Sarasota County Schools

Life-Threatening Allergies

In this Chapter

• Guideline Goals
• Background
• Legal Aspects to Consider
• What is a Life-Threatening Allergy?
• What is Anaphylaxis?
• Children's Description of an Allergic Reaction/Anaphylaxis
• Common Life-Threatening Allergies
  • Food
  • Latex
  • Insect Bite/Sting
  • Exercise-Induced
  • Idiopathic Etiology
• Safe School Environment
• Management of the Student
• Responsibilities of the Core Team
  • Healthcare Provider
  • Parent/Guardian
  • Student
  • School Registered Nurse
  • Health Room Aide
  • Food and Nutrition Services (FNS)
  • Educational Personnel
  • School Administrator
  • Bus Transportation Director/Bus Drivers
• Life-Threatening Allergy Notification/Education of Other Students and Parents
• Emotional Impact
• Treatment/Action Plan
• Epinephrine Auto-Injector
• References

GUIDELINE GOALS

Goals of the guidelines are to assure students’ safety and rights, the safety of other students, and to offer safe services performed in accordance with nursing practice standards which include nursing care planning, delegation, training, and monitoring of direct service providers and unlicensed assistive personnel.      

These guidelines will clearly identify roles and responsibilities of Sarasota County Core Team members consisting of, but not limited to: family, student, school nurse, health room aides, food and nutrition staff, educational personnel, school administration, transportation, and the physician.  They will ensure that emergency medical services (EMS) are engaged immediately in the sequence that puts the safety of the child first.    

These guidelines were developed through the collaborative efforts of the School Nurses of the Florida Department of Health in Sarasota County and the School Board of Sarasota County, the School Board of Sarasota County Food and Nutrition Services, and the Sarasota County School Health Advisory committee.

BACKGROUND  

Life-threatening allergies and associated anaphylaxis are on the rise and are a growing public health concern in the United States. “Anaphylaxis refers to a collection of symptoms affecting multiple systems in the body. The most dangerous symptoms include breathing difficulties and a drop in blood pressure, or shock, which are potentially fatal. Common examples of potentially life-threatening allergies are those to foods and stinging insects. Life-threatening allergic reactions may also occur to medications, latex rubber, in association with exercise” or may be of an unknown cause (idiopathic).  (Position Statement from American Academy of Allergy, Asthma, and Immunology (AAAAI Board of Directors - Anaphylaxis in Schools and Other Childcare Settings”-1998)   

From 1997 to 2007, the prevalence of reported food allergy increased 18% among children. In 2007, approximately 3 million children in the US were reported to have food allergies with the highest incidence (approximately 6%) occurring in young children under the age of three. Eight foods account for 90 percent of all food-allergic reactions in the U.S.: milk, eggs, peanuts, tree nuts (e.g., walnuts, almonds, cashews, pistachios, and pecans), wheat, soy, fish, and shellfish. Food allergies are the leading cause of anaphylaxis outside of the hospital setting. (AAAAI - "Allergy Statistics" 2009)

Life-threatening allergies to the venom of stinging insects (honey bees, bumble bees, wasps, hornets, yellow jackets, and fire ants) occur in 0.4% to 0.8% of children. (AAAAI -"Allergy Statistics" 2009).  For drug allergies, penicillin is the most common allergy trigger. Latex allergy affects 5-15% of the health care workers, but less than 1% of the general population. (AAAAI -"Allergy Statistics" 2009)

There is no cure for life-threatening allergies. The most important aspect of the management of children with life-threatening allergies is strict avoidance. School environments provide numerous opportunities for exposure to allergens (e.g., classrooms, recess, athletic events, parties, snacks, arts and crafts projects, incentives, buses). A school environment for a child diagnosed with a life-threatening allergy needs to be created to prevent exposure and to recognize and manage a reaction if exposure occurs.

LEGAL ASPECTS TO CONSIDER  

“A combination of state and federal laws guarantee access to education and to health and other support services that enable students with special health needs to attend school. Section 381.0056 F.S. mandates basic school health services for all students, s.1006.062 F.S. mandates assistance with medication and special procedures, and  s.1002.20 (3)(i) F.S, the Kelsey Ryan Act, allows public school students with a history of life-threatening allergic reactions to carry an epinephrine auto-injector and self-administer epinephrine while in school, participating in school-sponsored activities or in transit to or from school or school-sponsored activities if the school has been provided with parental and physician authorization.”(Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act - May 2006)

“The school district determines whether students with life-threatening allergies should receive services under Section 504 (Rehabilitation Act of 1973), Title 11 of the Americans with Disability Act (ADA), or the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA). If the district determines that the student should receive services under IDEIA, the school staff documents the related aids and services needed in the student’s IEP.  If it is determined that the student is eligible under s. 504, the school staff develops a Section 504 Plan to document the related aids and services school district will provide.  Attach the IHP developed by the school RN to either plan to document the health care services required by the student.”  (TAP, May 2006).
     

