SUKOYAKA
For Life-Long HealthNews Letter

18

Vol.

Published December 25, 2015
Public Interest Incorporated Foundation

Japan Association for
Improving School Lunch
3-12 Yotsuya, Shinjuku-ku, Tokyo 160-0004 Japan
Phone : +81-3-3357-6755
Fax : +81-3-3357-6756
URL : http://www.gakkyu.or.jp
Please click on the link above for back issues of Sukoyaka.

Actions to Prevent Food Allergy-related Accidents in School Lunches
To enable all school children to enjoy their school lunches with peace of mind
Wednesday, July 8

Name
Milk

Chicken pilaf
Shishamo fritters

Winter melon soup

Milk
Shishamo fritters
Chicken pilaf
Winter melon
soupMenu of an allergen-free lunch

Three school staff members provide care and attention while serving school lunches

Allergen-free lunch (egg-free Enshu kakiage(tempura of mixed vegetables))Final check on lunches
for students with allergies“Pointing andcalling” before
cooking to makesure staff have theright ingredients fora milk-free lunch

Students allergic to milk eat their lunchwith their teachers in the sameclassroom (the white line on the floor
indicates “no milk beyond this point”)

Photo: Shibafuji Elementary School in Kawaguchi and Fukuroi Chubu School Lunch Center

Participants
Takanori Imai
Yoko Eguchi

Instructor, Department of Pediatrics, Showa University School of Medicine
Former Senior Specialist for School Lunches, Sports and Youth Bureau, Ministry of Education, Culture, Sports, Science and Technology;
Vice Principal of Yayoigaoka Elementary School in Tosu, Saga
Masanori Osawa
Principal of Shibafuji Elementary School in Kawaguchi, Saitama
Naomi Takada
Teachers’ Consultant, Health Education Division, Aichi Prefectural Board of Education
Yasuko Harada
Former Diet and Nutrition Teacher, Fukuroi Chubu School Lunch Center; Diet and Nutrition Teacher, Iwata Minami Elementary School in Iwata, Shizuoka
Sachiko Yanagisawa Vice Chair, School Dietician Conference of Japan; Diet and Nutrition Teacher, Sanada Junior High School in Ueda, Nagano

Coordinator
Masayo Kaneda

Visiting Professor, Institute of Nutrition Science, Kagawa Nutrition University(Titles omitted, Japanese syllabary order)

In 2012, there was a tragic accident. An elementary school student in Tokyo died of suspected anaphylaxis after eating her school lunch. Based on the investigation conducted
immediately after the accident, the Ministry of Education, Culture, Sports, Science and Technology drew up and distributed the Guiding Principles of School Lunches to Cope with
Students’ Food Allergies in March this year in an effort to prevent any recurrence of the tragedy, and to ensure that all school children enjoy their school lunches with peace ofmind. This issue features a round-table discussion about the gist of the Guiding Principles between teachers involved in the process of the creation of the Principles. The discussion
explores what actions schools have or have not taken and what issues schools face in regard to students’ food allergies. We hope that this issue will help schools across Japanlaunch specific efforts to prevent recurrences of food allergy-related accidents.

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based on the research findings. In March 2014, the Cooperators’ Council issued the Final Report (hereafter the “Report”),
and then the Guiding Principles were drawn up based on theReport and issued in March this year.
I’m sure it was a challenge for all of you to put together
the Guiding Principles within such a limited period, but you
have created such a well-developed policy. Immediately after
the Principles were issued, the School Dietitian Conference ofJapan (hereafter the “SDCJ”) published the Report on Food
Allergy Survey*1 that offers contents as advanced as the Guiding Principles’. I intend to mention the research report too as
we move through today’s discussion.
I would like to ask you the gist and objectives of the Guiding Principles, and what you kept in mind in the process ofdeveloping them. I am certain each of you worked on the process from different professional standpoints. Ms. Eguchi, as
the MEXT official directly in charge of the Guiding Principles
at the time, could you tell us what actions MEXT took immediately after the accident?

Why “Guiding Principles for Food Allergies”?
- From drawing up the “Guidelines” to reporting on factfinding survey- Issues identified throughthe survey- MEXT’s view on the creationof the Guiding Principles- School principals’ and prefectural education boards’
views on the creation of the Guiding Principles- Diet and nutrition teachers’ and doctors’ views on
the creation of the Guiding Principles- Excerpt from the Report on Food Allergy Survey by
the SDCJ[Kaneda] December 2012 saw a tragic accident. A fifth grader in Tokyo died of suspected anaphylaxis after finishing her
school lunch. I wondered if the Guidelines for Coping with
Allergic Diseases at School (hereafter the “Guidelines”)
issued in 2008 by the Japanese Society of School Health(hereafter the “JSSH”) had not been able to help prevent thistragedy. Since this accident, the Ministry of Education, Culture, Sports, Science and Technology (hereafter “MEXT”) has
been making efforts to ensure that all schools use the Guidelines, and announced a wide range of actions to cope with foodallergies. In March this year, MEXT drew up and distributed
the Guiding Principles of School Lunches to Cope with Students’ Food Allergies (hereafter the “Guiding Principles”).
Today, I have teachers at this table who were involved in thecreation of the Guiding Principles that have rated as groundbreaking. As we go through the details of the Guiding Principles, I would like to ask them how the Guiding Principles
should be used, and how the measures stated in the Guiding
Principles should be implemented to cope with food allergies
children may have.
Fig.1: Guidelines

Issued by the JSSH

[Eguchi] The focus of my work at MEXT at that time wason hygienic control to prevent food poisoning, so the accident
came as a real blow.
We had to come up with something to make sure that suchan accident never happen again, while children with allergies
increased year after year. We were pressed to get a clear andaccurate picture of how schools deal with students’ food allergies, and to explore and determine what actions must be taken
as soon as possible. That is why the Cooperators’ Council was
set up.
[Kaneda] The survey began immediately, didn’t it?
[Eguchi] The JSSH conducted a survey on the overall pictureof allergic diseases. And when MEXT set up the Cooperators’Council, we conducted a sampling survey on school lunches,
instead of a complete enumeration survey*2.
[Kaneda] Could you talk about the fact-finding part of thesurvey?

Fig.2: Guiding Principles[Eguchi]- More and more school children have food allergies.
- The guidelines’ advice is not
fully implemented. Not all
schools have made the submission of student healthinformation sheets mandatory.
- Schools dealt with students’allergies in accordance with their parents’ requests, instead of a specified policy. This made thesituation surrounding food allergies complicated,and eventually led to human errors.
- People in charge, not schools as organizations, had
to deal with everything related to food allergies.

Issued by MEXT

- Cooperators’ council has been set up to prevent
any recurrence of worst-case accidents. The council wrote the “Final Report” on which the Guiding
Principles issued are based.
- SDCJ wrote the “Allergy Research Report.”

A complete enumeration survey showed that school children with food allergies made up 2.6 percent in 2004, andthe survey conducted in 2013 showed that the number rose
to 4.5 percent, a 1.7-fold increase.
Furthermore, although the Guidelines state that school
lunches should be prepared in accordance with student healthinformation sheets (hereafter the “health information sheets”)

Let me run through what actions have been taken since theaccident. In May 2013, the year after the tragedy, MEXT set
up the Council of Cooperators in Surveys and Research (hereafter the “Cooperators’ Council”) to explore what can be done

*1 Nutrition teachers and other relevant school staff members working at public elementary schools, junior and senior high schools, and schools for
special needs education were surveyed. 6,645 responses were obtained, and 6,610 were used as valid.
*2 A survey in which all data are thoroughly checked.

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created based on medical evaluations of students, this is not
fully followed in certain situations.
The survey findings in the end boiled down to the following three points: (1) School lunches provided according torequests from students’ guardians can easily complicate thewhole process of lunch preparation, and lead to human errors.
(2) There had been no organizationally coordinated efforts toprevent allergic reactions to food. (3) People in charge of issues related to food allergies often have to do everything todeal with the issues.

