Susan Lister runs a playgroup in Cambridge where they have learned to deal with epileptic, nut allergic, dairy intolerant and coeliac children.

With their first playschool looming for many young children with food allergy and food intolerance, Susan's strategies for coping could be just the thing worried parents need to have on hand when negotiating with their children's new playgroups.

It was 9am on a Monday morning and I was greeted by a very agitated parent. She had spent part of the weekend in A & E with Abigail, her 3 year old daughter who had had an anaphylactic reaction to something. They weren't sure what exactly, but the likely culprit was nuts. Would we be able to cope at playgroup, or would she have to leave?

My immediate and personal reaction was that of course we could cope, but to be fair to my staff I consulted them all. The collective reaction was the same, a deep breath and ‘yes, of course!’ After chatting to the parent we decided that we could cope, but in the interests of the child’s health we needed a little more time and more information to make sure that she would be safe with us. So Abigail stayed away for a week. This was enough time for the hospital to identify her precise allergens, and for us to think through our strategies. After a week we were all set.

Abilgail's Food
Abigail was allergic to all nuts, but in particular peanut and coconut. We were used to checking contents lists for food as she already had a problem with dairy products, so we began a regime where Abigail was not given anything which we (or her Mum) had not checked for ingredients. The rule was 'if in doubt, don't'. This applied to any food brought in by other children or parents such as birthday treats and Abigails's mum supplied a tin of treats that were safe and which were stored with other food. We also carefully checked ingredients on things like paint and play-dough to make sure that they were nut free (some oils contain nuts).

Emergency procedures
Unfortunately Abigail was very sensitive to her allergens, and even contact with nut traces was likely to cause anaphylactic shock, so that was another issue we had to consider. Staff were all happy to use an Epipen if necessary (we had had an epileptic child at playgroup a couple of years earlier, so received training then) and we arranged to have a training up-date.

We purchased a fluorescent-pink paint box that was highly visible in which to keep Abigail's emergency kit - the Epipen, contact phone numbers, GP details, medical conditions, hospital patient numbers (vital if she had to go to hospital) even some cash so that whoever accompanied her in the ambulance wouldn't be stranded. This was always kept on hand, even accompanying Abigail on school outings.

Outings
We regularly take the older children on outings so had to plan for these too. We always had Abigail's box with us and if we split up then her group had an extra mobile phone so the they could phone not only an ambulance but could phone another group for staff back-up if needed. When we take the children out, if we go to a café we explain that we need the table carefully cleaned. If we know it will be picnic benches we take a small paper tablecloth to cover the surface.

We developed all this through dialogue with her parents, her GP and our staff who were always consulted about what responsibilities they were prepared to undertake (administer the Epipen, accompany her to hospital etc). Abigail was with us for a total of five terms, and fortunately our precautions were adequate and she was well the whole time. This was six years ago.

Two years ago we had two children with multiple food allergies, but we knew about their allergies in advance, so were able to review strategies that we used with Abigail and adapt them accordingly before they started with us. Again dialogue with their parents and GP were both vital and helpful. Fortunately neither had a problem with handling things like flour or colouring This time their parents elected to provide all their foods themselves, so they brought a lunch box every day with their own food in. It was served in the same way as the children's snack, but on a separate plate.

Now add a coeliac
This year however, we have had to break new ground. We have two dairy intolerant children, one of whom has just been diagnosed as coeliac. The dairy free diet isn't a problem - we are very used to looking at labels, use dairy free margarine, and offer water or milk to all the children anyway, with 'dairy free' children having the option of goat's or soya milk if their parents wish to supply it. But to accommodate a Coeliac we had to think very carefully.

The most obvious area to look at is what she actually eats while at playgroup. Because Grace has only just been diagnosed the specialist wants her diet to be totally clean, with absolutely no possibility of cross contamination. Her mother is happy to supply gluten free bread and crackers, and her own margarine and marmite, so that it is all ‘'clean'.

But we have had to think about food preparation too. We now have a separate area of the kitchen in which to prepare Grace's food. A designated staff member cleans that area of the kitchen thoroughly, as we do not have sole use of the building so cannot be sure that the area has not been contaminated. We then place her food, a freshly washed knife, plate and cup (dried with a paper towel) on a cleaned area. We have a chopping board that is only used for her food and is not stored with the other kitchen equipment.

To produce 'clean' toast we use a toasting bag (www.toastabags.com) although we need to take care that the outside of the toasting bag does not come in to contact with her ‘clean' preparation area. The children are also offered fruit and vegetables, so some of it is washed and placed in Grace's area, and is prepared there, the surplus then being transferred to the other side of the kitchen after Grace's plate has been prepared

Having a special plate for children with special diets has never been a problem, and the matter is always discussed positively with the children, usually within likes and dislikes. They all know that Grace and Joe can not eat or drink some things that they can because it would make them ill. (Two children are about to have birthday parties, and have told their mothers that Grace will need to have special party food and that they will need to talk to Grace's mother about it.)

Both Grace and Joe are positive about their food intolerance and can confidently explain that they have special food so that they won't be ill. However, the dialogue with their parents is constant, and if one of them was at all unhappy about their special plate we have a contingency plan - each child would have their own plate (we don't at present because one of the important factors in our snack time is a concept of sharing our food).

Adult awareness
Adults have to be very ‘self-aware’ too. It would be very easy to handle the 'normal' food and then inadvertently handle something that Grace was going to eat. Grace attends Lunch Club where children and staff eat together, so we arrange the seating so that she always sits next to an adult who is deliberately 'gluten free' too. That adult will not help any of the other children with their lunches, to ensure that there is no possibility of cross-contamination, and has a gluten free lunch as well.

However, there are other things to consider with a coeliac child. We thought very carefully about our activities and routine, and decided that we would need to examine any substance that we used with the children. We have discovered that glue is OK, but that paint might not be, as some paints contain gluten! We have discussed this with the specialist (via Mum) who says that it should be okay as long as the gluten is not ingested so an adult has to help Grace wash her hands after painting, to make sure that it is done thoroughly.

In cooking activities we use non-gluten flour (e.g.buckwheat) although we are still experimenting, as some recipes do not take kindly to change. Be wary though - lots of unexpected products do contain it. Some brands of icing sugar and cake decorations, for example. It is also in a lot of things that you wouldn’t expect - like ketchup and some stock cubes. We are also about to try using gram flour to make playdough. (An alternative gluten free playdough can be got from www.wholesomehouse.co.uk).

The vital thing throughout has been communication - with the parents, with medical personnel, between the staff, and with the rest of the children - so that everyone understands what is going on. The children in particular need to understand so that they don't offer their food to Grace. Adults also have to be very vigilant at times when we sit together and share food. We have another child who is gluten-intolerant due to start with us in September, and when his parents ask us if we can cope we know that - like Bob the Builder - we can confidently say 'Yes, we can!'

Recipe for a safe environment

Ingredients
Large amounts of information (from labels, packets, manufacturers, specialists)
Lots of communications (some parents are unwilling to tell you how serious a condition is because they want their child to be seen as 'normal'. They also worry that they will not be accepted if the problem seems too large.)
Heaped spoonfuls of common sense
A pinch of the right kind of training.
Small quanities of the right kind of food
Large quantity of vigilance (clean hands, look at glue, paint dough etc)
A clean area in the kitchen

Method
Prepare all the ingredients with care.
Think carefully about how they will be put together.
Add medication available to taste.
Stir and activate the mixture by telling everyone.
Refresh the recipe by regular discussion.

First published in 2004

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