Note: IDEA was reauthorized, revised, and renamed in 2004. The Individuals with Disabilities Education Improvement Act of 2004 (IDEIA) became effective July 1, 2005.    

“Nursing services in Florida and Florida schools are regulated by the provisions of The Nurse Practice Act, Chapter 464, F.S., which specifies nursing training and qualifications, practice parameters, guidelines for the legal use of health aides or unlicensed assistive personnel in care provision.”  (TAP, May 2006).

For further clarification of the nurse’s role in delegation and supervision, see Chapter 64B9-14.001-003, Florida Administration Code (F.A.C.).  This rule describes the “Delegation of Tasks or Activities” (Chapter 64B9-14.002, F.A.C.), and the “Delegation of Tasks Prohibited” (Chapter 64B9-12.003, F.A.C.).  Internet sites for the text of state and federal laws that apply to children with special health care needs are provided in the reference section of this document. (TAP, May 2006)

WHAT IS A LIFE-THREATENING ALLERGY?

Allergic reactions begin when a predisposed student eats, inhales, or has contact with an allergen/protein that triggers an allergic response. The most common allergic response is when the immune system in the body responds by producing an antibody, IgE, to a particular allergen/protein. “The antibody circulates throughout the body sensitizing mast cells in the GI tract, lungs, etc.“  (FAAN, 2005) All of this happens the first time the student is exposed to the allergen/protein, but commonly there are no symptoms until the second exposure.

“The next time the student eats touches or inhales the offending allergen/protein, the immune systems sensitized cells protect the body from the 'dangerous invader' by releasing histamine and other chemicals. As a result, the individual experiences symptoms of an allergic reaction.”  (FAAN, 2005)  
     

Even trace amounts of an allergen/protein can produce a reaction.  Symptoms that the student will experience depend on location in the body in which the histamine is released. There is no way to predict how a reaction will develop. The severity of symptoms can change very rapidly and become a life-threatening reaction. 

WHAT IS ANAPHYLAXIS?

“Anaphylaxis is the potentially life-threatening medical condition occurring in allergic individuals after exposure to their specific allergens.  Anaphylaxis refers to a collection of symptoms affecting multiple systems in the body.  These symptoms may include one or more of the following.”  (FAAN, 2005):

Typical Allergy Symptoms:

Skin Symptoms:  

• Hives
• Swelling
• Itchy red rash 
• Eczema flare  

Gut Symptoms:

• Cramps 
• Nausea 
• Vomiting 
• Diarrhea

Respiratory Symptoms:

• Itchy, watery eyes
• A runny nose  
• Stuffy nose 
• Sneezing
• Coughing
• Itching or swelling of lips, tongue, throat
• Change in voice     
• Difficulty swallowing 
• Tightness of chest    
• Wheezing     
• Shortness of breath    
• Repetitive throat clearing   

Cardiovascular Symptoms:

• Reduced blood pressure
• Fainting
• Shock   
• Chest Pain  

Neurological Symptoms:

• A feeling of impending doom
• Weakness

“The most dangerous and potentially fatal symptoms include breathing difficulties and a drop in blood pressure or shock.  Common examples of potentially life-threatening allergies are those to food and stinging insects.  Life-threatening allergic reactions may also occur to medications, latex rubber, in association with exercise, or may be of an unknown cause.” (www.foodallergy.org/anaphylaxis).

“For some individuals, the reaction begins slowly and gradually gets worse, for others it develops more quickly and can become life-threatening within a few minutes, which is why all reactions need to be taken seriously and treated promptly. Early administration of epinephrine is crucial to treating anaphylactic reactions. It is better to err on the side of caution if in doubt give the epinephrine."  (FAAN, 2005) 

“Anaphylaxis can occur immediately or up to two hours following allergen exposure.  In about a third of anaphylactic reactions, the initial symptoms are followed by a delayed wave of symptoms two to four hours later [and possibly longer].” “This combination of an early phase of symptoms followed by a late phase of symptoms is defined as a biphasic reaction. While the initial symptoms respond to epinephrine, the delayed biphasic response may not respond at all to epinephrine and may not be prevented by steroids.  Therefore, it is imperative that following the administration of epinephrine the student be transported by emergency medical services to the nearest hospital emergency department even if the symptoms appear to have been resolved.”  (MaDOE, 2002).