[Yanagisawa]- Not all schools knew about the Guidelines.
- Due to inadequate internal communication at
schools, important documents are often passed on
only to certain staff, and do not reach school managers.
- Schools tried to cope with students’ food allergies
based only on requests from children’s guardiansinstead of health information sheets.

According to the Allergy Research Report by the SDCJ, 80
percent of schools answered “Yes” to the question, “Does yourschool follow the Guidelines?” Among the remaining 20 percent of the schools that answered “No,” about 3 percent didn’t
even know the Guidelines are available, which, naturally,astonished us. I think that, because the Guidelines are aboutallergic diseases in general rather than food allergies, they
are passed on to nursing teachers, instead of diet and nutrition teachers. Nevertheless, the boards of education informed
schools about the issue of the Guidelines, so schools shouldhave made sure that the Guidelines are about food allergies.
I also need to point out that, when this type of document isdelivered, school principals and vice-principals all too often
assume that anything relating to school lunches is diet andnutrition teachers’ responsibility, and leave everything up tothem. Furthermore, many schools tried to cope with students’food allergies based on requests from children’s guardians,
rather than the health information sheet.

[Kaneda] Problems were identified through the survey. Mr.
Osawa, what did you think when you saw the survey results?
Fig.3: Prevalence Rates for Allergic Diseases
among School Children
0.48
0.14

Anaphylaxis

4.5

Food allergies

2.6

Atopic dermatitis

4.9
5.5

Asthma5.8
5.7

2013 School Year
2004 School Year

5.5

Allergic conjunctivitis

3.5
12.8

Allergic rhinitis

9.2
0

5

10

(%)

15

Survey on Students’ Health Management in School Life,a project entrusted by MEXT to the JSSH (2013 School Year)[Osawa]Fig.4: “Do You Refer to the Guidelines for Copingwith Allergic Diseases at School?”- School managers did not know about realities surrounding school children’s food allergies.

(%)

All schools (n=6497)

As a school principal, I was truly surprised to learn thatthose in managerial positions did not know about realities surrounding school children’s food allergies. The survey findings
propelled me to take actions.
[Kaneda] Ms. Takada, you worked at school before you
joined the prefectural board of education. Could you tell us
your view based on your experience as a teacher and a member of the education board?

17.3 3.1

79.6

Junior high schools (n=856)

79.9

16.9 3.2

Common kitchens (n=1836)

80.0

18.5 1.5

Kindergartens (n=8)

Senior high schools (n=44)

87.5

12.5

70.6
40.9

Special schools (n=394)- Each school has a different policy to deal with theissue.
- The board of education needed to have specific policies in place.

20%

Elementary schools (n=3325)

Combined schools (n=34)(elementary and junior high)[Takada]17.6 2.7

79.7

11.8

50.0
83.0

Yes

17.6

No

9.1
14.5 2.5

We do not know anything
about the Guidelines

Source: Report on Food Allergy Survey, SDCJ

[Kaneda] I often heard they didn’t know about the health information sheet, too. Mr. Imai, what do you think?

The Aichi Prefectural Government already had a guideto coping with food allergies when I worked at school, so I
believed that schools in Aichi were fairly progressive in thatarea. However, a survey found that 54 municipalities in theprefecture had policies and systems significantly different
from each other. This really woke me up to the reality in which
schools did need to request the prefectural government to issue a comprehensive policy.

[Imai]- The Guidelines turned out to be challenging inmany respects.
- The health information sheet was not well understood by doctors and schools.

This survey revealed that the Guidelines are not used at all
schools across Japan. Some doctors pointed out that the Guidelines are too detailed; however, from medical specialists’ pointof view, they are not that detailed, and provide only bare-bones
information. The past twenty years saw a sharp increase in thenumbers of people with food allergies and accidents related tothese allergies. This served as a catalyst for dramatic advances
in food allergy care. I wouldn’t say no faults were found on[Kaneda] In 1988, there was an accident related to a foodallergy in Sapporo*3. Even after that, school nutritionists had
to handle everything connected to the issue. Probably schools
and boards of education across the country were unaware of
the severity of the issue.
The SDCJ also conducted an exhaustive research. Could
you please talk about it, Ms. Yanagisawa?

*3 In 1988, a sixth grader allergic to buckwheat ate buckwheat noodles in his school lunch. Feeling sick, he left school early, but had an asthma attack
caused by the allergy and began to vomit on his way home alone. His vomit became stuck in the trachea, choking him to death.

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the part of healthcare and physicians that provided their evaluations. And how schools handled the issue differed between
regions, and some ended up having their own ways. The healthinformation sheet was created amid the drastic change in thesituation surrounding food allergies, and so some people involved in school lunch systems may have found it challenging
to fill it out and submit it.

[Harada]- “I realized schools do need abasic policy provided by thecity government. I hope thegovernment will develop one
accordingly.”[Kaneda] With regard to the health information sheet, schools
had a poor understanding of the necessity to submit it, and,
consequently, they failed to give students’ guardians enoughinformation about the sheet. I think this is why the Guidelines
were not as well-known as they should be.
Also, as Mr. Imai said, it seems to have been difficult at firstto have the Guidelines endorsed by doctors.

In Fukuroi City, some guardians wrote “Nuts,” “Fruit ingeneral,” and “Cake” to fill in “Food your child is allergic to”
and “Other conditions that require supervision (open-ended)”in the health information sheet. So we had to have personal
conferences with them to find out exactly what allergies theirchildren had. If the children are allergic to many types of food,
we asked their doctors to refer them to medical specialists infood allergies.
Some municipal boards of education have yet to provide
specific policies. I heard that schools in these municipalities
take different approaches to the issue because of the absenceof the policies, and, consequently, children’s guardians do nottrust the schools, or teachers at these schools do not have ashared understanding of how to deal with food allergy problems. I believe that the Guiding Principles issued this time
will prompt the local governments to develop their basic policies regarding children’s food allergies so that school staff
will have much clearer idea of how to cope with the problems.

Analysis of Findings- Issues found through research findings at the Cooperators’ Council- Physicians’ and patients’ attitudes- Development of specific policies by municipal
boards education- Inadequate compliance with the Guidelines- Setting up a committee on food allergies[Kaneda] When the reality surrounding food allergies became clear, problems were identified and the Report was issued to specify the roles of schools, boards of education, andother entities involved. Ms. Eguchi, could you talk about what
was most discussed when the Report was compiled?

[Kaneda] Mr. Osawa, the Report states that the Guideline
must be followed. Could you tell us what efforts your school
made to follow the Guidelines?

[Eguchi][Osawa]- Ensure that schools follow the Guidelines to copewith students’ food allergies.
- Urge schools to cope with these allergies based on
doctors’ diagnoses.

- Problems in the process of document delivery
at schools caused inadequate adherence to the
Guidelines.
- Student health information sheets submitted must
be based on doctors’ diagnoses. This urged parents to understand that physicians’ advice is needed to protect their children’s lives.

Standards of intake through school lunches specify that
schools must refer to health information sheets and the Guidelines to cope with students’ food allergies, but in reality they
did not. So the Cooperators’ Council focused on two important
points: (1) Ensure that schools follow the Guidelines to deal
with food allergies. (2) Urge schools to “cope with food allergies based on medical specialists’ evaluations” systematically to prevent any accident related to food allergies.

One of the reasons why some schools failed to follow the
Guidelines is an inadequate process of document delivery.
Documents received from the board of education are delivered to those in managerial positions and then to someone incharge of the matter, and nothing happens afterward. Managers should study these documents and give those in charge
clear instructions on what exactly must be done; otherwise theimportant documents will only be archived before any actions
are taken.
With regard to health information sheets, the Cooperators’Council had an extensive discussion as to whether schools
should require students’ guardians to fill out the sheet in accordance with medical specialists’ advice. I suggested thatthey should to protect children’s lives. I believe that schools
and their teachers should have shared awareness that all criteria for judgment come from health information sheets. Thisurges parents to understand why specialists’ advice is a requirement, and to cooperate accordingly.

