I don’t want to be singled out. I just want to be safe: Balancing food culture and food allergy
In her April 2023 blog post, Dr Gina Rempel wrote about feeding children who live with eating and drinking difficulties. Dr Rempel so wisely wrote about eating as “very special life-affirming activities that many parents want their children to participate in even in the face of risk.” In her text, she linked this risk to aspiration. Without any doubt, there is risk involved, a risk which needs to be balanced against the multiple roles beyond physical nourishment that food plays.
Food is a means by which people express their culture, their emotions, and their faith (or not). Food is part of our identity – who we are as individuals, and where we see ourselves within a community. But these very functions of food present potential threats and may introduce risk for the estimated 6-7% of Canadian children with food allergy (1). Data from the Canadian Primary Care Sentinel Surveillance Network provide evidence that children with food allergy are significantly more likely to have certain diagnoses, including attention deficit/hyperactivity disorder, autism, and depression (2).
For children with food allergy and their families, risk exists every time a child eats. A reaction could occur due to mislabeled foods, a serving spoon that wasn’t properly cleaned, or a young child whose innate desire to explore their world through sensory play leads to accidentally eating something to which they are allergic. These are only a few examples that could lead to a food allergic reaction, the most severe of which is termed anaphylaxis, which can be fatal.
To begin to understand the risk, take a moment to reflect on every moment that you think about food, whether it be while making school lunches, planning a special occasion, arranging play dates, or organising holidays.
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A young child with a peanut and tree nut allergy may attend a school that has a “peanut and tree nut aware” policy. While this may seem reassuring on the surface, those who do not manage food allergy may not always remember the policy, thereby introducing the risk in an environment – the school – where children have the right to be safe. Indeed, an estimated 20% of pediatric anaphylaxis to a known allergen occurs in schools (3). In addition to the risk of a food allergic reaction, as many as one-in-three children with food allergy may also be bullied because of their allergy (4). While there is much discussion regarding school food allergy policies, it is unlikely that a one-size-fits-all approach will be universally satisfactory. Rather, decisions should be made within multiple other considerations: the chronological and cognitive ages of the children; the school’s proximity to emergency services; food allergy competence, confidence and ongoing training available to school staff; access to emergency medicine (i.e. epinephrine autoinjectors); and, psychological safety.
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Birthdays are major celebrations, especially for children. A cake with candles marks a rite of passage. But for a child with food allergy, that cake may also highlight how they are different from their friends. Consider a child who is allergic to eggs and wheat, two common cake ingredients. Will that cake be “safe” for them? Or will they need to eat something different, likely which they’ve brought from home? While our differences make us unique, many children desire to “fit in” with their friends. These feelings of being different need to be validated. Yet, children with food allergy must learn that by avoiding the food that will label them as being different is, in fact, necessary to keep them safe.
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Each culture, and each faith community uses food as a means to express who they are. A special celebration may be associated with a particular menu, year after year. For many, these traditions provide comfort and highlight continuity between generations. For families managing food allergy, recipes may need to be modified to comply with dietary restrictions. In some cases, traditional foods may need to be completely eliminated. These changes, no matter how necessary they are for the safety of the person with food allergy, may nonetheless create tension between family members. At minimum, there is often a steep learning curve, for those trying to modify recipes, for those trying to navigate a family potluck, and for those trying to educate family members about food allergy.
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Family vacations are times to make lasting memories. Whether these holidays are staycations or involve a long trip, food choices cannot be left to chance. Packing an allergy-safe picnic lunch to take along on a road trip involves some creativity. Meal planning for longer trips introduces new challenges, ranging from searching for accommodation with cooking facilities, to trying to pack enough food in a carry-on bag while still complying with airline and transport regulations.
As a parent managing their child’s food allergy, what actions should I take?
Ask questions!
What kinds of foods will be served?
Will there be a responsible adult present? Can I talk to this person about food allergies?
May I show you how to use an epinephrine autoinjector?
Are you familiar with the signs and symptoms of food allergic reactions? What are they?
What kinds of activities will be done? (consider cross-contamination for cooking, crafts, outdoor activities, etc.)
Do you have any questions for me?
Do you have my phone number saved in your phone?
Please call me if you have ANY questions
These are examples only, to help start a conversation.
Read labels every time!
Always triple check food labels – at the time of purchase, at the time of storage and at the time of preparation
If in doubt, call the manufacturer for clarification, and do not eat the food until a satisfactory answer is received
Be prepared!
Always have at least one (but ideally two), in-date emergency medicine (an epinephrine autoinjector) with the child. Know how to use it, and teach every responsible adult who takes care of your child when you are not present.
Meal plan. Snack plan.
Know that sometimes your child may feel left out, or be anxious. Sadly, many children with food allergy feel this way from time to time. Help them appreciate that some anxiety can help them make choices that will reduce their risk of reaction, while still doing other fun activities.
Support your child’s learning about, and advocacy for food allergy from a young age.
As a parent whose child doesn’t have food allergy, what actions should I take?
Know if your child’s friends have food allergy. If they do, speak with the parents (and if appropriate, the child as well). If they spend time at your home, consider having a few safe snack options on hand, that have been approved by the parent.
Learn about food allergy management. Education is key for safely navigating food allergy.
Ask questions and listen.
Know that food allergy is not a choice.