CHILDREN'S DESCRIPTION OF AN ALLERGIC REACTION/ANAPHYLAXIS

How a Child Might Describe a Reaction (by FAAN The Food Allergy & Anaphylaxis Network)

Children have unique ways of describing their experiences and perceptions, and allergic reactions are no exception. Precious time is lost when adults do not immediately recognize that a reaction is occurring or don’t understand what a child is telling them.

Some children, especially very young ones, put their hands in their mouths or pull or scratch at their tongues in response to a reaction. Also, children’s voices may change (e.g., become hoarse or squeaky), and they may slur their words. 

The following are examples of the words a child might use to describe a reaction:

• "This food's too spicy."
• "My tongue is hot [or burning]."
• "It feels like something’s poking my tongue."
• "My tongue [or mouth] is tingling [or burning]."
• "My tongue [or mouth] itches."
• "It [my tongue] feels like there is hair on it."
• "My mouth feels funny."
• "There's a frog in my throat."
• "There’s something stuck in my throat."
• "My tongue feels full [or heavy]."
• "My lips feel tight."
• "It feels like there are bugs in there." (to describe itchy ears)
• "It [my throat] feels thick."
• "It feels like a bump is on the back of my tongue [throat]." 

If you suspect that your child is having an allergic reaction, follow your doctor's instructions.

Copyright © 2010, The Food Allergy & Anaphylaxis Network    

COMMON LIFE-THREATENING ALLERGIES

Food

A food allergy can develop from any food. A food allergy is a medical condition involving the immune system.  Food poisoning, food intolerance, food aversions, or phobias are commonly mistaken for but are not considered food allergies because there is no immune response.  Eight foods account for 90 percent of all food-allergic reactions in the U.S.; milk, eggs, peanuts, tree nuts, (e.g., walnuts, almonds, cashews, pistachios, pecans), wheat, soy, fish, and shellfish. (www.foodallergy.org/section/common-food-allergens1)

“There is no cure or preventive medication available for food allergy. Avoidance of the food is the only way to prevent a reaction from occurring." (FAAN,2005)

“Most individuals who have experienced a food-allergic reaction knew what they were allergic to and unknowingly ate that food. In most cases, the allergy-causing food was an unexpected ingredient in another food. Another potentially serious cause of allergic reactions is cross-contact from an allergy-causing food to a non-allergy-causing food during food processing or preparation.“  (FAAN, 2005)

There is no way to predict how a reaction will develop.  The severity of symptoms can change very rapidly and become a life-threatening reaction.  Nevertheless with food allergies, “there are three specific pieces of a patient’s history that signify an increased risk for a severe reaction: a record of severe reactions in the past, an allergy to peanuts and or tree nuts, and the presence of asthma.” (The Food Allergy & Anaphylaxis Network (FAAN) Food Allergy News Sample)

School environments provide numerous opportunities for exposure to food allergens (e.g., classrooms, recess, athletic events, parties, snacks, arts and crafts projects, incentives, buses). A school environment for a child diagnosed with a life-threatening allergy needs to be created to prevent exposure and to recognize and manage a reaction if exposure occurs.

Additional considerations for Food Allergy Management in School include: (FAAN, Food Allergy News Sample)

• The Food Allergy Team should include, but not be limited to, the School Nurse, Principal, Food Service Supervisor, and Teachers.  A meeting should occur before the first day of school. 
• The parent shall provide a signed Medication/Treatment Authorization Form which outlines how to treat an allergic reaction.
• The student shall not share/trade food, utensils, cups, or water bottles.
• The Team should discuss the foods to be avoided, the symptoms of an allergic reaction, and what to do if a reaction occurs. 
• The Team should develop management strategies for lunchtime, snacks, field trips, and class parties.  See the School Board website - Food and Nutrition Services to download the Menu Modification Medical Statement. See the Forms section for documents and signs.
• The teachers should review lesson plans which include food. Non-food substitutes should be made. 
• The teachers should have a plan to alert substitutes to the presence of a student with a life-threatening food allergy. 
• Parents and food service staff should work together in reviewing menus and ingredients to determine what food students can and cannot eat, the issue of cross-contamination during food preparation should be reviewed and how the student is going to be identified in the lunch line. 
• A procedure for cleaning lunch tables and the surrounding areas should be established to remove any food allergens. 
• Teach proper hand washing and allow time to complete the procedure. 
• The School Nurse will educate the bus driver, classroom aides, and others concerning the symptoms of an allergic reaction and what to do if a reaction occurs.

