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Are you confident that the staff at your child’s school could (and would) deal with an anaphylaxis emergency?

I was. The headteacher has assured me that everyone is trained in how to spot an allergic reaction and how to administer an EpiPen. In fact, the school nurse came in to give refresher EpiPen training to everyone in January. However, in light of what I have now learned about one school catering company, I will be double checking that “everyone” means everyone and there aren’t any external staff responsible for my son’s well being at lunchtimes.

Last October, I heard from an Oxfordshire nut mum whose children went to a school where Caterlink provided the school dinners. She was appalled to discover that Caterlink’s Nut Allergy Guidelines stated that staff should “not administer medication under any circumstances”:

Caterlink nut allergy guidelines emergency action

Indeed, Caterlink’s Allergy and Special Diet Guide (at page 15) advises staff “You could save a life”:

Caterlink

The “What to do in an emergency” section (at page 40) reiterates the message: do not administer medication under any circumstances.

Our nut mum contacted Caterlink, setting out her concerns (for full details, see Do your school caterers know their auto-injectors from their antidotes?).

The company has responded that:

“Caterlink staff are not required (by law) to administer or store Epi-pens in the dining room. There are also many variables of an allergic reaction and I do not wish for Caterlink staff to second guess when or if they should be administering an auto-injector.”

This has been challenged by our nut mum, who believes a policy that reads “staff are not obliged to give emergency medication”, would be an improvement on the existing “do not administer medication under any circumstances”. Pointing out that if Caterlink are concerned staff do not have the knowledge to deal with an anaphylaxis emergency and would be ‘second guessing’, then a well researched policy would be a step in the right direction.

The other points she raised have been acknowledged by the company, who pledge to make changes ‘in line with the upcoming Food Information Regulations’. Although they give no indication of what these changes will be or when they will be made.

Our nut mum is not impressed:

“Caterlink do not seem to realise the huge responsibility they have in keeping allergic children safe and the part a good policy and good attitude can play in this. It would be a simple thing to get the right information to staff and give them the confidence to act in an emergency, yet it appears to be low down on Caterlink’s list of priorities.”

You would hope that, in a life threatening emergency situation, people would do whatever they could to save a life. However, you only have to think of the death of Emma Sloan, after a pharmacist refused to dispense an EpiPen without a prescription, to realise that, for some, written rules and regulations will hold sway.

If your child’s school dinners are provided by Caterlink and you agree that it would be preferable for the guidelines to state that “staff are not obliged to give emergency medication” (rather than “do not administer medication under any circumstances”) then you might also want to raise this with your school and the caterer. That way, if there was an anaphylaxis emergency and only a member of the catering team was available to assist, there wouldn’t be a nagging doubt at the back of their minds that giving the EpiPen was against policy.

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That’s the question posed by an Oxfordshire nut mum after she took a closer look at Caterlink’s Nut Allergy Guidelines. Here she tells us what she discovered.

“With the new 2014 school year came a new challenge, whether free meals for every child in reception, year 1 and year 2 would include nut allergic children. My twin boys, one with a tree nut allergy, one without, often ask to try school dinners, so I decided to find out about the new caterer’s nut policy.

After a failed attempt to obtain the policy from school, I contacted Caterlink direct and they sent me their Nut Allergy Guidelines for staff. I wasn’t especially surprised to see the meals were not guaranteed nut free, making it an easy decision to stick with packed lunch.

Screen shot Caterlink 6.10.14 nut policy

However, what I read in the emergency section so shocked me I knew it was only fair that other parents were made aware of it.

Caterlink, featured on BBC’s The One Show as the new school meals service was rolled out and supporter of the School Food Plan, are on the front line at the most dangerous time of day for food allergic school children. The company is a big player in the UK school and university meals business, so you’d expect them to know a thing or two about food allergies.

Yet there on the second line of their emergency advice it read ‘an antidote to administer to known nut allergy sufferers’. A term not usually associated with adrenaline auto-injectors such as Epipen – these guidelines were clearly not well researched. Worse was to come, in bold and underlined it read “do not administer medication under any circumstances”. So even if a first aider can’t be found – even if a 999 operator is telling them to – even if a child is dying and they are the only one there? A chilling thought. You would hope if a child’s life was in danger any one would use the Epipen, trained or otherwise, that’s what it is there for.

At my son’s school it’s unlikely Caterlink staff would be called on in an emergency, but the fact that this policy exists and is given such prominence was a real concern. The calculations of an insurance company may lurk behind it, but it’s an appalling position to put staff in. Signed by Managing Director, Neil Fuller, the advice ends “Remember, death from an allergic reaction to food can take place in less than 10 minutes”.

Screen shot Caterlink 6.10.14 emergency action

There were other problems; no mention of laying the person down, or sitting them up if they can’t breathe; ensuring they stay put until the ambulance arrives, reducing the risk of heart attack; no clear explanations of the differences between mild and serious signs of a reaction.

Outlining my concerns to Caterlink, I asked them to urgently review their emergency advice, suggesting 7 days, and to let me know what changes had been made. I also forwarded an example of a good policy found on the internet; St Paul’s Girls’ School’s policy shows a good understanding of nut allergies and anaphylaxis and makes clear an auto-injector should be used straight away. It doesn’t prohibit anyone from using it. Caterlink emailed back to say my comments had been passed on to the relevant people and I’ve heard nothing since.

Alerted to the danger of assuming everyone would be well informed about allergies in schools, I started asking more questions. My son told me pupils don’t wash their hands before lunch and everyone sits where they liked, including next to those eating peanut butter and chocolate spread. He’s unlikely to react to peanuts, but that’s not the case for the other two nut allergic children in his year.

A month into the term I attended the school’s Epipen training. There were no trainer auto-injectors available. Taking my own Epipen trainer into school the next day I discovered that, whilst many teachers had been trained in previous years, this was the first time for my son’s teacher (let me reiterate, that’s a month into school). The school is listening to concerns raised by myself and other mums of allergic children and we anticipate changes.

So please, if you don’t know your school policies, if you don’t know what happens at lunch-time, if you haven’t seen your school’s caterer’s nut policy – make enquiries and challenge anything you wouldn’t allow to happen at home. Schools are about education, but you may find you’ll need to educate your school about allergies.”

