That Food Makes Me SICK! - National Association for the Education ...

HEALTH
AND
SAFETY
“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 4.010.
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

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. 2002. Nicole Smith, ages 3–6.
No Lobster, Please! 2003. Robyn Rogers, ages 4–7.
No Nuts for Me. 1995. Aaron Zevy, ages 4–8.
The Peanut Butter Jam. 2001. Elizabeth S. Nassau, ages 5–8.
Taking Food Allergies to School. 1999. Ellen Weiner, ages 6–8.
The Food Allergy and Anaphylaxis Network at www.foodallergy.
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 2004 43

HEALTH
AND
SAFETY
Coping strategies for child care centers
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.
Develop written policies
An initial step in addressing a child’s food allergies is
to request a doctor’s statement that gives the specifics
of the condition, acceptable
food substitutions,
and instruction
in the event the child
is exposed to the problem
food. A written
policy should define
the family’s and the
teacher’s individual
responsibilities regarding
the child’s food
allergy.
A list of children and
their reactive foods
should be maintained
in the center’s food
preparation and serving
areas where it
is accessible to all
adults involved in
feeding children.
© Lois Main
Other suggestions
include
obtaining parental
authorization
and providing
appropriate training
to administer
emergency allergy
medication. Barber
(2001) advocates
making plans that cover
celebrations (such as birthdays),
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.
Thorough documentation is essential to managing a
child’s allergies in child care. State licensing and health
agencies can recommend what information about allergies
needs to be maintained in the child’s records. These
recommendations would also apply to food intolerances.
A list of children and their reactive foods
should be maintained in the center’s food
preparation and serving areas where it
is accessible to all adults involved
in feeding children.
Establish written emergency procedures
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.
Plan menus that consider food
allergies and intolerances
Careful menu planning is essential
in managing food allergies and
intolerances. When many foods
are eliminated or severely limited,
a child’s diet may be deficient in
nutrients that would normally be
supplied by the offending foods.
For example, a child with a dairy
allergy may be at risk for a calcium
deficiency, while a child with a
wheat allergy may need more iron
(Story, Holt, & Sofka 2000). To the
extent possible, children with food
allergies and intolerances should
eat foods similar to those served to
the other children to lessen feelings
of difference and isolation.
Allergy-specific cookbooks
can be helpful for guiding
those preparing meals for
allergic children. A wheat-free
cookbook can aid a center’s
kitchen staff struggling to
safely feed a wheat-allergic
child. Food label ingredient
lists also yield useful information.
(A packaged meat loaf may
include eggs, which would make it
off-limits for a child with egg allergies.)
Allergens are listed in a number of
different ways on food labels, but they may
To the extent possible, children with
food allergies and intolerances should
eat foods similar to those served to the
other children.
Young Children • March 2004

e 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 2004 45

HEALTH
AND
SAFETY
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. 2001. The parent’s guide to food allergies. New York:
Henry Holt.
Breault, J. 1999. 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. 1998. 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. 1995. Phoenix: Arizona Department
of Health Services.
NFSMI/UM (National Food Service Management Institute/University
of Mississippi). 2003. 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). 2000. 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. www.nal.usda.gov/fnic/etext/000004.html
American Academy of Allergy Asthma and Immunology. www.
aaaai.org
Asthma and Allergy Foundation of America. www.aafa.org
Child Care Nutrition Resource System. www.nal.usda.gov/
childcare/index.html
The Food Allergy and Anaphylaxis Network. www.foodallergy.
org
Life-Threatening Food Allergies in School and Child Care Settings.
www.healthservices.gov.bc.ca/cpa/publications/
food_allergies.pdf
National Food Service Management Institute/University of
Mississippi. www.nfsmi.org/Information/Newsletters
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). 1996. Lactose intolerance.
Chicago: Author. Online: www.eatright.org/Public/Nutrition Information/92_nfs43.cfm.
Barber, M. 2001. The parent’s guide to food allergies. New York:
Henry Holt.
BCMCF (British Columbia Ministry for Children and Families). 1999.
Life threatening food allergies in school and child care settings.
British Columbia, CAN: Author. Online: www.healthservices. gov.
bc.ca/cpa/publications/food_allergies.pdf.
Berman, C., & J. Fromer. 1997. Meals without squeals. Boulder, CO:
Bull Publishing.
Bruton, S., ed. 1998. 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: www.cde.ca.gov/nsd/nets/news/nt_1.
htm.
Duyff, R. 2002. 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: www.niaid.nih.gov/factsheets/food.htm.
Story, M., K. Holt, & D. Sofka. 2000. Bright futures in practice: Nutrition.
Arlington, VA: National Center for Education in Maternal and
Child Health.
Weiner, E. 1999. 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 www.naeyc.
org/resources/journal.
Young Children • March 2004