Nix Nut-Free Classrooms, New Allergy Guidelines Urge

Rather than site-wide food bans or allergen-restricted zones, allergy training, action plans, and available epinephrine to treat suspected anaphylaxis are recommended to address allergic reactions to food at child care centers and schools, according to new practice guidelines.

Not only has research found little evidence that food bans work, such restrictions can pose monitoring and adherence challenges, reported Susan Waserman, MD, of McMaster University in Ontario, and colleagues.

Indeed, such restrictions might reduce vigilance among students or staff, thus interfering with timely recognition and treatment of an unexpected reaction, they wrote in updated guidelines in the Journal of Allergy and Clinical Immunology.

The guidelines were endorsed by the American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Allergy, Asthma, and Immunology (ACAAI).

“Our goal is to help the school community understand the risk of allergic reactions — and offer evidence-informed guidance for managing it,” said Waserman, who was also chair of the guidelines panel, in a release.

The authors added that managing the risk of allergic reactions should not be confused with “totally removing risk,” as “it is not possible to totally remove the risk of allergic reactions in any settings.”

The guidance reflects those of U.S. voluntary guidelines on student food allergies released in 2013 by the CDC.

Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, the group consisted of 22 healthcare professionals, school administrators, and parents of children with and without food allergy, as well as a team of six research methodology experts. They conducted systematic literature reviews of the anticipated health effects of selected interventions for managing food allergy in child care centers and schools, considering their costs, feasibility, acceptability, and effects on health equity.

These recommendations were graded as “conditional” due to a lack of high-quality evidence, but included avoiding implementing site-wide food prohibitions (e.g., “nut-free” schools) or allergen-restricted zones (e.g., “milk-free” tables), except when students lack the developmental capacity to self-manage due to very young age (i.e., infants, toddlers) or physical or cognitive impairments in the following circumstances or in areas with no food ingredient labelling.

“Studies have not consistently found that these interventions lower the risk of allergic reactions or improve quality of life,” the authors wrote.

Instead, they suggested child care centers and schools may use other common-sense strategies to reduce the risk of reaction, such as providing adult supervision during snack and meal times, avoiding allergens in curriculum and fieldtrip activities, and promoting handwashing.

“Recommendations against restrictions such as ‘nut-free classrooms’ or ‘milk-free’ tables may seem problematic to some, or perhaps controversial,” Scott H. Sicherer, MD, of the Icahn School of Medicine at Mount Sinai in New York City, who was not involved with the research, told MedPage Today.

“I would have liked to see more examples of circumstances where such restrictions may be appropriate. This is not a ‘one size fits all’ circumstance, given different school/day care resources, and individuals with food allergy who also may differ in their needs,” he added.

Sicherer characterized some advice in the document as “very clear and straight forward – like ensuring that parents provide allergy action plans, and that school staff have training about allergic emergencies.”

Other recommendations, which were also graded as conditional due to a lack of high-quality evidence, included:

  • Implement allergy training and action plans
  • Use epinephrine to treat suspected anaphylaxis
  • Stock unassigned epinephrine autoinjectors instead of requiring students to supply personal autoinjectors


“I especially value the emphasis on encouraging having unassigned epinephrine autoinjectors (“stock epinephrine”) available for allergic emergencies, because first time anaphylaxis can occur at school in a person not previously diagnosed with an allergy,” Sicherer said.

The authors again stressed that the recommendations are labeled “conditional” due to the low quality of available evidence, and should not be quoted or applied out of that context.

“As more research becomes available, some of the recommendations might need to be updated,” Waserman concluded. “We hope to see more high-quality research conducted in the future.”