinated the publication. Ioana Agache and Andy Clark wrote the first draft of the manuscript. All authors participated in the revision of the manuscript including the discussion of the recommendations and gaps.

Conflicts of interest

Antonella Muraro has provided scientific advice for Meda. Graham Roberts has provided scientific advice for Danone and ALK-Abelló; Thermo Fisher and ALK-Abelló have provided consumables for their research activities. Jonathan O'B. Hourihane has received speaker fees from Mead Johnson, Nutricia, MSD, Pfizer, ALK-Abelló, and Stallergenes; Thermo Fisher has provided consumables for their research activities. Luis Miguel Borrego has received honoraria for lectures from MSD. Sabine Schnadt has support for travel to EAACI congress from Peanut Council and Novartis. Ioana Agache, Jennette Higgs, Angel Mazon, Magnus Wickman, Maria Said, Davide Parmigiani, Andrew Clark, Cezmi Akdis, Berber Vlieg-Boerstra, Penny Jorgensen, Harmieke van Os-Medendorp and Aziz Sheikh have no conflict of interests in relation to this manuscript.