Latex

Latex allergies are a reaction to the proteins in natural rubber latex, a milky sap produced by the Hevea Braziliensis rubber tree. There is an increased prevalence of latex allergies in children who have had multiple surgeries early in life and with healthcare workers.

Latex can result in an allergic reaction by direct contact with products containing latex such as balloons, elastic in clothes, rubber bands, pencil erasers, etc. Latex can also become airborne and cause respiratory symptoms. For example, as latex gloves are used, the proteins in latex may be carried on cornstarch powders that are used as a lubricant on some gloves resulting in respiratory symptoms.

In most cases, latex allergy develops after repeated exposure to natural rubber  latex products. Symptoms usually occur immediately following contact with latex. Allergic reactions can vary from mild to life-threatening. There is no cure for latex allergy, so avoidance of known latex allergens is the best method of treatment.

For lists of latex alternatives and latex-free products, visit the American Latex Allergy Association website at www.latexallergyresources.org.   To check out a product’s contents for sure, call the manufacturer.

• The School Nurse and Health Room Aide should have the option of vinyl/nitrile gloves in the Health Room.
• Food servers should avoid the use of latex gloves.
• Review the classroom environment as well as class projects.
• Often a student with a latex allergy will also have the potential for anaphylaxis by coming in contact with bananas, kiwi, or avocado.

Insect Bite/Sting 

"Insect allergies involve an allergic reaction associated with the venom or toxin-induced when bitten or stung by an insect.  There are thousands of biting and stinging insects in our environment. However, the insects most known to produce an anaphylactic reaction are fire ants, bumble bees, honey bees, wasps, yellow jackets and hornets."  (Selekman, 2006)

"To decrease the chance of insect stings, the following measures should be followed:

1.   Wear long-sleeve shirts, long pants, and shoes when outside; avoid loose clothes (they trap insects), black and bright colors, or flowery prints (wear light colors: white, green, tan, khaki)

2.   Don’t drink sweet liquids outdoors and wash hands and face after drinking these. Keep beverages capped, especially soda cans. 

3.   Keep garbage covered outside; if picnicking, do not sit near garbage cans.

4.   Avoid flowering bushes. 

5.   Avoid perfumes, hair spray, hair tonic…”.  (Selekman, 2006)

“Management and treatment of stinging insect anaphylaxis included prevention, immunotherapy, medic alert identification, and epinephrine if needed.“ (Selekman, 2006)

• Special consideration should be directed toward field trips.
• Time of year should also be considered for outdoor activities.  Bees, for example, are more abundant in the warmer months.
• Playgrounds and outdoor areas frequented by students should be regularly inspected for insect nests or ant mounds by school personnel.

Exercise-Induced

“Although rare, exercise can cause anaphylaxis. Oddly enough, it does not occur after every exercise session and in some cases, only occurs after eating certain foods before exercise.  Food-associated exercise-induced anaphylaxis is caused by a combination of eating a particular food, often celery or wheat, plus exercise within an hour or two after eating.”  (AAAAI, 2010)

• Class schedule may need to be modified in order to coordinate meals and snacks with P.E. class or recess.
• If a specific food is connected with a reaction, this food should be avoided as much as possible when increased physical activity is anticipated.

Idiopathic Etiology (Unknown Cause) 

This form of anaphylaxis involves an allergic reaction to an unknown substance or combination substances and/or environmental factors.  The specific allergen has not been identified; therefore planning is complicated. (Lechner and Grammer, 2010)

SAFE SCHOOL ENVIRONMENT

Sarasota County School District supports environmental policies that limit possible allergens in the facilities.  The use of airborne sprays that propel possible allergens in the air should be eliminated in all areas in which students visit.  Air fresheners and deodorizers, especially of food origin, are examples of products that should not be used.  Perfumes and fragrant body lotions/essential oils are examples of airborne scents that may cause allergic reactions and therefore should not be used by staff or students.

