ANAPHYLAXIS:

“Preventing Life-Threatening Food Allergy Emergencies in Schools:

A Resource for School Nurses and Administrators”

1. 1. Anaphylaxis is a life-threatening allergic reaction.

Allergies to foods and even to exercise after eating may result in a severe life-threatening reaction known as anaphylaxis. Because anaphylaxis occurs quickly, sometimes within minutes, it is important to:

• Identify students at risk
• Have appropriate preventive policies and procedures in place – particularly measures for avoiding the allergen
• Be prepared to manage an emergency quickly and effectively

An estimated 1% to 2% of the general population is at risk for anaphylaxis from food allergies and insect stings, with a lower reported prevalence for drugs and latex. The rates are higher (perhaps as high as 7%) in young children.

Failure to act quickly and treat appropriately may result in permanent disability or death.

2. 2. What is anaphylaxis?

Definition: Anaphylaxis is an immediate systemic hypersensitivity reaction affecting multiple systems of the body. It is the result of mediator release in cardiovascular, respiratory, gastrointestinal and cutaneous tissue.

Symptoms: The onset and course of anaphylaxis is variable. Common variable symptoms include:

• Sense of impending doom
• Cutaneous: Generalized warmth or flush, tingling or itching, angiodema, urticaria
• Upper respiratory complaints: lump in throat, throat tightness, hoarseness, difficulty swallowing, nasal congestion, runny nose, fullness in the ears.
• Lower respiratory symptoms: inspiratory stridor, chest tightness, wheezing or shortness of breath
• Cardio vascular symptoms: lightheadedness, faintness, palpitations, low blood pressure.
• Gastrointestinal symptoms: nausea, abdominal cramps, bloating, vomiting, or diarrhea

Laryngeal edema and cardiovascular collapse are the most frequent causes of death from anaphylaxis.

Patients who do not have life-threatening symptoms initially may progress to life threatening anaphylaxis. Adequate warning signs, such as hives, are not always present before serious reactions develop. The first warning signs may be only “a funny feeling in the mouth” or abdominal discomfort.

The most common causes of anaphylaxis in children include allergies to:

• Foods (e.g., to peanuts, tree nuts, milk, fish)
• Insect stings (e.g., yellow jackets, bees, wasps, and hornets)
• Medications
• Latex

How can exposures to these allergens occur?

¨Tasting ¨ Ingesting ¨ Inhaling ¨Touching ¨ Being injected or stung

3. 3.  How is Allergy with a Risk of Anaphylaxis Diagnosed?

By a patient’s history of reactions and possible causative agents, confirmed with appropriate testing (e.g, skin and/or blood tests, food challenges and/or elimination diets) by a trained physician.

Previous mild reactions to allergens do not preclude subsequent life-threatening reactions.

4. 4. How can schools help prevent anaphylaxis emergencies?

Protecting a student from exposure to offending allergen(s) is the most important way to prevent life-threatening anaphylaxis. Most anaphylactic reactions occur when a child is accidentally exposed to an offending food or is stung by a bee.

· School personnel should develop a system of identifying children with life-threatening allergies.

· A written Individual Health Care Plan (IHCP) for action should be devised by the school nurse in conjunction with the parent/guardian and should include:

o The child’s name and photograph

o Specific offending allergens (peanuts, bee stings, etc.)

o Plans for preventing inadvertent contact with a life-threatening allergen at school

o Warning signs of a reaction.

o Plans for emergency treatment.

· It is useful for the child to wear a Medic-Alert bracelet or necklace or to carry a card.

Every school with a child at risk for anaphylaxis needs a full-time registered school nurse.

If the school does not have a fulltime school nurse, the school nurse should carefully train and delegate responsibility to appropriate staff.

· The school nurse should be an advocate for the child at risk for anaphylaxis and work with the child’s parents, teachers, coaches, cafeteria staff, bus drivers and school trip planners to provide in-service training and devise avoidance measures and emergency procedures, e.g.:

• AAFA/New England suggests that either a “peanut-free” table/or “peanuts-allowed” tables be established in every school cafeteria or other eating area that serves a child with peanut allergy, as this is an extremely potent and often hidden ingredient.

· Train food service workers to avoid cross-contamination of foods (e.g., cooking, serving or cleaning up different foods with the same utensils dishes or sponges).

· “Latex gloves should be used only as mandated by accepted Universal Precautions standards. The routine use of latex gloves by food handlers and housekeeping should be discouraged” as latex sensitization or anaphylaxis can be precipitated among staff as well as students. Alternatives (e.g., vinyl gloves) can be considered. (See ACAAI and AAAAI 7/21/97 joint statement on latex gloves on their Web sites.)

· In the classroom: information should be obtained about students’ food allergies, and these foods should not be used for class projects, parties, snacks, holidays and celebrations, arts and crafts, science experiments, or cooking. Educate all students and their parents, teachers, substitutes, and volunteers about the risk. Discourage sharing of food.

· Encourage washing of hands both before and after eating to avoid spreading of allergens.

· Parents of a child at risk for anaphylaxis should be invited to accompany their child on school trips, but the child’s safety or attendance must not be conditioned on the parent’s presence. In the absence of accompanying parents or a registered nurse, another individual must be trained and assigned the task of watching out for the child’s welfare and handling any emergency.

5. What emergency plans for treatment of anaphylaxis should be in place?

· There should be a written action plan describing steps to take in an emergency.

• For children known to be at risk for anaphylaxis a physician’s order for epinephrine in case of emergency should be obtained. School staff should have written instructions from the physician, signed by the parents, on file. (Per Position Statement, of the American Academy of Allergy, Asthma & Immunology.)

· For any child with no previous history of anaphylactic reaction, discuss with the school physician/medical advisor the possibility of having a standing order to enable the immediate emergency use of epinephrine.

· Plan to call 911 as soon as epinephrine is administered. DO NOT DELAY!

· Conduct an emergency drill. (e.g., Do local EMTs carry epinephrine? Is the epinephrine in the school quickly available for use – not locked in a cabinet?)

“Epinephrine is the first drug that should be used in the emergency management of a child having a potentially life-threatening allergic reaction…There are no contraindications to the use of epinephrine for a life-threatening allergic reaction.”

“All individuals receiving emergency epinephrine should immediately be transported to a hospital even if symptoms appear to have resolved… Further treatments may be required, and therefore observation in a hospital setting is necessary. ..Additional epinephrine should be available during transport.”
From American Academy of Allergy, Asthma and Immunology (AAAAI) Position Statement. Treatment Strategies.

• All individuals responsible for the care of children (including teachers, school nurses, school bus drivers, coaches, counselors, lifeguards, etc.) need to have familiarity with basic first-aid and resuscitative techniques. This should include additional formal training on how to use epinephrine devices. (AAAAI Position Statement)*

6. 6. Other issues to plan for, e.g.:

• Re-entry to school after a traumatic incident
• Peer education to avoid endangering, isolating, stigmatizing or harassing children with food allergies.
• Confidentiality concerns

Review existing policies and procedures and 
create new ones if necessary

Reference:

*For AAAAI Position statement see: http://www.aaaai.org/media/resources/position_statements/ps34.stm

Disclaimer: AAFA/New England Chapter, including all parties to or associated with this resource packet, will not be held responsible for any action taken by readers as a result of their reading of this packet. Readers are encouraged to discuss medical treatment with the school physician and students’ physicians.©1999.

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