A message from ACAAI President Dana V. Wallace, MD, FACAAI
Back-to-school with allergies and asthma: Keeping our children safe!
Anaphylaxis–Asthma–Bullying: Where does it end?
Teach your patient to say: “I think I am having an allergic reaction. HELP ME!”
With vacations ending and tax-free shopping weekends over, we know that school is starting very soon. For the child with food allergies or asthma, and even more so for the parents of this child, starting or returning to school with a new teacher, often new classmates and ever changing staff, a daunting task lies ahead. The parents will need to advise, to collaborate, and often educate the school staff about how to recognize that their child is starting to have food-induced anaphylaxis or an asthma attack.
Before school starts or at least within the first two weeks, hopefully this allergic family schedules an educational counseling visit with you – their allergist. With the help of my husband, Ralph E. Cash, Ph.D. (Gene), a school psychologist, I hope to inspire you to develop a plan that will keep your patients safe at school. Be forewarned that while these suggestions are based, in part, on established guidelines, we are attempting to clarify what has been a blurred and overly complex message to schools about how to prepare for, recognize, and treat the allergic emergencies that occur at school. I ask that after reading this article you send us YOUR school emergency plan, your rationale, and examples of your successes or failures. We can then start to gather and to publish “cloud” knowledge.
The first step is for you, the allergist, to educate the parents and the patient about how to avoid their allergens or triggers, how to recognize early signs and symptoms of anaphylaxis or asthma, and when and how to ask for help. While you likely addressed these issues when the patient was first diagnosed, we all need repetition, repetition, and repetition before information becomes usable knowledge. Try using a combination of age-appropriate instructional videos, articles, and the patient/public portal of the ACAAI website. Also, be available to answer those thorny questions that do not always have a black or white answer. This is the time to have the patient demonstrate for you or a trained staff member how and when they would use their short-acting beta agonist (SABA) and/or their epinephrine auto-injector. For some patients, the actual demonstration of self-administered epinephrine in your office should be considered, as this could eventually save their lives. Your key messages for anaphylaxis education should be to administer epinephrine with the first symptoms of anaphylaxis and that antihistamines play no major role in anaphylaxis treatment. Be sure to explain that what may have seemed to be the benefit of Benadryl in the past was actually their own body’s protective mechanisms — natural release of epinephrine — that pulled them through, not the antihistamines. Likewise, the message about asthma is that the patient has a life-threatening disease, but when properly treated (SABA should always be in their back pocket or book bag), it can be controlled.
The next step is for you to review the new NIH Food Allergy Guidelines and perhaps brush up on the NIH Asthma Guidelines. Formulate an emergency treatment plan that not only you (and perhaps the parent), but also the teacher or cafeteria supervisor, who may have very limited medical knowledge, can understand and implement. When an allergic emergency occurs, it is usually the teacher (80 percent of the time), not the school nurse, that is the first to respond.
Having recently given the food allergy/anaphylaxis diagnosis some serious consideration, I believe that for each allergic food reaction, we need to separate the food reaction into “food allergy” or “food-induced anaphylaxis” so that our patients and school personnel get a clear message! I reached this conclusion partly through the persuasive efforts of Gene, my in-house school psychologist, who made me realize that we are often sending vague, mixed messages without consistent, clearly stated, and easily understood decision-making steps. The end result could very easily be delay of effective treatment and death from anaphylaxis or asthma. Since the definition and implications of this two-fold classification is still being debated, even among food allergy experts, I admit that these are MY personal, biased, but carefully considered, definitions.
Food-induced anaphylaxis: If any allergy patients (pre-diagnosed food allergy) has had a food-induced anaphylaxis (past history) anytime in the past (characterized by at least two systems of involvement, e.g., cutaneous and respiratory), and, subsequently, (e.g., at school) ingests that food allergen (exposure) and develops any sign or symptom of anaphylaxis (presumed reaction, e.g., even if only hives, or involving one system), consider this “food-induced anaphylaxis” and implement the “food anaphylaxis action plan” in this order:
1) Give auto-injectable epinephrine immediately
2) Call 911
3) Call the parents.
There is no place on this “food anaphylaxis action plan” for an antihistamine, a second-line drug, which does not start to work (i.e., to relieve itch) until approximately one hour after administration. Having “Benadryl” on the plan will only confuse those involved and delay appropriate treatment, which can prevent more severe anaphylaxis or even death. Furthermore, given a choice, non-medical (and at times even medical) caretakers will administer Benadryl and take a “watch and wait” attitude. If included in the plan, Benadryl will almost always inappropriately be given first (and at times, regrettably, last).
Food-induced anaphylaxis (equivalent): Patients (pre-diagnosed food allergy) who have had only single system involvement (e.g. only hives) in reaction to foods recognized to have a high risk of mortality (high risk past history to the big four: peanuts, tree nuts, shellfish or fish), and who may have been exposed to one of those allergens (presumed exposure) should be treated identically to patients who have had prior reactions involving two systems, as previously discussed (food anaphylaxis action plan). Any patient with asthma who also has ANY food allergy (pre-diagnosed asthma and food allergy) with one system of involvement (high-risk past history) and who may have been exposed to his or her allergen(s) (presumed exposure) may be treated in like manner (food anaphylaxis action plan). In my practice, those considered to have moderate or severe asthma would fall into this category.
