Food Allergy Booklet

8/9/2019 Food Allergy Booklet

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Setting the Standard

Managing Food Allergies in School

Managing Food Allergies Handbook - 2 -

Table of ContentsMessage ......................................................................................... 3Terms to Understand ...................................................................... 4Introduction ..................................................................................... 5

School Laws .................................................................................... 6Understanding Food Allergies and Anaphylaxis .............................. 7Signs and Symptoms/ Diagnosis/Prevention .................................. 9Treatment...................................................................................... 10Medications .................................................................................. 12Management plan for the School

Algorithm for Food Allergy Management ............................ 17 The Role of the Student ..................................................... 18

Parent/Guardian Support ................................................... 19

Guidelines for School Administration Support .................... 20

School Nurse Support ........................................................ 21

o Health History Planning ................................................ 23o Health History Forms .................................................... 24o Student Individualized Health Plan ............................... 28o Food Allergy Action Plan ............................................... 30o Transportation Student Food Allergy Form ................... 32o Food Service Student Food Allergy Form ..................... 33

Guidelines for Teaching Staff Support................................ 34

Classroom and School Environment Concerns .................. 35

Field Trip Issues ................................................................. 36o Field Trip Parental Permission Form ............................. 37

Coaches/Athletic Director/Club Advisors/

After-School Employees/Volunteers ................................... 40 Maintenance/Custodial Personnel Issues .......................... 41

Food Service Personnel Issues .......................................... 42

Cafeteria Accommodations ................................................ 43o Food Allergy Substitution Form ................................... 44

Transportation Personnel Issues ........................................ 46

Educational Resources/Training ........................................ 48 Steps to Take in the Event of a Food Allergy Reaction ...... 47 Internet Resources ............................................................. 49

References ......................................................................... 50


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MessageA dedicated group of individuals from the Laurel School District and Community

developed the Setting the Standard: Managing Food Allergies in School handbook.

The Laurel School District developed this handbook to have a consistent way of managing

food allergies and reactions in the school setting. The districts goal is to provide a safe

environment and provide reasonable care for students with life-threatening food allergies.

This handbook is to provide guidance in the management of food allergies at school.

This handbook was developed in collaboration with the following group members:

Mrs. Lori Dado, High School Nurse

Mrs. Debra Garrett, Elementary School Nurse

Dr. Sandra Hennon, Superintendent of Schools

Dr. Harold Dunn, Principal of Academic Affairs

Mr. David Spalding, School Psychologist

Mr. Edward Novad, Custodial/Maintenance Supervisor

Ms. Carrie Bonyak, Cafeteria Supervisor

Mrs. Laurie Pollio, Cafeteria worker

Mr. Joseph Sager, Transportation Supervisor

Mrs. Patricia Miles, High School Teacher

Mrs. Lori Hites, High School Teacher

Mrs. Linda Barletto, Guidance Secretary

Mrs. Dianne Callahan, Special Education Secretary

Mrs. Michelle Patterson, Parent

Mrs. Elizabeth Wilson, Parent

Ms. Sarah Wilson, StudentMs. Megan Patterson, Student

Ms. Ashley Mengel, Student


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Terms to UnderstandAction Plan - Steps used to care for a child who has been exposed to an allergen (food).

Anaphylaxis - A severe life-threatening reaction caused by an allergen (food).

Antihistamine A medication given in orally, intramuscularly, or intravenously to block an

allergic histamine response.

Child - All students ages 4-21.

Epinephrine - Medication used to help with respiratory and cardiac symptoms of an

anaphylaxis reaction.

Food Allergy - Hypersensitivity to food.

Handbook - a written guide to performing specific tasks.

Management - To respond and control a situation.

Plan of Care- a written plan to address medical needs of a student.


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IntroductionThe development of this handbook is to provide a comprehensive guide for school

personnel to follow in the event of a student experiencing a food allergy reaction while at

school.

The school system is a unique setting that has the responsibility to educate students

in grades kindergarten through twelfth grade. Children come into this setting with a vast

number of medical conditions and issues which affect the educational process. The school

nurse is the only medically trained person within these walls. Schools often have only one

school nurse to cover thousands of students. This leaves educators and other untrained

personnel to handle medical situations that arise in the absence of the school nurse. It is the

school nurses obligation to help school personnel understand and identify behaviors in

students which require medical attention. One of those conditions is food allergies.

Food can often lead to a severe life-threatening reaction. The school nurse must

attempt to limit the potential of these types of reactions from occurring. To carry this out, the

school nurse must have a plan. Due to the complexity of food allergies, the plan needs to

have collaboration among parent(s)/guardian(s), and all school departments; including

school nursing personnel, teachers, administration, guidance, food service, transportation

services, custodial staff, and any other school personnel. A comprehensive science-based

plan is essential for providing a safe and successful school experience for students with

food allergies.

This document contains information specific to students with food allergies.

Nevertheless, all students with serious health issues should have a comprehensive plan in

place.


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Understanding Food Allergies and AnaphylaxisFood allergies have increased over the past two decades (Mudd & Noone, 1995).

The Food and Allergy Anaphylaxis Network (FAAN) reports more than 12 million Americans

have food allergies; that is one in twenty-five or 4% of the population (FAAN, 2010). It is

estimated that food allergies affect up to eight percent of children under the age of three and

approximately two percent of the adult population with as many as forty to fifty percent of

those with a diagnosed food allergy are at high risk for anaphylaxis (Sheetz, Goldman,

Millet, McIntrye, Carroll, Gorak, Harrison, & Caricle, 2004). About ninety percent of food

allergies are caused by eight foods: peanuts, tree nuts, milk, eggs, fish, shellfish, soy, and

wheat. Most will be out-grown with age, but peanut and tree nut allergies are life-long (Mudd

& Noone, 1995). The alarming concern the Food and Allergy Network reports is that peanut

allergies have doubled in children over a five year period (1997-2002)(FAAN, 2010).

