INTRODUCTION
Food allergy (FA) is a chronic immune-mediated condition affecting an estimated 10 percent of adults and 7 percent of children in the United States, totaling more than 30 million affected individuals (Warren et al. 2020; Gupta et al. 2018). Clinical reactions range from mild symptoms such as sneezing and hives to life-threatening anaphylaxis requiring immediate epinephrine administration (Abrams 2022). In early childhood, the impact of FA is shaped not only by its prevalence but also by its unpredictability. Exposures can occur suddenly in routine settings such as childcare programs, schools, and public spaces, where young children may not be aware of what is occurring or able to reliably communicate early symptoms (Foster et al. 2015).
Beyond clinical risk, FA imposes substantial emotional and financial strain on families (Yang et al. 2025). Daily management requires careful food label reading, consistent communication, and ongoing vigilance in social and public environments. Families may face both direct and indirect costs related to specialist care, time away from work, emergency department visits, and higher grocery expenses for allergen-safe food alternatives (Bilaver et al. 2016).
Importantly, FA appears underrecognized among low-income populations. While national estimates suggest FA affects nearly one in 12 children (Gupta et al. 2018), diagnosis rates among Medicaid enrollees have been reported as low as 0.6 percent (Bilaver et al. 2021). Contributing factors likely include limited access to allergy specialists, fragmented care coordination, and inconsistent referral pathways (Bilaver et al. 2021). At the same time, children from lower socioeconomic status backgrounds experience higher rates of emergency department utilization for allergic reactions, suggesting that FA may go unrecognized until acute events occur (Bilaver et al. 2021). Together, such patterns may further exacerbate existing FA-associated health disparities in these populations (Dupuis et al. 2023; Yang et al. 2025).
Thus, understanding how FA risk is identified and managed in early childhood systems is critical. A comprehensive federal government program administered by the U.S. Department of Health and Human Services (HHS), Head Start (HS) provides a particularly important setting for this work. Because HS serves children and families who often face structural barriers to health care access, nutrition security, and stable housing, it is well-positioned to support early identification, prevention, and emergency preparedness (“Head Start Services” 2025). FA safety in this setting depends not only on individual- and family-level knowledge but also on program-level support, including accurate documentation, staff training, emergency protocols, food service practices, and epinephrine access.
Head Start as a Setting for Food Allergy Safety
HS is a federally-funded program that provides early childhood education, health, nutrition, and family support services to children under age five and pregnant women (“Head Start Services” 2025). Eligibility for enrollment in HS includes living at or below the federal poverty level, experiencing housing instability, or receiving public assistance, such as Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), or Supplemental Nutrition Assistance Program (SNAP) benefits. Since its inception in 1965, HS has served over 38 million children across the United States (“Head Start History” 2024).
HS programs are administered by local grantees and integrate health services, nutrition support, and family engagement into a broader prevention framework. In Illinois, 513 HS programs are operated by local grantees across the state, and HS grantees are supported by the Illinois Head Start Association (IHSA). Each year, grantees submit standardized program data to the national Office of Head Start, part of the Administration for Children and Families (ACF) within the HHS, which is then compiled into the Program Information Report (PIR). The annual PIR for Illinois (IL) provides a statewide snapshot of child health conditions and informs safety and prevention priorities (information about access to the IL PIR is provided under Data Availability).
Given the structural barriers to health care access experienced by many HS families, such programs provide a critical setting for improving FA safety. Unlike health conditions addressed through periodic screenings, FA risk is continuous and dependent on daily environmental exposures. Effective FA safety in HS settings, therefore, depends on accurate identification, consistent documentation, clear emergency protocols, and staff preparedness.
METHODS
A Collaborative Review of FA Burden and Preparedness in Illinois HS Programs
In January 2026, leadership from Northwestern University’s Center for Food Allergy and Asthma Research (CFAAR) and IHSA met to review health data reported in the 2025 Illinois PIR and discuss FA identification, burden, and management within HS programs.
CFAAR, part of the Institute for Public Health and Medicine at Northwestern University Feinberg School of Medicine, conducts epidemiological, clinical, and community-engaged research to improve the lives of community members affected by FA and asthma (Northwestern University Center for Food Allergy and Asthma Research 2024).
