Our work helps to keep children and adult participants safe and healthy.

Welcome to Food Allergies & Special Diets! Choosing and preparing foods which meet the needs of many children and adults can be difficult at times, but learning about food allergies helps us become more aware of how to keep the children in our care safe. We also need to be aware of what to look for if an allergy strikes. You will need the Participant Booklet packed with notes and tools that make your job easier and keep participants healthy & safe. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 1

Our work helps to keep children and adult participants safe and healthy. Do any of you know someone with a food allergy? Does it seem like more people have allergies now than 5 or 10 years ago? Studies show that the number of children with food allergies is increasing (Weiss, 2004). However, more research needs to be done to understand the factors responsible for causing them. Eight percent of American children and 4% of all Americans suffer from food allergies (U.S. Dept. of Health and Human Services, 2004). Children with food allergies deserve attention and the provider should be prepared with a plan to prevent an allergic reaction and responding to a food allergy emergency. Food allergies can be life-threatening, so making appropriate accommodations for participants with allergies is very important! In the Participant Booklet you have 2 comprehensive tools from NFSMI: Overview of Food Allergies, and Common Questions. These tools will help you prepare to meet the needs of the children in your care. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 2

A food allergy is an immune system response to a food that the body mistakenly believes is harmful. Components of a food that trigger the immune system are called food allergens. In response to a food allergen, the body forms antibodies, which attach to cells throughout the body. The next time the individual eats that food, the antibodies recognize the allergen and signal the body to release histamine and other substances that cause physical signs of an allergic reaction. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 3

The physical signs of a food allergy may include: a scratchy throat, abdominal pain, diarrhea, nausea, vomiting, stomach cramps, itching of the mouth, throat, eyes, skin, or any area, hives, swelling, especially of the eyelids, face, lips and tongue, lightheadedness or fainting, nasal congestion, runny nose, shortness of breath, wheezing, difficulty swallowing. A body s reaction to an allergen can range from relatively mild to severe. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 4

In some cases, a sudden, severe, and potentially fatal reaction called anaphylaxis can occur. Anaphylaxis is a condition that can occur when someone with an allergy is exposed to a specific allergen. It is potentially life threatening. The symptoms of anaphylaxis may occur right away, or up to 2+ hours after exposure to the allergen. The most dangerous symptoms include breathing difficulties and a drop in blood pressure or shock, which can be fatal. Anyone with a previous history of anaphylactic reactions is at risk for another severe reaction. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 5

Now it is time to watch a video about managing allergies in your facility. This video discusses what to do in a child care center. The rules are the same for the participants in any facility. Click the link on the class page or this video is available on www.nfsmi.org website - http://www.nfsmi.org/resourceoverview.aspx?id=492. You can use this video to train your staff or helpers on allergies. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 6

If a food product contains one of the 8 common allergens or an ingredient derived from one of these foods, FDA law requires that the product be labeled clearly with this information. The 8 major food allergens recognized by the Food Allergen Labeling and Consumer protection Act of 2004 are milk, egg, fish, shellfish, tree nuts, wheat, peanuts and soybeans. Ingredient is a broadly defined term that includes flavorings, colorings and incidental additives. A few other facts about the law: The law went into effect January 1, 2006. These eight allergens are said to be responsible for 90 percent of all allergic reactions associated with food. Approximately two percent of adults and five percent of infants and young children are believed to suffer from some form of food allergy. As FDA explains it, if a product contains the milk-derived protein casein, the product's label would have to use the term "milk" in addition to the term "casein" so that those with milk allergies would clearly understand the presence of an allergen they need to avoid. In the case of nuts, fish or shellfish, the law requires processors to go one step farther and identify the specific type of nut or species of fish. Let s review the Big 8 most common food allergies. Peanuts. This includes anything peanuts or peanut oil or peanut butter are in: ground nuts, mixed nuts, nut pieces, chocolate candies, candy bars, ice cream. Other sources may be energy bars, cultural foods, especially African, Mexican, and Asian, specifically Chinese, Indian, Indonesian, Thai, and Vietnamese, pet foods, salad dressings, granola, cereals and arachis oil, another name for peanut oil. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 7

It is very important to read ingredient labels because ingredients are not always obvious. For example, some brands of peanut butter contain soy; soy sauce contains wheat, and Worcestershire sauce and several Caesar salad dressings contain anchovies. Also many items contain unexpected ingredients, and one cannot assume what the ingredients may be. Eggs may be in egg substitutes, pasta, cosmetics, shampoos, medicine, specialty drinks. Milk may be in non-dairy products, tuna, deli slicers, and restaurant prepared steaks, which may have butter added during preparation. Products with soy as a main ingredient include: tofu, miso, soy sauce, tamari sauce, natto, tempeh. Hidden sources of soy products include: hydrolyzed vegetable protein (HVP), textured vegetable protein (TVP), lecithin, monodiglyceride, monosodium glutamate (MSG), vegetable oil, vitamin E. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 8