[Kaneda] What was the reaction from the Japan Medical Association, after they also studied the Report?
[Imai]- It is vital that students with food allergies and theirguardians acquire accurate knowledge and findmedical specialists who provide treatment and advice that suit their needs.

They show their approval, basically, but I have to admit thatreactions differ between regions. Food allergies are among themost challenging areas for general practitioners, while many
doctors and hospitals are committed to treating food allergy-related illnesses. It is vital that patients and people close
to them also acquire accurate knowledge of food allergies andfind physicians who will provide correct diagnoses.

[Kaneda] In that sense, the Report served as a major driver.
Ms. Takada, were the school principals’ association and the
JSSH asked to work on the issue as a problem schools face?

[Kaneda] What do you think, Ms. Harada?

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[Takada][Kaneda] It is notable that the Report prodded municipal governments across the nation to create their own manuals.
We also have to watch what moves these governments will
make according to the manuals they have created. It is truethat local boards of education and governments are different
organizations. But then schools cannot make any moves unlessthere is a basic municipal policy in place. Mr. Osawa, what do
you think?

- An official notice prompted
Aichi Prefecture to set up acommittee on food allergies
consisting of various people
engaging in work related to theissue to explore what must be
done.
- School principals also share information, keeping in mind the importance of getting clear pictures of realities their schools face andtaking actions.

[Osawa]- Some cities have yet to set its own policy in place.

It all depends on what stance the municipal board of education takes. When I asked boards of education for their policy on children’s food allergies, some maintained that schools
should handle them on their own if they can. So the reality
is that municipal boards of education do not have any shared
policy in place.

Aichi Prefectural Government set up the Committee to Cope with Food Allergy-related Problems in School
Lunch last year after receiving the notice “How School
Lunch Systems Should Cope with Food Allergy-related
Problems” in March 2014. The notice was addressed to those
involved in healthcare, schools, and firefighting. So the committee consists of medical specialists in allergies, people fromthe Japan Medical Association, PTAs, prefectural firefighting
and public security sections, municipal boards of education,school principals, nursing teachers, diet and nutrition teachers
working independently or in school kitchens, kindergartens,preschools, and much more. All these people discussed whatshould be done from their professional standpoints. Then thecommittee compiled a collection of case examples of nearmisses in the context of school lunches.
These examples were collected through a survey of all
schools in the prefecture conducted by the School Lunch Committee of Aichi Elementary and Junior High School Principals
Association. The response rate was reportedly 100 percent.
I believe that the school principals became aware of theneed to get clear pictures of what is really happening attheir schools as they received the official notice. These caseexamples were also used when the prefectural government
compiled examples of near misses, which were delivered toschools across Aichi at the end of the last school year.

[Kaneda] Ms. Eguchi, could you talk a little bit about this?
[Eguchi ]- Policies that city governments are expected todevelop are mentioned in the announcement, andmore and more local governments create their own
policies.

MEXT suggested in the Report that municipal boards ofeducation have a clear understanding of realities pertinent
to food allergies school children have, like how kitchens for
preparing school lunches are managed by municipal governments, and how school cooks are allocated, before they develop and present their policies. So the realities are included in
the announcement of the policy. I believe that more and more
municipal governments and boards of education are graduallyfollowing the suggestion.

Contents of the Guiding Principles and How
to Apply Them

[Kaneda] What about Nagano Prefecture?

- Objectives of the Report and the gist of the Guiding
Principles- Differences between the Guidelines and the Guiding Principles- The Guiding Principles consist of four major
sections: great principles, check sheet, comments,
general theory- Effects of a notice from boards of education[Yanagisawa]- Nagano has started to create amanual, and is waiting for city
governments to develop theirpolicies.

[Kaneda] Ms. Eguchi, could you tell us about the basic stance
the Guiding Principles take and the gist of them?

Nagano Prefectural Government has been creating its own
manual since the end of the last fiscal year to officially issue it
in June this year, but the process is somewhat behind schedule. Ueda City Government has not had any official manual inplace, so it is currently working toward establishing its policy.
When safety is considered top priority, problems related tofacilities and personnel surface. I heard many guardians saythat preschools took good care of what their children ate while
schools don’t at all. I think it is necessary to explain to guardians why schools cannot.

[Eguchi]- The Report aims to “help ensure that school children with or without food allergies alike enjoy
school lunches.” This is stated under the primary
purpose of the Guiding Principles “safety is given
the highest priority to prevent any accident.”- The Guiding Principles focus on how school lunch
programs should cope with food allergy problems.
- With the great principles in mind, check realities
schools face using the check sheet, study the key
points of comments, and assign roles and move
forward referring to the general theories.

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The Report emphasizes that it rests on two basic ideas:(1) It helps ensure that school children with or without
food allergies alike enjoy school lunches. (2) It helps comeup with school lunches from perspectives of children withfood allergies, and, to achieve this goal, ensure that safety
is given the highest priority for accident prevention. The
Guidelines are about allergic diseases in general, while the
Guiding Principles are specifically about school lunches.

Data 1[Imai]- “We emphasized more than anything else that our top priority
must be to create a system forproviding safe school lunches.”

I was involved in the process of creating the Guidelines in2008. I have to admit that the contents of the Guidelines inlight of school lunch programs were somewhat unsatisfactory.
Then the tragic accident occurred, which prompted the creation of the Guiding Principles. Thanks to the efforts all theteachers on the committee put in, we successfully created awell-developed policy.
The Guidelines were issued in 2008 to present the directionof how school lunch systems should deal with food allergy
problems. However, the direction alone was not enough forpeople engaging in the lunch systems. Therefore, the Guiding Principles were written and edited so that it is practicaland helps ensure safety. As mentioned before, to make safety
our top priority, the Guiding Principles focus on creatinga system for providing safe school lunches and emphasize
the importance of it. Nutritional value, how lunch plates
look, what children’s guardians want, and advice fromtheir doctors come next.

Fundamental Principles of
Actions to Cope with Students’
Food Allergies at School● School lunches will be served even to students with foodallergies. To do so, safety must be the highest priority.
● Actions must be systematically taken by a committee onfood allergies or any other relevant organizations.
● Students’ guardians must complete and submit their children’s Student Health Information Sheets based on physicians’ evaluations in accordance with the Guidelines for
Coping with Allergic Diseases at School.
● As a general rule and as a way to ensure safety, schools
must choose between eliminating allergy-causing foodsfrom school lunches altogether or serving all students thesame lunches that contain allergy-causing foods.
● Take into consideration the capacities of facilities andequipment as well as personnel at the school and its kitchen*1, and do not take any overly complicated approach tocope with students’ food allergies.
● Boards of education etc.*2 should present their policies
on how to cope with students’ food allergies, and support
schools in their efforts.

[Kaneda] So the Guiding Principles give safety the highest
priority. Mr. Osawa, schools have been taking measures todeal with food allergy issues over the years. Have you heard
any opinions about the Guiding Principles?
[Osawa]*1 “Kitchen” in the Guiding Principles refers to all cooking facilities forschool lunches, including schools’ own or common kitchens.
*2 “Boards of education etc.” in the Guiding Principles refer to publicschools’ boards of education as well as school owners, such as national university corporations that own schools attached to national
universities, and incorporated educational institutions that own private schools.

- The Guiding Principles is easy to understand andapply for those involved in school lunch systems,
who were appallingly unaware of food allergy problems, and those working on the front line of the systems.
- Anyone can develop allergic reaction to certain
food anywhere and anytime. The Guiding Principles works well to make schools become keenly
aware of the fact.

Source: The Guiding Principles of School Lunches
to Cope with Students’ Food Allergies, MEXTThe Guiding Principles begin with the six “Great Principles of Actions to Cope with Students’ Food Allergies at
School” that must be kept in mind, and then it moves onto the “Check Sheet” for checking realities surrounding
schools to identify problems. All school teachers and staff
members study the key points of “Comments” on the itemson the sheet to share an understanding of them and move
forward, undertaking their own roles. Then they proceedwith their work in these roles, referring to “General Theories” as they face certain situations.

