National Food Service Management Institute Staff Development Day February 20, 2015

Managing Food Allergies in School Nutrition Programs

 An Overview of Food Allergies,  Reading and Managing Food Labels,  Accommodating Students with Food Allergies,  Avoiding Cross Contact, and  Promoting Food Allergy Management in Your School.  An Overview of Food Allergies,  Reading and Managing Food Labels,  Accommodating Students with Food Allergies,  Avoiding Cross Contact, and  Promoting Food Allergy Management in Your School. Topics for Today

Pre-assessment: Test your food allergy knowledge

Lesson 1: All About Allergies

 Describe a food allergy, its symptoms, and treatments.  Distinguish between food allergy and food intolerance.  Identify the major 8 food allergens.  Demonstrate reading food allergens on a food label. All About Allergies Objectives

What is a Food Allergy? Food Allergy An immune-mediated adverse reaction to a food protein Body’s Immune System Body identifies a food protein as dangerous creates antibodies (Immunoglobulin E (IgE)) against the protein EVEN A BITE can result in an allergic reaction.

This food is too spicy. My tongue is hot (or burning). It feels like something is poking my tongue. My tongue (or mouth) is tingling. My tongue (or mouth) itches. My mouth feels funny. There is a frog in my throat. There’s something stuck in my throat. My lips feel tight. My throat feels thick. It feels like there is a bump on the back of my tongue. How a Child Might Describe Symptoms

One or more symptoms can occur within minutes up to 2 hours and can be MILD to SEVERE Trouble swallowing Shortness of breath Repetitive coughing Voice change Nausea & vomiting Diarrhea Abdominal cramping Drop in blood pressure Loss of consciousness Death may occur Swelling Hives Eczema Itchy red rash Allergic Symptoms

 A serious allergic reaction  Rapid in onset  May cause death FoodInsect VenomMedicationsLatex Anaphylaxis

An epinephrine auto- injector is used to treat anaphylaxis. Trade names for this device include EpiPen, Emerade, Twinject, Adrenaclick, Anapen, Jext, Allerject, and Auvi-Q. Medication to treat Anaphylaxis Picture courtesy of About.com

Reaction and Epinephrine Concerns  Where are the devices kept in the school; are they accessible?  Do you need to be trained to administer an autoinjector?  What if it inject the person, and they are not really having an allergic reaction?  How do substitutes know how to respond?  Do the phones near you get an outside line to call 911?  Will local EMTs have epinephrine when they arrive?

What is a Food Intolerance? Food Intolerance An abnormal physiological response to eating Involves the Gastrointestinal System  Food intolerance presents with symptoms affecting the skin, respiratory tract, and gastrointestinal tract; individually or in combination. Detrimental reaction (nausea, diarrhea, vomiting).  Come on gradually, not life threatening, affect the body’s organs  Symptoms are often confused with food allergies. Medical name: Non-allergic Food Hypersensitivity

 Absence of an enzyme to digest food  Irritable bowel syndrome  Food poisoning  Sensitivity to food additives  Recurring Stress  Celiac Disease Treatment is determined between the Licensed Physician and the patient. Causes of Food Intolerance

An immune reaction in the small intestine only to eating gluten, a protein found in wheat, barley and rye. There is no cure. Follow a strict gluten-free diet to manage symptoms and promote intestinal healing. It is not considered life-threatening, but can have acute neurological symptoms. Celiac Disease

Food Allergy Background  More than 3 million children have some type of food allergy.  Prevalence of food allergies among children increased 18% during 1997–2007.  Allergic reactions to foods have become the most common cause of anaphylaxis. (1,6)  Food allergies affect an estimated 4%–6% of children in the United States. 1 (1, 2)

The Major 8 Food Allergens Eggs Milk Peanuts Tree Nuts Fish Crustacean Shellfish* Soy Wheat

Only one (1) way to Prevent an Allergic Reaction Strict Avoidance of Known Food Allergens

Food Allergen Labeling and Consumer Protection Act (FALCPA) Food labels must declare major food allergens in plain language: Milk, eggs, fish, shellfish, peanuts, tree nuts, soy, and wheat Either in the ingredient list by either of these two methods: “Contains” followed by the name Example: “Contains: milk and wheat” Parenthetical statement in the list of ingredients Example: “albumin (egg)”

Label Samples Contains….. Parenthesis…

Subscribe to food allergy recall notices and a have system to take action if you serve the product being recalled Recall Notifications

Not regulated Not safe for people with known food allergies “May Contain” statement “..made on equipment that also makes….” Precautionary Labeling

Hide and Seek Label Reading Activity 1. Work in small groups to read product labels. 2. Identify major allergens in each product and review food allergy handout. 3. Select a spokesperson for the group to share 2 observations with the large group.

