Q. Should peanuts be banned from schools?

A. Consider this real-life scenario:

Mark, age 5, is severely allergic to peanuts and has already had three episodes of anaphylaxis, one requiring hospitalization. He has been kept out of preschool because the family could not find a school that satisfied their stringent requirements. They are now about to enroll Mark in kindergarten and are requesting a letter of medical necessity from me and the pediatrician to order that his school prohibit peanuts and peanut products from Mark's classroom, as well as from the school cafeteria.

The social and legal aspects of this question are very similar to those of airline peanut exposure. Many preschools and some schools have in fact banned peanuts from the classrooms and cafeterias. Whether they do so largely depends on the number of students affected in the school and community, parents' efforts, and the willingness of the school system and community to make accommodations.

There are good arguments for both sides. Peanut allergy is a potentially life-threatening condition; it would make sense to eliminate any possibility of exposure in a setting with young children who cannot be expected to understand all the problems of management, let alone the implications of having a life-threatening reaction. On the other hand, without foolproof methods of guaranteeing peanut detection 100 percent of the time, there is no way to enforce a true "peanut-free" school. It would be difficult to do detailed inspections of all food brought into school by other students, assuming that everything had an ingredient label, and most families would not be expected to have adequate knowledge of peanut allergy to be able to make school lunches peanut-free -- nor could they be expected to have that motivation. As with peanut-free flights, some also argue that a "false sense of security" results from a school that claims to be peanut-free, resulting in decreased vigilance and monitoring over time.

Another problem is that older children who never have to face dealing with "real-life" situations of hidden exposures, such as cross contamination, because they have been in peanut-free environments at home and at school, may be at a disadvantage when they go to college and eventually are on their own. In addition, there is the consideration of the children with other life-threatening food allergies. Do we also ban milk, eggs, wheat, soy, tree nuts, seafood, etc., from schools to accommodate these other students? These are by no means easy questions to answer and are the subject of many debates in local communities. Fortunately, most schools and families usually are able to agree on very practical school plans.

Preventative Measures
 
In most cases, compromise solutions are reached, such as having a peanut-free table in the cafeteria or a peanut-free room. Some schools have a designated peanut table or area where all the peanut products are eaten, leaving the rest of the cafeteria peanut free. These zone approaches are generally quite satisfactory because the actual risk in a dining hall with good ventilation and no exposure to the actual cooking fumes is very low, particularly for anaphylaxis. Of course, every effort needs to be made to minimize your child's sense of isolation; he or she should be able to pick several friends to sit at the peanut-free table.

In addition to cafeteria precautions, students are given age-appropriate education in allergy and what the consequences of anaphylaxis are. The dangers of sharing foods and snacks must be discussed. This education often must begin with the school nurse explaining these issues to administrative staff. For preschools and lower grade classes with very young, difficult-to-monitor children and classes with multiple peanut-allergic students, a peanut-free classroom might end up being an easier approach for teachers and staff.

The key to the success of any preventive plan is access to and availability of epinephrine. This can not be overstated. Without easy access to epinephrine in areas where food and eating occur, potential disaster awaits. This can be a problem, particularly for children who, because of their age, do not have permission to carry their epinephrine with them and are therefore dependent on the school nurse for their epinephrine.

Many schools have to share one nurse, so an individual school may only have the nurse there a few days each week. In this common situation, the nurse has the ability and legal authority in many states to train a designee in the use and administration of epinephrine. This designee can be a teacher, principal, secretary, or any individual in the school able and available to perform this crucial function in the absence of the school nurse. You need to know exactly what the school nurse's weekly schedule is and to whom she has designated the responsibility for administering epinephrine on the days she is not present in the school. You should have this plan in writing from the school nurse and principal.