Children spend eight hours a day for a total of one hundred eighty days in school, and within

this time they can eat two meals each day plus snacks. Keeping this in mind, the chance of

having an allergic reaction related to a type of food is high. According to Mudd and Noone

(1995), in studies of fatal and near fatal anaphylaxis reaction to food, a majority of the

children who died from food- induced anaphylaxis ingested the food at school. Most school

nurses already institute the Food and Allergy Anaphylaxis Network Food Allergy Action plan

to follow in the case of a food reaction. However, treating the reaction is not enough.

Schools need to limit exposure to help prevent an attack from occurring.

An allergic reaction begins with a predisposed individual ingesting a food (by eating,

inhaling, or through contact with mucus membranes). This causes the body to produce an


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antibody that initially attaches to the surface of cells. This initial process yields no

symptoms and will go unnoticed. However, the next time the food is ingested, the proteins

in the food attached to these antibodies cause the body to release a histamine response

that causes an allergic reaction (Formanek, 2001). A reaction can occur within minutes to

hours after ingestion. Symptoms can be mild to life threatening. The specific symptoms that

a student experiences depends on the location in the body in which the histamine is

released. If the allergic reaction becomes severe, it is then known as anaphylaxis, a life-

threatening event (Smith, 2005). Food allergies are the leading cause for anaphylaxis

outside of the hospital setting. Other common causes of anaphylaxis include allergies to

latex, medications, and insect stings.

This handbook will focus on food allergies although some of the information provided

is appropriate for other causes of allergic reactions that can cause anaphylaxis.


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Signs and SymptomsAllergies can affect almost any part of the body and display a vast number of

symptoms. Anaphylaxis includes the most dangerous symptoms, including, but not limited

to: breathing difficulties, a drop in blood pressure, or shock, which are potentially fatal.

Common signs and symptoms of allergic/anaphylactic reactions may include:

Hives CoughingItching (of any part of the body) WheezingSwelling (of any body parts) Throat tightness or closingRed, watery eyes Difficulty swallowingRunny nose Difficulty breathingVomiting Sense of doomDiarrhea DizzinessStomach Cramps Fainting or loss of consciousnessChange in voice Change of skin color

DiagnosisThe diagnosis of allergy with a risk of anaphylactic reactions is made based on the

patients history and confirmed with appropriate skin and/or blood tests done by

appropriately trained allergy specialists.

PreventionAvoidance of a specific allergen is the basis of management in preventing

anaphylaxis. Avoiding the food that produces the allergic problems is tricky. Many of the

common food allergens (peanuts, nuts, fish, shellfish, milk, soy, egg, wheat) are hidden o

accidentally introduced into everyday items that are not obvious to the untrained person.

However, it is definitely possible to reduce a students exposure to allergenic food within the

school setting.

(Source: Position statement- American Academy of Asthma Allergy and Immunology)Accessed fromhttp://aaaai.org/medicaesources/academy_statements/position_statements/ps34.aspon 3/5/2010.
http://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asp


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TreatmentThere is no cure for food allergies. Strict avoidance of food allergens and early

recognition management of allergic reactions to food are important measures to prevent

serious health consequences (FAAN, 2010). Accidental food ingestion can occur despite

avoidance measures. Treatment should be immediately available for these emergencies.

The school nurse is responsible for obtaining and keeping all treatment protocols for

students with food allergies. According to school policy, all medications must be

accompanied with a written physician order for treatments and medications prescribed. The

students parent/guardian must also sign these orders. The school nurse will initiate the

Food Allergy Action Plan (See page 31). This action plan will provide easy to follow steps

for recognizing and treating a reaction and provide key actions to perform for managing the

allergic reaction.

Epinephrine and antihistamine medications are the drugs of choice and should be

administered immediately in an emergent situation of a child having a potentially life-

threatening allergic reaction. Epinephrine injection is available in a number of self-

administration delivery devices (See pages 13-15). There are no contraindications to the

use of epinephrine for a life-threatening allergic reaction. After the administration of these

medications, the student should be transported via ambulance to be evaluated. No one can

predict the events of neither anaphylaxis nor how a student will respond to treatment.

Emergency room personnel MUST evaluate all students after having an allergic reaction.

Epinephrine should be put in locations that are easily accessible to school personnel and

students. These locations must be known by everyone. Students that are old enough to


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self-administer epinephrine should carry their own. For younger children, the epinephrine

device should be kept in the classroom and passed from teacher to teacher as the child

moves through the school (e.g., from classroom to music to PE to lunch), or kept in areas

that are easily accessible to everyone.

All students, regardless of whether they are capable of epinephrine self-

administration, will still require the help of others because the severity of the reaction may

hinder theirattempts to inject themselves. Adult supervision is ALWAYS recommended.

All school personnel need to be familiar with basic first-aid and resuscitative

techniques. This training should include how to use Epinephrine devices. School

employees need to be familiar with these techniques. This will ensure that everyone will

know what to do if a reaction occurs. Quick response and treatment will save lives.


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MedicationsEpinephrine kits are available by prescription only either as a spring-loaded self-

injectable device (Epi-Pen, Epi-Pen Jr; Dey Laboratories, Napa Valley, Calif) or as a

preloaded syringe (Ana-Kit; Bayer Laboratories, Spokane, Wash). The syringe has a

locking notched plunger, which is rotated to enable each of the 2 doses (0.3mg each)

contained in the barrel for self-injection. The spring-loaded auto-injector devices has 1 dose

but may be preferred because of its simplicity of use.