This is my personal opinion, but let me tell you that those
who have had the most difficult time are children with foodallergies, their homeroom teachers, diet and nutrition teachers, school cooks, and anyone else working on the front line ofschool lunch systems. This is because those in schools’ managerial positions as well as all school teachers and staff members had these problems: (1) They were appallingly unawareof food allergy problems they could face. (2) They had only
poor knowledge about food allergies, and were unaware thatallergic reactions caused by food can threaten children’s lives.
(3) Schools had no policy in place to cope with students’ foodallergies. (4) Schools had no clear policy on what to do in an
emergency. In this light, the Guiding Principles play a very
effective role in protecting children, which everyone on thefront line would do everything they can to achieve.
Furthermore, in one workshop, we were told about a student who’d had no allergy to food in school lunches showed anallergic reaction by the time he/she left school at four and was
taken by ambulance to a hospital. This means that anyone
could develop an allergic reaction to food anywhere and[Kaneda] The Guiding Principles are structured in a way thatis easy for people engaging in school lunch-related work tounderstand, and it answers almost all questions they may have.
That’s wonderful.
Now, I would like to ask for views you have from your professional stance. Mr. Imai, could you go first?

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anytime. This fact urged us to set up a school committee onfood allergy problems.
I still hear some school managers say that they had no students with food allergies at their schools. So I firmly believethat training sessions for school principals should deal withfood allergies, and hands-on lessons on how to use EpiPen®
should be part of the discussion about these allergies. This will
help school managers as well as all teachers and staff members
become aware of how severe food allergy-related problems at
school can be.

Photo 1: Allergen-free meals and alternative mealsdelivered from the school lunch center to schools(Courtesy of Fukuroi Chubu School Lunch Center) (see the cover)[Kaneda] What do you think about this, Ms. Harada?
[Harada]Allergen-free meals andalternative meals are divided
into bags for each school andloaded on the passenger seat.

- It is important to provide training sessions also for
those in managerial positions.
- Approval from those in managerial positions facilitates the process of having a policy in place to copewith food allergy problems.

Homeroom teachers receive
these special meals from thedelivery personnel.

The Rationale for the Guiding Principles Is“Safety Is Our Top Priority”

Fukuroi City Government holds training sessions on foodallergies for school managers, nursing teachers, diet and nutrition teachers, and those who work for kindergartens andpreschools in April every year. These sessions help school
managers learn more about food allergies and what the city
government does to deal with food allergy-related problems.
So the sessions encourage school managers to participate also
in training sessions on how to cope with students’ food allergies at their schools, and in interviews held before the sessions.

- Student health information sheets completed
based on doctors’ evaluations must be submitted.
- Taking measures based solely on information provided by guardians may lead to accidents.
- The “two alternatives” is meant to prevent accidents and ensure safety.
- It is vital to involve school managers.

[Kaneda] I would like to ask about the rationale for the Guiding Principles. What about Aichi Prefecture?

[Kaneda] Did these training sessions start because the municipal board of education finalized and announced its policy
on food allergies?

[Takada]- Schools based their actions on unclear information provided on student health information sheets,
which caused many accidents.
- To safeguard “children and people working on thefront line of school lunch systems” always facing
risks, the Guiding Principles presents the “two-alternatives” policy.

[Harada]- Everyone involved in the school lunch programattended training sessions as instructed by the municipal board of education. This raised their awareness of food allergies and prompted them to takeactions.

I have received many questions, including ones about the“two alternatives,” and some of them are difficult to answer.
When asked if the Guiding Principles are rather regressive,
I answer, “Safety is our top priority,” because the Guiding
Principles indicate that the overall safety of school lunch systems’ approach to food allergies has improved, as stated in the“Principle ideas of school lunch systems’ approach to food allergies” on page 37. We have asked Mr. Imai for advice in lightof the importance of protecting children and people working
on the front line of schools.
Furthermore, because we have to choose between the “twoalternatives,” we ask students’ guardians to submit their children’s health information sheets in order for school administrations to determine whether they should take actions toprevent any food allergy-related problems.
To urge guardians to complete their children’s health information sheet with accurate information, we plan to ask themto obtain medical specialists’ evaluations if their children stilldevelop severe allergic reactions to eggs or milk when they
enter elementary school, or if they need to list on the healthinformation sheet with foods other than specific raw materials
or any other equivalents, or numerous types of food. Many
accidents and near misses have occurred because schools basetheir actions on unclear information provided on the sheets,

Yes. Public schools in the city had handled food allergy
problems differently. The opening of the new Chubu School
Lunch Center prompted schools across the city to establish
their policies on how to cope with students’ food allergies. To
ensure that all schools share an understanding of the issue, allschool managers, nursing teachers, diet and nutrition teachers,
school nutritionists, and any other people engaging in school
lunch programs attended training sessions held by the board ofeducation. These sessions helped all participants understandhow important it is to have their policies on coping with foodallergies in place, and prompted them to take actions.
To start the whole process of creating an official school
policy on food allergies, they have to ensure the safety of
everything from how to provide the meals and what is done in
the classroom. I believe that the sessions help a great deal in
making sure that they work on the process accordingly.

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those engaging in school lunch programs, and led to an increase in the number of accidents.
So it was decided that we should stop accepting requests
from children’s guardians and require them to submit physicians’ evaluations to improve actions schools take. The
new requirement to submit health information sheets made theprocess of selecting foods to eliminate easier, and so it madeour work easier.

or they take multi-phased actions. The “two alternatives” ispresented as part of the Guiding Principles to prevent any accidents and near misses.
[Kaneda] What do you think, Mr. Imai?
[Imai]- If a student still has an allergy that requires theelimination of certain food from school lunches
when he/she enters elementary school, medical
specialists’ evaluation is needed.
- Many children with only mild allergies are forced toeat lunches specifically for children with more serious allergies.

Two Alternatives

Data 2As the underlying idea behind approaches schools take tocope with students’ food allergies in the context of school
lunch systems, schools are advised to choose between
serving all students lunches containing foods thatmight cause allergic reactions and eliminating such
foods altogether from lunches. Serving alternative foods,
or meals prepared in a multi-phased manner to make them
non-allergy-causing is not advised. That is, schools shouldchoose either (1) eliminating allergy-causing foods altogether from lunches for all students or (2) serving all
students the same lunch containing allergy-causing
foods. (See page 37 of the Guiding Principles.)90 percent of children’s major allergies to eggs, milk,
wheat, and soy beans disappear by the time they turn six, so
the number of new first graders who still need meals free fromthese foods is not large. In other words, if children still havethese allergies after they turn six, the allergies tend to be serious cases. Therefore, new first graders with these allergies areadvised to undergo checkups by medical specialists to receive
evaluations as to whether they can now eat the allergy-causing
food or their allergies are severe cases. Accurate evaluations
allow children with only mild allergies or free from any allergies to enjoy regular school lunches without any concerns.

Source: The Guiding Principles of School Lunches
to Cope with Students’ Food Allergies, MEXT

- The volume of information students’ guardians
provided to schools about food-related problems
their children had continued to increase to the extent that people engaging in school lunch programs
at these schools could no longer handle well. This
led to a rise in the number of accidents. Hence, thesubmission of student health information sheets
became a requirement, instead of voluntary notices
from guardians.

[Yanagisawa]- Measures schools had to take were becoming increasingly complicated and cumbersome. The twoalternatives that the Guiding Principles specify improved the situation.

According to a survey conducted by the SDCJ, 95.1 percent
of surveyed dieticians answered yes to a question that asked
if they feel nervous as they try to cope with food allergy-related problems. Most are afraid of oversights, errors, or contamination, which are followed by an increase in the numberof students whose lunches require special care, and accidental ingestion. Before the issue of the Guiding Principles, themeasures they had to take were becoming increasingly complicated. For example, they had to debate whether to eliminate
eggs by the gram, or whether they could add up to 20 g of eggs
or up to 50 cc of milk.