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The safety of nut allergic flyers has come under the spotlight this week, after Fae Platten (aged 4) “lost consciousness on a plane when a selfish passenger ignored three warnings not to open a packet of nuts”. Fortunately, she recovered having been given the EpiPen but was “left with badly blistered lips and a swollen tongue”.

As Maureen Jenkins, Clinical Director of Allergy UK explained:

“Airborne particles from nuts have the potential to kill those who are allergic to them. These particles are even more readily inhaled from the recycled conditioned air in an aircraft.”

Whilst Ryanair deserve credit for making the announcements asking passengers not to eat nuts, for me this incident highlights the need for all airlines to implement an actual ban. Can you picture the scenario if an airline said  “Well, we said we weren’t selling fireworks, and we politely asked people to refrain from lighting them, but unfortunately he had a box in his hand luggage and he didn’t see the problem…”. Ludicrous, exactly.

To be meaningful a request needs to be enforceable. Picture the scenario if the police had no power to enforce speed limits. Although there is a 30 mph sign at the sign of the road, someone is run over by a driver doing 70. Would society find it acceptable for:

  • The police to say they did all they could: they put up a speed limit sign.
  • The driver to say I like driving my car fast: that’s my right. If I might hurt someone, well, what are they doing out and about and trying to cross a road?

Yet these types of justifications are raised when airlines say “we made a PA announcement” and passengers say “it’s my right to eat peanuts” and “so don’t take your allergic child on a plane”.

At the moment, nut allergic families are grateful for the 30 mph sign. However, as the Ryanair incident illustrates, even when an airline makes a request, that may not be sufficient.

As I understand it, it’s the dust from nuts which makes them pose a particular airborne risk. The confined space of an aircraft cabin with its recycled air then compounds the problem. It’s not the same as sitting on a bus or train. And added to that, it’s a damn sight easier to summons an ambulance when you’re not at 30,000 feet.

So if there is a nut allergic passenger, and nuts onboard could be potentially life threatening: don’t nuts need to be banned?

How can nut allergic passengers reduce their risk of an in flight reaction?

According to a 2013 study by Professor Greenhawt and colleagues, the following steps might reduce a nut allergy sufferer’s chance of an allergic reaction on a plane:

  • Making a request for accommodation from the airline.
  • Wiping down your tray table.
  • Not using the plane’s pillows or blankets.
  • Asking for a nut free buffer zone.
  • Asking the flight staff to make a request announcement that passengers do not to consume nut containing products.
  • Requesting a peanut free and/or tree nut free meal, or not eating the airline food at all (Sam Sadleir’s experience on Virgin Atlantic highlights the benefits of taking your own safe food onboard).

For those airlines who provide buffer zones, it seems a typical request would be for 3 rows either side of the nut allergic passenger. However, the Jet Blue website, for example, states they will organise “a buffer zone one row in front and one row behind the allergic person”.

In Fae Platten’s case, the man with the bag of nuts was four rows away. The Mirror reported that although Fae’s mum rushed her to “the front of the plane, the air conditioning meant there was no way she could get away from the nut particles circulating in the air”.

It therefore seems that whilst the risk reduction strategies might help ordinarily, a buffer zone or an unenforceable polite PA request would not cover the scenario of someone sensitive enough to react to airborne proteins, where a selfish and/or ignorant passenger decides to go ahead and launch nut particles into the air regardless.

What happened to Fae (and also the reaction suffered by a 9-year-old girl on a flight to Dublin earlier this month) underline what could happen when flying with a nut allergy. Whilst I don’t think these incidents would necessarily make us swear off air travel with our son, they will serve to heighten my anxiety next time we fly.

I’m just hoping that the press coverage of both of these incidents sparks a review of the airlines’ policies, and leads to them banning nuts (after all, the alternative solution of banning nut allergics would surely be disability discrimination!).

Please sign the petitions to ban nuts from planes…

Lynn Noble from Ballyclare has launched a petition to all airlines to ban nuts and nut products from planes. If you haven’t already, please do sign and share the petition. The more attention this issue can receive the better.

Lianne Mandelbaum (@NoNutTraveler) is also campaigning in the US for nut allergic people to be able to fly safely on commercial airlines. In her powerful speech from a FARE event, she asked:

“Does a child have to die on an airplane in order for airlines to enact policies to protect allergic passengers?”

Sign her petition requiring airlines to institute a Bill of Rights for food allergic passengers here.

Which airlines are nut allergy friendly?

Last November, the Anaphylaxis Campaign produced a chart setting out the published policies for different airlines: Food allergies – airline comparison.

How have you fared in practice? Below are the details of the experiences Joanne, Steph and I had with Wizz Air, Thomson and Monarch respectively. It would be extremely useful to know which airlines accommodate nut allergies well – please post a comment below to share any recommendations!

Monarch Airlines

“We flew to Faro with Monarch in March 2014. Before booking, I had called Monarch customer services to ask about their nut policy. I was assured that all I had to do was to call them after we had booked, to add a note of my son’s allergy to our booking. They sent me an email confirming that:

  • We could bring our own food onboard (as they couldn’t guarantee their inflight meals would be free of nut traces).
  • A note would be added to our booking so the check in, security and cabin crew staff are aware of D’s allergy and know we are carrying EpiPens.
  • The sale of nuts would be restricted on our flights.
  • The cabin crew would make an announcement asking passengers to refrain from eating any nuts or nut based products they may have with them.

I booked our flights, called customer services again, and was told D’s allergy had been noted against our booking. I called a couple of days prior to departure and again was assured that D’s allergy had been noted against our booking.

When we arrived at Manchester to fly out (and again when we arrived at Faro for the return journey), D’s allergy had NOT been noted against our booking!

We had to go through the rigmarole of the check in staff adding the details onto the system – which wasn’t straightforward at Faro when I spoke zero Portuguese and the check in lady had limited English.

Once these problems were overcome, the security, gate and cabin staff could not have been more helpful. They didn’t sell nuts and they did make the PA announcement as promised.”

(Louise, March 2014)

For the full story, see Holiday in Portugal with a nut allergy.

