Is the concept of “peanut-free schools” useful in the routine management of peanut-allergic children at risk of anaphylaxis?

Parents of school-age children with food allergies and potential anaphylactic reactions want their children to have an unburdened and risk-free everyday school life. Thus, particularly in the case of peanut allergy, demands for peanut-free schools are put forward. The position paper of the food allergy working group of the German Society for Allergology and Clinical Immunology (Deutsche Gesellschaft für Allergologie und klinische Immunologie) highlights why the concept of peanut-free schools does not protect peanut allergic children, but rather bears potential disadvantages and risks for all those involved. The focus on peanut as a potential trigger of anaphylactic reactions ignores other relevant triggers. In order to address the fears and concerns of patients, parents, and school staff, it is mandatory to develop various coping strategies. These should enable and ensure the safety and participation of food-allergic pupils in classes and other school activities. Therefore, it is important to implement adequate measures for allergen avoidance and emergency treatment for students with confirmed food allergies.


Introduction
The call for "peanut-free schools" is based on the idea of enabling school-age children with peanut allergy and either previous anaphylactic reactions or a high risk of experiencing such a reaction to enjoy an unburdened and risk-free school life. The following article critically discusses the concept of "peanut-free schools" taking into account the risks and disadvantages, experience with concepts of this kind, as well as data on eliciting doses in order to definitively arrive at useful recommendations for dealing with (peanut-)allergic children in the school setting.

Educational disadvantage due to limited choice of schools
This type of concept is associated with enormous expectations on the part of parents of affected children and creates the impression that schools without this designation are "unprotected places". As such, the supposed protection offered by attending a "peanutfree school" can have a major influence on the choice of school and result in an educational disadvantage for the allergic child; however, an allergic child should also have the freedom to choose a school according to his or her abilities (musical, bilingual, teaching focus, etc.). If the label "peanut-free school" is the deciding factor in the choice of school, a child may be disadvantaged in terms of his or her interests and abilities.

Stigmatization and exclusion of affected individuals
In addition, the risk that a peanut-allergic child at a "peanut-free school" ("special school") will be stigmatized will remain. The ban on peanuts for all students could engender a greater lack of understanding on the part of unaffected children and increase the risk of psychological distress and exclusion for allergic children [1,2].

Misjudgment of high-risk situations
The perception of supposed safety at a school designated to be "peanut-free" carries the risk for those affected that everyday situations both outside and inside the school are misjudged due to an altered risk assessment [3,4]: "handing over responsibility to the school" can lead to greater anxiety in situations outside the school, especially when the affected child needs to fend for itself. It carries the risk of deprivation of the allergic child outside the school setting: no sports clubs (since these are not peanut-free), no children's choir, and, ultimately, stagnation in their development of social interaction, including the ability to take responsibility and develop self-respect for oneself.
A supposedly safe environment at school can also result in teachers no longer making appropriate risk assessments and, for example, teachers receiving no training in emergency management, or only inadequate training. But also on the part of the affected child, the fact that they are in a place deemed to be safe can result in them not having their emergency medication on them at all times.

No reduction in severe reactions at schools in the USA with a peanut ban
A retrospective study of public schools in the USA with and without peanut-restrictive policies showed that banning peanuts from being brought from home or offered in school, as well as peanut-free classrooms, do not affect the incidence of adrenaline administration at school [2]. Only the concept of making peanutfree tables available for affected children in school canteens emerged as beneficial; however, overall, only a small number of anaphylactic reactions were reported in schools without peanut-free tables. 1 On the other hand, one must also consider the possible negative effects of such measures. For example, representatives of US patient organizations report that parents of peanut-allergic children are increasingly requesting physicians to issue certificates allowing their children to freely choose where they sit in the canteen, in order to avoid the social isolation of affected children due to peanut-free tables or an increased risk of confrontation with other children.

