You can establish a virtual blockade around your home to prevent unfriendly foods from being smuggled across the border, but when you ship your toddlers off to daycare or your little tikes off to preschool, they enter a world where allergenic foods are often readily available, temptations are strong, and ignorance is rampant.

To safeguard your children when they leave your protective fortress, you often need to re-create the safe environment of your home wherever you choose to send your child — daycare, preschool, summer camp, or even at the home of a relative or one of your child’s friends.

Parents always face a few difficult decisions in which they seek to do what’s best for their family and healthiest for their children. The decision of whether to send a child to daycare or preschool, especially a child who requires special care, can be even more taxing. Some families have limited options.

In single-parent homes or in homes where both parents must work to make ends meet, the option of one parent staying home is immediately off the table. Parents may consider asking a family member to provide child care, but if family members don’t live nearby or don’t exactly qualify for the job or want it, this option is off the table, as well.

With no suitable choices, the decision to send junior to daycare or preschool has already been made. In families that have multiple workable solutions, the decision-making process may be a bit more thorny, especially if your child is severely allergic to multiple foods.

As with most decisions regarding food allergy, the bottom line is whether the potential benefits justify the risk. You can significantly minimize the risks by following all the precautions I recommend in this article, but you can never completely eliminate the risk of accidental exposure, even in your own home.

To accurately weigh the risks of sending your child to daycare or preschool, consider the following factors:

• Age: As children pass through their preschool years, they become more and more capable of assisting with their own care and managing their food allergy. Two-year-olds have virtually no self control or awareness of their allergy or their surroundings and require much more vigilance from the childcare providers.

Three-year-olds typically have some understanding of their food allergy and may even have enough self-control to resist the offer of some tempting food.

By the age of four or five, children with food allergy who are properly educated about avoidance at home have considerable understanding of their food allergy and can truly play some role in protecting themselves.

• Place and providers: If you’ve been fortunate enough to locate a daycare provider or preschool that seems to be very knowledgeable about food allergy, this may make your decision easier. On the other hand, if you’re not really comfortable with any of the preschools available, then foregoing preschool or at least waiting another year may make more sense.

• Allergy types and severities: Finding a safe environment may be easier if your child has a single peanut allergy than if your child has multiple, severe food allergies. Although peanut allergy can certainly be deadly, preschools are often much more aware of peanut allergy, and you may even be able to find a peanut-free preschool.

If your child is severely allergic to milk, egg, or wheat, accidental exposures certainly pose a greater risk, and you have almost no chance of finding a preschool that completely eliminates these common foods.

Daycare and preschool offer some valuable benefits in terms of social skills, but very little academic benefit. Personally, I think the academic benefits are minimal and blown way out of proportion.

Daycare and preschool can, however, accelerate a child’s development of social skills and, in some cases, lighten the load on the parents and enable them to pursue their own personal and professional goals. This, in turn, may improve the overall emotional well being of some families.

Only you can decide what’s best for your family, but don’t think you have to send your children off to preschool out of fear that your they’ll fall behind in school if you don’t. Preschool offers little to nothing in the way of academic development that your child can’t get at home.

Social skills are important, however, so if you decide to keep your child home during the preschool years, seek out other opportunities for your child to interact with other children.

Generally speaking, the younger the child, the more care the child requires. By the time your child heads off to kindergarten, she can pretty much take care of the basics on her own. At this stage, most schools are pretty well equipped to deal with food allergies, especially now that food allergies are so prevalent.

Unfortunately, at the age when an allergic child requires the most care and vigilance — during the daycare and preschool years — providers are often ill-equipped to deal effectively with food allergies. Most daycare providers and preschools don’t even have a food allergy policy or procedures in place to guide them.

During these early years, toddlers and preschool age children are at particularly high risk when it comes to food allergy because:

• They move fast.
• They put almost anything in their mouths and share food without concern.
• They’re often messy eaters.
• Many can’t keep their hands to themselves.
• Children under the age of three have little understanding of their food allergy and may even be more tempted to share food because they’ve been deprived of certain items at home.

Three- and four-year-olds usually start to gain an understanding of their food allergy and begin to protect themselves to some degree, but they still need lots of supervision.

These factors make it especially important that you choose a daycare or preschool carefully and then work with the facility to establish all necessary policies and procedures to keep your child safe. In the following sections, I highlight the most important food allergy factors to consider when selecting a preschool or daycare center for your child.

When shopping for a daycare center or preschool, should you insist on an allergen-free environment? For children over the age of six, I’m generally not a big proponent of prohibiting peanuts or other common allergenic foods.