Wizz Air

“hello…just thought I would share my latest travel experience with Wizz air….that flies mostly on the continent but also to Luton, Doncaster, Glasgow and Liverpool. I was amazed to find they had a promotion on board where if you bought an alcoholic drink you got a free packet of peanuts!!! and they also sold peanuts. I asked them discreetly if they would not promote or sell peanuts on the flight and they were very happy not too. On the outward journey they made an announcement on the tannoy and on the way back they just didn’t sell/promote them. I have emailed the company to thank them and also suggested they looked for alternative snacks… I am keen to show gratitude and have extended the opportunity to provide further info if need be… “

(Joanne, June 2014)

Thomson

“I was disappointed with Thomson airlines though – they had no record of M’s allergy despite being informed by the holiday company, and the rather dismissive stewardess on the inbound flight just said, “does he have his epipen?” when we told her! Practically speaking though, this didn’t cause a problem as we took snacks and bought pringles that M could eat if he felt a bit peckish; we hadn’t ever intended to have the airline food. Last week we did get an apology from Thomson after I made my concerns known to Sovereign, the holiday company… hopefully it might make a difference next time, or to someone else in the same boat (or on the same plane!) as us.”

(Steph, May 2014)

For more details of Steph’s trip to Gran Canaria, see Steph’s story: Holiday in Gran Canaria with a nut allergy.

Who have you flown with? Please do share your experiences by posting a comment below – let’s start a list of helpful airlines!

Sources

Further information

 

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When is a nut not a nut? When it’s a peanut. Unless it’s on a “may contain” label, in which case it might be…

The difference between peanuts and tree nuts

One of the first things you learn when entering the nut allergy world is that there’s a difference between peanuts and tree nuts. In fact, it was the taxi driver taking me to visit my son in hospital who turned out to be The Knowledge on allergies and taught me the distinction.

Peanuts (aka groundnuts) are legumes, botanically related to foods like peas, beans and lentils. Whereas tree nuts include almonds, hazelnuts, walnuts and so on. A person can be allergic to peanuts, tree nuts or both.

At the moment, my son’s only known food allergy is to peanut. Our doctor’s advice is to avoid all nuts. However, some people only avoid their specific allergens, meaning, for example, some purely peanut allergic people eat tree nuts (and vice versa).

Peanuts and tree nuts must be distinguished on an ingredients label

In the UK, food allergen labelling law requires the label to state if a prepacked food or alcoholic drink contains one of the top 14 food allergens (or an ingredient made from them). From December, the way in which ingredients are displayed will change, so that the allergens must be highlighted (for example, in bold). The obligation to provide details of allergens will also be extended to foods sold loose and when eating out.

Under both the current law and the law from December 2014, the list of 14 allergens distinguishes between:

  • Peanuts, and
  • Certain nuts (i.e. almonds, hazelnuts, walnuts, cashews, pecan nuts, Brazil nuts, pistachio nuts, macadamia nuts and Queensland nuts).

A bag of peanuts and cashews should state “peanut” and “cashew nut” separately in the ingredients list. The manufacturer couldn’t simply put “Ingredients: nuts”, as this would certainly not cover peanuts.

Could the manufacturer put “Ingredients: peanuts and nuts”? It seems not. I asked the Food Standards Agency (FSA) whether a food company also has to name the specific type of tree nut. They advised that:

“a product containing tree nuts such as Walnuts, Brazil nuts, Almonds etc, as ingredients would by law have to make a clear reference to these particular nuts on the label.”

“May contain nuts” warnings

Under section 15 of the Food Safety Act 1990 it is an offence to sell food which is falsely described or labelled in a way which is likely to mislead as to its nature, substance or quality. However, the specific allergen labelling rules (including the requirement to differentiate between peanuts and other nuts) only apply to intentionally added ingredients and do not cover accidental cross contamination during the manufacturing process. (For more information, see Deciphering UK food allergen labelling law.)

The use of precautionary labels (“may contain nuts”, “not suitable for nut allergy sufferers”, “produced in a factory that also processes nuts” etc) is voluntary. Whilst the FSA has issued best practice guidance and the label cannot mislead as to the food’s nature/substance/quality, there is no legal duty to use a “may contain” label, nevermind a specific form of may contain wording. So, if a product is at risk of cross contamination from almonds, there is no obligation to state “may contain nuts”. Ditto if a peanut product is made on the same line: there is no duty to put “may contain peanut” on the packaging. In addition, the obligation to distinguish “peanut” from tree nuts applies to intentional ingredients.

Suppose a food company produces a biscuit which does not contain peanut or any tree nuts in the ingredients. The food company assesses the manufacturing process and decides there is a demonstrable and significant risk of cross contamination from both peanut and walnut. They could decide not to use any  precautionary label whatsoever. However, suppose they do decide to use a “may contain”, could they state:

  1. May contain peanut and walnut
  2. May contain peanut and nuts
  3. May contain nuts
  4. May contain peanut, or
  5. May contain walnut?

I asked the FSA whether “may contain nuts” could encompass peanut too and they confirmed:

“General statement such as “May contain nuts” will generally refer to both peanuts and tree nuts…”

Therefore, the company would be within their rights to use options 1, 2 or 3.

I don’t know whether 4 and 5 would be acceptable. Can a company pick and choose its may contains? Or does stating “may contain walnut” imply there isn’t a cross contamination risk from, for example, peanut?

Which companies bracket peanuts with nuts?

To me, it feels like a specific reference to peanut in a may contain warning is relatively unusual. Mars bars and Kelloggs Frosties spring to mind. However, the phrase is nowhere near as common as “may contain nuts”. Perhaps that’s because the cross contamination risk from peanut is rare compared to all the other tree nuts. Or perhaps the tendency is for manufacturers to lump peanuts and tree nuts together as “nuts” for may contains.

In practice, how many companies specify “may contain peanut” and how many use “may contain nuts” to mean both peanut and tree nuts? And for those who have some products stating “may contain peanut”, do they ALWAYS differentiate, or might some products in their range state “may contain nuts”?