This collaboration between CFAAR and IHSA was not designed as a formal epidemiologic study. Instead, it aimed to serve as a descriptive, stakeholder-informed review using publicly reported and administratively compiled IL HS program data, interpreted through the practical experience of HS leadership and the FA expertise of CFAAR.
The collaborative review was guided by four key objectives:
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Clarify how “life-threatening allergies” are defined, captured, and documented in the annual IHSA IL PIR.
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Compare reported allergy-related counts with expected FA burden based on previously published pediatric prevalence estimates.
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Identify operational factors that influence FA prevention and emergency response in HS settings.
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Develop program-level priorities to strengthen FA documentation, preparedness, training, and resource allocation.
Key themes from the stakeholder discussions were synthesized to identify systems-level opportunities for improving FA safety and equity in Illinois’ HS programs.
RESULTS
PIR Data and Leadership Insights
The 2025 Illinois PIR detailed 27,742 enrolled children and pregnant women, including 27,023 children across 513 HS programs. Among enrolled families, 6,238 had incomes at or below 100 percent of the federal poverty line, 17,029 received public assistance (TANF, SSI, and SNAP), 2,015 were experiencing homelessness, and 843 were children in foster care (Table 1).
PIR data show that health insurance coverage increased over the enrollment period. At enrollment, 25,349 children had health insurance, including 23,499 enrolled in Medicaid and/or CHIP. By the end of enrollment, 25,942 children had health insurance, including 24,146 enrolled in Medicaid and/or CHIP. The number of uninsured children decreased from 1,674 at enrollment to 1,081 by the end of enrollment. Such findings highlight the role of HS programs in connecting children and families to health coverage.
Leadership discussions then shifted to FA prevalence, chronic disease documentation, and FA preparedness. The 2025 Illinois PIR reported 384 cases of “life-threatening allergies,” making it the third most common chronic health condition listed. The top nine most common chronic health conditions reported in the 2025 Illinois PIR are summarized in Table 2.
Stakeholder discussions clarified that the PIR category of “life-threatening allergies” does not represent overall FA prevalence; rather, it reflects clinician-documented severe allergies, including FA, medication allergies, insect-sting allergies, and other allergies associated with risk of systemic anaphylaxis. Discussions also clarified that reported cases are based on medical provider documentation from required physical examinations and health records, rather than systematic symptom screening or parent-reported FA concerns. Based on this collective understanding, the 384 reported cases should not be interpreted as the number of children with FA in Illinois HS programs. Instead, this figure likely represents a narrower group of children with documented severe allergy risk. Because the category is not food-specific and depends on clinician documentation, it may underestimate the broader burden of FA and FA-related risk among HS participants.
Although physician evaluation is required before HS enrollment, the group concluded that there is no standardized PIR methodology for capturing symptom concerns, allergy severity, or specific triggers. As a result, documentation practices may vary across HS sites. Even with these limitations, both parties agreed that, when compared with national pediatric FA prevalence estimates, the number of documented life-threatening allergies appeared low relative to the size of the Illinois HS population (Gupta et al. 2018). This observation is consistent with prior findings showing lower FA diagnosis rates among Medicaid enrollees (Bilaver et al. 2021). HS leadership also noted that although health insurance coverage is high among HS participants, access to specialty care and timely diagnosis remains inconsistent. Variation in program-level preparedness may further contribute to differences in real-world FA safety across HS sites.
DISCUSSION
Food Allergy at the Intersection of Health and Inequity
FA management in HS settings requires attention to both clinical safety and social context. For many families served by HS, FA care may be complicated by food insecurity, housing instability, limited access to preventive care, transportation barriers, and difficulty obtaining specialty appointments (Cockerham et al. 2017). Such challenges may delay FA recognition, complicate long-term management, and increase reliance on emergency care for allergic reactions (Bilaver et al. 2016).