 Describe a food allergy, its symptoms, and treatments.  Distinguish between food allergy and food intolerance.  Identify the major 8 food allergens.  Demonstrate reading food allergens on a food label. Lesson 1: All About Allergies Review What questions do you have before we proceed?

Lesson 2: Reading and Managing Food Labels

 Discuss how to determine allergens that are not the major 8, in bulk items, and USDA foods.  Outline methods for managing food labels. Objectives for Lesson 2

Bulk Foods, USDA Foods, and Not the Major 8 Allergens  Read ingredient statements  SOP for handling bulk  Bulk and USDA – SAME labeling requirements  Prevent cross contact: Multiple Lots Scooping out of bulk Cleaning bulk containers  90% = Major 8  10% = Not Major 8  Examples:  Sesame  Strawberries  Mustard  Sulfites

Strategies to Manage Labels and Ingredient Lists

Communicating Food Allergy Label Information School Nutrition Staff School Nurse Students, Parents or Guardian Website, handouts, other With Whom? When? What method? (face-to-face, phone, )

Managing Allergies in a School Video Clip

 Discuss how to determine allergens that are not the major 8, in bulk items, and USDA foods.  Outline methods for managing food labels. Lesson 2 Review

Lesson 3: Accommodating Students with Food-Related Disabilities

 Review laws essential to accommodating students with food allergies.  Develop a food allergy action plan.  Describe ways to work with distributors, brokers, and manufacturers to purchase foods to meet the needs of students with allergies. Objectives for Lesson 3

Respect and Protect Children with Food Allergies  Civil rights and privacy must not be violated  Prevent a child with food allergies from being singled out  Be alert to prevent and address bullying from other children and/or adults

Federal Laws Prohibits discrimination against qualified persons with disabilities in programs or activities of any agency of the federal government’s executive branch or any organization receiving federal financial assistance. [Examples of programs receiving federal assistance: National School Lunch Program, School Breakfast Program, Fresh Fruit & Vegetable Program, After School Snack Program] Rehabilitation Act of 1973

Federal Laws (continued) Individuals with Disabilities Education Act (IDEA) 1975, Part B 2006 Requires a free and appropriate public education be provided for children with disabilities aged Americans with Disabilities Act (ADA) 1990 and 2008 Amendments Broadens and extends civil rights protections for approximately 50 million Americans with disabilities.

Respect Privacy Laws HIPAA The Health Insurance Portability & Accountability Act (1996) - Requires all medical records disclosed be kept properly confidential. - Gives the patient rights control how health information is used. FERPA Family Educational Rights and Privacy Act (1974) - Protects the privacy of health information entered into a student’s record

Student’s Rights and Responsibilities Rights Be provided nutrition services at school without discrimination. Responsibilities  Be proactive in allergy avoidance.  Notify adult if:  Ingestion of known allergen  Bullying because of allergy

Tools Schools Use to Implement Laws Individualized Education Plan (IEP) 504 Plan (Section 504 of the Rehabilitation Act of 1973)

Accommodating Children with Special Dietary Needs in the School Nutrition Programs Guidance from USDA

Recognize: Know the symptoms of an allergic reaction, who is authorized to administer medication and where the medication is stored. React: Quickly administer medication or call emergency services, delay could result in deadly consequences. Review After an allergic reaction emergency, review with those involved what went smoothly and what needs improvement. Preparation is the Key to Success

Five (5) priority areas 1(4) : 1.Ensure the daily management of food allergies in individual children. 2. Prepare for food allergy emergencies. 3. Provide professional development on food allergies for staff members. 4. Educate children and family members about food allergies. 5. Create and maintain a healthy and safe educational environment. Food Allergy Management Plan

Food Allergy Action Plan 1 (5) Recommended for each child with a known food allergy

Strategies to Accommodate Students with Food Allergies  Menu planning, label reading, follow HACCP principles  Know the requirements for serving food to students with special dietary needs.  USDA FNS Guidance for serving children with disabilities and special dietary needs in child nutrition programs STEP 1 STEP 2

School Meal Requirements  Schools must make substitutions in the reimbursable meal for disabled students whose disability prevents them from consuming the school meal as prepared.  No extra charge  A disability determination can only be made by a licensed physician.

Child’s Safety Licensed Physician School Administrator Nurse School Nutrition Faculty Others Family Parents Child Communication / Education The Partnership Communication / Education Step 3

 Implement the directives in the Special Dietary Form signed by a licensed physician.  If the form indicates the student has a DISABILITY, School Nutrition Services is required to make the accommodation.  If there is no disability, the accommodation is optional. Step 4: Accommodating Students with Food-Related Disabilities Step 4

Licensed Physician Provides  5 Key Elements  What the disability is  How it restricts the diet  Major life activity affected  Food(s) to be omitted  Food(s) to be substituted

Accommodating Students with Other Food-Related Disabilities Food Related Disabilities  Diabetes  Phenylketonuria (PKU)  Food Anaphylaxis  Celiac Disease Other Accommodations  Texture  IV  Tube Feeding

Allergenic Foods Accommodating Students Activity 1. Work in small groups to identify the allergens listed on the product ingredient statements from three manufacturers. 2. Record on the activity sheet which product can be served to which student. 3. Select a spokesperson for the group to share 2 observations with the large group.