It’s yet another may contain conundrum and one that is deeply unhelpful for those people only avoiding certain types of nuts. How frustrating if you are only avoiding peanut, to have to steer clear of products labelled “may contain nuts” potentially unnecessarily. And by specifying peanut or the type of tree nut in the “may contain” label, food companies would be reaching a wider customer base. Foodnavigator-USA.com reported last week how the “Nut Allergy Ecosystem” survey carried out by Rich Products showed how one child’s nut allergy impacts the shopping habits of a wide circle of people, including the child’s family, friends, classmates, teachers etc. The article pointed out that nut free labels are therefore a “missed business opportunity”. It seems to me the same is true for specific may contain details.

If anyone has information on those brands which differentiate between peanuts and other nuts in their precautionary labels, please do post a comment below – I would love to hear from you. I do plan to contact the leading supermarkets to see whether they specifically refer to peanut in their advisory labels – update to follow when I receive the replies.

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How do you draw the line between safe and risky food for your nut allergic child? I’ve been giving a lot of thought to this of late, when compiling the Nutmums.com nut free food directory.

What do I actually mean by the phrase “nut free food”?

When grocery shopping I would consider the following types of foods as safe for D:

  • Fresh fruit and vegetables (even if loose on display, as they would be washed before eating).
  • Fresh meat (either pre-packed and with no nut warning on the label, or from a butchers or farm shop who has confirmed the meat hasn’t been in proximity to nuts).
  • Dedicated “nut free brands”, namely those who proudly state their product is “nut free” or “nut safe” on the label.
  • Other pre-packed foods which contain no mention of nuts in the ingredients and have no “may contain nuts” or equivalently worded warning.

Then I read that “nut free” claims are largely unregulated (see below).

Then there’s the problem of deciphering a food manufacturer’s allergen controls. We avoid foods with nut warning labels. However, given “may contain” labelling is voluntary, if there is NO label, how do I know if a product is safe? I contact the manufacturer: but what questions should I ask? Does it need to be made in a nut free factory? If the factory handles nuts, but it’s made on a separate line to nut products, is that enough? Or can it be made on the same line, but still be “nut free” if the manufacturer’s allergen controls are stringent enough?

Sometimes it feels a bit like the more you learn, the less you know…

Intentional ingredients and “may contains”

In the UK, if a prepacked food or alcoholic drink contains one of the top 14 food allergens (or an ingredient made from them), this must be declared on the label. From December 2014, the duty to provide allergen information will be extended to foods sold loose (for example, in a bakery or over a deli counter) and when eating out. However, the allergen labelling requirements, both now and from December, only cover those ingredients which have been intentionally added to the food’s recipe. They do not cover accidental cross-contamination, where an allergen has got into the food accidentally during the manufacturing process. (For more information, see Deciphering UK food allergen labelling law).

Food manufacturers are therefore not obliged to give “may contain” warnings, to alert consumers to a potential cross contamination risk. “May contain” labels are voluntary. You cannot look at a packet and guess the manufacturer’s motivation for adding the line “may contain nuts”. They may be acting responsibly and trying to inform consumers of a genuine cross contamination risk. Or they may simply be trying to cover themselves if a consumer has an allergic reaction, irrespective of the size of the risk.

Even where you are dealing with a responsible manufacturer, the “may contain” label doesn’t convey how much of an allergen may have got into a product. Even “may contain nut traces” does not indicate there are only “trace” amounts (whatever trace means).

Similarly, if the label is silent as regards “may contains”, you cannot assume the food is therefore safe. Yes, the manufacturer MIGHT have employed exemplary allergen control measures and, after a thorough assessment, has determined that there is minimal cross contamination risk and therefore a nut warning is not necessary. On the other hand, the manufacturer might be well aware that its allergen controls are slap dash, but has decided against the use of a warning label. In each case, the level of risk is anyone’s guess.

Our family’s approach is therefore to avoid anything labelled “may contain nuts” (or equivalent wording) and to contact the manufacturer for more information where the label is silent.

When SHOULD a food manufacturer use a “may contain nuts” warning?

In 2006, the Food Standards Agency published Guidance on Allergen Management and Consumer Information. The guidance is voluntary but sets out, for food companies, what the FSA views as best practice as regards cross contamination controls and “may contain” labelling. It’s worth a read.

The guidance states (at page 5) that:

“Advisory labelling should only be used when, following a thorough risk assessment, there is a demonstrable and significant risk of allergen cross-contamination.”

What’s so special about nuts?

One thing the Tesco “may contain nuts” labelling fiasco illustrates is that, in a food manufacturer’s eyes, there seems to be something special about nuts. As health journalist Alex Gazzola commented “Why is it always nuts – and never (it seems) fish nor sesame?”. I agree: after all, Tesco labelling didn’t used to state “Recipe: No eggs. Ingredients: Cannot guarantee egg free. Factory: No eggs”.

I expect the “thing about nuts” is a combination of the total number of people diagnosed with a peanut and/or tree nut allergy, combined with the propensity of peanuts and tree nuts to cause anaphylaxis, plus the fact that peanut (according to the FSA) is “the most common cause of fatal food allergy”.

In addition to this, it seems that nut dust is one of the trickier things to control, with the FSA guidance stating that:

“Cross-contamination by small pieces of allergenic foods such as peanuts, tree nuts and sesame seeds can be exceptionally difficult to manage and therefore may warrant additional consideration for use of advisory labelling.”

If there are nuts elsewhere in the factory, does that automatically mean a product isn’t nut safe?

Not necessarily. Whilst, in an ideal world there would be dedicated production facilities for allergenic products, the FSA guidance (at page 18) notes that it is possible to separate products by:

  • Keeping them in different parts of the production area.
  • Using physical barriers between the production lines.
  • Using dedicated equipment.
  • Minimising unnecessary movement of materials.
  • Having appropriate scheduling of production runs, including cleaning the equipment between runs.
  • Managing re-work, ensuring that residual material containing an allergen is not re-worked into a product not containing the allergen.
  • Separating the air supply, where practical.

So it follows that manufacturers can make a nut safe product, even if there are nuts in the factory, if they implement sufficiently robust allergen controls.

How does a manufacturer assess a “demonstrable and significant risk” of nut cross contamination?