“It is most likely that, in the face of a natural disaster or emergency, all students will be sent home from school. However, in the event that environmental hazards exist that would prevent the student from leaving the school or that may precipitate an allergic episode, emergency medical services must be aware that environmentally fragile students with life-threatening allergies may be in the affected school.  Every effort should be made to remove the student with life-threatening allergies safely, and ensure that emergency medications are available to the student”.  (TAP, 2006)

MANAGEMENT OF THE STUDENT WITH A LIFE-THREATENING ALLERGY

Medically diagnosed life-threatening allergies are managed using a core team approach (see Student Life-Threatening Allergy Notification Flow Chart).  The team’s goal is to ensure the safety and well being of the student.  Upon identification of a student with a life-threatening allergy, members of the core team implement these guidelines and take responsibility for their role as outlined below. (The majority of the following information on Responsibilities of the Core Team was taken from the Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act - May 2006.)

RESPONSIBILITIES OF THE CORE TEAM
Healthcare Provider

The physician/healthcare provider manages the medical care of the student with life-threatening allergies. The physician should provide information and guidance to the school RN to use in developing the Individual Health Plan (IHP).  Physicians should take into consideration the resources available in the school to assist students with their care.  

To safeguard student health, the physician should: 

• Provide the school nurse with all medical documentation as requested, including written orders on the Medication/Treatment Authorization Form and emergency information specific to the needs of the student which should include steps to ensure reliable, prompt access to an epinephrine auto-injector.
• Be accessible by phone or fax to review or contribute to the IHP and for emergency orders.
• Educate the student and the parent/guardians regarding prevention and management of allergic exposure.
• Determine the level of self-care allowed based on the student’s knowledge, developmental level, and abilities.

Parent/Guardian

The school health policies should delineate roles that promote partnership between parents and the school.  According to the School Health Services Act (Section 381.0056 F.S.), “School health services supplement, rather than replace, parental responsibility.”

For children to receive safe, consistent services while in school, it is important for parents and guardians to:

• Inform the school as soon as possible when a student is newly diagnosed as having an allergy or when a previously diagnosed student enrolls in a new school.  Ideally, parents should work with the school staff prior to their child’s admission to ease the student’s transition into the school environment.
• Participate in the IHP conference as soon as possible after diagnosis and at the start of each school year.
• Work with the school core team to develop a plan that accommodates the child’s needs throughout the school including the classroom, the cafeteria, after-care programs, during school-sponsored activities and on the school bus.
• Provide and hand carry all medications and supplies associated with the medical management of the student’s allergies to the school health room.  The parent may want to consider filling extra prescriptions for epinephrine and storing them in different locations throughout the school.
• Notify the school core team of any changes of enrollment in aftercare programs, or school-sponsored activities.
• Provide written medical documentation for nutritional changes signed by the student’s physician and any changes as indicated. 
• Complete the Allergy History and Health Emergency Information Form.
• Monitor and replace needed or expired medication immediately.
• Accept financial responsibility in the event the student requires emergency transportation for medical care.
• Provide the school with a signed Medication/Treatment Authorization Form and any subsequent orders when there are any changes in the medical management that affect care in the school. 
• Provide any other signed documentation as required by the Florida Department of Health in Sarasota/Sarasota School Board.
• Provide the student with a medical identification tag or jewelry, and encourage the student to wear at school.
• Educate the child in the self-management of their allergy including:
  • Strategies for avoiding exposure to allergens.
  • Symptoms of allergic reactions.
  • How and when to tell an adult they may be having an allergy related problem.
  • Assessment for self-medication administration.
• Review policy and procedures with school staff, the child’s physician and the child (if age appropriate) after a reaction has occurred.
• Report any change in health status to the RN assigned to the school.
• Notify school/ health room of any change in emergency contacts or enrollment.

Student

To remain active and healthy, the student with life-threatening allergies must assume some of the responsibilities in following the medical management plan designed by their health care provider as well as their IHP.  Medication and supplies must be handled safely to prevent accidental injection of other students or staff. 