Food allergy is expensive
The above scenarios highlight four possible ways that food allergy presents potential threats and may introduce risk. But no discussion about the impact of food allergy would be complete without consideration to the financial cost of managing the condition.
In the months prior to the COVID-19 pandemic, Manitoba families managing their child’s food allergy reported average food costs of ~$200 more per month than families whose children do not have food allergy (5). To put this in context, over the course of a year, this excess corresponds to about two weeks’ pay (6). But food prices have increased in recent months, by as much as 8%.7 These increases fall on the heels of price increases since the start of the pandemic, (8,9) with increases expected through 2023 (10). For families managing food allergy, these increases, estimated at $100-$200 more per month, were dramatic, even in the early days of the pandemic (11). With both families and food banks feeling the strain of increasing food prices, families with allergy-related dietary restrictions may find themselves in situations with few alternatives. As consequences of limited alternatives, parents of children with food allergy may limit their food intake, in order to provide allergy-safe food for their child; or, they may have to make difficult decisions about renewing emergency medicine.
Steps to help support families managing food allergy
If seeing families in a clinical setting, consider entering into respectful conversations about the cost of food, and about health insurance (for emergency medicine)
When contributing food to a local food bank, consider selecting foods that do not contain common allergens (e.g. milk, eggs, wheat, peanuts, tree nuts, fish, shellfish, soy, sesame or mustard)
May is Food Allergy Awareness Month. Food Allergy Canada notes that “When a child has a dual diagnosis of a developmental delay or other condition in addition to food allergy, parents have to take extra steps to ensure the child’s safety.” A team approach that includes the child, caregiver(s), health care providers, and educators, can help enhance safety and participation for the child. Take a moment to consider what food means to you. Take time to consider how food allergy may presents potential threats and may introduce risk. Take an opportunity to support those living with food allergy.
Interested in learning more?
CHILDREN WITH DIVERSE NEEDS AND FOOD ALLERGY
FOOD ALLERGY AND SCHOOLS
FOOD ALLERGY EDUCATION VIDEOS INTENDED FOR KINDERGARTEN TO GRADE 4 (VIDEO 1) AND GRADE 5-8 (VIDEO 2)
References
1. Clarke AE, et al. Temporal trends in prevalence of food allergy in Canada. J Allergy Clin Immunol Pract. 2020;8(4):1428-30.e5.
2. Singer AG, et al. Prevalence of physician-reported food allergy in Canadian children. J Allergy Clin Immunol Pract. 2021;9(1):193-9.
3. De Schryver S, et al. Food-induced anaphylaxis to a known food allergen in children often occurs despite adult supervision. Pediatr Allergy Immunol 2017;28:715-7.
4. Fong AT, et al. Bullying and quality of life in children and adolescents with food allergy. J Paediatr Child Health. 2017;53:630-5.
5. Golding MA, et al. The excess costs of childhood food allergy on Canadian families: a cross-sectional study. Allergy Asthma Clin Immunol. 2021;17(1):28.
6. Statistics Canada. Employee wages by industry, annual. Available online at https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1410006401&pickMembers%5B0%5D=1.8&pickMembers%5B1%5D=2.3&pickMembers%5B2%5D=3.2&pickMembers%5B3%5D=5.1&pickMembers%5B4%5D=6.1&cubeTimeFrame.startYear=2018&cubeTimeFrame.endYear=2022&referencePeriods=20180101%2C20220101 on 20230410
7. Charlebois S, et al. Canada’s food price report, 12th edition. 2022. Available online at https://cdn.dal.ca/content/dam/dalhousie/pdf/sites/agri-food/Food%20Price%20Report%20-%20EN%202022.pdf on 20230410
8. Charlebois S, et al. Canada’s food price report, 10th edition. 2020. Available online at https://cdn.dal.ca/content/dam/dalhousie/pdf/sites/agri-food/Canada%20Food%20Price%20Report%20Eng%202020.pdf on 20230410
9. Charlebois S, et al. Canada’s food price report, 11th edition. 2021. Available online at https://cdn.dal.ca/content/dam/dalhousie/pdf/sites/agri-food/Food%20Price%20Report%202021%20-%20EN%20(December%208).pdf on 20230410
10. Charlebois S, et al. Canada’s food price report, 13th edition. 2023. Available online at https://cdn.dal.ca/content/dam/dalhousie/pdf/sites/agri-food/Canada%27s%20Food%20Price%20Report%202023_Digital.pdf on 20230410
11. Golding MA, et al. Changes in food-related costs during the COVID-19 pandemic among families managing food allergy. Front Allergy. 2022;3:915014.
Published May 1, 2023
About the author
Dr. Jennifer Protudjer PhD is the Endowed Research Chair in Allergy, Asthma and the Environment; and, an associate professor in the Department of Pediatrics and Child Health, University of Manitoba; a research scientist at the Children’s Hospital Research Institute of Manitoba; an epidemiologist with the Clinical Trials Platform at the George and Fay Yee Centre for Healthcare Innovation; Section Head, Allied Health, of the Canadian Society of Allergy and Clinical Immunology.; and, sits on the steering committee for Canada’s National Food Allergy Action Plan She also holds an adjunct professorship in the Department of Foods and Human Nutritional Sciences, University of Manitoba; and, and is an affiliated researcher at the Karolinska Institutet, where she completed her post-doctoral training. Her primary research interests include environmental risk factors for, and societal consequences of allergic disease, using both quantitative and qualitative methods.