Food allergy & Anaphylaxis in the school setting: 2016

Food Allergy &
Anaphylaxis in the
School Setting
Nathan Hare MD, FAAAAI
Allergy Partners of Lewisburg
2016

Disclaimer
This presentation is designed to present guidelines for
school nurses, principals and staff. This presentation is
for informational and educational purposes only.
Those involved in the creation of this presentation,
including Nathan Hare, M.D. and Allergy Partners, PA, will
not be held responsible for any treatment taken by
viewers as a result of their interpretations of the
information provided.

What is an Allergy?
An immune response to a formerly
external trigger (called an allergen).
• Food
• Insect Sting
• Medicine
• Latex
• Pollen
• Mold
• Dust mites
• Animal Danders
• Insects
The immune system’s attempt to protect you
from the allergen leads to symptoms

• 8 Foods cause 90% of food allergies:
Milk Egg
Peanut Wheat
Soy Tree nuts
Fish Shellfish
• Approximately 8% of children have a food allergy
• Roughly 2% have peanut allergy
Food Allergy
Sicherer SH, Sampson HA. Food allergy: Epidemiology, pathogenesis, diagnosis, and treatment.
J Allergy Clin Immunol. 2014 Feb;133(2):291-307; quiz 308. doi: 10.1016/j.jaci.2013.11.020. Epub 2013 Dec 31.

• Usually the food has to be ingested
• Rarely it can occur with contact
• Does not usually happen with inhalation
Food Allergy Reactions
Young MC1, Muñoz-Furlong A, Sicherer SH. .Management of food allergies in schools: A perspective for allergists. J Allergy Clin Immunol. 2009
Aug;124(2):175-82, 182.e1-4; quiz 183-4. doi: 10.1016/j.jaci.2009.04.004. Epub 2009 Jun 3.

• 0 to 2 hours after ingestion
Food Allergy Reactions: When
do they occur?

Food Allergy: Management
• Avoid eating the food allergens
• Learn how to read a food label
• Have a Food Allergy Action plan in place
• Have injectible epinephrine on hand (2 doses)
• Consider wearing a medical alert bracelet
• Immunotherapy: possibly

• “16% to 18% of children with food allergy experienced a
reaction in school
• Nearly 25% of peanut/nut-induced allergic reactions in
school/day care were reported to be before diagnosis
• In a survey of school epinephrine administration,
approximately 25% of recipients had no previous diagnosis”
Food Allergy Reactions at School

• In the children registered in the US Peanut and Tree Nut
Registry, 79% of reactions occurred in the classroom, usually
with skin contact during craft projects, such as peanut butter–
containing bird feeders, and only 12% of reactions occurred in
the cafeteria.
• In Massachusetts, the majority of the reactions occurred in
the classroom (46%), followed by the health office (17%),
playground (10%), and cafeteria (9%).
Where do the reactions occur?

Best Practice
• Read food labels every time
• No food sharing or trading
• Practice good hand washing before and after eating
(note: hand sanitizer does not remove the food –
soap/water and/or hand wipes are okay)
• Prevent cross contamination/cross contact of foods,
utensils, eating areas, classroom surfaces, etc.
• Clean and disinfect all surfaces
• Substitute food items in classroom lesson plans and
special events
Children’s Hospital St. Louis, Food Allergy Management and Education
http://goo.gl/t0Kn5t

• Bar soap, liquid soap, and commercial wipes were effective in
removal from hands
• alcohol-based hand sanitizer was not
• Table surfaces contaminated with peanut butter were
effectively cleaned by soaps and commercial cleaning agents
but not dishwashing liquid alone.
Cleaning Peanut Butter Residue

• Not studied
• Risk Stratification- who is more likely to contact
an allergen unintentionally
• Less of an issue as children age
• Older children – more common to have an
allergen-free table or classroom
To Ban, or Not to Ban?