Daily FA management can also place a disproportionate financial strain on families with limited resources. Allergen-safe foods and substitutes are often more expensive than their conventional counterparts; and families may have fewer options when relying on food-assistance programs, shared kitchens, shelters, or childcare-provided meals (Bozen et al. 2020; Anagnostou et al. 2025). For these families, the burden of individual vigilance to ensure safe FA management can be greatly aided by support from the organizations where children eat, learn, and receive care. HS programs are uniquely positioned to provide this support because they operate at the intersection of early childhood education, nutrition, health access, and family services.
Comprehensive FA preparedness requires accurate identification and documentation, individualized emergency action plans, access to epinephrine, trained staff who can recognize and respond to anaphylaxis, and clear communication among families, educators, food service teams, and health care providers (Sicherer and Simons 2017). Within this context, strengthening FA preparedness within HS programs can help to reduce preventable allergic reactions, improve emergency readiness, and support earlier recognition of children who need formal evaluation for FAs.
Opportunities for Program-Level Interventions in Head Start Settings
Takeaways from the Illinois PIR analysis and CFAAR-IHSA partnership discussions point to the need for a coordinated approach to FA preparedness in HS settings. Rather than viewing FA safety as a single intervention, such as epinephrine availability alone, the partners envisioned it as a three-part framework that includes: 1) clinical emergency preparedness, 2) education, documentation, and referral systems, and 3) food access and allergen exposure prevention. Together, these domains can help close the loop and create an integrated FA safety framework that connects recognition, referral, documentation, prevention, and emergency response and can be applied at HS sites.
Clinical Emergency Preparedness: Epinephrine Access and Response Systems
Epinephrine is the first-line and only effective treatment for anaphylaxis, where timely administration is critical and lifesaving (Kemp et al. 2008). IHSA leadership shared that Illinois HS grantees store epinephrine auto-injectors on the premises for children with clinician-provided prescriptions. However, access gaps remain for children who may experience anaphylaxis without a prior FA diagnosis or personal prescription available on site.
Stakeholders agreed that expanding access to stock, undesignated epinephrine could strengthen the program’s ability to respond to allergic emergencies, particularly those involving children with previously unidentified FA risk. Emergency preparedness at HS sites could also include standardizing and stipulating procedures for epinephrine storage locations and tracking expiration, developing and practicing clear emergency protocols, and establishing consistent procedures for documentation and follow-up. These steps are especially important in early childhood settings, where children may not be able to recognize or clearly communicate symptoms of anaphylaxis.
Education, Documentation, and Referral Systems: Staff Training and Response Confidence
Epinephrine availability must be paired with staff who are prepared to recognize and respond to allergic reactions and trained to use it. Although it was shared that HS programs conduct annual FA trainings, there is no standardized protocol, so the content depth, and delivery of these trainings may vary across sites. Standardized, high-quality training should include recognition of early and severe anaphylaxis symptoms, timely epinephrine administration, use of emergency action plans, and hands-on practice with epinephrine trainer devices. Epinephrine administration training has been proven to further improve staff confidence and promote more consistent responses during high-pressure situations (Shiraishi et al. 2019).
Food Access and Allergen Exposure Prevention: Food Environment Support and Safety
Reducing allergen exposure in HS settings requires coordinated food safety practices across classrooms, cafeterias, and food-service operations. Key strategies that can be implemented at HS sites include clear allergen labeling, cross-contact prevention training, standardized food substitution practices, and consistent communication among families, staff, and food-service teams. Partnerships with food vendors and meal providers may also improve the availability of allergen-safe options for children with FA.
Food environment support is also an equity issue. HS leadership noted that many HS families face financial and logistical barriers to managing FA, particularly because allergen-free foods can cost two to three times more than conventional alternatives (Bajaj et al. 2025). HS sites could leverage their national reach by building partnerships with both allergen-free food brands and nonprofits. Securing Safe Food and FOODiversity are examples of organizations expanding access to shelf-stable, gluten-free, and top nine allergen-free foods for individuals facing food insecurity (Securing Safe Food 2020; FOODiversity 2023). Without institutional supports such as affordable substitutions, safe meal accommodations, and consistent food safety practices, families with limited financial resources may bear a disproportionate burden in maintaining allergen-safe diets for their children.