The student should:

• Be proactive in the care and management of their allergies and reactions based on their developmental level.
• Demonstrate competence in the use of an epinephrine auto-injector (age-appropriate as per physician’s order).  See Forms Section for checklists. 
• Self-administer (age-appropriate) emergency medications when needed.
• Notify the teacher or responsible adult if he/she has used the Epinephrine auto-injector.
• Carry Epinephrine auto-injector on their person in a safe manner per physician orders at all times.
• Familiarize self with the location of authorized medication if not carrying on their person.
• Collaborate with core team members in the development of the emergency plan of care and IHP.
• Wear medical identification tag or jewelry while in school if provided by parent/guardian.
• Avoid exposure to any known allergens and avoid eating anything with unknown ingredients.
• Notify an adult immediately if they believe that they may have come into contact with a potential allergen.

School Nurse

The school nurse functions under the scope of practice defined by Florida’s Nurse Practice Act.  

The functions of the school nurse are:

• Establish communication with student’s parent and physician to obtain documentation of medical diagnosis and treatment.
• Maintain a working relationship with the student’s parent/guardians and healthcare provider and act as a liaison between the student’s health care provider and the school.
• Develop a written IHP for each student with a diagnosis of severe and/or life-threatening allergy in coordination with core team members.
• Share the IHP with all core team members.
• Participate in IEP or 504 meetings to provide relevant health information.
• Review and update the IHP whenever there is a change in medical management or the student’s response to care.
• Educate the core team members regarding the signs and symptoms of anaphylaxis and how to implement the emergency response plan.  
• Administer and activate emergency procedures.
• Provide a developmentally appropriate presentation for classmates of the child regarding the allergy, if applicable with parent and student permission.
• Coordinate plan of care with physician and family annually.
• Collaborate with the principal to provide the above services.
• Maintain appropriate documentation of the training and care provided, and monitor the documentation of services provided by others.
• Respect the student’s confidentiality, right to privacy and serve as the student advocate.

Criteria for Safe Nursing Delegation
“The safety of the student is the primary consideration in the delivery of all health-related services provided in the school.  The school nurse is responsible for training and monitoring the individual designated to perform these services. Section 1006.062(1)(a), F.S. specifies that the school principal designates school staff to perform health services in the absence of the nurse.  However, only the professional nurse may delegate the authority based upon nursing judgment and suitability of the individual to perform the task or activity to be delegated.  Recognition of this distinction between designation to perform and  delegation of nursing tasks is critical to the provision of safe care in the schools”.  (TAP, 2006).

Health Room Aide

Health room aides (HRA) perform under the administrative supervision of the School Principal and have the guidance and direction of the school nurse for health-related issues.  The HRA performs services within the school health services program according to the written policies and procedures in the School Health Services Manual.

The functions of the Health Room Aide are:

• The HRA will be familiar with the IHP of the student with life-threatening allergies.
• Be trained (by the school nurse) about the signs and symptoms of anaphylaxis and demonstrate competency in the use of an epinephrine auto-injector.
• Provide emergency treatment and supportive care, in accordance with the established emergency care plan, for students having an allergic reaction.
• Assist parents and school staff in assuring the student has supplies that are up to date at all times.
• Maintain accurate student health records.
• Maintain student confidentiality.
• Be knowledgeable about the activation of emergency services (call 911 first, then notify the principal, parent/guardian, and school nurse).

Food and Nutrition Services (FNS) 

Food service staff members may play a critical role in providing an allergy safe environment for students.

The functions of FNS staff are:

• Receive physician documentation on foodborne allergies of an allergic student.
• Work with the members of the Core Team to implement the IHP.
• FNS manager will recognize the symptoms of an allergic reaction.
• Know all emergency procedures for an allergic reaction.
• Keep information about allergic students readily available.
• Avoid cross-contamination from snacks or other foods, including the possibility of extra table cleaning precautions.
• Make accommodations within means of the National School Lunch Program.
• Food service personnel will notify FNS manager or lunchroom aide if a student appears distressed.
• FNS manager and lunchroom aide should be knowledgeable about  the signs and symptoms of an allergic reaction and how to implement the emergency response plan if a student is exposed to a life-threatening allergen.
• Substitute personnel will be informed about the student.

Educational Personnel (teachers, aides, coaches, lunchroom aides; before & after school program staff)

The functions of the Educational Personnel are:

• Receive child-specific training by the School RN about the signs and symptoms of an allergic reaction and how to implement the emergency response plan if a student is exposed to a life-threatening allergen.
• Keep information about their student’s allergies in a place where a substitute will have easy access.
• Be familiar with the IHP of students in their class.
• Inform substitute teachers about the student.
• Support students without violating their sense of privacy.
• Avoid cross-contamination of allergens in environment.
• Promote good hand-washing techniques allowing adequate time for personal hygiene.
• Promote tolerance for differences to discourage harassment.
• Provide a physical environment conducive to children with allergies.
• Review lesson plans to reduce allergens in areas such as science experiments or art projects as examples.
• Notify the parent or guardian of a student with food allergies that they are responsible for providing classroom snacks intended for use during the school day.