“Food Allergy”: Patients, without asthma or with only mild asthma (pre-diagnosed food allergy) who have had a previous reaction to a lower risk of mortality food (e.g. milk or egg) involving only one system (low-risk past history) and who may have been exposed to a food to which they are allergic (presumed exposure) may be provided with an alternate “food allergy emergency plan.” With inadvertent exposure to this food allergen and only a single system of involvement (low-risk reaction), the patient could be administered an antihistamine and closely observed. Any sign or symptom of a second system of involvement (presumed reaction) would be the signal to move into the food anaphylaxis emergency plan, as described above. Realizing that this may add confusion for school personnel, I believe that choosing to use the “food anaphylaxis emergency plan” for ALL food allergic patients would be an appropriate, and perhaps the safest, alternative.
As in food-induced anaphylaxis, we need to deliver the message that asthma must be recognized and treated early and that, if prescribed, the SABA should be used before exercise—always.
But how do the patient and parent get this accomplished at school? I asked Gene to address where the parent should start for getting help at school, how to develop a school safety plan, the pros and cons of peanut-free zones in schools, and preventing bullying for the allergic child.
Developing a school safety plan for food allergic and asthmatic students
Food allergies are fairly common and potentially lethal. To put the problem in prospective, in a school of 1,000 students, statistically 20 students will be allergic to peanuts, 17 to milk, 14 to shellfish, 10 to tree nuts, and five to fish. If an allergic student is exposed to his/her specific allergen(s), a potentially fatal anaphylactic reaction could occur. In addition, up to half of allergic/asthmatic students have been bullied by being threatened with allergen exposure. As a result, every school needs both a safety plan for medical emergencies and a bullying prevention plan in place before a crisis occurs.
Collaboration between the school and community is necessary to develop plans that will work for the student body and culture of each particular school. It is critical that the school principal is on board and takes leadership in plan development. The team creating the plans should be made up of all key players in the community and the school, ensuring a cultural balance that is truly representative of the students, parents, and staff. If this team reactively forms after a crisis situation involving a particular student, it would be best NOT to invite members of that family to be part of the team, because the plans must serve all students and not just one. However, the family of that student should be allowed to review the plans after they have been formulated and offer feedback.
Who to include on your school safety plan team
School principal (or his/her designee, as long as the designee clearly represents the administration and has decision-making authority)
Teachers (at least two who are interested in student health issues)
School social worker
School cafeteria manager
Parents of food allergic/asthmatic children (representatives from at least two families)
Parents of non-allergic children (representatives from at least two families)
Attorney (preferably a parent)
At middle and high schools, one allergic/asthmatic and one non-allergic student
The school principal can add key members in addition to those listed above
While formulating the plan, team members should incorporate all the elements of the acronym CREATE:
- Collaborate to develop the school safety plan for food allergic and asthmatic children
- Respond effectively to community concerns
- Educate all staff and students about recognizing the signs and symptoms of food allergic reactions and the critical importance of implementing appropriate interventions
- Avoid allergenic foods to the extent possible
- Treat signs of anaphylaxis immediately with epinephrine to save lives
- Evaluate the effectiveness of the plan regularly
Collaborate on safety plan development
Without a multi-disciplinary planning team, which is representative of the entire school community, even the best crafted action plan will fail. Pooling knowledge of community values, expectations, and religious or culturally-based beliefs as well as the expertise of a number of different professional disciplines is likely to make a plan not only evidence-based, but also sensitive to the needs of the students and families in each individual school. The plan must also be simple and straight-forward enough for virtually any school staff member to carry it out in an emergency.
Critical steps in the plan for dealing with food anaphylaxis might be as follows:
Step #1: First responder or patient (if auto-injector is carried) administers epinephrine
Step #2: Call 911
Step #3: Inform school principal
Step #4: Retrieve individualized anaphylaxis treatment plan and call parents
Step #5: Re-administer epinephrine if condition stays the same or worsens
Step #6: Possibly administer antihistamine, if available
Step #7: Cooperate with emergency medical personnel
Respond to community expressions of dissatisfaction
Although it takes many people working together to create a school-wide safety plan that can help ensure child safety, it only takes a few disaffected individuals to sabotage the effort. In many cases, problems could be avoided simply by consulting with individuals who express disagreement or concerns about the plan, although these individuals do not necessarily have to be members of the planning team. Feeling disenfranchised, unrepresented, or left out is the most common reason for anger, resentment, and undermining of action plans.
Educate students, staff, and parents
Education is the key to saving lives at school. The school nurse should be a key leader of the education effort, but where a school nurse is not available, a local physician or well-prepared staff member can provide the training. The education should be for all school staff as well as for students, but the emphasis must be on educating teachers, because they generally are the first to notice a possible allergic reaction and the ones who typically must take charge. Approximately 80 percent of allergic reactions at school take place in classrooms. The perfect time to educate students is during bullying prevention education.