Stinging Insect Allergy
• Honey Bee
• Yellow Jacket
• Yellow-Faced Hornet
• White-Faced Hornet
• Paper Wasp
• Fire Ant
• An estimated 0.4-0.8% of children, and 3% of adults, have
potentially life-threatening reactions to stings.
http://goo.gl/wi7PFc

Stinging Insect Allergy:
Management
• Venom allergy immunotherapy
• Venom Allergy Anaphylaxis Action Plan
• Have injectible epinephrine on hand (2 doses)
• Medical Alert Bracelet
• Behavior modifications to reduce risk of
exposure

• Poor recognition of allergic reactions
• Inconsistent treatment of reactions with
epinephrine
• Inadequate food allergy management plans
Deficiencies in Managing Food
Allergies at School

• For children in the US Peanut and Tree Nut Registry, Sicherer
et al found that in 32% of the cases, school personnel did not
recognize the symptoms of an allergic reaction.
• Nowak-Wegrzyn et al showed that although all but 1 school
had personnel trained to administer epinephrine, 22% had no
backup staff, and 16% had no medications available.
• Watura found 64% of the students with nut allergy had no
available medications of any kind, and only 26% had
epinephrine.
Recognizing & treating reactions

• A rapid, sudden onset, life-threatening,
allergic reaction.
• Most likely triggers at school:
• Food
• Insect Sting
• Rarely, exercise or cold air exposure
Anaphylaxis

• Mouth: Itchy, swelling of tongue and/or lips
• Throat: Itchy, tightness/closure, hoarseness, trouble
breathing/swallowing
• Skin: Itchy, hives, redness, swelling, red watery eyes
• Gut: Nausea, vomiting, cramps, diarrhea
• Lung: Short of breath, wheeze, repetitive cough
• Heart: Pale or blue skin color, dizzy/faint, weak pulse
• Neurological: Sense of “impending doom,” irritability, change
in alertness, mood change, confusion
Allergy / Anaphylaxis Symptoms
http://goo.gl/Fp12Sp

• Skin - itching, rash, hives, swelling, flush
• >90%
• Respiratory - wheezing, cough, chest tight, dyspnea,
runny nose
• 40-60%
• Cardiovascular - loss of consciousness, lightheaded
• 30-35%
• Gastrointestinal –nausea, vomiting, diarrhea, abdominal
pain
• 25-30%
Anaphylaxis: Signs & Symptoms

• Epinephrine (repeat in 5 minutes if no improvement)
• ~25% of the time a second dose is needed
• “If there is any doubt, it is generally better to administer
epinephrine.”
• Call 911
• Benadryl
• “H1 antihistamines are considered second line to
epinephrine and should not be administered in lieu of
epinephrine in the treatment of anaphylaxis.”
• Have them lie down and elevate their legs
Management of Anaphylaxis
http://goo.gl/oDh4CD

• “Study on fatal and near-fatal food-induced anaphylaxis in
children and adolescents by Sampson et al in 1992 reported
that 4 of the 6 fatalities but none of 7 near-fatal reactions
occurred in school. “
• The “fatalities were associated with significant delays in
treatment with epinephrine, with no child receiving
epinephrine sooner than 22 minutes after symptoms and a
mean treatment time of 75 minutes.”
• As a rule, the sooner epinephrine is given, the better the
outcome.
Why Epinephrine?

Injectible Epinephrine
• EpiPen (https://www.epipen.com/)
• Adrenaclick (http://adrenaclick.com/)

Generic
• http://www.epinephrineautoinject.com/

• The Food Allergen Labeling and Consumer Protection Act
(FALCPA), PUBLIC LAW 108–282—AUG. 2, 2004
• mandates that the labels of foods containing one of the eight
major food allergens (milk, eggs, fish, crustacean shellfish,
peanuts, tree nuts, wheat, and soy) declare the allergen in
plain language, either in the ingredient list or via:
• • the word “Contains” followed by the name of the major
food allergen (i.e.) “Contains milk, wheat”
• • a parenthetical statement in the list of ingredients – (i.e.)
“albumin (egg)”
Food Allergy Labeling
http://www.stlouischildrens.org/sites/default/files/fame/files/Laws_aug2014.pdf