School Administrator

The Principal or his/her designee should enforce district policies to assure implementation of the services needed for the student’s plan of care as follows:

• Be aware of the federal and state laws governing the educational requirements for students with special health needs.
• Promote tolerance for differences to discourage harassment.
• Provide a physical environment conducive to children with allergies.
• Coordinate with the school nurse to make sure medications are appropriately stored, and be sure that an emergency kit is available containing a physician’s order for epinephrine and /or Benadryl. 
• Establish an emergency protocol with the Core Team.
• Designate school personnel to be trained to administer medications in accordance with state statutes governing the administration of emergency medications.
• Ensure that school staff interacting with the student on a regular basis attends scheduled training in order to understand life-threatening allergies, recognize symptoms and know what to do in an emergency. 
• Facilitate the implementation of the IHP developed by the Core Team.

Bus Transportation Director/Bus Drivers

The functions of the Transportation Director and Bus Drivers are:

• The designated school bus driver should receive notification by the Bus Transportation Director of a student who has life-threatening allergies and should know how to implement the emergency response plan if a student is exposed to a life-threatening allergen. 
• Identification of the high-risk student
• The school bus driver must be knowledgeable about the activation of emergency services (911) and have the means of communicating emergency calls.
• Maintain policy of prohibiting eating on school buses.

LIFE-THREATENING ALLERGY NOTIFICATION/EDUCATION OF OTHER STUDENTS AND THEIR PARENTS

The School Board of Sarasota County supports each student’s rights and seeks a balance for each student to support free choice in food selections and a safe environment for those students with life-threatening allergies.  Efforts will be made to create a safe environment for the students to include environmental cleaning, safe zones in cafeteria areas and thoughtful and kind communication regarding possible limitation of offending allergens in the classroom during special snack times.  Communication to classmates and their parents will be done after team review and consensus by the school nurse, administration, teachers and student’s parents and will be worded to include consideration for all students.  

With the permission of the student and parents/guardians, the teacher or the school nurse may educate the class about the special needs of an individual with life-threatening allergies and use this as an opportunity to educate students regarding allergen avoidance and the need for immediate notification if a student is exposed to an allergen.  Emphasize what the student can eat as well as what must be avoided. (See food allergy - sample lesson plan and food allergy signs in the Forms section.)

Be a PAL: Protect A Life™ From Food Allergies is an educational awareness program designed to help parents and educators teach students what food allergies are and how to help their friends who have food allergies. (See Food Allergy and Anaphylaxis Network-http://www.foodallergy.org/be-a-pal and food allergy-Be a PAL: Protect A Life™ From Food Allergies Poster.

EMOTIONAL  IMPACT 

“Chronic illness in children invariably poses many challenges to families.  As children proceed through stages of cognitive, emotional and social development, their emotional responses and self-management strategies evolve."

If a life-threatening allergy is identified in a young child, the burden of prevention is initially fully upon parents.  There may be an increase in anxiety around age 7 when a child’s cognitive development allows them to appreciate the possibility of serious reactions and as they move toward more independent functioning at school and with peers.

The transition from childhood to adolescence marks another time of increased risk. Although fatal food-allergy reactions are rare, they are most common among teenagers and young adults.  This may be due to adolescents’ willingness to take risks, to faulty perceptions of risk, testing limits, or because they are more fearful of not fitting in socially than they are of having an allergic reaction.“  (Greenberger, April 2010)

In addition, how other students react to the student who has a life-threatening allergy impacts the child’s emotional health.  “Beware of bullies who harass allergic students, threaten to make them eat an “unsafe “food” when there is a food allergy, or threaten them with any type of life-threatening allergen.” If there is a problem, such as harassment and bullying, it should be discussed with the guilty student and the parents as soon as possible. Be sure everyone understands this type of behavior is inappropriate” and follow the harassment/bullying procedure as per school guidelines. (FAAN,2005)

TREATMENT / ACTION PLAN

Because an anaphylactic reaction can occur at any time or any place, it is imperative that members of the core team are familiar with their roles/responsibilities and be comfortable with administering and/or supervising treatment.