 Work with distributors, brokers, and manufacturers to purchase foods to meet the needs of students with allergies.  Get specifications, ask for clarification, develop a relationship with your key partners.  TIP: When getting information for USDA Foods, call the manufacturer, not USDA or the State Agency. Communication with Key Partners

 Review laws essential to accommodating students with food allergies.  Develop a food allergy management plan.  Describe ways to work with distributors, brokers, and manufacturers to purchase foods to meet the needs of students with allergies. Lesson 3 Review

Lesson 4: Avoiding Cross Contact

 Distinguish cross contact from cross contamination.  Demonstrate strategies to avoid cross contact.  Discuss strategies to manage food outside of the cafeteria. Objectives for Lesson 4

Cross Contact vs. Cross Contamination Cross Contact  Allergen accidentally transferred from a food containing an allergen to a food or surface that does not contain the allergen.  Cooking does not reduce or eliminate allergen. Cross Contamination  Microorganisms from different sources contaminate foods during preparation and storage.  Cooking does reduce or eliminate microorganisms.

Avoid Cross Contact – Potential Sources  Food handling and preparation  Insufficient handwashing  Insufficient cleaning  Shared equipment and utensils  Cutting boards, counters  Griddles  Splatter or steam from cooking  Salad bars, buffets, serving stations

 Color Coding  Isolate ingredients containing allergens  Individual preparation of menu items with allergens  Sticker or color code wrapped food  Standard Operating Procedures for handwashing and cleaning  Include allergen risk assessment in the Food Safety Plan based on HACCP Avoid Cross Contact – Prevention Ideas

Standard Operating Procedures Write, train, follow, monitor, and verify SOPs Clean and Sanitize Clean with soap, hot/warm water, and friction; WILL REMOVE ALLERGEN RESIDUE Sanitize to reduce microorganisms that cause disease; WILL NOT REMOVE ALLERGEN RESIDUE

 Of particular importance for managing food allergens.  Examples:  NFSMI’s HACCP-based Cleaning and Sanitizing Food Contact Surface SOPs  NFSMI’s Serving Safe Food to Student with Food Allergies SOP Examples of Sanitation SOPs

Food Safety Plan based on HACCP GOAL: Control/prevent/minimize food safety hazards that may cause illness or injury Biological Chemical Physical Radiological Bacteria Allergens Plastic Heavy metals Viruses Pesticides Glass Contamination Parasites Sanitizers Metal of water supply Food additives

Step by Step Avoiding Cross Contact Activity 1.Work in small groups to put the ingredients in order of preparation to prevent cross contact. 2.Identify opportunities for cross contact and consider if cross contact could occur in your school. 3.Select a spokesperson for the group to share 2 observations with the large group. 4.Record findings on the handout.

Strategies to Manage Food from Outside Sources and Outside the Cafeteria Outside food sources contracted to serve in the cafeteria  Restaurants  Caterers  Pot lucks  Classroom projects  Club/Sports events Outside food sources served outside the cafeteria Nutrition Services food served outside the cafeteria  Breakfast in Classroom  Fresh fruit and Vegetable Program  After School Program

Reduce the Risk Food from Outside Sources Activity 1. Work in small groups to determine how to provide services to a child with known life-threatening food allergies. 2. Each group has a different child and a different situation. 3. On the flip chart paper, record the actions you would take to provide for the child. 4. Select a spokesperson from your group to share the situation and the actions.

 Distinguish cross contact from cross contamination.  Demonstrate strategies to avoid cross contact.  Discuss strategies to manage food outside of the cafeteria. Lesson 4 Review

Lesson 5: Promoting Food Allergy Awareness

Identify food allergy resources to promote awareness in schools. Objectives for Lesson 5

 Determine knowledge level and training needs for school nutrition staff and school colleagues.  Verify process to respond to product recalls due to allergens.  Brainstorm what action to take after attending this course.  Identify food allergy resources. Outline Methods to Boost Food Allergy Knowledge and Awareness

 Provide professional development on food allergies for staff  Teach all children, parents, and families about food allergies. Food Allergy Training CDC Recommendations for Schools

RESOURCES USDA CDC

RESOURCES (continued) National School Boards Association National Education Association (NEA) Health Information Network

Managing Food Allergies in Schools - Video Summary

Identify food allergy resources to promote awareness in schools. Lesson 5 Review

Roundtable Discussion Gallery walk Roundtable Discussion

Post-assessment Test your food allergy knowledge

 What questions may I answer for you?  Make sure you sign the class roster Training Wrap-Up

National Food Service Management Institute The University of Mississippi