Epi-Pen is available in 2 forms, Epi-Pen Jr and Epi-Pen. The Epi-Pen Jr is used for

children weighing 10 to 20 kg (22 to 45 lb). The Epi-Pen is used for those weighing greater

than 20 kg (45 lb). All those responsible for using epinephrine kits should be familiar with

these kits and the instructions for their use. Training devices and brochures outlining most

aspects of handling and administering epinephrine are available from the manufacturers.

Source: American Academy of allergy Asthma & Immunology 1996-2010 retrieved on March 5, 2010 a

www.aaaai.org/members/academy_statements/position_statements/ps34.asp
http://www.aaaai.org/members/academy_statements/position_statements/ps34.asphttp://www.aaaai.org/members/academy_statements/position_statements/ps34.asphttp://www.aaaai.org/members/academy_statements/position_statements/ps34.asp


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Epi-Pen (old)

(Source: Dey Pharmacueticals - Accessed fromhttp://www.epipen.comon3/5/2010.
http://www.epipen.com/http://www.epipen.com/http://www.epipen.com/http://www.epipen.com/


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Epi-Pen (new)

(Source: Position statement- American Academy of Asthma Allergy andImmunolo )
http://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asp


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Twinject

(Source: Shionogi Pharma, Inc. - Accessed fromhttp://twinject.comon March3, 2010.
http://twinject.com/http://twinject.com/http://twinject.com/http://twinject.com/


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Algorithm for Food Allergy Management

Source: New York School Health Service Center, retrieved on March 16, 2010 atwww.schoolhealthservicesny.com
http://www.schoolhealthservicesny.com/http://www.schoolhealthservicesny.com/http://www.schoolhealthservicesny.com/


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The Role of the StudentThe students play a vital role in managing their food allergy reactions. A student

must be responsible for identifying and notifying staff of potentially life-threatening

symptoms at the onset. This could be a difference between getting prompt treatment or a

delay in response that can be fatal.

The student will:

Be trained to use and expected to carry Epi-pen and Benadryl (Antihistamine) at all

times while participating in school and school-related activities (The school nurse or

the students health care provider will train the student. The training will be

documented and return demonstration will be witnessed).

Be responsible to eat safe foods, not to share foods/utensils with/from other

students. NO SHARE PLAN.

Sit in designated areas in cafeteria as indicated in Students Individual Health Plan.

Be an advocate for self.

Seek assistance whenever needed.

Be responsible to report signs and symptoms at first onset to responsible person

(The Nurse will be notified immediately by that person). Administer Epinephrine at first onset of symptoms under adult supervision (A trained

adult may assist if needed).

Be responsible for own care during after school activities.

Be responsible for being observant and careful not to be around others eating,

example snack area, concession stands, etc.

Know signs and symptoms of anaphylaxis.

Follow plan as written.


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Parent/Guardian SupportParent/Guardian(s) are an integral part of the entire process for managing food

allergies. The parent/guardian(s) must be involved in all aspects of the planning phases in

order for the school district to provide the safest possible care to their child while attending

school.

The Parent/Guardian(s) will:

Provide information to school nurse on food allergies when a child enters school.

Notify the school nurse of any changes in medical care associated with food allergies

once a child is an active student in school.

Provide all required documentation per school policy for medications and treatment

protocols related to food allergy management.

Will assist in writing the Food Allergy Management Plan.

Will comply with the Food Allergy Management Plan as written.

Provide medications and documentation as required by school medication policy for

student.

Support the schools efforts to reduce chances of anaphylaxis.

Communicate openly with school personnel.

Communicate directly with school nurse, cafeteria supervisor, and transportation

supervisor related to concerns for their childs food allergy.

Provide snack alternatives and food item choices for their child.

Communicate with child to discuss care/plan for After School Activities because

there are no medical personnel on site.

o Parent and child will be responsible for any or all arrangements for after schoo

activities. Student is responsible for carrying Epinephrine.

o Staff on site will be educated about food allergy management plan but will be

instructed to call 9-1-1. Should an emergent situation arise (Food Allergy

Action Plans will be easily accessible in designated areas).


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Guidelines for School Administration SupportThe Laurel School Administrators are the foundation to the school buildings operating

efficiently. Managing students with food allergies will require administrator support and

guidance for the management plan to run smoothly. The administration will:

Support the Food Allergy Management Plan as written.

Will guide staff as necessary, to implement and follow the plan.

Responsible for all enforcement and disciplinary actions associated with not following

the Food Allergy Management Plan as written.

Enforce current school procedures (Student Handbook) regarding no food or drinks in

halls, at lockers, anywhere except cafeteria.


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Develop a procedure to notify all employees of those food-allergic students in the

buildings.

Review all cafeteria procedures related to food handling and cross-contamination

and special menu alternatives.

Work with the transportation supervisor to set up procedures to handle emergencies

and to prevent students from bringing food items on the bus.

Notify Transportation, Cafeteria, and Maintenance/Custodial Supervisors of all

identified students with food allergies. The supervisors will notify their staff.

Will provide Transportation Department with identification cards and the procedure

for handling a food allergy reaction on school bus.

Work with the administration and the maintenance department with the development

of proceduresconcerning proper and routine cleaning of classroom areas.

Notify all district employees of the location of the emergency action plan and

emergency medications.

RED binder will contain Food Allergy Action Plan for each identified student.

These binders will be located in Nurses Offices(2), Gymnasiums(3), the Athletic Trainer

Office(1), Cafeterias(2), and Front Offices(2), and Transportation Office(1). Copies will

also be in room 402 on second floor of the high school building (1).