A thorough risk assessment requires an evaluation of the “likelihood of allergen cross-contamination across the supply chain”, namely from raw materials right through to the finished product. The guidance includes a flowchart (at page 11) which helps food companies decide if a “may contain nuts” label is required. Broadly:

  • The company must decide whether there is a probable (likely) or remote (unlikely, but still possible) risk of cross contamination from nuts.
  • In assessing whether the risk is probable or remote, the question of whether products are made on shared equipment is key. If “a food is manufactured on a production line or equipment that comes into direct contact with allergen containing materials”, the guidance appears to suggest (at page 24) that this automatically puts the cross contamination risk in the “probable” risk bracket.
  • If the risk is “remote”, a nut warning label is not appropriate. However, if the risk is “probable”, then from that starting point, you go on to look at whether the risk can be managed.
  • The company needs to consider the physical form and the characteristics of the nut-containing material. For example, nut oils are likely to pose a lower risk than whole nuts (or pieces of nut). It can be difficult to remove nut powder or particulates from machinery. 

The guidance states (at page 26) that there IS a risk of cross contamination UNLESS:

  • There is clear demonstrable evidence of a ‘visually and physically clean’ or equivalent standard, or
  • Assessment of the end product as consumed indicates little or no allergenic protein remains.

So, my reading of all this is that:

  • shared lines or equipment
  • the fact you’re dealing with peanuts and tree nuts

both point to the need for a “may contain” label. However, IF tests show there are in fact no nut traces in the final product, a may contain label ISN’T necessary.

A positive “nut free” claim

Last November, I read an article in the Economic Voice that concerned me. A survey had found that:

“3 out of 4 allergic consumers would purchase products claiming to be ‘allergen free’ on the label – despite these claims being largely unregulated.”

Whilst the FSA guidance states that where a manufacturer makes a positive “Free From” or “made in a nut free factory” claim, this should be “based on specific, rigorous controls to ensure their validity”, the point we come back to is that the guidance itself is voluntary.

I confess: I would assume something that declares itself to be “nut free” (1) didn’t have nuts in the ingredients and (2) the manufacturer at best had “specific, rigorous controls” in place, or had at least assessed the chance of cross contamination as “remote” (and therefore not needing a may contain warning).

I do understand that:

  • It is impossible to absolutely 100% guarantee that a food is nut free, even dedicated nut safe brands such as Kinnerton and Just Love Food Company acknowledge this.
  • If there was the tiniest speck of allergen in a food, there is the question of whether current allergen testing methods could pick this up.

But surely putting a “nut free” label on a packet, when there were either (1) nuts in the ingredients or (2) the cross contamination risk was “demonstrable and significant”, would be labelling food “in a way which is likely to mislead as to its nature, substance or quality” (which would therefore breach section 15 of the Food Safety Act 1990)?

I don’t know the answer to this and it seems like yet another grey area in food allergen labelling.

Surely a consumer shouldn’t be required to think this hard about what a food label means? We need to know what’s in our food and be able to make a risk assessment from the food label alone. Shouldn’t a food do exactly what it says on the tin?

The Nutmums “nut free food” directory

So, in summary, when compiling the nut free food directory, I have included those brands who:

  • State on their product labels they are “nut free”. (Please do double check with the manufacturer if you disagree with my approach on this); or
  • Have products which don’t list nuts as an ingredient and don’t state “may contain nuts” (or equivalent wording) and who have given some assurance on their website (or by email to me) that their products are nut safe.

As ever, manufacturers do change their recipes (and their production arrangements), so please do check the product label for yourself each time, and make your own enquiries of the manufacturer, if you are in any doubt about whether something is safe.

I will add to the list as I come across more nut free brands and products but if you have any product recommendations, do let me know!

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No sooner had I blogged my list of the wrongs that need righting in the world of nut allergies, than another one reared its ugly head.

Yesterday, the #TescoMayContainNuts campaign received some fantastic (and much deserved) national media coverage. There were articles in the Daily Mail, The Times, The Guardian, plus discussion on Loose Women and The Wright Stuff (which having watched Loose Women, I haven’t had the energy to view).

My perspective as a mum to a child with a life threatening peanut allergy is that, if there’s a real risk of cross contamination from peanuts or nuts, I would like to know about it. May contain labels therefore serve a useful purpose, provided they ARE genuine. The food allergic community needs to take a stand against blanket, back-covering precautionary labels. The campaign is therefore an extremely worthy cause (and if you haven’t already, then please do sign and share the Petition). It is excellent news that it is being highlighted in the national press and on national television.

That said, some of the coverage does seem to smack of the media not grasping the seriousness of the issues at stake.

The Daily Mail, for example, states “New rules come into effect in December which will make the labelling of possible food allergens compulsory”. However, allergen labelling is already compulsory now. By failing to explain the purpose of “may contain” labels and that the issue relates to accidental cross contamination rather than intentional ingredients, there’s a risk that Joe Public will perceive allergy parents to be asking for labels to make no reference to nuts.

This certainly seems to be a misconception of some of those commenting on the thread.  One consistent theme running through the comments was of “moaning” and “whining” mothers, who wanted the labels removed so we could bag some compensation if there ever was a reaction. Another angle was criticism for feeding our children processed junk: why didn’t we just cook fresh food from scratch? However, as the Petition states, may contains have been added to “everything from baked beans to pizza, butternut squash, potatoes, fruit juice and more”. And from the perspective that a severe nut allergy is a disability, would the mother of a child in a wheelchair be told “why can’t you just shop somewhere with a wider door”?

I know I should dismiss some of these folk as trolls or beyond education, however, for me, this highlights the fact that an awful lot of work needs to be done to help those who are fortunate enough to be free of allergies, to understand the potential severity and the impact on the lives of those who are affected.

Which brings me on to Loose Women. The segment started with the presenters having a cackle about “nuts”, before briefly mentioning the Tesco petition and then having a discussion largely dominated by Nadia Sawalha claiming “we’ve lost the plot” and complaining about her local restaurant having to stop serving Nutella pizza.

Whilst Coleen Nolan talked sense when she said:

“If I had a child who suffered from it I wouldn’t think it was an overreaction AT ALL”

the discussion concluded with posing the question whether everyone should “have to compromise their love of nuts”?.

This completely misses the point of the labelling issue at stake. I appreciate that the rules surrounding ingredients and “may contains” are hard enough to decipher for those of use grappling with them on a daily basis. However. surely the tabloids and TV presenters should be aware of the basic gist and be able to convey this to their audience?