Preventing exposure to allergens continues in your home. Please find the Food Allergy Fact Sheet in the Participant Booklet. There are 4 steps to prevention. First, create a food allergy policy. Second, create an individual food allergy policy for each participant that has a food allergy. Third, take precautions to avoid exposure to possible food allergens. It is best to prepare food for the child with food allergies first when preparing meals and snacks and to change gloves when preparing and serving foods containing known allergens. Some schools and child care centers do not permit the presence of foods the allergic child cannot have. Fourth, be aware of food labels, and know how to read ingredient labels. Be on the alert for ingredient changes, and read packages each time a product is purchased. Become very familiar with ingredients related to the specific allergen in question. Communicate with anyone who will be caring for the participant with food allergies. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 9

Creating a food allergy policy will help you and all those working with children to be proactive in case a student has an allergic reaction. Write out the policy with actions to be taken in the event of an allergic reaction. Develop an emergency plan specifically designed for your home. Be sure to let parents know about any reactions or exposures to an allergen. If you allow outside foods, it is important to limit them to pre-packaged foods with complete ingredient lists. Check all ingredient labels for allergens. Make sure all participants wash their hands when entering your home and before and after meals and snacks. This will help prevent cross-contamination. Be sure to keep information about a child with food allergies confidential. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 10

It is essential to create an individual food allergy plan for each participant with a food allergy. The first step is to obtain the completed medical statement from parents/guardians. These forms are available from your sponsoring organization. If you need clarification, do not hesitate to talk with the parents/guardians, and to work with them to create a plan to treat a reaction, should it occur. Write out your plan and review it with the parents/guardians. Keep the plan handy to refer to as needed. Make sure anyone else who might help care for the child is aware of what to do, and able to carry out the plan. Also be certain you have any necessary medications from the parents, and that you understand how and when to give the medication(s), and that you keep all medications in a secure place. Should you need to administer medication, it will be important to remain calm to carry out the plan and keep the children safe. You will want to work with the parents to create an affordable plan using the tools at your disposal. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 11

There are preventive actions that will help in minimizing children s exposure to food allergens. Be sure to wash your hands with soap and water before and after each task. Water alone or hand sanitizer alone does not remove food allergens. Wash all utensils and cookware before and after each use. Wash all food contact surfaces before and after each use. Use designated cutting boards AND work areas to prepare food for children with food allergies. Store foods in such a way so that allergy-safe foods do not come in contact with other foods. Be sure to prepare the allergy-safe foods first. Clean tables and chairs before and after meals and snacks. Do not allow trading or sharing food, food utensils, or food containers. Make sure to avoid foods that a child is allergic to in art projects or cooking activities. It is important to limit food to specific areas in the home. Even such items as body lotions, sunscreens, shampoos, and creams should be approved by parents, as some may contain allergenic ingredients that could be ingested. Other family members that may have access to food and food contact surfaces must be informed of the allergy issues and precautions necessary to keep kids safe. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 12

Know how to read ingredients labels. You will find that on most ingredient labels the top eight foods causing allergic reactions will be listed, using their common or usual name. Labels should be checked for warning statements that begin with may contain, produced on shared equipment, produced in a plant that uses. These foods should be avoided in order to avoid even possible allergens. Check labels for allergens on every product each time the product is purchased. When the label is unclear, the manufacturer should be called. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 13

Sometimes a reaction to food is not an allergy at all but instead is another type of reaction called a food intolerance. Food intolerance is an adverse reaction to food that does not normally involve the immune system. Food intolerance can produce some of the same symptoms as food allergies but it develops through different mechanisms. Food intolerance is more common than food allergies. A person with a food intolerance may be able to eat small amounts of the offending food. A true food allergy causes an immune system reaction that affects numerous organs in the body. There are several types of food intolerances. The most common food intolerance is lactose intolerance, which is caused by the lack of the enzyme lactase and results in the inability to properly digest lactose, the sugar in milk and milk products. Common symptoms of lactose intolerance include gastrointestinal cramping and pain, bloating, nausea, gas and diarrhea. In young children, lactose intolerance is usually caused by digestive diseases or injuries to the small intestine. A diet order for a milk allergy is much more restrictive than an order for a special diet due to lactose intolerance. Instructions for participants with lactose intolerance may just be to avoid drinking milk, whereas if a participant has a true milk allergy they should not be given any food item that contains any milk or dairy products in any form. Serving Lactose free milk will address a milk allergy and still be a reimbursable meal. Gluten intolerance is a food intolerance that is associated with celiac disease. Celiac disease is an inherited autoimmune disorder that affects the digestive process of the small intestine. In celiac disease foods containing gluten cause damage to the intestines and can cause malabsorption of nutrients. Sources of gluten include wheat, rye, barley and sometimes oats. For more information about celiac disease, refer to the Celiac Disease Information Sheet in the Participant Booklet. Because symptoms of food allergies and food intolerances can be similar, it is important that these symptoms are diagnosed by a physician. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 14