Priority must be given to the support and protection of all pupils with food allergies
Supporting and actively protecting at-risk pupils with chronic diseases, in this case (peanut) allergy, in their everyday lives should be a priority [5]. The stringency of risk reduction measures can be adjusted to the sensitivity of the affected child. It is always advisable for all children to wash their hands before and after eating. when using food in lessons, e.g., when a class eats breakfast together, when cooking, or during handicrafts that materials are used that neither exclude children nor put them at risk of an allergic reaction.
In this context, one should also always consider those children who react to elicitors other than peanut. Although peanut is the most frequent elicitor of anaphylaxis in childhood, there are a number of other relevant triggers, such as milk, egg, and various edible nuts, that are relegated to the sidelines due to the focus on "peanuts", thereby depriving children affected by anaphylaxis elicitors other than peanut of due respect for their allergy [6,7]. Thus, the desire or demand to protect a group of pupils with severe allergic reactions (to peanut) would be at the expense of other pupils with similarly severe reactions to other allergens and negatively affect their disease management.

Eliciting doses differ from individual to individual
A major misconception created by the concept of "peanut-free schools" is the implication that even the tiniest quantities of the allergen need to be avoided in order to prevent hazardous reactions. However, this is not always the case. An international working group showed that less than 5% of all peanut-allergic children reacted to an eliciting dose of 1.5 mg peanut protein (equivalent to around 6 mg peanut = around 1/200th of a peanut kernel) with objective symptoms [8]. All these reactions were mild.
According to a recent publication, in which children with equivocal peanut allergy underwent oral peanut challenge, a third (n = 525) of 1634 challenged children with suspected peanut allergy (78%) or precautionary avoidance of peanut without suspicion (22%) reacted positively [9]. While 28% of the reactions were elicited by the administration of 25 mg of peanut (equivalent to around 1/50th of a peanut kernel), 38% of the children only reacted after a dose of over 1 g of peanut (equivalent to a whole peanut). Only 10% (n = 55) of the children that tested positive experienced an anaphylactic reaction, whereby the age of the tested child represented a risk factor, as well as the dose of peanut administered. For example, 13-to 18-year-olds had a three-fold higher risk for an anaphylactic reaction compared to 6-to 12-year-olds.
If one looks only at the anaphylactic reactions, there are children in whom even small doses of 25-100 mg peanut (around 1/50th to 1/10th of a peanut kernel) elicit anaphylaxis. This was the case in 9% of the mostly older individuals with peanut allergy. A good quarter (27%) of children required a dose of between 200 mg and 1 g peanut (around 1/6th of a whole peanut) to show anaphylactic symptoms. 40% only experienced an anaphylactic reaction after a dose of between 5 and 20 g peanut (approximately four to seven peanut kernels). These observations highlight the fact that the eliciting dose for severe reactions significantly differs from individual to individual and that very small doses are sufficient to elicit anaphylaxis in only a small number of peanut allergics.

Fear of severe reactions through inadvertent exposure via inhalation and skin contact unfounded
There are reports that the mere inhalation of peanut protein is sufficient to cause severe reactions or even anaphylaxis. However, this could not be demonstrated in targeted investigations [10][11][12]. It also does not appear that an allergy-relevant quantity of peanut protein capable of triggering severe symptoms can be airborne [13,14]. Fear of severe reactions due to skin contact with contaminated material or door handles is also unfounded. Contact of this kind can at most cause mild skin reactions [15,16].
On the other hand, expecting an allergic reaction as a result of smelling or seeing peanuts can trigger a fear response that sometimes resembles an allergic reaction. Since fear responses are a potential differential diagnosis, it is possible to misjudge the risk status in both directions (incorrectly assessing an allergic reaction as a fear response and incorrectly assessing a fear response as an allergic reaction). These fears need to be combated through targeted education or patient information and, where necessary, an additional intervention in a medical environment (hospital/medical practice) during which the patient comes into contact with the allergen. A recently published study impressively showed that information on the minimal risk of allergic reactions due to mere skin contact as well as experiencing allergen contact significantly reduced anxiety in patients and their families and increased quality of life [12].
Although severe allergic reactions through inhalation or skin contact alone are unlikely, the use of a relevant allergen should be avoided in the classroom and other school environments in order to avoid causing even mild reactions and fostering anxieties. For example, it is advisable in cookery or baking clubs not to use ingredients to which a child in the class is allergic. In the case of peanut-allergic pupils, the authors recommend avoiding peanut flips, roasted peanuts, and whole peanuts in shells both in the classroom and at school events.
K Is the concept of "peanut-free schools" useful in the routine management of peanut-allergic children at risk. . . 171

