At Creekside Park Elementary School in Muldoon, lunchtime can be complicated.
There's a soft-spoken kindergartner so allergic to peanuts that she needs to sit at a table declared nut-free. Her allergy, the girl's mom told her class on the first day of school, is severe enough that even airborne exposure could trigger a potentially deadly reaction.
In the school kitchen, there's a freezer compartment full of district-provided meals specially-made for another girl who gets sick if she consumes any animal byproducts.
And there's the school's cafeteria manager, Joy Johnson, who has memorized the laminated collection of cards spelling out each child's allergy: potatoes, soy, milk, corn, apples, legumes.
This is the new reality of lunch in the Anchorage School District.
As more children are diagnosed with serious food allergies, Anchorage schools are devoting more time and resources to accommodating them.
That means lunch trays filled with district-prepared, allergy-free meals of ground bison and sweet potatoes and full-time nurses at each school. It means EpiPen trainings and "Peanut Reduced Environment" signs. It means one school declared entirely "cinnamon-free." And it means each teacher, aide and cafeteria worker becomes an ad-hoc allergy expert, charged with keeping children safe from an accidental exposure through a system of checks and counter-checks.
The stakes are high.
The district counts about 1,500 students known to have an allergy serious enough to trigger anaphylactic shock, which without treatment can be deadly in minutes. That's 3 percent of the student population.
About 12,000 students -- one in four -- have a documented allergy of some type, said Nancy Edtl, the head of student health services.
Though the district has many safeguards in place, "it does keep me up at night sometimes," she said.
Overall, 4-8 percent of children have a food allergy, compared with 2-3 percent of adults, said Dr. Melinda Rathkopf, a pediatric allergy specialist in Anchorage.
"We do know food allergies are increasing," Rathkopf said.
Part of the recent increase may be that doctors are now better at diagnosing food allergies.
But the prevailing theory is the "hygiene hypothesis."
The idea is that by being born and growing up in sterile environments and taking lots of antibiotics we've put our immune systems out of a job, Rathkopf said.
Doctors who have studied kids raised in farm environments and exposed to healthy amounts of dirt found they are less likely to have food allergies, she said.
People can be allergic to almost anything: Rathkopf and Anchorage allergist Jeffery Demain documented the first known food allergy to bowhead whale and seal in an Inupiaq boy.
But children are mostly allergic to a predictable handful of foods, including milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat.
Lots of children rely on the Anchorage School District for food. The district serves 17,000 lunches every weekday, and more meals to kids from low-income homes before and after school. Nearly half of all district students are eligible for free and reduced lunch.
By law, the district has to offer food alternatives for kids with restricted diets.
Before last year, the district did a haphazard job of it, said LaDonna Dean, a registered dietician who is the district's head of student nutrition.
"I started getting these phone calls," Dean said from her office at the district's central kitchen. "Where the mom is saying, 'My kid is on the free program and you have nothing on the menu that my kid can eat. And I can't afford to send a lunch for my kid every day.'"
Dean knows how scary it can be for a parent to send a severely food allergic child to school. Her own son has five food allergies that can trigger anaphylactic shock. She chose his preschool in part because it was a "peanut-free environment."
So she developed a menu of optional meals that were free of the eight most common allergens.
(The district doesn't ever serve anything with peanuts in it -- or even buy from producers that can't guarantee their products are peanut-free.)
Most of it was easy substitution, she said, swapping tortillas for brown rice, say, or omitting a bun.
Occasionally she has to get creative. She buys local markets out of bison for kids who can't eat other proteins.
In the 2012-13 school year, the district handed out 3,037 special allergy meals.
Schools have ordered 1,144 such meals since classes began in Anchorage in August. .
Student nutrition has a self-sustaining $19 million budget separate from the district's operating budget, funded by what families pay for school lunches, federal reimbursement of free and reduced lunch programs and grants, Dean said.
How much more it costs the school to offer individualized meals hasn't been worked out yet, she said.
"I know I expect to be making a lot more of them in the future," Dean said.
BUSY SCHOOL NURSES
Every school in the district has employed a full-time nurse for the past six years, said nursing head Nancy Edtl.
Before that, elementary schools had part-time nurses. But the demands became overwhelming, said Edtl.
"Things were just getting more and more complicated at more and more schools," she said.
Part of the reason: a rise in serious food allergies, along with chronic conditions such as diabetes and asthma.
Nurses see an average of 30-80 kids per day in each school, according to Edtl.
Dealing with food allergies is no small part of their job, especially on the elementary level.
School nurses such as Lillian Anderson, who has a cheery office at Creekside Park Elementary, work in tandem with teachers and cafeteria staff to stay on top of allergies.
Anderson has teachers practice sticking emergency epinephrine injectors (EpiPens) into oranges.
That way, she says, they'll be less shaky if they ever need to plunge one into a child's leg.
She also tries to be sensitive to kids who hate sitting at special "peanut-free" tables.
"It's so hard to be different as a child," she said.
Nurses also train others in the building about how to keep cross-contamination from triggering a reaction, and how to respond in an emergency.
The district used its own EpiPens, kept on hand for undiagnosed kids who don't have their own, more than 20 times last year, according to Edtl.
No data on how many EpiPens had been administered overall was available.
So far, it's working. The district says there hasn't been a food allergy fatality that happened at school in recent memory.
Rathkopf, the Anchorage pediatric allergist, says the only one she knows of occurredat the child's home.
Even with accommodations and training, sending a severely allergic child to school feels like a roll of the dice for some parents.
Jeanie Long's son just started kindergarten at an ASD elementary school she'd prefer not to name. He's severely allergic to peanuts and carries an EpiPen in his backpack.
After a meeting with the school nurse, principal and kindergarten teachers, the decision was made to have the boy eat at a peanut-free table with two other allergic boys, Long said. But that doesn't feel like enough to her, she said.
Her son is so allergic that he could have an reaction just from being touched by another child with peanut butter on his or her hands, she said. And kindergartners touch each other all the time, she said. So her goal is to get peanuts out of the classroom entirely, and is working with the principal and district to make that happen, she said.
Until then, Long said, she and her husband take turns going to school to eat lunch with their son every day.
Reach Michelle Theriault Boots at firstname.lastname@example.org or 257-4344.
By MICHELLE THERIAULT BOOTS