• The Individuals With Disabilities Education Act
• Section 504 of the Rehabilitation Act of 1973
• The Americans with Disabilities Act, 1990.
Food allergy at School:
Federal Statutes

Section 504 of the Rehabilitation Act of 1973
• “Students with life-threatening food allergy fall under this law,
as their health condition meets its definition of
handicap/disability; i.e., a physical condition that substantially
limits one or more major life activity (i.e., eating, breathing).”
• “A 504 Plan is a written management plan outlining certain
accommodations made by the school that address the
student’s food allergy.
• Examples of 504 accommodations may include, but not be
limited to, special seating arrangements, curriculum
adjustments, field trips, special school events and staff
training. “

• For schools participating in a federally-funded school nutrition
program, USDA regulations 7 CFR Part 15b require
substitutions or modifications in school meals for students
whose disabilities restrict their diet
• The Family Education Rights and Privacy Act of 1974
(FERPA)
• Schools should be careful if they attempt to somehow
identify or publicize a student’s food allergy without
consent from the student’s parents/guardians
Food allergy at school:
Federal Statues continued

• The School Access to Emergency Epinephrine Act
(2013)
• “encourages states to implement policies
requiring schools to stock undesignated
epinephrine auto-injectors for use in
emergencies “
Epinephrine auto-injectors at
school: Federal Law

Food Allergy &
Pennsylvania Law
• Overview of Life Threatening Allergies in the School
Setting
• http://goo.gl/RUjVmq
• Pennsylvania Guidelines for Management of Food
Allergies in Schools
• http://goo.gl/guppeM

School Access to Emergency
Epinephrine (Act 195 of 2014)
• 1. A school entity or nonpublic school may authorize a trained
school employee to:
• a. Provide an epinephrine auto-injector that meets the
prescription on file for either the individual student or the school
entity or nonpublic school to a student who is authorized to self-
administer an epinephrine auto-injector;
• b. Administer to a student an epinephrine auto-injector that
meets the prescription on file for either the individual student or the
school entity or nonpublic school;
• c. Administer an epinephrine auto-injector that meets the
prescription on file for the school entity or nonpublic school to a
student that the employee in good faith believes to be having an
anaphylactic reaction.
• http://goo.gl/2B427k

• A physician or CRNP may prescribe epinephrine auto-injectors in the name of the
school entity or nonpublic school.
• A school entity or nonpublic school may maintain a supply of epinephrine auto-
injectors.
• If the school maintains a supply they shall designate one or more individuals to
be responsible for the storage and use.
• Individuals responsible for the storage and use must successfully complete a
training approved by the Department of Health.
• The law does not differentiate between licensed and unlicensed school staff.
Therefore, all school staff designated to administer an epinephrine auto-injector
must successfully complete a Department of Health approved training.
http://goo.gl/2B427k

• The Good Samaritan Law shall apply to a person who
administers an epinephrine auto-injector pursuant to this
section.
• If school staff are authorized to administer an epinephrine
auto-injector, regardless of whether it's a student's individual
prescription or from the school's stock, they must be trained
using a Department of Health approved course.
http://goo.gl/2B427k

• The closer to the child it is kept, the better
• They should be allowed to carry it on them if possible, and if
they are old enough and competent to do so.
• The quicker a child with anaphylaxis is treated, the better the
outcome.
• If not possible to keep it on the child, it should be kept at most
within a few minutes away, in an unlocked location.
Epinephrine: Where to keep it?

• Poor recognition of allergic reactions
• Inconsistent treatment of reactions with
epinephrine
• Inadequate food allergy management plans
• EAP: Emergency Action Plan
Deficiencies in Managing Food
Allergies at School

• For 100 randomly selected children registered in the US Peanut
and Tree Nut Allergy Registry, Sicherer et al. found that an EAP
was in place in only 33% of the cases, and during a reaction, it
was followed only 73% of the time.
• Rhim and McMorris surveyed 109 schools in Michigan and found
EAPs were in place for only 16% of the students, and only 21% of
school policies addressed the issues of reading labels and hidden
ingredients.
• Nowak-Wegrzyn et al interviewed parents and school
representatives of 132 schoolchildren with food allergy. Of those
students who had food-induced allergic reactions in school, 14%
had no physician’s order for treatment.
Inadequate food allergy
management plans