.


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Health History and PlanningThe school nurse is responsible to seek out information pertaining to any student with

identified food allergies.

When a student enrolls in school, information is gathered regarding medical

conditions and health history (See pages 24-27). When a parent/guardian identifies a child

has having a food allergy the school nurse makes contact with the parent/guardian

regarding the extent of the allergy and treatment as prescribed.

Once a food allergy is identified, the school nurse will implement the process and

obtain necessary documentation required under school policy. The school nurse will:

Acquire written medical documentation accompanied with parent signature.

Initiate the Individual Health Plan which can be part of a IEP or 504 plan or stand

alone(See page 28).

Initiate the Food Allergy Action Plan on the student (see page30).

Epinephrine will be available as needed.

Notify all necessary school staff of medical condition and protocol.


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Health History Forms Grade K-6Laurel School District

Health History Form

Today's Date__________________________

Child's Name_____________________________Birthdate_____________Male__________

Female________Parents are: ___Married ___Single ___Divorced ___Separated ___Widowed

Child is living with:___Mother___Father ___Both ___Guardian (Name please):

__________________

If leaving with guardian, what is the relationship to the child?_______________________________________

Have any members of the immediate family died? _____Yes _____No

How many people live in the same household as the child?__________________________________________

Who looks after this child during the day?_______________________________________________________

Are there any problems such as housing, employment, food, etc?___________________________________

Has this child attended: _____Head Start _____Pre-school (where)___________________________

Does your child fall, stumble or bump into things frequently? _____Yes _____NoHow do you feel your child's development compares with other children as brothers or sisters?

_____Same _____Slower _____Faster

Child Health History:

Did the mother have any illness during pregnancy? _____Yes _____No

Did the baby come on time? _____Yes _____No

Did the baby have any special problems in the first six months? _____Yes _____No

At what age did the child sit alone without support?_______________________________________________At what age did the child walk alone?__________________________________________________________

At what age did the child begin to say two or three words together?___________________________________

Does your child have complete bowel and bladder control? _____Yes _____No (if no explain)

Does your child have complete bowel and bladder control? _____Yes _____No (if no explain)_________________________________________________________________________________________

Can the child use the toilet without help? _____Yes _____No

Does the child wet the bed? _____Yes _____Occasionally _____Frequently _____No

Has your child been under a physician's care during the last 12 months?

_____Routine Care _____No _____Other (specify)________________________________

Is there anything about your child's health that concerns you?

_____Yes _____No

Has your child been under a dentist's care during the last 12 months?

_____routine care _____No _____Other (specify)____________________________________

Does your child have any allergies?

Medication _____Yes _____No Food _____Yes _____No Insect Stings _____Yes _____No

Pollens/molds/spores ____Yes ____No Plants _____Yes _____No Other (specify)

If answered Yes, tells us the kind typeof reaction your child has.

Child has:

Contacts ____Yes _____No Glasses _____Yes _____No Hearing aid _____Yes _____No

Orthodontic _____Yes _____No Braces/appliances _____Yes _____No Other

(specify)___________An Equal Rights and Opportunities School District


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List medications that your child is currently taking. Include the reason for the medication

Medication Dose Reason

Has your child ever been hospitalized or had an operation? _____Yes _____NoHas your child had any other illness, accident, or broken bones? _____Yes _____No

When Name of hospital What for

Has your child had any of the following? Give details.

Speech problems

Vision problems

Hearing problems

Emotional problems

Physical disability or other limitations

Family Health History: (Place an "X" in the box to any problems the child's parents, grandparents, brothers

or sisters have had and indicate the relationship in the space provided).

Allergies Eye disease Learning problems

Anemia Hearing problems Multiple sclerosis

Asthma Heart Disease Muscular dystrophy

Cancer Nervous breakdown High blood pressure

Diabetes Kidney problems Sickle cell

Epilepsy/seizures Lead poisoning Tuberculosis

Drug/Alcohol Addition Mental retardation

List Family Members:

Relationship Age Name Any Medical

Problems

Occupation or

School

Educational

Level

Mother

Father

Brother(s)

Sister(s)

Is there anything else you would like us to know about your child?_______________________

______________________________________________________________________


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Health History Form Grade 7-12 (front)Laurel School District

Health History Form

Today's Date__________________________

Child's Name_____________________________Birthdate_____________Male__________

Female________

Parents are: ___Married ___Single ___Divorced ___Separated ___Widowed

Child is living with:___Mother___Father ___Both ___Guardian (Name please):

__________________

If living with guardian, what is the relationship to the child?________________________________________

Have any members of the immediate family died? _____Yes _____No

How many people live in the same household as the

child?___________________________________________

Who looks after this child during the

day?________________________________________________________Are there any problems such as housing, employment, food,

etc?____________________________________

Child Health History:

Has your child been under a physician's care during the last 12 months?_____Routine Care _____No _____Other

(specify)____________________________________

Is there anything about your child's health that concerns you?

_____Yes _____No

Has your child been under a dentist's care during the last 12 months?

_____routine care _____No _____Other

(specify)____________________________________

Has your child had any new immunizations? _____Yes _____No

Please list names and dates

received:_________________________________________________________________________________

_________________________________________________________________________________________

Does your child have any allergies?

Medication _____Yes _____No Food _____Yes _____No Insect Stings _____Yes _____N

Pollens/molds/spores ____Yes ____No Plants _____Yes _____No Other (specify)

If answered Yes, tells us the kind typeof reaction your child has.