position article A reliable diagnosis as a basis for effective management strategies
Above all, a reliable diagnosis is crucial for the appropriate management of a food allergy. The diagnosis should also facilitate an assessment of the eliciting dose and, ideally, be based on double-blinded placebo-controlled challenge testing. One must bear in mind that, also in peanut allergy, a natural tolerance can develop and re-evaluation at regular intervals is advisable [17]. This is important for all parties involved: For the parents, to enable them to better judge whether (and to what degree) their child is actually (still) allergic. For the physician, so that they can clearly identify patients with food allergy and make the diagnosis not only on the basis of elevated specific IgE. For pupils, so that the necessary measures can be based on a clear diagnosis.

Sound risk assessment needs to be learned and practiced
Optimal disease management includes a realistic assessment of hazardous situations. This needs to be learned and practiced-for each anaphylaxis trigger. In addition to information provided by the treating pediatrician and specialist dietician/nutritionist, AGATE (Arbeitsgemeinschaft Anaphylaxie -Training und Education e.V.) anaphylaxis training and education programs are suited to this end. These are offered by interdisciplinary teams at various locations in Germany (www.anaphylaxieschulung.de). Education programs are available not only for parents, but also for children, adolescents, teachers, and carers. The German Allergy and Asthma Association (Deutsche Allergie-und Asthmabund, DAAB) also offers advice, information, an e-learning program, and webinars on the subject for patients as well as teachers and carers. The aim of these measures is to establish optimal disease management for those affected and their families, recognize fears and concerns, and work to counteract these, thereby ensuring the best possible protection against allergic reactions in everyday life while achieving good integration in social structures.

Conclusion
The concept of "peanut-free schools" is not expedient for allergy sufferers and their parents and is potentially fraught with risk. What does make sense in the case of diagnosed food allergy is to implement appropriate measures in schools for allergen avoidance and emergency treatment for all food-allergic pupils, thereby enabling and ensuring pupils' safety and participation in classes and other school activities (Table 1). To this end, sufficient information, education, Table 1 Fears and concerns of affected individuals when confronted with food allergens at school, and possible management strategies using peanut as an example School = dangerous? What can the school with peanuts trigger in . . . ?

Pupils with peanut allergy
Parents of peanut-allergic children

Insecurity
Fear of an allergic reaction in their child Fear of administering medication/doing something "wrong"/ causing "harm" Fear of supposed peanut contact (in school food, via fellow students, in the classroom) Fear that their child will be harassed by teachers/fellow students Fear of stressful situations due to conflicts with parents and students on the subject of: "We'll bring to school and eat what we want" My parents are scared for me Fear of being "powerless" and "unable to act" due to not being present Fear of liability in emergency situations (duty of supervision, liability for accidents, etc.) Lack of understanding from teachers/ fellow students, fear of exclusion and bullying Highly "protective" behavior Fear of outings/excursions, activities such as cookery classes, etc.

What are the possible management strategies? School as a place for all to learn together and inclusively for life
Accepting the food allergy and learning to live with it Getting background information on food allergies per se, thereby learning to identify misinformation, e.g., "inhaling peanut causes death from anaphylaxis." Formulate local preventive strategies (e.g., avoiding allergy elicitors when cooking and baking together, voluntary avoidance of, e.g., peanut flips at celebrations and on school trips) Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.