At the same time, HS programs can serve as trusted access points for parent- and patient-facing education on infant feeding and allergy prevention. In addition to supporting children with established FA, HS sites could provide families with resources on current guidance for early introduction of common allergenic foods, beginning around six months of age when developmentally appropriate and aligned with pediatric guidance (Du Toit et al. 2015). This is especially relevant for families with infants enrolled in Early Head Start (EHS) or with younger siblings at home. By pairing safe meal accommodations for children with FA with practical prevention-oriented education for families of infants, HS programs can support both immediate food safety and earlier, more equitable access to allergy prevention information.
Future Directions: Coordinating and Integrating Food Allergy Safety
This novel collaboration between IHSA and CFAAR, informed by the 2025 Illinois PIR, highlighted the need to move from isolated FA safety practices at HS sites toward coordinated systems that help close the loop between recognition, referral, documentation, prevention, and emergency response practices for children with FA.
HS operates at the intersection of education, nutrition, family support, and health care access for children facing social and structural barriers. Strengthening FA systems in this setting has the potential to reduce preventable harm, improve emergency preparedness, and advance health equity during early childhood. By connecting clinical guidance with daily program practices, HS programs can help ensure that children with known or suspected FA are identified, supported, and protected in the settings where they learn and eat.
Although this insight article focused on IL HS programs and was conducted through a collaboration between IHSA leadership and CFAAR, its implications can be extended more broadly to childcare centers, schools, and other early learning programs. Across the U.S. and globally, educational settings face similar challenges in identifying FA, preventing exposures, supporting families, and responding to allergic emergencies (Santos et al. 2022). Aligning program-level protocols with clinical guidance and public health initiatives can help create safer, more inclusive environments where all children, regardless of socioeconomic status, are protected and supported.
Author Contributions
MY and SV from CFAAR met with LMF and DE from the IHSA to discuss the focus and thematic purpose of the paper, clarify HS program context, and establish a collaboration aimed at advancing FA awareness and support. All members of the study team contributed to the development of the paper design, thematic framework, and interpretation. All authors participated in preparing the initial manuscript and its first revisions. MY and SV critically revised the final version. All authors approved the final version to be submitted for publication and are responsible for the accuracy and integrity of the content.
Conflict of Interest Disclosures
R. Gupta reports research support from the NIH (R21 ID AI135705, R01 ID AI130348, U01 ID AI138907), FARE, Rho, Inc., Melchiorre Family Foundation, Sunshine Charitable Foundation, Walder Foundation, UnitedHealth Group, Thermo Fisher Scientific, Genentech, and the National Confectioners Association (NCA); serves as a medical consultant/advisor for Aimmune Therapeutics, Before Brands, AllerGenis LLC, Kaléo, Inc., Novartis, Genentech, DBV Technologies, and FARE; is employed by Ann & Robert H. Lurie Children’s Hospital of Chicago; and is professor of pediatrics and medicine at Northwestern University Feinberg School of Medicine. CM Warren reports research support from FARE, National Institute of Allergy and Infectious Diseases, and Genentech, Inc. and is currently employed by Northwestern University and Northwestern University Feinberg School of Medicine. The rest of the authors declare that they have no relevant conflicts of interest.
Data Availability
The Head Start Program Information Report (PIR) is publicly accessible through the Head Start Enterprise System (HSES) at https://hses.ohs.acf.hhs.gov/. Under “All Users: PIR Report,” users may request login credentials via the contact information provided on the site to obtain access to annual PIR datasets.
Funding
The authors have no funding sources to report.
Abbreviations
ACF, Administration for Children and Families; CFAAR, Center for Food Allergy and Asthma Research; CHIP, Children’s Health Insurance Program; FA, food allergy; FARE, Food Allergy Research & Education; HHS, U.S. Department of Health and Human Services; HS, Head Start; IHSA, Illinois Head Start Association; PIR, Program Information Report; SNAP, Supplemental Nutrition Assistance Program; SSI, Supplemental Security Income; TANF, Federal Temporary Assistance to Need Families