Child has:

Contacts ____Yes _____No Glasses _____Yes _____No Hearing aid _____Yes _____No

Orthodontic _____Yes _____No Braces/appliances _____Yes _____No Other

(specify)___________

An Equal Rights and Opportunities School District


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List medications that your child is currently taking. Include the reason for the medication.

Medication Dose Reason

Has your child ever been hospitalized or had an operation? _____Yes _____No

Has your child had any other illness, accident, or broken bones? _____Yes _____No

When Name of hospital What for

Has your child had any of the following? Give details.

Speech problems

Vision problems

Hearing problems

Emotional problems

Physical disability or other limitations

Family Health History: (Place an "X" in the box to any problems the child's parents, grandparents, brothers

or sisters have had and indicate the relationship in the space provided).

Allergies Eye disease Learning problems

Anemia Hearing problems Multiple sclerosis

Asthma Heart Disease Muscular dystrophy

Cancer Nervous breakdown High blood pressure

Diabetes Kidney problems Sickle cell

Epilepsy/seizures Lead poisoning Tuberculosis

Drug/Alcohol Addition Mental retardation

List Family Members:

Relationship Age Name Any Medical

Problems

Occupation or

School

Educational

Level

Mother

Father

Brother(s)

Sister(s)

Is there anything else you would like us to know about your child?___________________________________

______________________________________________________________________


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Sample Individual Health Care PlanLaurel School District

SPECIAL NEEDS HEALTH CARE PLAN

Student Name Date of Birth

Parents/Guardians Name Phone (H)

Address Phone (W)

Phone (C)

Alternate Contact Names Phone (H)

Address Phone (W)

Phone (C)

Primary Health Care

Provider

Phone

Specialty Provider Phone

Specialty Provider PhoneSpecialty Provider Phone

MEDICAL DIAGNOSIS

ALLERGIES (Medication, Food, Bees, Environment)-

Special Recommendations for care___________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

SPECIAL PROCEDURES / SPECIAL DESIGNED INSTRUCTION

PROCEDURE PHYSICIAN ORDER FREQUENCY



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SPECIAL PROCEDURES / SPECIAL DESIGNED INSTRUCTION

MEDICATIONS GIVEN AT SCHOOL

MEDICATION DOSE ROUTE FREQUENCY

MEDICATIONS GIVEN AT HOME

MEDICATION DOSE ROUTE FREQUENCY

SPECIAL CONSIDERATIONS / NEEDS

Diet orFeeding Toileting / Diapers

Positioning Naptime/Sleeping

Outdoor Activities /Sunscreen

Transportation

AdditionalNeeds

Follow Food Allergy Action Plan for Food allergy reaction

Attached to this form

___________________________________________School Nurse Date

____________________________________________

Student/Parent Date


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Food Allergy Action Plan (back side)

Source: Food Allergy and Anaphylaxis Network, retrieved on March 16, 2010 at www.foodallergy.org


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Transportation Student Food Allergy Emergency CardStudent: _____________________________Date of Birth: ___________MEDICAL ISSUE______________________________TREATMENT ______________________________

Parents: __________________________________

Address: __________________________________

Home Phone: ________________

FIRST CONTACT Mothers NAME:_____________________CELL: ____________________________

SECOND CONTACT Fathers NAME____________________PHONE:________________________CELL: _________________________

OTHER CONTACT:NAME:___________________PHONE:_________________NAME:___________________PHONE:_________________

PHYSICIAN:NAME:_______________________PHONE______________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Emergency Checklist for Bus Transportation

Allergy Symptoms:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Treatment: Benadryl 2 tsp by mouth. Epi-pen IM________________________________________________________________________Students Response:

If has Epinephrine and/or Benadryl with them they are to administer immediately

Driver Reponse:1. STOP BUS IMMEDIATELY (in a safe area).2. Call Mr. Sager or Mrs. Polivka immediately provide bus location

They will call 9-1-1 and parents.3. Stay with bus and students. Never Leave.4. If trained assist with students Epinephrine administration if warranted

5. Begin CPR if warranted.

This form is for students with life-threatening food allergies and other issues such as foodintolerances to be completed by your Health Care Provider regarding your childs medicalcondition.


STUDENTPHOTO


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Food Service Student Food Allergy Emergency Card

Student: _____________________________Date of Birth: ___________MEDICAL ISSUE______________________________TREATMENT ______________________________

Parents:__________________________________

Address: __________________________________

Home Phone: ________________

FIRST CONTACT Mothers NAME:_____________________CELL: ____________________________

SECOND CONTACT Fathers NAME____________________PHONE:________________________CELL: _________________________

OTHER CONTACT:NAME:___________________PHONE:_________________NAME:___________________PHONE:_________________

PHYSICIAN:NAME:_______________________PHONE______________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Emergency Checklist for Cafeteria Workers

Allergy Symptoms:________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________

Treatment: Benadryl 2 tsp by mouth. Epi-pen IM________________________________________________________________________Students Response:

If has Epinephrine and/or Benadryl with them they are to administer immediately

Cafeteria Response:1. Clear area surrounding the student. Allow privacy.2. Follow Food Allergy Action Plan for student.3. CONTACT SCHOOL NURSE IMMEDIATELY.

4. Call Supervisor immediately. They will call 9-1-1 and parents.

5. Stay with students. Never Leave.6. If trained assist with students Epinephrine administration if warranted7. Begin CPR if warranted.

This form is for students with life-threatening food allergies and other issues such as foodintolerances to be completed by your Health Care Provider regarding your childs medical condition.


STUDENTPHOTO


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Guidelines for Teaching Staff SupportThe teaching staff is an important component for managing student medical

conditions. They are the eyes and ears inside the classroom. The teaching staff routinely

observes students and are able to pick out unusual mannerisms for a particular student.