The suggestion that the submission of student health information sheet should be a requirement was discussed at experts’ meetings, and it was eventually accepted. Schools had
based their actions solely on information that children’s
guardians provided for a long time. Consequently, schools
had to deal with numerous requests from guardians toeliminate certain types of food from school lunches, and,as it turned out, many of such requests were based only
on their assumptions. Handling these requests exhausted

Fig.5: What Makes You Feel Nervous when It Comes to Dealing with Students’ Food Allergies?
There might be oversights, errors, or contamination
The processes for coping with allergies are becoming increasingly complicatedStudents whose lunches require special care are increasing
Accidental ingestion
Students may develop new allergy symptoms
Whether processed products are delivered as ordered
Teachers’ and staff members’ awareness
There are no standardized criteria
Additional servings
Something might happen on my day off
Paperwork is time-consuming and makes us even busier
Exercise-induced anaphylaxis
Changes in students’ conditions are not immediately communicatedWhether we can accurately decide to use the EpiPen®
People may think food allergies are the cause of a student’s illness
No medical expert (physician) is available for consultation
Other

89.1

56.7
61.1
57.1
48.6
29.1
44.4
28.8
21.8
38.9
48.4
42.2
18.0
19.8
25.8

23.2
1.9

0

20

40

60

80

100 (%)

Source: Report on Food Allergy Survey, SDCJ

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Some schools in municipalities have their own kitchens, oruse common kitchens. Some facilities and equipment are new,and the others are old. So it is vital that municipal boards ofeducation accurately understand the realities that each school
faces and see how much can be done to deal with food allergy-related problems before they set a specific policy.

The two-alternatives policy specifies that schools are advised to choose between eliminating allergy-causing foods altogether from school lunches or serving all students the same
lunch containing such foods. The SDCJ conducted the survey
at just the right time. The process dietitians have to go throughis now less cumbersome, which has effectively prevented accidents.

[Kaneda] Does that mean disparities in the levels of facilities
and equipment at local public schools do not make an issue?

[Kaneda] I assume some students’ guardians asked why theschool had to change the way it had prepared lunches for theirchildren.

[Eguchi] Ideally, all schools should use equally good facilities and equipment. However, achieving such equality often
requires extra budgets. So, while the boards of education
should look ahead as they move forward with the process systematically, they need to decide on their policies in a phasedmanner so that they will carefully consider what can be doneat each of these phases.
They proceed this way to ensure thorough hygiene control.
So, in light of accident prevention, it is policymakers’ major
responsibility to promote a systematic approach to cope withstudents’ food allergies.

[Yanagisawa]- The Guiding Principles can smoothly win support
from children’s guardians when school managers,
including the principal, are behind the ideas.
- Explain well that the principles are to ensure safety.

I made sure that the school’s policy is in place, and that theschool principal and teachers in managerial positions attended meeting of the school’s committee on food allergies. Thenthese school managers explained to guardians. This worked.
The guardians understood our point.

Holding Emergency Training Sessions andCreating a Manual[Takada] We understand how guardians feel. The two alternatives discontinued what schools had done for their children
before. Some schools had a hard time with some guardians.
So, to ask for their understanding, we tell them that the national and municipal governments’ policies give the highest
priority to their children’s safety, and that we are in the processof getting a clear picture of what has been done to cope withfood allergy-related problems.

- EpiPen® workshop uses a set of DVDs about the
Guiding Principles.

[Kaneda] I heard that the Report was written after the accident and workshops on how to use EpiPen® were held acrossthe nation.
[Imai]- More and more workshops are held, but how to use
EpiPen® has not yet become common knowledge.

Setting Specific Policies- Municipal boards of education should develop their
specific policies.
- These policies should be made in a phased manner.

I think that MEXT, the Ministry of Health, Labour andWelfare, the JSSH, and pharmaceutical companies have held
hands-on EpiPen® workshops. Nevertheless, how to use EpiPen® has not yet become common knowledge.

[Kaneda] With safety being the highest priority, and thetwo-alternatives policy in mind, the city board of education
presented policies on facilities, equipment, and personnel forschool kitchens, and stated that it will support schools’ efforts.
Ms. Eguchi, what exactly are the policies presented by theboard?

[Yanagisawa]- Hands-on lessons provided through the DVD
turned out to be helpful and vital.
- The content of the DVDs is structured in a way thatis easy for viewers to understand, so it had a great
effect.

[Eguchi]- Be flexible to the progress at schools.
- Municipal boards of education gain an understanding of realities surrounding school lunches before
setting their policies.
- Carry out these policies systematically according
to the conditions and progress.

We held a training session on food allergies for all schoolstaff in April using DVDs (training materials on how schools
cope with allergic diseases) that had been distributed with the
Guiding Principles in January this year. A student had beentaken to a hospital by ambulance due to food-dependent exercise-induced anaphylaxis, and two new first graders that
had EpiPen® entered the school. These facts raised the entire school’s awareness of the importance of the injector, andprompted our principal to hold the workshop for school staff
to learn more about food allergies and to receive training on
how to use EpiPen®.
The DVD first shows a wrong response to an allergic reaction, asks viewers to think what is wrong with the response,and illustrates what they should keep in mind in certain cases.
The way this flow is structured is easy to understand. I also
liked the way it presents how to use EpiPen®. Instead ofgiving a lecture, it is designed like a hands-on training
where viewers need to think themselves. We practiced us-

Specific Policies

Data 3Developed as fundamental guiding principles of actions tocope with students’ food allergies● Basic policy on the school and its kitchen’s facilities,
equipment, and personnel allocation● Policy on how to handle information provided to prepare
for emergencies● Policy on planned efforts and an emergency manual
Source: The Guiding Principles of School Lunches
to Cope with Students’ Food Allergies, MEXT

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[Eguchi]ing the injector after listening to how to use it, but someforgot to take the cap off, and others did not press and holdit firmly enough to hear it click. We might not be able to use
it properly had it not been for the training. And teachers
who took the training say they are glad they did. I think
there should be more opportunities like this made available to school teachers and staff members.

- Studying the Guiding Principles and taking lessons
the DVDs provide as a whole set can be even more
helpful.

Yes. The DVDs, EpiPen®, and a summary of the Guidelines
for trainers are packaged with the Guiding Principles for distribution. Using all of these as a whole set can be more helpful
than using each of them as separate materials.

Photo 2: Simulated emergency treatmentof an allergic reaction to food
(Courtesy of Moriyama Elementary School in Moriyama City)[Osawa]- Decision-making authority should not be given to aparticular person. Each school should remind daily its teachers and staff members that they should
turn to emergency responses it specifies.

Homeroom
Teacher

I have read this emergency response manual at one schoolthat says, “the school principal checks what is happening,gives instructions, determines whether to inject EpiPen®, anddirects someone to make an emergency call.” It would not savethe student’s life. My school has a manual that assumes “anyone is authorized to decide to use the injector on the spot
as necessary before receiving instructions from the principal.”

EpiPen ® is used as necessary.

[Takada] I heard that, at some schools in Aichi Prefecture,they were allowed to call an ambulance or use EpiPen® only iftheir principals or nursing teachers decide to do so. Today at
all schools, anyone can administer EpiPen® if they decide
it is necessary, and they must call an ambulance as soon as
possible after that. It has been made clear that they shouldtake these critical actions without waiting for their principals’
instructions.

Committee on
Food Allergies

Receiving Information from First Graders’Kindergartens or Preschools

Committee on Food Allergies

Data 4- Schools cannot provide the same level of care askindergartens and preschools.
- What a school principal should do and keep in mind.
- Information about allergies children have should beshared across their school years.

How to Use the EpiPen®

(1) Remove the injector
from the case(4) Press the tip of the injector onto the outerthigh until it clicks, and count to five

[Kaneda] Schools need to get information about food allergies their new first graders might have from their kindergartens and preschools. Could you tell us about what elementary
schools do for that?

If the patient cannot
administer it him/herself:
The injector can beadministered with clothes on.

