Food allergy & Anaphylaxis in the school setting: 2016

Food Allergy & Anaphylaxis in the School SettingNathan Hare MD, FAAAAIAllergy Partners of Lewisburg2016

Disclosures

•None

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 WheatSoy 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.

http://www.ncbi.nlm.nih.gov/pubmed/24388012




• 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.

http://www.ncbi.nlm.nih.gov/pubmed?term=Young%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=19493563

http://www.ncbi.nlm.nih.gov/pubmed?term=Mu%C3%B1oz-Furlong%20A%5BAuthor%5D&cauthor=true&cauthor_uid=19493563

http://www.ncbi.nlm.nih.gov/pubmed?term=Sicherer%20SH%5BAuthor%5D&cauthor=true&cauthor_uid=19493563


• 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 Educationhttp://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/)

EpiPen

Adrenaclick

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

http://goo.gl/RUjVmq

http://goo.gl/guppeM

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

School Access to Emergency Epinephrine (Act 195 of 2014)• 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

School Access to Emergency Epinephrine (Act 195 of 2014)

• 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

http://goo.gl/4UhlTi

http://goo.gl/4UhlTi

http://allergyready.com/

http://allergyready.com/

http://www.allergyhome.org/schools/



http://goo.gl/Tu4fh

http://goo.gl/Tu4fh

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

http://www.foodallergy.org/

http://www.aafa.org/

http://www.kidswithfoodallergies.org/

Thank you!

• Questions? Comments?

• Nathan Hare MD, FAAAAI

• 570-522-8111 (office)• www.allergypartners.com/lewisburg• https://www.facebook.com/APLewisburg

• [email protected]• @AllergyTele

http://www.allergypartners.com/lewisburg

mailto:[email protected]

Food allergy & Anaphylaxis in the school setting: 2016

Health & Medicine

Transcript of Food allergy & Anaphylaxis in the school setting: 2016