Shock Tactics

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There's only so much anyone can do to prevent children with allergies from coming into contact with foods that might kill them. But at St. Andrew's Primary School, in the western Sydney suburb of Marayong, the attitude is plain: not on our watch. For the past seven years, the 830-pupil school has been tightening the blanket around its eight most vulnerable kids. It encourages parents to visit the tuck shop at the start of each year to compile a list of snacks that they're happy for their children to buy; photos of the allergic pupils are stuck up inside the shop so parent helpers know whom they're serving. When a child brings a birthday cake to class, pupils with allergies aren't allowed a piece - but they can fetch a safe, homemade cupcake from the canteen freezer so they can join the party. And while the school hat is blue, the allergic children are asked to wear a yellow one. "If a child with a yellow hat goes down in the playground," says acting principal Kim McDonald, "we'd probably be dashing over there even faster than we normally would."

A New South Wales government working party recently prepared draft guidelines on the management of severe allergies in schools that, when adopted, will move the state's schools toward the St. Andrew's model. But there are sticking points. The state's biggest teachers' union is set to reject any plan that would require teachers to administer the EpiPen, a syringe preloaded with adrenaline that can save the life of someone experiencing the severe allergic reaction known as anaphylaxis. And the issue of how to manage allergies in schools has been enlivening normally soporific Parents and Citizens meetings for some time. Try telling some parents of non-allergic kids that they perhaps shouldn't put peanut butter sandwiches in their child's lunchbox, just in case he or she swaps it with an allergic friend. "There's been a lot of hot air in this debate that hasn't done anyone any good," says Dr. Connie Katelaris, a clinical immunologist at Sydney's Westmead Hospital. "We've got schools that are so highly protective they've gone ridiculous . . . and others that have been slow to move and the kids are at risk."

Momentum is with those pushing for greater protection of vulnerable pupils. The incidence of food allergy in the Western world has risen over the past 25 years: it now affects 5-8% of Australian children. Mostly, these are mild or moderate conditions in which exposure to the allergen (usually milk, egg, peanut, tree nuts, fish, crustaceans, soybean or wheat) may irritate the skin. But for some sufferers, exposure can trigger a massive immune response whose symptoms may include a potentially fatal narrowing of the airways or drop in blood pressure. Doctors estimate that between 10 and 20 Australians die each year from anaphylaxis, which accounts for about 1 in every 450 hospital casualty admissions.

Though doctors aren't sure why allergic disease is increasing, most subscribe to the so-called "hygiene hypothesis," which postulates that compared to previous generations, today's children grow up in cleaner surroundings and aren't exposed to the same onslaught of germs and parasites. "The immune system isn't busy with infection any more," says Dr. Robert Loblay, director of the allergy unit at Sydney's Royal Prince Alfred Hospital, "so it's turned its attention to what should be harmless substances."

Of these, it's the peanut that the body's IgE antibodies most commonly target as enemy invader No. 1. Studies suggest that peanut allergy in England and Australia has doubled or even tripled since the late 1980s and now affects about 2-3% of pre-school children (and unlike other food allergies, peanut sensitivity tends to stick around for life). Why is this happening? Doctors speculate that in response to the trend toward eating less red meat, more nursing mothers have sought protein from alternative sources such as nuts. Protein molecules from these nuts may then be transferred to the infant through the breast milk at a time when the immune system is most prone to develop allergies.

Three children died in N.S.W. in the 13 months to April after inadvertently consuming peanut. One of them - 13-year-old Hamidur Rahman of Sydney - was on a school excursion at the time. More than usually disturbed by the circumstances of his death - he was participating in a game that involved licking peanut butter off a spoon - the country's leading allergy support group, Anaphylaxis Australia Inc., has prepared a report for the upcoming coronial inquest.

While nearly all immunologists understand the anxiety that allergies can cause sufferers and their carers, many oppose what they say are futile attempts to make public places allergen-free. Schools and daycare centers that have tried to ban all children from bringing nut products have acted on the premise that some kids are so highly allergic that they don't need to ingest the allergen to go into anaphylaxis - merely touching or smelling it can set them off. While strictly true, that argument has been "vastly overplayed," says Westmead's Katelaris. "There's been too much emphasis on these extremely rare occurrences, and a lot of policy making has been driven by that."

Maria Said, AAI president and coauthor of the draft guidelines, has a different reason for opposing bans. "If you told me that peanut was forbidden at a particular school in Sydney and I went and checked, you could bet your bottom dollar that I'd find it there," she says. "Banning can create a false sense of security: staff can sit back and say, I don't need to know much about the EpiPen because nothing will ever happen here.'"

Others feel that bans (or at least strong recommendations) are justified in daycare centers where the trading of lunch items and potentially dangerous contact between children who don't understand allergy are real possibilities. Deaths from anaphylaxis are more common among teens and adults than under-fives, but any kind of attack causes distress for all involved. "I suppose I'm in the school that says, What's wrong with Vegemite?" says Prof. John Ziegler, head of the department of immunology/allergy at Sydney Children's Hospital, Randwick. True, he says, you can't have people at the gate "frisking the kids for contraband sandwiches . . . but in general, if you tell the other parents we've got this problem, that should make a difference."

Many allergy lobbyists have little sympathy for teachers who refuse to use the EpiPen, whether because they're squeamish about needles, worried about lawsuits or think it's beyond the call of duty. RPA nurse Carol Field runs a weekly class for parents and caregivers of allergy sufferers at which most attendees feel they've mastered the EpiPen after 20 minutes' instruction. "At the end of the day, people have to take responsibility," says AAI's Said. "And if teachers can't do that in the playground, then maybe they're in the wrong profession." n