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Preventing and responding to severe allergic reactions in schools

Food allergies in children and young adults may feel more like a stigma than a chronic medical condition. For children with diagnosed life threatening allergies, medical alert identification, in the form of a bracelet, necklace, or belt loop tag, may promote stereotyping or create a basis for teasing. On the other hand, it can save valuable response time and better safeguard the child's health.1

In recent years, the number of children requiring treatment for severe allergic reactions and anaphylaxis continues to increase.2 3 4 According to data collected by the Centers for Disease Control and Prevention, hospital discharges for juveniles with a diagnosis related to food allergy grew from 2,615 in 1998-2000 to 9,537 in 2004-2006.5 This increase in severe reactions to foods has prompted parents and physicians to better communicate with schools to best protect children from accidental exposure to allergens.

Although proper medical diagnosis, allergy testing, and remedial measures taken to avoid exposure to allergens - where at all possible - is a primary line of defense against severe reactions,6 an appropriate and timely response, including access to epinephrine, are also critical tools in the immediate treatment of anaphylaxis after allergen exposure has occurred.

Appropriate and Rapid Identification of an Allergic Reaction


There is no one symptom that defines anaphylaxis; rather, anaphylaxis is a life-threatening reaction that may present with a variety of symptoms.7 While loss of consciousness or difficulty breathing may be fairly obvious, coughing, stomach cramps or a runny nose may be less clear; however, all have the potential of being a symptom of a life-threatening reaction.8

Students with a diagnosis of asthma, for instance, are at especially high risk both for suffering anaphylaxis and for receiving delayed treatment because the reaction may be mistakenly believed to be asthmatic.9 For these reasons it is critical that all individuals responsible for the care of students are informed about the potential seriousness of allergic symptoms and do not delay in ensuring that the child receive treatment promptly upon experiencing known symptoms.10

While some may consider "peanut free zones" in school cafeterias, for example, to cause segregating and stigmatizing of children, it may very well be a convenient and safe way to ensure that children are removed from accidental exposure to allergens.

The commonwealth's leadership role in keeping school children safe


The commonwealth is a recognized leader in efforts to protect students with allergies in schools. It established the Life-Threatening Food Allergies in Schools Task Force, made up of parents, medical and nutrition experts, school officials and representatives from leading allergy organizations. Massachusetts has developed comprehensive guidelines for schools on how to plan and respond to life threatening allergic reactions, laid out in the publication, "Managing Life Threatening Food Allergies in Schools."11

The commonwealth further allows pharmacies to sell non-patient-specific stock supply epi-pens to schools, and encourages having epi-pens in schools to treat anaphylaxis.12 School nurses may train unlicensed individuals to administer epinephrine to students with diagnosed allergies.13 Schools also must permit students with life-threatening allergies to carry and administer prescribed epinephrine.14 Additionally, Massachusetts requires all new bus drivers to receive training in epi-pen administration.15

The commonwealth goes further and requires state school systems to submit forms to the Massachusetts Department of Public Health each time epinephrine is administered.16 Epinephrine administrations in Massachusetts schools have increased from 127 administrations in 2003-2004 to 198 administrations in 2009-2010.17

Peanuts and tree nuts are consistently the most frequently reported allergens.18 While all food allergies have the potential to be life threatening, peanut and tree nut allergies are of special concern because they are believed to be responsible for 92 percent of severe and fatal reactions.19 20

While a small number of students may react from coming in contact with minute amounts of an allergen, such as breathing in airborne peanut particles or coming in contact with peanut oil, most individuals with peanut allergies only experience severe reactions after consumption of a peanut product.21 The amount an individual would have to consume to have a reaction varies, but can be as small as 1/5000th of a teaspoon.22

In Massachusetts, the most common trigger for an allergic reaction at school is food, believed to be the trigger for 43 to 46 percent of reactions requiring epinephrine administration.23 However, in up to 46 percent of cases, the triggering allergen is unknown. Further, in roughly 25 percent of cases, the individual experiencing the reaction was unaware that he had an allergy.24

Studies suggest that exposure to a food for the first time at school is the trigger in 20 percent of anaphylactic episodes in schools.25 Registered nurses reportedly administered epinephrine in 87 to 92 percent of cases while other parties reportedly administered it in 8 to 13 percent of incidents.26

Although the objective is not to stigmatize or treat any differently those students with known food allergies, school districts should consider establishing seating arrangements in the cafeteria and designated areas of allergy-free zones.
Additionally, school policies should address events in which students bring foods to share into the classroom - such as class parties and birthdays - as those foods, even if believed to not contain the allergen, often present exposure risks for students with severe allergies.27

Access and Administration of Epinephrine


Immediate access to epinephrine has been demonstrated to significantly reduce fatalities from anaphylaxis.28 29 While ideally a licensed professional, such as a school nurse, would be available to administer epinephrine, there should always be multiple adults at a given site trained to administer epinephrine.30 Adults responsible for the care of children in an organized setting should be trained to administer epinephrine.31