This provides valuable information and prompts actions when necessary. These skills will

prove life saving in the event of an anaphylactic reaction. In order to be consistent with all

aspects of care in managing food allergies at school, the teaching staff will:

Utilized a Standardized Substitute notification folder. This MUST be used and

kept in standard location ________________by all staff to notify a substitute

teacher of students with food allergies (and all medical needs)

Be familiar and comply with Food Allergy Management Plan Handbook.

Follow Individual Health Plan and Food Allergy Action Plan as written.

NEVER use food items of any sort in classroom activities.

Only use permitted food items at elementary parties. (May allow fruits and

vegetables, no dips, food provided by cafeteria? If Pizza is furnished by

cafeteria sauce may contain NUT particles and may need glueten free crust)

Ensure a safe classroom environment by not eating at desk or supplying any food

items.

Immediately wash desk with soap and water and dry with separate disposable towel

if area becomes contaminated with any food item.

Know signs and symptoms of anaphylaxis.

Know the location of the Food Allergy Action Plans.


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Classroom and School Environment ManagementIt is essential to manage the school environment in order to limit the exposure of food

allergens in the school. Everyone must work together to keep the school environment safe

for all students. Since it is important to maintain a safe environment the following will occur

within the school buildings:

Family Consumer Science classroom- check name for consistency

The food science classroom will be NUT-FREE at all times. No nuts or any

products containing or products processed in nut factories will be used (this

will limit cross-contamination and air-borne exposure of food allergens).

Procedures for using Family Consumer Science classroom for any afterschool activities must follow NUT-FREE requirement to prevent cross-

contamination.

Tables must be properly cleaned using soapy water clean, using individual

disposable cloths (one per table) and dried with using individual clean

disposable cloth (one per table).

Snack areas

o These areas will remain behind closed doors.o These items are not available during the school day.

o Students with food allergies will be instructed that this is an off limits area unless

no one else is in the area.

Nuts from outside venues

The Laurel School District has no way to enforce nuts coming from an outside source.

We can only discourage others from bringing in foods that contain nuts.


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Field Trip Parental Permission Form

The _________________is planning a field trip. Please review the following trip details and

complete, sign; and return the bottom portion of this form to the club advisor(s) no later than

______________________(due date).

Field trip to_______________________________________________________________

Date of trip ______________Time and place of departure___________________________

Mode of transportation ______________________________________________________

Advisor in charge________________________________Phone______________________

Cost of trip_________Members should bring_____________________________________

_________________________________________________________________________

Detach bottom and return to club advisor(s)

--------------------------------------------------------------------------------------------------------------------------

__________________________has my permission to participate in the field trip

to_________________________ on ___________________________________________

During the activity I may be reached at:

Address__________________________________________________________________

Phone___________________________ Alternative Phone__________________________If I cannot be reached in the event of an emergency, the following person is authorized to

act in my behalf:

Name_________________________Phone____________________________________

Relationship to participant__________________________________________________

Physicians name________________________________Phone____________________

Ambulance Preference_____________________________________________________

Other comments__________________________________________________________

Signature of parent/legal guardian____________________________Date____/____/____



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Laurel School DistrictField Trip - Medical Information

Name__________________________Date of Birth________________________________

Home Address_________________________Home Phone__________________________________________________

IN CASE OF EMERGENCY CONTACT:(1) Name____________________________Phone________________Phone___________Address__________________________________________________________________

(2) Name____________________________Phone________________Phone___________Address__________________________________________________________________

HEALTH INFORMATION: (Please state the facts in connection with the following)

Describe any condition requiring medication as a treatment:___________________________________________________________________________________________________________________________________________________________________________

List any allergies and tells us what happens if exposed_______________________________________________________________________________________________________________________________________________________________________________

Any surgery in the past year?____ If yes, please state nature:________________________

Name of Primary Care Provider:_______________________Phone___________________

Indicate health history information below: A check means yes. Please explain any checksin the space provided.

Respiratory problems- Asthma,Tuberculosis, persistent cough, etc.

Emotional or mental disorders

Heart problems- high or low bloodpressure, Rheumatic Fever, etc.

Recent exposure to a contagiousdisease

Stomach or intestinal problems-ulcers, jaundice, hernia, colitis,indigestion, etc.

Currently under medical care

Eye, Ear, Nose, Throat-Hayfever, earinfections, impaired sight or hearing

Physical limitations

Nervous disorder-convulsions,epilepsy (seizures), dizziness, etc.

Kidney, gall bladder or liver disease

Skin diseases Diabetes or hypoglycemia

Muscular/Skeletal- arthritis, recentfractures

Please explain any checks:__________________________________________________


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Laurel Field Trip Form- Medical Information Continued

RECOMMENDATIONS AND RESTRICTIONS:Any treatment to be continued_________________________________________________

Any medication to be administered (specific dosages). All medications must be brought toevent in their original containers according to school medication policy._________________

__________________________________________________________________________________________________________________________________________________

Any medically prescribed meal plan or dietary restrictions____________________________________________________________________________________________________

Is there any other information that staff need to know about your child?___________________________________________________________________________________________________________________________________________________________________

List any special accommodations that are needed in order to participate in the program:_____________________________________________________________________________________________________________________________________________________

Parental Authorization for Emergency Medical CareMust be signed by parent/guardian

If medical information changes I agree to notify the school district. I herby authorize you, inthe event of an emergency, that is, when you are unable to reach me for authorization or

when circumstances require immediate action, to proceed according to good medicalpractice with treatment of my daughter/son. Also, I authorized the hospital attendingphysician, or other health care specialist administering the treatment to release pertinentinformation to the insurance company assuming coverage for the same.