When you’re in the market for a daycare center or preschool, however, particularly if your child has a peanut or tree nut allergy, an environment void of all problem foods is, of course, ideal. The question is, how accessible are allergen-free facilities? The answer depends on which foods your child is allergic to.

In the past, allergen-free preschools and daycare centers were unheard of, but now I would estimate that about half of all preschools are peanut-free zones. As for other allergenic foods, including milk, egg, and wheat, you’re unlikely to find any school that bans these foods or is even open to considering implementing restrictions.

When choosing a daycare center or preschool, all other factors being equal, a school that restricts or prohibits the food that your child is allergic to is a better choice than one that allows it. However, finding such a facility can present a huge challenge, particularly if your child is allergic to something other than peanut.

Never get lulled into a false sense of security that allergen-free really means allergen-free. Peanut-free, for example, merely means other children are less likely to pack peanut butter sandwiches for lunch or snack on peanut butter crackers.

It means your child has much less of a chance of being accidentally exposed to peanut, because a lot less of it will be spread around the classroom and cafeteria. Peanut-free, however, does not mean that all the other parents read every label as carefully as you do and that everything other kids bring in is completely peanut-free.

As you go about investigating daycare centers and preschools, you may be shocked at the differences you find from one place to another. The knowledge and experience at childcare facilities generally falls into one of the following three categories:

• Uninformed and inexperienced: The facility has had few or no children with severe food allergy and has very little knowledge of food avoidance and emergency treatment. An uninformed, inexperienced staff is not reason alone to scratch the facility off your list.

A facility that’s excellent in other areas of childcare and willing to learn and implement effective food allergy policies and procedures may still be an excellent choice.

• Misinformed: The center has been thoroughly misinformed about food allergy and has a policy in place that’s not even close to meeting your child’s needs. A common example would be a policy and procedures inspired by a family who says, “my child only has a mild peanut allergy, so you don’t need to worry too much.

It’s fine for him to eat cookies and candies as long as peanut is not a main ingredient. And since he has only broken out in hives before, my doctor says he does not need an epinephrine prescription.” This school may approach your child with the same bias, which could create a very dangerous situation.

• Well-informed and sufficiently experienced: You luck out and find a center that has been whipped into shape by other families who’ve approached food allergy with the same vigor and vigilance as you.

Inexperience with food allergy is much less common today than it was just ten years ago. With the rising prevalence of food allergy, most centers that care for young children have had to deal with food allergy and develop at least a few standard procedures for dealing with it.

Even if the childcare facility you choose is well-informed and has had experience dealing with food allergies in the past, don’t assume that the staff knows how to properly treat your child.

The size of a childcare facility is less important than the ratio of children to caregivers. For example, a preschool with a child-to-teacher ratio of 6-to-1 is typically safer than a preschool with a ratio of to-1, even if the preschool with the 6-to-1 ratio is much larger overall.

During mealtimes, snack times, parties, and other activities when eating is involved, an adequate number of caregivers is particularly important to supervise the children and ensure that all food remnants have been cleaned from the tables and from the children immediately before and after eating.

A cafeteria or other designated area for eating can help reduce exposure and food contamination by keeping food out of the classrooms where children spend the bulk of their time. Larger preschools and daycare centers are more likely to have designated eating facilities.

If you’re lucky, you may stumble upon a daycare center or preschool that has its own nurse. This is only likely to happen in a larger facility, so if you opt for something smaller, a nurse may not come with the package. Knowing whether you need a nurse Is the absence of a nurse sufficient grounds for crossing a facility off your list?

Not really, as long as the facility has the following in place:

• A cooperative staff committed to maintaining a safe environment for all children.

• Information and training required to limit your child’s exposure to allergenic foods. (You may need to become the trainer and resource person.)

• Instructions, training, and medicines to respond to allergic reactions quickly and effectively. (Again, you may be the main source for instructions and training.)

• A competent surrogate for the nurse — typically the school administrator — responsible for implementing and maintaining all the policies and procedures needed to keep your child safe.

When researching the best options for your child, speak to the nurse or whoever’s in charge of attending to health-related issues. This conversation can give you a much better idea as to whether this facility is the right place for your child.

Engage the nurse or surrogate nurse in a discussion about your child’s food allergy and try to get a sense of the following:

• Does this person really get it?
• Does this person understand food allergy and how dangerous it can be?
• How much experience does this person have caring for children with severe food allergy?
• Does the person fully grasp that even tiny food exposures can be deadly and that they need to be prepared to treat allergic reactions immediately?

Once you’ve selected a daycare or preschool, engage in a more detailed discussion with the nurse or administrator. The section, “Teaming Up with Your Child’s Daycare Center or Preschool,” guides you through the essential meetings and training sessions and provides additional tips on how to team up with your child’s daycare center or preschool for optimum safety.