Some key messages to convey to all school staff:
Serious consequences —even death from anaphylaxis — usually are caused by:
- Failure to recognize the early symptoms of anaphylaxis
- Failure to follow the emergency action plan carefully
- Calling parents first before giving appropriate medication (epinephrine)
- Lack of knowledge about how to administer epinephrine
Educating the allergic student and the parents is primarily the responsibility of the allergist and the pediatrician. The school staff needs to reinforce the education process so that the child has the age-appropriate information necessary to identify a possible allergic reaction.
Avoid allergenic foods
The food allergic student must be aware of situations to avoid, learn how to identify hidden food allergies, recognize that it is not primarily the responsibility of other students (or even school staff) to avoid allergic foods, and be aware that it is unlikely that other students will make his/her food allergic problem a high priority. In most cases, it’s best for the food allergic child to minimize discussion of the food allergy and to avoid “wearing it on her/his sleeve.” In other words, try not “to make a big deal” about having food allergies. The school facilities — the cafeteria, the classroom, and the other social areas — must have clear food content labeling. The student must learn to identify safe and unsafe foods.
Treat suspected anaphylaxis immediately and effectively
Each food allergic/asthmatic child must have a “go-to” person at school, as well as two backups. The school nurse and school counselors are appropriate people for the job. The child must be allowed to leave any setting, e.g., the classroom, without asking permission to go directly to this person or to one of the backup staff members if he/she is concerned that he/she may be having an allergic reaction. Once anaphylaxis is considered, epinephrine should be administered. Epinephrine administration is the only action that can save lives during an anaphylactic reaction. The staff and student must have a key phrase that will be used to alert everyone that the child is at risk. The suggested phrase is “I think I am having an allergic reaction. PLEASE HELP ME!”
Any child experiencing suspected anaphylaxis should receive epinephrine and then 911 should be called. When the child is mature enough to recognize that he/she is having a serious allergic reaction and has the skill necessary to self-administer epinephrine, he/she should carry an auto-injector at all times. Finding the student’s specific anaphylaxis treatment plan and calling the parents can wait until the emergency care is administered. The severity of an anaphylactic reaction cannot be predicted based on severity of a past reaction or level of positivity of the allergy skin test or blood test.
While individualized anaphylaxis treatment plans at school identify the allergic child and should be part of the planning for food allergy emergencies, they should NOT be retrieved at the moment of crisis if this in any way delays the administration of epinephrine. There could be children with food allergies who are not recognized or identified to the school who experience life-threatening anaphylaxis. There may be children of “low-responder” parents who minimize or deny the presence of symptoms. Or this may be the child’s first allergic reaction, as 25 percent of first reactions to peanut and tree nuts occur at school.
Evaluate the effectiveness of the safety plan regularly
Once a safety plan is developed and agreed on by the team, it should be followed for all students and only modified based on the team’s annual review or the school board’s action (not because of one or two demanding parents). It should be reviewed and revised, if necessary, before the beginning of each school year by the existing team or a new team of similar composition. Objective data, as well as information about school community satisfaction with the plan, should be collected periodically and made available to the review team and community members.
Show the school safety plan for food allergic and asthmatic students to parents of allergic children and reassure them that this plan was carefully constructed with input from medical personnel, school staff, and parents. Likewise, assure parents that a bullying prevention program, either mandated by the school district or developed by a similar team, is in place. Every school should have a bullying prevention program tailored to the needs of the student population and the community. There is no “one size fits all” program available.
Please note that most food allergen exposures could be prevented with measures less strict than requiring allergen- or peanut-free tables or zones in schools. Such areas frequently cause more problems than they solve. One published study, for example, showed that 85 percent of unintentional exposures among peanut-allergic children occurred at schools that prohibited peanuts.
Pro argument for banning allergic foods at school:
- It may reduce the potential for allergic food exposure from the environment.
- Where does one draw the line? Which foods and how many will be banned?
- Banning allergens gives a false sense of security.
- Accidents occur even when foods are banned.
- Bans place burdens on unaffected families.
- Legal ramifications may result from absolute bans.
The only published controlled study about contact and inhaled peanut butter exposure showed no severe symptoms, only local skin reactions from contact in a small percentage of patients. Reported observational studies have not shown any life-threatening reactions or fatalities from skin contact with allergic foods. There have only been two serious reactions (wheezing and hives in each patient) from inhaled peanut materials. There have been no known fatalities from inhaled or skin contact with peanuts. Anaphylaxis from inhalation of allergens is more common with steam from shellfish and fish than from inhaled peanut and tree nut allergens. Most anaphylactic reactions result from ingesting food to which the individual is allergic.
Sometimes the cure can be worse than the problem. Having effective safety and bullying prevention plans in place are generally better strategies than attempting to eliminate allergens from all or parts of a school.