• Wu and Hill surveyed school nurses from 47 schools in
Indianapolis and found that 53% of the schools had no policy
for management of anaphylaxis and the remaining 47% had a
policy that consisted only of calling 911.
• Weiss et al performed a national survey of 400 school nurses
and found staff training was in place for 78%, 43%used
guidelines provided by the state, and 32% followed guidelines
developed by an outside organization.
• Watura surveyed 83 schools in the United Kingdom and found
9% of schools were unable to state what they would do in the
event of an allergic reaction; representatives of 1 school
stated they would ask the child.
Inadequate food allergy
management plans

Tips for developing a good
Food Allergy management plan
• School policies should address the issues of reading
labels and hidden ingredients
• Have an Emergency Action Plan (EAP) in place for all
children with food allergy and venom allergy.
• Staff should be trained on how to manage anaphylaxis
• Run anaphylaxis drills regularly!
• Follow the EAP during a food or stinging insect allergic
reaction
• Have a school policy for the management of anaphylaxis
that goes beyond calling 911
• Consider following a published set of guidelines

Example Guidelines: Food Allergy
Management & Education
• The recommendation is that every school with a child at risk
for anaphylaxis has a full time registered professional nurse on
staff, responsible for the development of the Individual
Healthcare Plan (IHP), or Emergency Care Plan (ECP)/Food
Allergy Action Plan (FAAP).
• Every child at risk for anaphylaxis will have one or more of the
following: Emergency Care Plan (ECP)/Food Allergy Action Plan
(FAAP), an Individual Health Plan (IHP) and/or a 504 plan to
include a specific classroom plan

Example Guidelines: Food Allergy
Management & Education
• The school will contact local Emergency Medical Service (EMS) to
inform them that a student with life-threatening allergy is enrolled
(note: not all ambulances carry epinephrine)
• Staff will be trained on food allergy prevalence, symptoms and
reaction prevention at least annually and as needed. Drills should also
be practiced
• All necessary staff should be trained in epinephrine auto-injector
administration
• All necessary staff should be aware of epinephrine auto-injector
location (unlocked)
• Develop an emergency shelter-in-place (disaster) plan

• Identify a person who will be responsible for
calling emergency medical services
• Identify the person who will document each
treatment and the time that each is rendered.
• Emergency medications should be up-to-date and
complete.
• Everyone who will be directly involved in patient
care should be able easily to locate necessary
supplies and be prepared to begin treatment so
that no time is lost in implementing emergency
measures.
• Do it regularly!
Anaphylaxis Drill
http://goo.gl/oDh4CD

Take Home Points
• A food allergy is an immune reaction to a food.
• Anaphylaxis is a sudden onset, life-threatening allergic
reaction.
• Three areas important to managing food allergy and
anaphylaxis in the school well:
• Excellent recognition of allergic reactions
• Consistent treatment of reactions with epinephrine
• Superb food allergy management plan

• Children’s Hospital St. Louis: Food Allergy Management
and Education (http://goo.gl/4UhlTi)
• Allergy Ready (http://allergyready.com/)
• online course for teachers, administrators and other
school personnel
• http://www.allergyhome.org/schools/
• National Association of School Nurses
• http://goo.gl/Tu4fh
Food Allergy Resources for Schools
http://goo.gl/C206VZ

Advocacy foundations
• FARE (Food Allergy Research and Education)
www.foodallergy.org
• Asthma and Allergy Foundationof America (AAFA)
www.aafa.org
• Kids with Food Allergy Foundation
www.kidswithfoodallergies.org

Thank you!
• Questions? Comments?
• Nathan Hare MD, FAAAAI
• 570-522-8111 (office)
• www.allergypartners.com/lewisburg
• https://www.facebook.com/APLewisburg
• ndhare@allergypartners.com
• @AllergyTele

Food allergy & Anaphylaxis in the school setting: 2016

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