After you select a daycare center or preschool for your child, your real work as child advocate begins. Now, you must make sure that your child’s caregivers are knowledgeable and skilled in caring for your child and that they understand specifically which foods your child needs to avoid and what sort of care to provide in the event of a reaction.

In the following sections, I provide guidance on how to educate your child’s caregivers; select, train, and equip staff members to provide quick, effective emergency care; assist the facility in developing clear, comprehensive procedures for preventing accidental exposure to problem foods; and work with the facility and other parents to establish it as a peanut-free zone.

Food allergy organizations have developed a variety of educational materials specifically for schools and preschools. These can be very helpful, especially if you’re dealing with a facility that has limited experience caring for allergic children. The Food Allergy and Anaphylaxis network has an excellent training program complete with a video and written materials. Visit www.foodallergy.org for details.

Anyone you place in charge of caring for your child — daycare providers, teachers, school nurses, camp counselors, even grandma and grandpa — must be fully informed of your child’s food allergy.

When sending your child off to preschool or daycare, provide a fact/instruction sheet with the following information, and make sure that everyone in the setting who will have contact with and responsibility for your child reads and understands the information:

• Your child’s name and photo: Caregivers must know your child’s name and face.

• Type of food allergy: Everyone should know that your child has a food allergy and be able to identify the foods and ingredients that your child must avoid. The food allergy sheets in earlier article can assist you in providing detailed information.

• The need for your seal of approval on any food items: Specify that only the foods you approve are to be given to your child. In addition, encourage the school’s staff to carefully read food labels prior to giving your child a particular food. They should know that manufacturers sometimes change the ingredients they use, so they must read the label every time.

• The dangers of cross-contamination: Cafeteria workers need to be aware of the potential dangers of cross-contamination, so they follow proper food preparation techniques. All cooking utensils and surfaces must be cleaned thoroughly before preparing and serving your child’s food.

• The necessity for cleanliness: Cafeteria workers, dining room supervisors, your child’s caregiver, and others must be aware that your child needs to eat off of a clean table with clean utensils. In addition, students should wash their hands with soap and water after eating.

Set up a face-to-face meeting with your school’s nurse, administrator, and all other parties involved in your child’s care, distribute your fact/information sheet at the meeting, and encourage staff members to ask questions. Follow up with regular reminders over the course of the school year and any updates from your child’s doctor.

Figure below provides a form you can fill out and distribute to your child’s caregivers. This form can assist caregivers in preventing your child from accidental exposure, but the form is no substitute for a treatment plan. See “Planning for possible emergencies,” for details on preparing and training for possible reactions.

The lunchroom, whether it’s a separate cafeteria, a designated eating area outside the classroom, or the same room in which your child spends most of his day, is the main battle ground for fighting accidental exposure to food allergens.

Fortunately, a good dose of vigilance, proper cleaning procedures, some common household cleaning agents, hand soap, and a little elbow grease can help your child’s daycare center or preschool win the battle and provide your child with a safer place to eat.

The following sections describe three simple policies and procedures for creating an allergy-friendly eating area. Whenever requesting special arrangements for your child, attend to both physical and emotional needs.

Even very young children are sensitive to being singled out, particularly if it isolates them from their classmates and makes them a target for teasing. When asking for special treatment for your child, make it clear that the accommodations are to be accommodating, creating a situation as close to “normal” as possible.

After every meal or snack, a kitchen worker or staff member should thoroughly clean the tables, especially if children are eating in the room in which they spend most of their day. Following are some guidelines on proper cleaning:

• Use common household cleaning agents. As I explain in earlier article, these cleaning agents have been proven effective in removing even the most stubborn remnants of peanut butter and other allergens.

• Clean carefully and thoroughly. Rub hard, don’t simply swipe a rag over the tables and chairs. Scrub any globs of food off the surface.

• In a cafeteria, before eating, wipe down the table where the child with food allergies will sit. This is especially important if the child is eating during a second or third lunch shift.

I recommend that all children wash their hands before and after eating. The pre-wash is primarily for sanitary purposes and to prevent your child from ingesting any food allergens she may have picked up from toys or other objects.

The post-wash is more important for preventing allergic reactions — to reduce the likelihood that another child who ate a food that would make your child sick will spread it around the classroom or inadvertently rub it on your child. Remember, kids at this age can’t keep their hands to themselves.