(2) Hold the injector inyour dominant hand

Make suretheir pocket
contains
nothing thatgets in the way.

[Imai]- School teachers and staff members should beaware that elementary schools cannot afford toprovide care as elaborate as kindergartens andpreschools’.
- Schools should ensure that they have information
about new first graders’ food allergies shared by
the children’s kindergartens and preschools.

(5) Make sure the orange needle
cover is extended(3) Remove the blue
safety cap

Before use

After use

Generally speaking, preschools are smaller than schools, so
preschools can afford to provide more elaborate care. This gap
can cause a sense of dissatisfaction in new first graders’ guardians. This may be difficult, but schools need to be well awareof the guardians’ dissatisfaction and where it comes from,and explain to them why schools cannot give the same levelof attention as preschools. Children’s food allergies do not go
through changes just because they enter elementary school,

Source: The Guidelines for Coping with Allergic Diseases
at School: Abridged Version, MEXT and the JSSH

[Kaneda] It is a great step forward that, in addition to papers,
training materials like this set of DVDs are made available sothat teachers and staff members think and practice together.

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so preschools and elementary schools maintain basically thesame ideas about food allergy-related issues and how to copewith them. So their student health information sheets (“Allergic Disease Information Sheet for Preschool”) ask almost thesame questions. I believe that, before they have new first graders, elementary schools should communicate with kindergartens and preschools to learn about how severe these children’s
allergies are, what they had for lunch, and what stances theirguardians have.

dergartens, preschools, elementary schools, and junior highschools will be possible.
[Yanagisawa]- Information about allergies students have should
be included in their health information sharedacross kindergartens, preschools, elementary
schools and junior high schools.

When junior high school teachers visit elementary schools
for information about their prospective students, their conversation inevitably focuses on student guidance. So I think thatthe overall dietary guidance plan should cover food allergies,
and diet and nutrition teachers should be included in liaisoncouncils of kindergartens, preschools and elementary schools
as well as of elementary and junior high schools.

[Kaneda] It would be great if each municipality has a system
in which each child’s medical record about his or her food allergies is automatically shared with schools he or she goes to,from nursery and elementary schools to high school.
[Eguchi]- To ensure safety, kindergartens, preschools, elementary schools, and junior high schools are working toward sharing students’ health information.

Approach to Food Allergies in the Classroom- Care given to children with allergies- Guidance given to their classmates- Explanations given to children’s guardians

Kindergartens, preschools, elementary schools, and juniorhigh schools are currently working on creating a system forsharing their students’ health information. I believe the system
will cover the sharing of health-care-related information, andI think it necessary also to share information about allergic reactions the children have had and how they have been handled
to ensure safety.

[Kaneda] Mr. Osawa, could you talk about what homeroom
teachers should consider to help children correctly understandfood allergies that their classmates have?
[Osawa]- School managers provide support.
- Schools ensure they have accurate information about children with allergies.
- Set up a committee on students’food allergies, and determine
detailed procedures for serving
allergen-free meals.

Homeroom teachers need support from school managers
in coping with that. In 2010 the school I was working at had
a new student who had to come to school with EpiPen®. We
collected information from his preschool. And I went to his
medical examination with his guardian and our nursing teacher to interview his doctor for relevant health information about
the student and what our school should do to help him lead anormal school life. Before he entered school, we provided an
opportunity for him and his parents to experience a school lifeand school lunch, and visited his doctor again to double-check
what our school should keep in mind and to learn where we
can find his EpiPen® in an effort to prepare ourselves. During
lunch hours, our vice principal and nursing teacher have provided support that the student and his homeroom teacher need.
He is now a sixth grader, and it seems that he hasn’t had any
serious problems related to his allergy.
This year, 8 out of 44 first graders at my school have foodallergies, and one of them brings EpiPen® with him to school.
We already had four students with allergies, so we worked
with our school physician and set up a committee to explore
approaches to cope with food allergies that 12 students in total
have, especially the first graders.

Photo 3: Principal, nursing staff, and diet and nutrition
staff interview a guardian about her child’s allergy(Courtesy of Moriyama Elementary School in Moriyama City)[Kaneda] As school principal, could you talk a little bit about
how to share students’ health information across kindergartens, preschools and schools, Mr. Osawa?
[Osawa]- “We send teachers to kindergartens and preschools to collect information about our prospective first graders to prepare for any food allergies
they might have.”

We send our teachers to kindergartens and preschools
where children scheduled to enter our school are currently enrolled. The teachers interview directors and teachers there tolearn about each of the prospective first graders. Informationacquired through the interviews is compiled and used for classcomposition, and serves as important notes we must refer tofor students’ health, safety, and hygiene.
[Kaneda] Each municipality is responsible for creating its
own shokuiku (dietary education) promotion program. If the
program includes how to cope with food allergies children
have, sharing students’ health information across their kin-11

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Lunch boxes
students bring are
kept here

Photo 6: A school nutritionist prepares lunch
trays for children with allergies

Photo 4: Lunch boxes students bring are
kept in the teachers’ room

A student’s school bag with an EpiPen ® isplaced on a shelf marked with red lines(Courtesy of Shibafuji Elementary School in Kawaguchi City)[Kaneda] Children with allergies each receive care tailoredto them. What about care for the other children in the sameclassroom?
[Osawa]- Illustrate the realities of food allergy-related issues
for all children (including those with allergies) andtheir guardians to raise their awareness and gain
their understanding.
- Ask children to protect their friends’ lives.
- Telling children about food allergies in detail evokes
a sense of responsibility to protect their friends.

Photo 5: A student’s school bag with an EpiPen® isplaced on a shelf marked with red lines(Courtesy of Shibafuji Elementary School in Kawaguchi City)

At a parent-teacher meeting, we tell all students’ guardiansthat a certain number of first graders have food allergies andthey each need special care, so we have a system in place toprotect them. This way the guardians understand the situation,and tell their children why some of their classmates had to betreated differently at lunch time.

We consulted a medical specialist who advised us to do
everything children and their guardians expect us to do. So we
decided to take the following specific measures: (1) Creatinga document that shows a course of action we take at school tocope with food allergies our students have, and sending copies of it to guardians to gain their understanding. (2) Providing guardians with charts of school lunches to be served thefollowing week to ask them to red-mark foods their children
cannot eat. (3) Their children lay their charts of the day’s lunchon their trays every day. (4) Their teachers check the charts
before the lunch is served. (5) After checking the charts, theteachers set their seals on the students’ name cards. (6) Starting from April this year, nursing teachers, school nutritionists, specialist subject teachers, and support personnel work
together to help first graders. (7) The teachers check students’
name cards (the size of a business card) on their chests for any
foods crossed out to indicate that they cannot eat them. (8)All meal plates for first graders with allergies are prepared in
the classroom of first graders in Class 1. (9) Of these plates,
those for children in Class 2 are carried to their desks by theirteacher. (10) Children with milk allergy develop an allergic
reaction just by touching milk. So a white line is drawn on theclassroom floor to indicate a non-milk area where the children
and their teacher eat lunch together. (See the cover)We would like them to be self-reliant in the future, so we areconsidering how far we should take care of them at lunch time.
The care we provide has caused no problems so far, though.
These children’s classmates serve food, eat their meals, andput away their trays, taking the differences for granted. I heardthat their guardians thank our school physician for the care we
provide.

[Kaneda] So children do not discriminate against their classmates with allergies.
[Osawa] No, not at all.
[Kaneda] First and sixth graders alike? Have you done anything special?
[Osawa] Just asking them to cooperate in protecting theirfriends’ lives is enough.
[Kaneda] Ms. Harada, could you talk a bit about this?
[Harada]- An explicit illustration of food allergies their friends
have encourages children to embrace the friends
as they are.

We show a picture story in classrooms with children withfood allergies in the beginning of the school year and tell students, “X (a classmate) can’t eat eggs because she will havethis reaction if she does. As her friends, please take care so she
won’t eat food with eggs in school lunches.” Children understood this without difficulty. I thought they are fully ready toprotect their friends.
[Kaneda] How about junior high schools?