Activity 2: Food Allergy Scenarios Refer to the Allergy Scenarios handout in the Participant Booklet 1. This activity will review what we have learned about keeping participants with life threatening food allergies safe when we prepare and serve food. In each scenario, a day care provider makes at least one error. As you read the scenario think about what the error is and how it could be corrected. 2. Decide what actions the day care provider makes in food preparation and/or service that might lead to a problem for a participant with a life threatening food allergy. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 15

Activity 3: What Can They Eat? 1. Refer to the What Can They Eat? handout in the Participant Booklet 2. Choose a food allergy from the three listed write it on the worksheet in the blank space at the top of the worksheet. 3. Next, find the Ingredient Labels for Lunch Items handout in the Participant Booklet. *In the list of ingredients, put the name of the food source of the major food allergen in parentheses after the common or usual name of the ingredient when that name does not already appear in the ingredient statement; or * Immediately after or adjacent to the list of ingredients, put the word contains followed by the name of the food for each of the major food allergens present in the food s ingredients. 3. Use the labels to determine whether you correctly selected food items that a person with their chosen allergy would not be able to consume. Take about 3 minutes to review the labels and to complete the instructions above. 4. Did you accurately choose which items a person would not be able to eat? Use the answer key provided on the following page to check your answers. It is very important to read all labels each time they are purchased, since some foods may contain unexpected ingredients, and the ingredients may have changed from the last time the product was purchased. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 17

Activity 3: What Can They Eat? Answer Key Meatballs- Milk, Soy, Egg Crinkle Cut Fries- Soy Biscuits- Milk, Soy Chicken Nuggets- Milk, Soy Mashed Potatoes- Milk Creamed Corn- None Hotdogs- Soy Hotdog Buns- Milk. Soy, Egg Cheese Ravioli- Milk, Egg, Soy Tacos- Milk Cheese Pizza- Milk, Soy Carrot & Celery Sticks w/ Ranch Style Dressing- Milk, Soy, Egg Some of the ingredients in these food items may have surprised you. Now you understand why it is important to read every label for possible allergens even if you don t think the product contains any allergens. Food ingredients in a product can change without warning, so continue to check the label even if you have read it before. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 18

The Meal Modification Form gives us a snap shot of the food allergy offender. Let s take a closer look at this tool. Please refer to it at this time in the Participant Handbook. The CACFP Meal Modification Form (4-B) should be updated on an annual basis. However, meal modifications will continue until a licensed physician requests that the modifications be changed or stopped. Meal modifications should not be made unless the statement with the required information is on file. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 19

Some food allergies or intolerances are severe enough that they may cause a disability. Disability in this case means: Any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment or is regarded as having the impairment. What are major life activities? Breathing, speaking, caring for oneself, performing manual tasks, walking, seeing, learning, working would all be considered major life activities. Program regulations differ for allergies that are considered disabilities and for those not considered disabilities. Food allergies that result in anaphylaxis or in celiac disease will both likely be considered disabilities. The licensed physician is to determine if the allergy or intolerance is a disability that requires food service accommodations. The regulations require providing substitutions and/or make accommodations to assure that the participant does not eat foods that will harm them. If the medical authority that is authorized by Kansas State Law to write medical prescriptions (licensed physician-md or DO, OR a physician s assistant-pa, or an advanced registered nurse practitioner-arnp authorized by their responsible licensed physician) has determined that the participant s food allergies or food intolerances cause a disability, the provider must obtain the meal modification form from the physician that identifies the participant s disabling condition and how the disability restricts the participants diet, the major life activity affected by the condition and the food or foods that are to be omitted from the diet and food or choice of foods that must be substituted. Meals must meet the participant s requirements not necessarily the CACFP requirements. Some food allergies or intolerances do not result in a disabling condition. A meal modification form from the recognized medical authority such as a physician, nurse practitioner or physicians assistant must be obtained that identifies the foods that are to be omitted and foods to be substituted. Any substitution must meet the CACFP meal pattern for the meal to be reimbursable. Staff need to keep the participant safe. The provider should work with the participant s parent to discuss the foods the participants can and can t eat. You can make the experience safer by Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 20

carefully following each participant s plan. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 20