Caregivers must supervise the hand-washing ritual and make sure that the children wash their hands properly. Keep these tips in mind:

• A thorough scrubbing with a moistened wipe does the trick. A superficial swipe with a wipe is inadequate.
• A good, thorough hand washing with soap and water followed by a thorough drying of hands with paper towel also works.
• Antibacterial gels are not effective in removing food allergens.

If the childcare facility has one of those cloth towel rollers for drying hands, it could pose a risk of accidental exposure. If your child dries her hands on the same portion of a towel that another child wiped her hands on, any allergens on that towel could wipe off onto your child’s hands. Paper towels or a hot-air hand dryers are best.

Distancing your child from other children who are eating the foods that can trigger reactions is an important measure for preventing accidental exposure, especially in daycare and preschool. The trick is to provide safe seating without unnecessarily isolating your child. Here are three effective options:

• Designate a peanut-free table. If your child is allergic to peanut, chances are she won’t have to eat alone. In some cases, the peanut-free table may be used for children with other food allergies, as well, because these tables are typically cleaned more thoroughly and supervised more closely.

• Draw up a seating arrangement so children with the same food allergies are less likely to be accidentally exposed to the problem foods.

• Arrange the seating to provide a little buffer around your child. Your child may need to be seated next to children who are not eating a problem food or be seated between two empty places to create a buffer zone.

Caregivers should also enforce a no-food-sharing policy during all eating activities. Preschool kids love to swap foods and try the exotic foods that they’ve never seen in their own homes, particular when they’re young, but food sharing is a big no-no, and anyone supervising eating activities must strictly enforce the no-sharing policy.

Kids move fast and can shoot across a table or across a room faster than a paper wad. The lunchroom may also have a fair share of sloppy eaters and kids who talk with their mouths full. Close adult supervision is key to preventing accidental exposure.

Because peanut is notorious for triggering potentially severe reactions, many daycare centers and preschools have formal peanut restrictions in place. If your child is allergic to peanut, and the facility does not ban or restrict peanuts, you can advocate for various restrictions:

• Formal peanut-free facility, in which the administration officially prohibits children from bringing in anything with peanut as an ingredient.

• Voluntary peanut-free facility in which parents are encouraged to pack peanut-free lunches and snacks for their children.

• Peanut-free tables, where your child can eat lunch and snacks.

A peanut-free school can be achieved several different ways. If the administration agrees that peanut prohibition should be a universal policy, then they mandate this policy and communicate it to all the parents. In some instances, the school may be reluctant to enact a formal policy but will let it happen on a more voluntary basis.

The administration may be willing to provide you a list of names and addresses of the other parents, so you can communicate with them directly. Figure below shows a sample letter that I offer to parents who want to ask other parents for their cooperation in keeping a facility peanut free.

You may need to modify the letter to better suit your needs, but the general tone of the letter has proven very successful in persuading parents to cooperate in creating a safer environment.

One of the rules I stress is that reactions happen, no matter how many theoretically-effective avoidance maneuvers you have in place. So even after taking all the steps to prevent reactions, you must provide the childcare facility with the training and medications it needs to treat your child effectively in the event of a reaction.

Every daycare center and preschool has some sort of policy or procedures in place for storing and administering medications. Find out where the medications are stored and who’s in charge of administering the medications to your child.

Because allergic reactions can become very serious very quickly, medications must be readily accessible at all times. In some cases, childcare facilities store all medications in a central area, such as the nurse’s station or the administrator’s office. In other cases, your child’s teacher or primary caregiver is entrusted with the medications.

Which option is best? That depends on several factors:

• How far away from the central location is your child during most of the day, and especially during and after lunch, snack time, and parties? If your child’s primary caregiver has to run through long halls or to another building to get to the medicines, she may need her own supply.

• Is the central location accessible at all times? If the central location is off limits or locked at certain times, then the facility may need to store a set of spare medications in another room.

• Who’s responsible for giving the medication? If responsibility belongs to both the nurse and the teacher or other caregiver, then the teacher or other caregiver should have ready access to their own set of medicines. If, on the other hand, the teacher does not even know how to administer the medications, having access to them makes little sense.

Clearly label and organize all medications and store your child’s emergency action plan, with the medications to avoid any confusion in the event of an emergency.

I prefer that medications not be under lock and key, simply because locks throw another obstacle in the way of a speedy, effective response. If medications must be under lock and key, make sure two or three people have a key immediately available at all times.

Almost every daycare center and preschool places someone in charge of storing and dispensing medications — typically the school nurse or the facility’s administrator. To ensure that a competent individual is always on-call, establish a failsafe system with fully-trained staff members in place:

• Appoint a minimum of two (preferably three) staff members to act as emergency responders in the event of a reaction. Having only one fully trained individual on call is an accident waiting to happen. A single sick day or other staff member emergency would put your child at risk.