_______________________________ ________Parent/Guardian Signature Date

Insurance Company Name_________________________Policy Number_____________________Insurance Company Address________________________________________________________Insurance Company Phone Number__________________Subscriber Name__________________

Laurel encourages persons with disabilities to participate in its programs and activities. If you anticipateneeding any type of accommodation or have questions about the physical access provided, please contact theschool in advance of your participation or visit.



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Food Service Personnel IssuesThe food service personnel have an extremely difficult position in maintaining a safe

food preparation area and a safe eating area for all students. This is particularly difficult if

there are air borne food allergies. Therefore, the cafeteria will not prepare, purchase, or

serve any foods containing or processed with NUTS. This will prevent cross-contamination

and will provide a potentially less dangerous area for students with food allergies. The food

service personnel will help ensure a safe area by:

Any student with known food allergies will be provided by the school nurse a

Standard Food Allergy Substitution Form (See pages 44-45)to be completed and

returned to the school nurse and then forwarded to the cafeteria supervisor.

Cleaning tables using soap and water and a separate disposable clean cloth (one per

table) and dried using a separate disposable clean towel (one per table to prevent

cross- contamination).

Perform routine cleaning as directed by supervisor of food preparation areas.

Follow the direction of the supervisor regarding any food allergy issues as necessary.

Knowing the signs and symptoms of anaphylaxis.

Being familiar with the Food Management Plan.

Knowing the location of Food Allergy Action Plan.

Following the Food Allergy Action Plan.


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Cafeteria AccommodationsThe cafeteria area is one of many potential dangers for a student with food allergies.

Therefore, this area must become a safer place for students to eat and socialize. Because

of the potential risks both the elementary and high school cafeterias will not purchase,

prepare, or serve food items containing NUTS. The following recommendations have been

decided upon by the committee members:

All students with food allergies are required to sit in designated areas in the cafeteria

for exposure issues. This is MANDATORY at the elementary level, but is voluntary at

high school level. It is available to all students with food allergies.

The designated food allergy tables will be put up after use and no one is permitted to

use them for any reasons once they are cleaned and set aside.

Any function that uses and occurs in the cafeteria MUST hire a Laurel Cafeteria

worker on-site (paid for by the group requesting use of cafeteria). This will ensure

proper equipment cleaning and limit cross-contamination from use.


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MilkCommon School Items School Substitutions Could Include[] Milk [] No substitutes for milk

Soy (Note: Most of our food items contain soy or soy oil.)Common School Items School Substitutions Could Include[] All Bread Items (Soy Oil) [] Yogurt

[] Purchased Entrees (burrito, nuggets [] String Cheese[] Corndog, hamburger, ravioli, etc.) [] Sun Chips

[] Salad Dressings/Dips [] Potato (Fresh)

[] Most Purchased Snack/Dessert Items [] Hot Dog (no Bun)[] Fresh Fruits and Vegetables

EggCommon School Items School Substitutions Could Include

[] Eggs [] Hamburger on Bun

[] Breaded Entre Items [] Hot Dog on Bun[] Tuna Sandwich [] Peanut Butter/Uncrustable Sandwich

[] Mayo Products [] Cheese Sandwich[] Waffle/French Toast

[] Cakes

[] Muffins/Quick Breads

[] Most of School-Prepared Breads

FishCommon School Items School Substitutions Could Include[] Fish Nuggets (Fun Fish) [] Hamburger on Bun

[] Fishwich on Bun [] Cheese Sandwich

[] Breaded Fish Entrees [] Turkey, Ham or Beef Sandwich

[] Tuna Sandwich [] Chicken Nuggets

FOODS TO OMIT

_______________________ _______________________ ____________________________________________ _______________________ _____________________

_______________________ _______________________ _____________________

FOODS TO SUBSTITUTE*

_______________________ _______________________ _____________________

_______________________ _______________________ _____________________

*Some substitutions may not be available or allowed.

Substitutions must be products commonly available in the district warehouse.

Nutrition Services 724 658 9056 ext. 1945Lori Dado, High School Nurse 724 598 9932

Debra Garrett, Elementary School Nurse 724 658 9056 ext 2941



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Transportation Personnel IssuesRiding a school bus to school is a milestone in every childs life. Parents put their

children lives in the hands of responsible drivers every day. Students with food allergies

place their lives at risk everyday despite being transported to school. Bus drivers can help

reduce the potential dangers for students with food allergies by following the suggestions:

When/If a seat on the bus becomes contaminated proper cleaning of the bus seats is

necessary. Use soap and water and a separate disposable clean cloth (one per seat)

and dried using a separate disposable clean towel (one per seat to prevent cross-

contamination) when a seat becomes soiled or contaminated by food.

Perform routine cleaning as directed by Transportation supervisor. Follow the direction of the supervisor regarding any food allergy issues as necessary.

Knowing the signs and symptoms of anaphylaxis.

Being familiar with the Food Management Plan.

Knowing the location of Food Allergy Action Plan.

Following the Transportation Student Emergency Information Sheet for students with

food allergies (See page 32).

Do not allow any food items on the bus as written in the Student Handbook.

Do not give students any food items for any reason.


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Steps to Take in the Event of a ReactionThe best approach to reacting to an anaphylactic reaction caused by food is to be

educated and prepared. This handbook is designed to help with both. In the event of an

anaphylactic emergency the following steps should be followed:

Food Allergy Action Plans are located in a RED binder and will be accompanied by

epinephrine and antihistamine for easy access. The locations of these binders will

be: (11)

o Nurses Offices (elementary & high school).

o Cafeteria Offices (elementary & high school).

o Transportation Office.

o Front Offices (elementary & high school).

o Gyms (elementary & high school).

o Athletic Trainer Office

o Room 402 of the high school.