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[Yanagisawa] Few junior high school students have food allergies. But I saw some students check on their friends who
used to have ones.

[Kaneda] As mentioned a while ago, some allergy symptoms
appear all of a sudden, don’t they?
[Imai][Kaneda] Mr. Imai, do you have any comment?

- New allergy symptoms at preschools in Tokyo
made up 60 percent.
- Foods that often trigger new symptoms are fruit(mostly mild symptoms), shellfish, nuts, and wheat(, which are most allergy-causing depends on children’s age).
- Junior and senior high school students are more
subject to FDEIA.
- There are other factors that may induce FDEIA, so
schools should be alert.

Must-dos for Children with Severe Food
Allergies- Understand the concerns that guardians haveabout their children’s severe food allergies.
- Note the following when providing counseling:- Consider their concerns well when giving an explanation to guardians, and try to make improvements
according to the situation.
- Be aware that allergic reactions to food can belife-threatening.
- Listen to and understand guardians’ concerns first,
then explain actions schools take in detail.

In that case, there is nothing we can do. According to thissurvey conducted by the SDCJ, new allergy symptoms madeup 30 percent. And a survey on allergies at preschools conducted by the Tokyo Metropolitan Government found that 60
percent of allergy symptoms children had developed were new.
Despite these facts, some school managers are still unaware of
the severity of this issue, and so they remain inexperienced
in dealing with students’ food allergies. This is a significant
obstacle to crisis management.

[Imai] For guardians with children with severe food allergies,
the allergies are a life-threatening issue, while many school
teachers and staff members have not witnessed any serious allergic reactions. This gap in awareness can lead to problems
or serious situations.
[Eguchi] It is important to listen to what guardians have tosay. We should understand their concerns, and then explainclassroom situations in detail for them. This way the school
and guardians can work out differences in stance, and make
improvements according to what the children need.

2
3

3 AB

Fig.6: Food Allergens

2 2
C

DE

4 Fish[Kaneda] So, Mr. Imai, it is vital for schools to talk to people
in different positions and provide counseling.

F
Chicken eggs

6

Milk

Chicken eggs

38.3

5 Buckwheat
6
Fruit[Imai]

Shellfish䠄䠂䠅Shellfish
Fruit
BuckwheatFish

6

Peanuts (A)Roe (B)
Soybeans (C)Nuts (D)Meat (E)Wheat- Give an explanation that covers the guardian’s concern.
- A school manager joins interviews with guardians
to share information and to explain the school’s
stance clearly and elaborately and asks for theirunderstanding.

Wheat

8

Milk

15.9

Other (F)

Source: Japanese Pediatric Guidelines for Food Allergy 2012,
Food Allergy Committee,Japanese Society ofPediatric Allergy and Clinical Immunology[Kaneda] What are common food allergens?
[Imai] Only a few children develop new allergy symptoms
caused by milk or chicken eggs after they reach school age,while many begin to experience allergic reactions to somefruits, shellfish, and nuts. There are many cases of allergic reactions to fruits, but these reactions are usually mild. The mostcases of FDEIA induced by exercise are caused by wheat, andnew symptoms of this allergy should never be underestimated.

As Ms. Eguchi said, we should listen to guardians first, andthen give an explanation that covers their concerns and issues
they have with the school. This makes them feel more satisfied.
[Harada] Fukuroi City also experienced some cases whereproblems arose when it used a multi-phased approach in the
beginning. Then, in the following year, the municipal committee studied the Report and decided to adopt the two-alternatives approach for the city’s school lunch program. It alsodecided that a school manager must join the interviews withguardians that had been conducted by only those in charge offood allergy-related problems before taking any actions. During the interviews, the manager explains the school’s policy onfood allergies students have, and those in charge of the problems explain actions the school takes. This has made the wholeprocess smooth.

[Takada] Quite a few junior and senior high school students
develop FDEIA during their morning or afternoon exercise forextracurricular activities because of food they had for breakfast. This means students do develop new allergy symptoms
including FDEIA that are totally unexpected. So we should notassume that children whose health information sheets indicate“no allergy” will have no allergic reaction. We should particularly be careful about transfer students who have enrolled in
the beginning of a new semester because we may not have any
information about their health.

New-onset and Food-dependent Exerciseinduced Anaphylaxis[Yanagisawa] Some junior high school students develop
symptoms of FDEIA during sports games outside school, so it
is vital to share information about students with relevant people. Many don’t know anything about FDEIA, so we call theirattention to the allergic reaction by telling them that juniorhigh school students and high school students are more likely
to have it than elementary school children.

- New food allergy symptoms- Food-dependent exercise-induced anaphylaxis(FDEIA)- Emergency action to take when any symptoms appear

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Fig.7: What Has Caused Food Allergy-related Accidents?
33.6

New symptoms

14.7

Diet and nutrition staff overlooked allergens

9.5

Guardians overlooked allergens

New symptoms

3.0

Change of scheduled foods
Suppliers delivered wrong food

1.3
3.5

Students forgot to bring their alternative lunch from home
Allergens failed to be eliminated during the cooking process

4.3
4.5

Allergen-free meal failed to be served

18.7

Errors in checking before lunch was served

1.7Children’s accidental ingestion

37.1

Other
0

10

20

30

40 (%)

Source: Report on Food Allergy Survey, SDCJ

seems mild because the condition can take an unexpected
turn. Our principal does appreciate that we don’t have to hesitate to call an ambulance.

According to a medical specialist, food is not the only causeof FDEIA. Perspiration, anti-acne drugs, and many other different factors can trigger the allergic reaction. So we need tolearn much more about what may induce FDEIA.

[Takada] If the hospital that the student needs to go is in a faraway location, the fire department informs the hospital immediately. Once, an air ambulance took over transport while anambulance was on its way to the hospital. Allergy symptoms
children develop can take an abrupt turn, so it is vital to call an
ambulance as soon as possible.
I can’t emphasize enough the importance of consulting
MEXT’s Guiding Principles at all times, administering
EpiPen® whenever necessary, and calling an ambulancewith no hesitation.

[Takada]- Each school should have a shared understandingof food allergies to prepare for any emergency.
- Communicate regularly with the fire department toshare relevant information.
- In an emergency, call an ambulance first and foremost. Do not hesitate to administer EpiPen® before
the student is taken to a hospital.

The manual for coping with students’ food allergies published by Gifu Prefectural Government last year included
request items intended for ambulance workers so that they
immediately see what they should keep in mind when taking achild to a hospital. I heard that the fire department appreciatesthat because having information beforehand prepares themwell for an emergency.

To Effectively Apply the Guiding Principles- From the perspectives of school principals/managers- From the perspectives of nutrition teachers- From the perspectives of the board of education- From the perspectives of medical specialists[Yanagisawa] There is a fire station right next to our junior high school. They asked us to share relevant information
about our students so that they can figure out which hospitals
they should take them to when something ever happens. If thechildren had any allergic reactions during their extracurricular activities away from school, the fire station can share theinformation with the ambulance crew called to emergency
transport. So we provided them with relevant personal information about our students with EpiPen® after receiving theirguardians’ consent.

[Kaneda] Finally, could each of you talk about how schools
can effectively apply the Guiding Principles?
[Osawa]- Based on the Guiding Principles, school principals
should provide leadership in coping with any allergy-related problems.

As a school principal, I believe that I am responsible forproviding leadership in building relationships of trust between school, our students, and their guardians to protect
children’s lives. As the Guiding Principles state, we shouldreport and share examples of different types of near misses,
and we must be consistent in our action to provide or not provide school lunches in accordance with the two alternatives. I
intend to keep in mind the Guiding Principles at all times as
I remind our school teachers, staff members, and any otherrelevant people that they should stay alert.

[Harada]- A regular system to work with the fire department
and hospitals should be in place.
- Since symptoms children develop can take an unexpected turn, arrange emergency transport immediately if a student shows any allergy symptoms.