• Provide each designated emergency responder with a copy of your child’s Food Allergy Emergency Action Plan, and review the plan with your emergency responders in person.

• Train each emergency responder to administer medications. They need to know how to spot signs of a reaction, how to assess the severity of a reaction, when to administer each medication, how much medicine to give, and how to give it.

If you’re sending in epinephrine autoinjectors, all emergency responders should be trained on how to administer the shots. Use a trainer device to demonstrate autoinjector use, and then have the people in charge of giving the shots demonstrate its use back to you to make sure they follow the proper technique.

• Let all your child’s caregivers know who the emergency responders are and how to contact them. They should also need to know how to spot the early warning signs of a reaction and be aware of the importance of quick, decisive action.

• Identify the nearest emergency medical facility, make sure their EMT’s (Emergency Medical Technicians) carry epinephrine, and supply a phone number to call immediately in the event of a severe reaction. Onsite emergency treatment coupled with immediate professional medical care is required for severe reactions. Sometimes one or two shots of epinephrine are not enough.

• Meet with the emergency responders before the school year and intermittently during the school year. Provide detailed information and instructions during the initial meeting. Subsequent meetings can be informal and brief but are still important.

Consider staging a drill in which your child’s caregivers respond to a mock emergency situation, so they know just what to do, whom to contact, where the medications are stored, and how to administer them.

For better or worse, snack time is often the highlight of the day in preschool. It boggles my mind why some people think that a child needs to eat every two or three hours, but apparently the majority of parents and preschools think that children will somehow pass out from hunger if they don’t have something to eat every couple hours.

Perhaps how snack time is handled should be one of the main considerations in your daycare or preschool selection. In any event, the following list describes the most common snack-time scenarios:

• No snack time: Children simply don’t bring snacks, which cuts down on opportunities for accidental exposure.

• Fruits or vegetables: Some “progressive” schools allow children to bring only fruits or vegetables, or the school serves fruits or vegetables for snacks.

• Parent-approved snacks: The school provides all snacks, but consults parents for input. If you can get on the snack selection committee, work with the school to choose snacks that are safe for your child. This could even work if your child is allergic to something other than peanut, such as milk, egg, or wheat.

• Parent-provided snacks: Parents send in the snacks with or without parental guidance. This isn’t always the best-case scenario for a child with food allergies. Even if other parents know about the allergy, they may not be as careful as you are about making sure the snacks they buy or prepare are truly allergen-free.

In this case, you may volunteer to be the go-to parent for snacks or to work with a team of other parents in the class to provide safe snacks.

• Counterproductive snack suggestions: Some facilities may actually recommend that parents send in snacks that contain the very allergenic food your child is allergic to. The facility may, for example, insist that peanut butter be a regular snack item. Here’s where you need to step in and make your voice heard.

The key to safe snack- and meal time for your child lies in your ability to provide all your child’s food or at least guarantee that the food being provided by the school and other parents is safe.

Traditionally, parties provide an opportunity to let down your hair, break rules and routines, indulge your desires, and throw caution to the wind. Unfortunately, just about everything that many parents think makes a party fun increases the risks for people who have a food allergy:

• Any activity that breaks the routine, including parties and field trips, increases the likelihood of accidental food exposure.

• Party foods — cookies, candy, cake, and other finger foods — are often too tempting for a child to resist.

• Well-meaning parents often send in risky foods that they fully believe are safe. They often don’t realize that the innocent sugar cookies they bought were contaminated by peanut at the bakery or that a benign looking candy, such as jellybeans or candy corn, might actually contain peanut or egg.

• Lots of party foods contain peanuts or tree nuts. This is especially true around the holidays. We always see clusters of reactions around the major holidays, especially Halloween and Christmas.

So how can you keep parties safe? Follow three rules:

• No foods without the prior approval of the allergic child’s parents. This is the granddaddy of all party rules.

• No exceptions to the first rule. No matter how safe or innocent the food may appear, never break, bend, or otherwise misinterpret the meaning or importance of rule number one.

• Send in a safe party food. To make sure that your child is not pooped out of the party, caregivers must inform parents in advance of an upcoming party, so you can send in a safe party food — an allergen-free cookie, cupcake, or other suitable alternative.

If the school is planning a field trip or other outing off school grounds, work with your child’s caregiver to ensure a safe trip and make sure the emergency medications travel with your child. For the unplanned parties and activities, go with plan B.

Ask the caregiver to keep an approved party food on hand in the event of an unplanned party or if you forget to send something in. This could be a cupcake stored in the freezer or box of favorite cookies with your child’s name on it stored in the cupboard.