To help navigate the variety of requests for meal substitutions, these flow charts will help lead you to the correct decision for some of the possible situations. In the Participant Booklet, please locate the Flow Charts The first step in the process is for the parent and/or medical authority to request food items or milk to not be served to the child due to allergy, intolerance or medical reason, and for the Meal Modification form to be completed. The second step is to determine whether the condition is a disability or an intolerance. If the condition is a disability, the home or center MUST provide a substitute that is acceptable for the child with allergies. It does not necessarily need to meet CACFP requirements. The meal can still be claimed as a creditable meal. If the condition is NOT a disability, the home or center MAY provide the item. If the item is provided and the substitute meets CACFP requirements, the meal can be claimed as a creditable meal. If the substitute is NOT creditable, for example, substituting almond milk for cow s milk, the meal cannot be claimed. If the home or center opts not to provide a substitute, and the parent brings the entire meal, the meal is NOT a creditable meal. However, if the parent provides a substitute which meets CACFP requirements, AND the home or center provides at least ONE component, the meal can be claimed as creditable. If the substitute the parent provides is NOT creditable, bringing juice in place of milk, for example, then the meal CANNOT be claimed. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 21

This slide deals with parent requests for food or milk substitutions that are NOT related to allergy or intolerance, or any other medical reason. If the family is vegetarian, or has a religious reason for requesting a substitution, or simply has a preference for something other than what is served in the home or center, no meal modification form is needed, UNLESS the request is for a modification of milk. Then a modification form IS required. If milk is the food in question, the home or center is to establish a policy. An alternative food item MAY be provided by the home or center, but is not required. If a creditable food or milk item is provided, and the substitute meets CACPF standards, and the meal can be credited. If the item does NOT meet CACFP standards, then the meal is NOT creditable. If the parent provides the substitute, even if the substitute is creditable, the meal CANNOT be claimed. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 22

There are 2 sample Meal Modification Forms in the Participant Booklet. Answer the following questions: 1. Are the forms complete? 2. What information is lacking on each form? 3. Are they signed by the correct authority? 4. Other questions? Both samples are missing #2 specify the food allergy/intolerance, medical condition, or disability. There is no detail provided as to the condition that would necessitate a modification. Also, #4, type of special diet, #5, modified texture, #6, modified thickness of liquids, and #7, special feeding equipment, #9, medical authority signature and contact information. The parent has signed the form, but failed to complete it and to obtain the physician s or other medical authority s signature. The medical authority, a physician, doctor of osteopathy, physician s assistant, or registered nurse practitioner, did not make the diagnosis, provide the details of the diet order, and sign the form as required. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 23

In the Participant Booklet, you will find the Fluid Milk Substitutions List. A fluid milk substitution must meet the nutrient equivalency of cow s milk. The column titled USDA Criteria per cup is the nutrient profile for cows milk. These are the nutrient requirements that must be met by the fluid milk substitution for it to be an acceptable product. To meet the requirements to be an acceptable substitute for fluid cow s milk, there must be at least 276 mg calcium, 8 grams protein, 500 IU Vitamin A, 100 IU Vitamin D, 24 mg magnesium, 222 mg phosphorus, 349 mg potassium, 0.44 mg riboflavin, and 1.1 mcg Vitamin B12. The products found on this list have been found to be creditable substitutes for cow s milk, as pertains to the nutrition content. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 24

Look at the Almond Milk and Rice Milk labels found in the Participant Booklet. Are they the products you should purchase for Maddie Doe if her meal modification form says it is Not a Disability? No. Why or why not? They are NOT creditable. If served, the meal cannot be claimed. How do you tell? The product is not listed on the Fluid Milk Substitution Chart. What if it IS a Disability? The doctor s orders on the meal modification form must be followed and meal may be claimed. Almond milk and rice milk have only 1 gram protein, and cow s milk has 8 grams protein. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 25

The number of participants with food allergies has been increasing significantly. These allergies CAN be life-threatening. Day care providers must be willing to accommodate these participants and able to make the necessary adjustments for their care. By having a plan and following it, being cautious, reading labels, and providing appropriate substitutions, homes and child care centers can do their part to keep safe the children in their care. An additional handout, FARE Tips for Avoiding Your Allergen, has been included in the Participant Booklet that summarizes the clues on two pages. Keep this handy for quick reference as needed and as a resource to use when training staff. A list of resources is also available in the Participant Booklet. Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 26

Now it is time to take the post-test. Thank you all for participating in this class. We hope this information has helped answer some of the questions you may have about food allergies and special diets! If you have further questions, please contact your sponsor or the Child Nutrition and Wellness Team at KSDE Food Allergies & Special Diets * Child Nutrition & Wellness, Kansas State Dept. of Education 27