Can you imagine such a facile debate taking place about any other life threatening condition?

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If you can’t trust the NHS, who can you trust…

My daughter recently passed a peanut challenge. I should have left the hospital happy and relieved that, rather than following in her big brother’s footsteps, she had escaped the shadow of life threatening food allergy. And happy and relieved was how I felt, in the main. Yet there was also something bugging me: I had been required to sign a disclaimer that the hospital food might contain nut traces.

On one hand, the hospital were saying the same as any restaurant would say: there are nuts in the kitchen and therefore we can’t “guarantee” our meals are 100% nut free. However, restaurants don’t ask you to sign a document. When eating out, there’s also usually the scope to chat through with the chef or manager what they would do to minimise the cross-contamination risk. If you don’t like what you hear, you can take your business elsewhere.

If my son has an allergic reaction resulting in a hospital stay, would I be happy for him to eat food that I had acknowledged may contain nut traces? No. He would be fine eating the hospital’s sealed juices, jellies and ice cream (and such like), which are prepacked and bear an ingredients list. However, we would have to bring in safe food for his “main courses” from home. Having your child in hospital is a stressful and draining enough time, without the additional burden of co-ordinating going home for food supplies.

What if a food allergic adult was admitted to hospital (for whatever reason, allergy related or not) and didn’t have a supportive family or friends who could bring in safe food? Would they be faced with a choice of risky food versus no food?

And shouldn’t a hospital, of all places, understand the need to feed a severely allergic child food that is free of their allergens?

I sensed a new allergy induced headache coming on…

Conflicting food labels and customer service information

Then the other Saturday, I read a Tweet from Waitrose about its Woodland Friends Easter egg hunt box, advising it wasn’t nut free. What? But there were no nuts in the ingredients … there was no “may contain nuts” warning on the pack … and hadn’t a fellow nut mum told me they were on the Waitrose list of foods suitable for those avoiding nuts? Hackles immediately up, I joined in the thread. It transpired that the Tweet had been wrong and Waitrose confirmed they WERE nut free.

Although this turned out to be a false alarm, it highlighted the importance for allergic customers of a company’s food labelling and website (or customer service channels) telling the same story.

These two incidents got me thinking about the various food allergy bees in my bonnet. Whilst I’m not by nature the militant, campaigning type, there seems to be an ever increasing list of wrongs to right in the world of nut allergy. What’s fuelling this indignation on my part? Some might say it stems from a sense of injustice that my child has a life threatening food allergy. I think there’s more to it than that. To me, it’s more about:

  • Seeing policies and customs which could (at worst) endanger my child’s health or (at best) exclude him in some way, and
  • Realising that the issues could could easily be remedied, but aren’t, because they benefit someone’s commercial interests or form part of an institution’s system.

In addition to safe hospital food and consistent allergy information, here are the other items on my nut mum manifesto:

An end to back covering may contain labels

This one hardly needs any introduction. May contain labels serve a useful purpose IF used genuinely to flag a potential risk of cross contamination during the manufacturing process. They are not helpful if used simply as a back covering measure, either where the risk is incredibly remote or where they are slapped on to every product indiscriminately.

At the end of last year, Alpro began adding “may contain traces of almonds and hazelnuts” to all of its soya products, despite planning apparently exemplary allergen controls. Tesco have now added “also, may contain nuts” to seemingly every own brand product, even including items such as orange juice, ham and prepared vegetables (sign the Petition here).

Defensive nut warning labels undermine the legitimate warnings. And if we get to the point of may contain saturation, where almost every product carries a nut warning, food shopping with confidence for your allergic child will become impossible.

Take a stand on nut allergy discrimination

In Wheeldon v Marstons, an employment tribunal, at a preliminary hearing, held that a chef’s severe allergy to nuts was a “disability” under the Equality Act 2010. It seems only a matter of time before this principle is confirmed by a higher court. Then, going forward, whether it be:

  • A restaurant refusing to make a single nut safe dish.
  • A nightclub banning EpiPens.
  • A party venue refusing to cater for an allergic child’s birthday.
  • A nursery refusing an allergic child a place.
  • A school excluding allergic children from school dinners.

… the spotlight needs to be shone on incidences of nut allergy discrimination and those found responsible held to account.

Introduce unassigned EpiPens in schools

In the US, an estimated 20-25% percent of children with peanut or nut allergies have their first reaction at school before they’ve been diagnosed. If my daughter suffered anaphylaxis, even with my express permission, the nursery or school would not treat her with one of my son’s EpiPens. They would have to call 999 and hope the paramedics arrive in time.

The US has the School Access to Emergency Epinephrine Act. Caroline Sloan has launched a campaign for EpiPens to be more widely available in Ireland following the death of her 14-year-old daughter Emma in December 2013 (sign the Emma’s Voice Petition here).

Isn’t it about time the UK followed suit?

GPs and health visitors to warn new parents of the peanut allergy risk

Given a child has a higher peanut allergy risk if they (or an immediate family member) have a food allergy or other allergic condition (such as hayfever, asthma or eczema), why don’t GPs and health visitors warn of the the associated (potentially life threatening) peanut allergy risk when prescribing blue inhalers and eczema creams to babies?

It seems that GPs are prompted by their computer at nearly every appointment to ask how many units of alcohol you consume in a week (love to know the stats on how many women say “erm, 10”, but I digress…). If the system can give this prompt, why not a “peanut allergy warning” prompt when issuing asthma and eczema medications to infants?

Are there any more?

So these are the food allergy bees in my bonnet. Do they tally with yours? Or are there more injustices out there which I’ve not yet encountered in the nut allergy world?

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Last week there was a storm on social media, when Tesco said the following about “Also, may contain nuts” warnings on its Facebook page:

Tesco screen shot may contain nuts

(click here for the full thread, which stands at 219 comments at the time of typing).

This, understandably, sparked an outcry from those with nut allergies and those with nut allergic children. It would mean all Tesco own brand products were off limits for those avoiding products labelled “may contain nuts”. Would this approach be adopted by other manufacturers? And surely not ALL products could be at risk of cross contamination from nuts? This smacked of a indiscriminate blanket measure, which would surely fly in the face of the Food Standards Agency’s best practice guidance, which although voluntary, sets out that manufacturers should only apply a traces warning when “following a thorough risk assessment, there is a demonstrable and significant risk of allergen cross-contamination”.