Individual Food Allergy Action Plans will be included on every student with a known

food allergy.

A step by step procedures are outlined by the plan.

Follow the plan as written

Never hesitate to administer Epinephrine- It is always better to give than NOT. There

are no harmful effects for not giving epinephrine but if delayed it may be fatal.

Always call for help.

Always call 9-1-1.


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Educational Resources- TrainingEducation is one of the key components to managing food allergy emergencies.

Everyone in a school setting must be trained to be able to recognize and react in order to

help a student who is suffering from a food allergy reaction. All educational programs will be

conducted by the school nurse. Education will include but not limited to:

All parent volunteers will be required to attend an annual Mandatory food allergy

training prior to volunteering in the school district (This will be done at the first PTO

meeting at the elementary school and will be done during the first month of school for

the high school parent(s)/guardian(s) and again in the spring.

Food allergy awareness program will be conducted to all students annually at gradeorientations.

Food allergy awareness programs will occur at the Kindergarten and seventh grade

parent orientation programs.

A mandatory in-service for all school personnel will be provided for all district

employees (teaching staff, clerical staff, cafeteria personnel, transportation

personnel, custodial/maintenance staff.

Food allergy training program and epinephrine administration training will be

available on the school website at all times.

The school nurse will notify key personnel through department supervisors of known

students with food allergies and appropriate information sheets will be provided.


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Internet Resources

Adrenaclick-www.adrenaclick.com

American Academy of Allergies and Immunologywww.aaaai.org

Asthma & Allergy Foundation/NEwww.aafa.org

Epi-pen-www.epipen.com

Food Allergy and Anaphalaxis Network-www.foodallergy.com

Twinject-www.twinject.com
http://www.adrenaclick.com/http://www.adrenaclick.com/http://www.adrenaclick.com/http://www.aaaai.org/http://www.aaaai.org/http://www.aaaai.org/http://www.aafa.org/http://www.aafa.org/http://www.aafa.org/http://www.epipen.com/http://www.epipen.com/http://www.epipen.com/http://www.foodallergy.com/http://www.foodallergy.com/http://www.foodallergy.com/http://www.twinject.com/http://www.twinject.com/http://www.twinject.com/http://www.twinject.com/http://www.foodallergy.com/http://www.epipen.com/http://www.aafa.org/http://www.aaaai.org/http://www.adrenaclick.com/


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ReferencesAdrenaclick Drug information. Retrieved on March 2, 2010 atwww.adrenaclick.com.

American Academy of Asthma Allergy and Immunology Accessed from

http://aaaai.org/medicaesources/academy_statements/position_statements/ps34.aspon 3/5/2010.

Asthma & Allergy Foundation /NE. (1999) [Electronic version] Anaphlylaxis. Preventing life-

threatening food allergy emergencies in schools. A resource packet for school

nurses and administrators. Accessed atwww.aafa.orgon February 1, 2009.

Epipen Drug Information. Retrieved on March 2, 2010 atwww.epipen.com.

Food Allergy Management Algorithm (2009). New York Health Services Center. Retrieved

on March 1, 2010 atwww.schoolhealthservicesny.com

Food Allergy & Anaphylaxis Network (2005). School food allergy program. Retrieved

February 2, 2009 fromwww.foodallergy.org/school/html .

Formanek, R. (2001). Food Allergies: When food becomes the enemy. US Food and Drug

Administration, accessed on March 5, 2010 from

http://fda.gov/fdac/features/2001/401_food.html.

Gaudreau, J. (2000). The challenge of making the school environment safe for children with

food allergies. Journal of School Nursing, 16(2), 5-10.

Mudd, K. & Noone, S. (1995) Management of severe food allergy in the school setting.Journal of School Nursing, 11(3), 30-32.

Munoz-Furlong, A. (2004). Food allergy in schools: concerns for allergists, pediatricians,

parents, and school staff. Annuals of Allergy, Asthma & Immunology, 93(5), 47-50.

Sheetz, A., Goldman, P., Millett, K., Franks, J., McIntyre, L.,Carroll, C., Gorak, D., Harrison,

C., & Carrick, M. (2004). Guideline for management life-threatening food allergies in

Massachusetts schools. Journal of School Health, 74(5), 155-160.

Smith, M., Anaphylaxis: Severe allergic reaction. Individualized healthcare plans for the

School Nurse, SunRise Press, MN, 2005.

Twinject Drug Information. Retrieved on March 2, 2010 atwww.twinject.com.
http://www.adrenaclick.com/http://www.adrenaclick.com/http://www.adrenaclick.com/http://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://www.aafa.org/http://www.aafa.org/http://www.aafa.org/http://www.epipen.com/http://www.epipen.com/http://www.epipen.com/http://www.schoolhealthservicesny.com/http://www.schoolhealthservicesny.com/http://www.schoolhealthservicesny.com/http://www.foodallergy.org/school/htmlhttp://www.foodallergy.org/school/htmlhttp://www.foodallergy.org/school/htmlhttp://www.twinject.com/http://www.twinject.com/http://www.twinject.com/http://www.twinject.com/http://www.foodallergy.org/school/htmlhttp://www.schoolhealthservicesny.com/http://www.epipen.com/http://www.aafa.org/http://aaaai.org/medica%20/resources/academy_statements/position_statements/ps34.asphttp://www.adrenaclick.com/

Food Allergy Booklet

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Transcript of Food Allergy Booklet