Fukuroi City’s board of education cooperates with the fire
department and hospitals. We considered the time needed fortransport from school to hospitals, and made sure that we cancall an ambulance even when the reaction the student shows[Kaneda] Ms. Harada?

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[Harada]
Data 5: Framework for Promoting Actions
to Cope with Allergic Diseases- Request the board of education to help create aproper environment based on the Guiding Principles.

Medicalassociation, etc.

Roles of municipal boardsof education

The Guiding Principles set a perfect stage for schools toreview their complicated multi-phased approaches. The principles also urge schools without a well-developed approach toundertake the challenge of gaining guardians’ understandingof the two-alternatives policy. For these schools to become capable of coping with students’ food allergies safely, the boardof education should have a solid system in place. I intend tovoice this based on the Guiding Principles.

Give advice on
guiding principles and provide support

Provide information andrequest cooperation

Provide guidance and support

Report status

Schools’ actions(1) Set up a committee on foodallergies(2) All teachers and staff members work together(3) Hold training sessions onwhat allergy diseases are
and practical training for
emergencies[Yanagisawa]

Fire department
Fire headquarters

Homeroomteacher

Nursing
staff

Headteachers

Principal Vice
Principal

Guidelines

Student Health
Information
Sheet

Diet and Relevant School
physinutrition staff
staff etc. members ciansStudents’guardians

Students’
doctors

System for cooperation- We will promote the well-structured and easy-toapply Guiding Principles to put them into practicaluse at schools.

Source: Fundamental Ideas about How to Cope with
Allergic Disease at School, MEXT and the JSSH

To protect children’s lives, all teachers—including
those who have not been involved in actions to handle students’ food allergies—should take training to prepare forany emergency, and school principals should show leadership in developing their schools’ policies based on theboard of education’s policies. And it is critical that schools,
students’ guardians, the medical association, and the fire
department share as much information as possible to copewith children’s food allergies within an extensive framework. Furthermore, they must be well aware that, to ensurethat students enjoy school lunches knowing that the foods
are perfectly safe to eat, the submission of students’ healthinformation sheets completed based on doctors’ diagnosis
and actions based on the Guidelines are required.

The Guiding Principles are well received because they areeasy to read and understand. We advise our diet and nutrition
teachers to study them as part of our school-wide effort, which
we believe is crucial. The principles are well structured, so
handling problems caused by food allergies at school will beeasier if we understand and apply them correctly. Diet and nutrition teachers and school nutritionists on the front line ask
many questions at workshops and training sessions because
they are unsure about so many aspects of food allergy-related issues. Some of them brood over minor details. We shouldshare the information that will help people in different circumstances solve their problems so that we will work together
toward preventing accidents based on the Guiding Principles.
[Takada][Imai]- A board of education should develop its basic policy, set up a committee on food allergies, illustrate
subject matters that training sessions deal with,and add information to its guide based on lessons
learned from onsite experiences.

- MEXT, boards of education, and schools must fulfill
their own roles.
- Principals should take the lead in bringing theirschools together to raise their awareness and takeactions as organizations.
- Schools without manuals yet should refer to the
Guiding Principles as they decide on their practicaldirection and work toward it.
- The Guiding Principles should be used to informand educate people who should be involved but
have no interest in food allergy issues, and thus nosense of urgency to take action.

As the Guiding Principles state, I believe that municipal
boards of education should draw up their basic policies forcoping with students’ food allergies, and local governments
and schools should set up a committee on food allergies toestablish systematic approaches. Besides, we should explore
what support can be provided for training sessions and local
governments’ efforts.
This round-table discussion has clarified what the Guiding
Principles suggest. We should also complement them withwhat needs to be done to cope with allergy-related problems at
school, and reflect any changes in this year’s guide to handlingthose problems at schools across the prefecture.

As I said, MEXT, municipal boards of education, andschools each must do what they are required to do. On thefront line at schools in particular, principals must show
leadership so that nutrition teachers, school nutritionists,
nursing teachers, homeroom teachers, and all the otherteachers consciously play their roles. And many schools
and school kitchens are lagging behind in developing approaches to cope with students’ allergies. I believe that the
Guiding Principles will contribute significantly to theseschools’ efforts to have practical approaches in place.
It is also vital to have attention from people who should
be involved but have no interest in food allergy issues, andthus no sense of urgency to take action. We must find a way
to get them moving.
I hope that the Guiding Principles will serve as a catalyst for gradually raising the national level of approaches
to students’ food allergies.

[Eguchi]- The awareness that an accident could happen at
any time should be maintained.
- To protect children’s lives, school principals should
show leadership in working with relevant organizations, and take systematic approaches in accordance with their schools’ policies based on theboard of education’s policy.

Schools has become more alert and taken actions since theaccident. We have to make sure that this awareness will bemaintained.

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In addition to hygiene control, I believe it is important tocontinue holding training sessions and to be on the lookout for
information to share at all times as a way to prevent accidents
caused by food allergies.
With the population of children declining, we shouldmake sure that our children would lead safe and enjoyable
school life. We hope that all schools across Japan will study
the Guiding Principles and apply them widely and meaningfully. Thank you.

[Kaneda] Today, we discussed the Guiding Principles thatclearly state the ideas regarding how to cope with students’food allergies. The teachers involved in the process of creating
the principles elaborated on the ideas. I hope the discussion
will help schools to ensure that their manuals follow the principles, or to create new manuals based on the principles if they
have not created ones. In any case, schools are advised to takeprompt actions.

Data 6: Student Health Information Sheet Use Rates
Hokkaido

80% or more
50% - 80%
50% or less

Ms. Yasuko Harada

Akita

Aomori

Yamagata

Iwate

Ishikawa

ToyamaNiigata

Fukushima

Miyagi

Yamaguchi

ShimaneTottori

Hyogo

Kyoto

Fukui

NaganoGunma

Tochigi

Saga

Fukuoka

Hiroshima

Okayama

Nara

Shiga

Gifu

Yamanashi

Saitama

IbarakiNagasaki

Oita

Ehime

Kagawa

Osaka

Mie

Aichi

Shizuoka

Tokyo

Chiba

Kumamoto

Miyazaki

Kochi

Tokushima Wakayama

Okinawa

Kagoshima

Ms. Sachiko Yanagisawa

Kanagawa

Source: Report on Food Allergy Survey, SDCJ

Ms. Naomi Takada

Ms. Masayo Kaneda

Mr. Takanori Imai

Ms. Yoko Eguchi

Mr. Masanori Osawa[Editor’s Postscript] Today’s round-table discussion left me with a deeper understanding of how significant the theme ofthis issue is. I was also astonished to learn that many schools across Japan are still unaware that the food allergies children
suffer can cause life-threatening reactions.
Therefore, we edited this issue so that it provides detailed information as clearly as possible. We also decided for the
first time to distribute copies of the Sukoyaka Newsletter Volume 18 to all public elementary and junior high schools acrossthe country. We truly hope that this effort will help schools understand and act on the Guidelines for Actions to Cope with
Students’ Food Allergies at School published in 2008, and the Guiding Principles of School Lunches to Cope with Students’
Food Allergies we discussed, thereby preventing recurrences of accidents caused by food allergies. We believe this will help
children enjoy their school life with peace of mind.

The English edition or the Japanese edition of this volume is available for distribution. Please inquire at the Association Secretariat by
FAX or E-mail, with your name, telephone number, E-mail address, and the number of copies required as well as the postal address
to which the copies should be sent.
Japan Association for Improving School Lunch
3-12 Yotsuya, Shinjuku, Tokyo 160-0004 Japan
TEL +81-3-3357-6755 FAX +81-3-3357-6756 E-mail kaizen@gakkyu.or.jp
No part of this text, photos or figures from this volume can be copied, reproduced, or reprinted without the Association’s consent. Those who wish
to quote or reprint any part of this newsletter for educational purposes are asked to submit an Application for Permission for Reprint/Quotation form
to the Association. The form is available for download on the Association’s website. Please contact us should you wish to order additional copies touse for educational purposes.

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