Tesco initially explained that the reason for this change was “due to the labelling laws changing at the end of this year”:

Tesco screen shot may contain nuts 2

This line was repeated several times and only served to incite more outrage, given the new allergen laws coming into force on 13 December 2014 do not change the position on may contain labelling (they are and will continue to be voluntary).

Surely this couldn’t be true? Yet, as one commenter on the Facebook thread noted, it was all going on a little too long for an April Fool…

Then the Tesco back track began on Wednesday morning:

Tesco screen shot may contain nuts 3

This was followed by several more customer service responses, clarifying that a “may contain nuts” warning would only be used where there was a risk of cross contamination. More detail was provided by Danny on Wednesday afternoon:

Tesco screen shot may contain nuts 4

So, all’s well that ends well? Despite a customer service social media response reminiscent of Alpro, it seems the upshot for nut allergic families is that Tesco are shifting from the recipe/ingredients/factory format to the phrase “may contain nuts”, and that advisory labelling will continue to only be used where there is a cross contamination risk. This tallies with the advice they gave me back in January (see Tesco nut allergy advisory labelling is changing).

It therefore looked like the storm had blown over. However, it seems the furore has prompted customers to focus on just how many Tesco products are now labelled with a nut allergy warning. This is a trend which has been going on for some time… here are two of the more surprising (read: irritating) examples I’ve come across:

Tesco ham may contain nutsTesco orange juice may contain nuts label

Check out the @Tesco_R_Nuts twitter feed for more…

It makes you wonder whether Laura and Daniel and colleagues did simply make a PR gaffe, or whether they know something about the may contains policy the public as yet don’t…

At least we have a choice in where to shop. So if one supermarket decides to slap a “may contain nuts” warning on every product, unless they have a monopoly on a particular product market, we can vote with our feet and take our business elsewhere. I guess the problem would be if they all did it. But then, if it ever got to that stage, before we all begin growing our own and living the Good Life, fingers crossed the Food Standards Agency would be able to intervene.

Update (15 April 2014) – Please sign the Petition!

Allergy mum Clare Hussein is petitioning Tesco to stop using blanket ‘may contain nuts’ labels. She is:

“calling on Tesco to act now to change its labelling procedures to ensure they are true reflections of risk. They need transparent traceability for all ingredients so a may contain label is only used with real need.”

To see the full Petition, click here: http://change.org/tesconuts … please sign and share this link.

Update (29 April 2014) – Tesco confirms “may contain nuts” has been put on products it shouldn’t…

Fantastic news: Tesco have conceded to #TescoMayContainNuts campaigners that “Recently how we label has changed and in that changeover the “may contain” statement has been put on products it shouldn’t and caused a lot of confusion and anguish amongst our customers – for which we are very sorry.”.

See screen shot below for one example (taken from this Facebook thread):

Tesco screen shot may contain nuts 29.4.14

 

If you haven’t already done so, please do sign and share the Petition – let’s get unnecessary labels removed from every product on which they’ve been put “but shouldn’t” have been!

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Have you heard about “universal free school meals” and the School Food Plan? It will affect anyone with a child in reception, year 1 or year 2 from this September (and potentially ALL primary school children in years to come).

September 2014: free school meals

Last September, Deputy Prime Minister Nick Clegg announced that, from September 2014, the following pupils and students will be eligible for a free school meal:

  • ALL infant school pupils in state funded schools in England (so children in reception, year 1 and year 2).
  • Disadvantaged students at sixth form colleges and further education colleges.

This announcement came on the back of the publication of the the School Food Plan in July 2013, in which Henry Dimbleby and John Vincent recommended that the government should embark on a phased roll out of free school meals for all children in all primary schools.

The government’s stated aim is to provide infant school children with a “hot, nutritious meal at lunch time”, in order to “improve academic attainment and save families money”. Nick Clegg said:

“My ambition is that every primary school pupil should be able to sit down to a hot, healthy lunch with their class mates every day.”

So far, so laudable. And a policy that states that all infant school children will receive a free school lunch, must include food allergic children too, right?

On reading about the plan, the first questions that spring to my mind were:

  • If my son has a school lunch, will this be nut free?
  • Even if the ingredients are nut free, will the school cook / catering company understand that he cannot have products which say “may contain nuts”?
  • Will the school kitchen staff understand about cross contamination?
  • If the school can make him a nut free meal, will there be any variety? (I’ve heard several stories of allergic children currently on school dinners having the option of jacket potato… or jacket potato. Every single day).
  • If the school lunches won’t be nut safe, might he be the only child eating a packed lunch whilst everyone has school dinners?

Can schools BAN packed lunches?

A further important point is whether schools have the power to ban packed lunches. The School Food Plan infers in several places that headteachers will indeed have this power. For example, the summary of the plan says:

“We have put together a ‘checklist for head teachers’… This includes everything from chucking out prisonstyle trays and getting teachers to eat in the dining hall, to banning packed lunches (it can be done!).”

The checklist itself suggests that headteachers:

“Make sure packed lunches are not a ‘better’ option. Ban sugary drinks, crisps and confectionery, or offer prizes and other incentives for bringing in a healthy lunch. Some schools ban packed lunches outright. If you want to do this, try starting with your newest intake (pupils in reception or year 7). The ban will then apply to all the years that follow them, until it extends to the whole school.”

The Q&A for headteachers is even more explicit, stating at question 11:

“As a Head Teacher, you have the power to decide whether you want to allow pupils to bring in a packed lunch instead of taking up their free school meal. We have seen schools where the Head Teacher has successfully banned packed lunches across the whole school. This clearly takes a clear commitment and excellent communication with pupils and parents.”

So, from this, packed lunches can be banned (and the clear inference is that they should be). The only reference I could see to the contrary was at question 6 of the Q&A, which says:

“be aware that UFSM does not necessarily lead to 100% take up of meals. Because of food allergies, absences, religious beliefs and those who will insist on carrying on with packed lunches, take up usually hovers between 85% and 90%.”

The Anaphylaxis Campaign also noted (in October 2013) that:

“As far as possible we would like to see the severely allergic child to have school meals with their peers … Parents of children with very severe and complex allergies should note that the plan does still allow packed lunches from home.”