Epinephrine, in the form of an epi-pen, is easy to administer with minimal training and is life-saving, and the administration in response to a life threatening reaction is generally protected by Good Samaritan laws.32 Delays in administration of epinephrine are frequently the cause of deaths resulting from allergic reactions.33

It may be reasonable to consider further extensions of the Massachusetts "Good Samaritan" laws to explicitly exempt from liability those persons who administer epinephrine to children in good faith attempts to render emergency care; in much the same way the commonwealth exempts those rendering CPR and defibrillation services.34

While prevention is the most critical component of protecting children with life threatening allergies, every reaction cannot be accounted for. The relatively high number of students with no prior knowledge or diagnoses of an allergy that experience severe allergic reactions, along with the number of students with allergies who have a severe reaction triggered by an unknown allergen, emphasize the limitations of prevention and the importance of on-site identification and response.35 Added state protections, for example, may be necessary to hold harmless those individuals who respond by administering epinephrine in good faith situations.

1. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 49 (2002).

2. American Academy of Allergy, Asthma, and Immunology. Allergy Statistics, (2010).

3. American Academy of Allergy, Asthma, and Immunology. Allergy Statistics, (2010).

4. Amy M. Branum & Susan L. Lukacs, National Center for Health Statistics, Food Allergy Among U.S. Children: Trends in Prevalence and Hospitalizations, 10 NCHS Data Brief 1 (2008).

5. Amy M. Branum & Susan L. Lukacs, National Center for Health Statistics, Food Allergy Among U.S. Children: Trends in Prevalence and Hospitalizations, 10 NCHS Data Brief 1, 4 (2008).

6. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 7 (2002).

7. American Academy of Allergy, Asthma, and Immunology, Anaphylaxis(END ITALIC) (2013) available at www.aaaai.org/conditions-and-treatments/allergies/anaphylaxis.aspx (last visited April 1, 2013).

8. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 6-7 (2002).

9. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 7-8 (2002).

10. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 7-8 (2002).

11. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools (2002).

12. Mass. Dep't of Public Health, Advisory Regarding Stock Supply of Non-Patient Specific Epinephrine for Schools, (Feb. 14, 2012). ("The Board of Registration in Pharmacy and the Drug Control Program strongly support all prescriber and pharmacy efforts to provide stock epinephrine in a pre-measured, auto injector device to Massachusetts public and private schools to facilitate emergency treatment of anaphylaxis reactions.")

13. 105 CMR 210.000 (2012).

14. Mass. Gen. Laws ch. 71 § 54(b) (2013).

15. Mass. Gen. Laws ch. 90 § 8(a) (2013).

16. 105 CMR 210.000 (2004); School Health Unit, Mass. Dep't of Public Health, Report of Epinephrine Administration (2010-2011) (2010); Asthma and Allergy Foundation of America, Massachusetts State Honor Roll, (2012) available at www.aafa.org/display.cfm?ID=5&sub=105&cont=654 (last visited Apr. 4, 2013).

17. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

18. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

19. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 2 (2002).

20. American Academy of Allergy, Asthma, and Immunology. Allergy Statistics, (2010).

21. Jill F. Kilanowski & Ann Salter, Peanut Allergy in the School Environment Myths and Facts (2007) available at www.netwellness.org/healthtopics/ch/peanut1.cfm (last visited April 8, 2013).

22. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 2 (2002).

23. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

24. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

25. NIAID-Sponsored Expert Panel, Guidelines for the Diagnosis and Management of Food Allergy in the United States: Diagnosis of IgE-Mediated Food Allergy, 126(6) The Journal of Allergy and Clinical Immunology S1, S1-S68, (2010) available at www.jacionline.org/article/S0091-6749percent2810percent2901566-6/fulltext#sec4.2 (last visited Apr. 8, 2013).

26. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

27. Scott H. Sicherer et al., Clinical Report Management of Food Allergy in the School Setting, 126(6) Pediatrics 1232, 1236 (2010); National School Boards Association, Safe at School and Ready to Learn: A Comprehensive Policy for Protecting Students with Life-Threatening Food Allergies (2012); Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools (2002).

28. The Food Allergy & Anaphylaxis Network, Managing Food Allergies in the School Setting: Guidance for Parents 1, 5 (2011).

29. National School Boards Association, Safe at School and Ready to Learn: A Comprehensive Policy for Protecting Students with Life-Threatening Food Allergies 7 (2012).

30. National School Boards Association, Safe at School and Ready to Learn: A Comprehensive Policy for Protecting Students with Life-Threatening Food Allergies 49 (2012).

31. National School Boards Association, Safe at School and Ready to Learn: A Comprehensive Policy for Protecting Students with Life-Threatening Food Allergies 30 (2012).

32. National School Boards Association, Safe at School and Ready to Learn: A Comprehensive Policy for Protecting Students with Life-Threatening Food Allergies 49 (2012).

33. Massachusetts Dep't of Education, Managing Life Threatening Food Allergies in Schools 7-8 (2002).

34. Mass. Gen. Laws ch. 112 § 12(v).

35. School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of Public Health, Data Health Brief: Epinephrine Administration in Schools 2009-2010 (2011).

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