So, whilst the position isn’t 100% clear, it seems that a school can impose a packed lunch ban, but make a concession for those with food allergies or certain religious beliefs.

What does the School Food Plan say about food allergies?

Very little, so far. The key provision relating to allergies is set out in the Q&A for Headteachers as follows (click to enlarge):

School Food Plan headteacher FAQs 19 Feb 2014The good news is that more  detailed guidance is expected soon…

How does the School Food Plan tie in with the Children and Families Bill?

The Children and Families Bill: food allergies

The Children and Families Bill is currently passing through Parliament and is expected to be enacted as the “Children and Families Act 2014” soon. The Bill covers a wide range of areas, such as family law, childcare providers and parental leave.

In October 2013, the Government announced that the Bill would be amended to include a duty on schools to support pupils with long-term health needs, namely:

“The appropriate authority for a school … must make arrangements for supporting pupils at the school with medical conditions”

In doing so, the authority must “have regard to guidance issued by the Secretary of State”. The government is consulting on this statutory guidance at the moment (the consultation will end on 14 March 2014).

The duty (and related guidance) aim to ensure that children with long term health needs have full access to education. The current draft guidance refers to food at paragraph 39, providing that:

“it is not generally acceptable practice to: … send children with medical conditions home frequently or prevent them from staying for normal school activities including lunch”

For more details, see the Anaphylaxis Campaign’s report of the Bill’s progress through Parliament.

The Children and Families Bill: free school meals

In addition to the duty to support pupils with long-term health needs, on 23 January 2014, the Government announced its:

“intention to amend the Children and Families Bill, which is currently before Parliament, to place a legal duty on primary schools to offer free meals to all pupils in reception, year 1 and year 2 from this September. The legislation will also include a power to extend the policy to additional year groups in future.”

In summary…

  • Primary schools will be under a legal duty to provide free school meals (to children in reception, year 1 and year 2) from September 2014.
  • It seems that, although headteachers have the power to ban packed lunches, food allergic children may be exempted from this ban.
  • The detailed guidance for schools regarding how to keep food allergic children safe is still awaited.

I was chatting recently to the head of nutrition at a catering company which supplies many schools. Her view that there shouldn’t be a problem with nuts, in that most schools already veto both foods with nuts as an ingredient or those labelled “may contain nuts” or equivalent wording. Whilst that was reassuring for me to hear, the situation may not be so straightforward for those with multiple allergies (and I imagine if you are dealing with allergies outside of the “top 14”, it will be trickier still).

If a school can’t provide a safe school meal for an allergic child, and a parent has to instead provide a packed lunch, this raises questions of both:

  • “Exclusion”: the child with the long term health condition being unable to join in school lunches with their peers.
  • Cost: who should be paying for the packed lunch alternative?

And, if a policy of “free school meals for all” excludes food allergic children, could there potentially be an argument that this is treating a disabled child less favourably than another child? If a school says “allergic children can bring packed lunches”, would that be a reasonable adjustment for a disabled child? Or is it reasonable to expect a school to adapt its menu options to provide safe alternatives for allergic children?

Let’s hope it doesn’t become necessary to even think about such arguments. Fingers crossed the forthcoming guidance for schools will inspire confidence that food allergies CAN be catered for and that free school meals really are for “all”.

Further reading

 

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On the Wednesday evening before Christmas, 14-year-old Emma Sloan tragically died from anaphylaxis on O’Connell Street in Dublin. She had been for a meal with her family at a Chinese buffet and had eaten satay sauce (which contains peanuts) by mistake. She had a known nut allergy but did not have her adrenaline auto-injector with her that evening. When she began to suffer an allergic reaction, her mother went into a nearby chemist to ask for an EpiPen. The pharmacy said they were unable to give out an adrenaline auto-injector without a prescription and advised the family to go to A&E. Emma died a few metres outside the chemist. RTÉ has reported that the Pharmaceutical Society of Ireland has launched an investigation.

Any report of an anaphylaxis death is incredibly sad to read. In this case, there is the added question mark of whether the pharmacy could and should have supplied the emergency adrenaline.

Could a similar tragedy occur in the UK?

It seems so. According to the EpiPen website, in the UK, EpiPens are “only available on prescription from your doctor”. From what I’ve read (and I hasten to add I have no medical/pharmacy background), although adrenaline is a “POM” (prescription only medicine) an exemption exists allowing it to be “administered” in an anaphylaxis emergency. However, I am not clear if this means a UK pharmacist could “dispense” adrenaline in an anaphylaxis emergency.

The “orange cross” scheme in Scotland

In Scotland, whilst adrenaline auto-injectors are only available on prescription, Community Pharmacy Scotland (CPS) launched a campaign last summer in respect of anaphylaxis emergencies. The scheme has been backed by Lib Dem MP Jo Swinson, who suffered anaphylaxis and required an adrenaline injection in May 2013.

Under the scheme, wherever a Scottish pharmacy displays an orange anaphylaxis treatment cross, that pharmacy can provide “trained help in an anaphylaxis emergency”.

I contacted CPS for further details and they have confirmed this means that participating pharmacies will each stock at least one adrenaline injection 300mcg per dose (adult) and at least one adrenaline injection 150mcg per dose (child). The producers of both Epipen and Jext have also provided the pharmacies with training and support materials. 

CPS told me:

“Anaphylaxis is an issue with which community pharmacists are well placed to advise patients (even around correct use and expiry etc of pens), so we feel it was important to raise awareness for the pharmacies as well as the public. So far around 890 of our pharmacies have opted in and should be showing the orange cross within their pharmacy premises.”

Until we get to the stage where adrenaline auto-injectors are held in public places (nurseries, schools, restaurants, shopping centres, railway stations etc) in the same way as some venues hold defibrillators, schemes such as the CPS orange cross scheme are a very welcome and reassuring step in the right direction.

Please England, Wales and Northern Ireland: can you follow suit?

Update: UK pharmacists’ powers in life saving emergency

Please see extremely interesting comment from a pharmacist on the Nutmums facebook page (thank you, Kristeen).

Sources and further information

(image courtesy of Community Pharmacy Scotland)