The Epinephrine auto-injector is the treatment of choice for a life-threatening anaphylactic reaction.  However, treatment, when prescribed, is always student specific.  Some physicians are prescribing Benadryl (antihistamine) along with the auto-injector.  The antihistamine in conjunction with the epinephrine may be given in an effort to decrease the symptoms and severity of the reaction.  Antihistamines, however, should not be used in place of epinephrine.  It is important that each member of the core team knows specifically what the treatment is for that particular student. 

Once epinephrine is used, call EMS and “request an ambulance equipped with epinephrine and a responder trained to administer this medication” (FAAN, Food Allergy Action Plan) Send the used epinephrine auto-injector with the student to the Emergency Room.

EPINEPHRINE AUTO-INJECTOR EMERGENCY FIRST AID FOR ANAPHYLACTIC REACTION   

The IHP will include age-appropriate accommodations for the student medically approved per the Medication /Treatment Authorization Form to have epinephrine administered or self-administered in accordance with the Kelsey Ryan Act.  The school nurse in conjunction with school administrator and teacher will assess the ability to perform self-administration, maturity level to function in an emergency, past life-threatening allergy episode and history of action taken by the student.  Once the safety and performance of the student have been assessed, the student can carry epinephrine in a rigid container attached to the student’s body.  A second dose of medication is encouraged to be available at the school in case the student forgets it.

“The auto-injector is a disposable drug delivery system with a concealed needle that is spring activated.  The active ingredient is epinephrine, the treatment of choice in allergic emergencies (anaphylactic reactions) because it quickly constricts blood vessels, relaxes smooth muscles in the lungs to improve breathing, stimulates the heartbeat and works to reverse hives and swelling around the face and lips.” (http://www.epipen.com)

Initial symptoms of anaphylaxis may represent a potentially fatal outcome and should be treated as a medical emergency, whether the symptoms occur gradually or suddenly.  Even mild symptoms may intensify rapidly, triggering severe and possibly fatal shock.  Usually, symptoms occur immediately following the sting or bite; death may occur within minutes. 

Symptoms, which often vary according to individual response, include the following:

• A sudden sense of uneasiness/anxiety
• Flushed skin
• Widespread hives
• Itching around the eyes
• Dry, hacking cough
• A constricted feeling in throat/chest
• Wheezing
• Facial edema or swelling (i.e. lips, tongue, and eyes)
• Abdominal pain
• Nausea or vomiting
• Difficulty breathing
• Hoarseness or thickened speech
• Confusion
• A feeling of impending doom

"These symptoms may escalate swiftly to anaphylactic shock characterized by cyanosis, reduced blood pressure, collapse, incontinence, and unconsciousness.  Epinephrine given after the onset of low blood pressure may not prevent death.”(http://www.foodallergy.org: Information About Anaphylaxis)

Do not hesitate to use the auto-injector if you suspect a serious allergic reaction, "err on the side of caution.”  (FAAN, 2005)

Epinephrine is available by prescription only.  Florida Department of Health in Sarasota County and Sarasota County School Board will supply each school with a stock Epi-Pen in the event of an undiagnosed allergic reaction.  Epinephrine needs to be stored in a dark place at room temperature (59-86 degrees Fahrenheit).  Exposure to light and extreme temperatures may inactivate the medication. Check the medication color (it should be clear) and expiration date.  Notify the student’s parents when a replacement is needed. (FAAN, 2005)

REFERENCES

• Adrenaclick Training and Instructions: www.adrenaclick.com
• American Academy of Allergy, Asthma and Immunology (AAAAI) Board of Directors: Position statement: Anaphylaxis in Schools and Other Childcare Settings”-1998)
• American Academy of Allergy, Asthma, and Immunology (AAAAI)  “Allergy Statistics - 2009”. Retrieved July 30, 2010, from  www.aaaai.org/media/statistics/allergy-statistics.asp
• American Academy of Allergy, Asthma, and Immunology (AAAAI)  “Patients & Consumers Center: Tips to Remember: What is Anaphylaxis”  Retrieved July 30, 2010, from www.aaaai.org/patients/publicedmat/tips/whatisanaphylaxis.stm
• EpiPen Training and Instructions: www.epipen.com
• Food Allergy and Anaphylaxis Network (FAAN). How A Child Might Describe A Reaction. Retrieved July 30,2010 from http://www.foodallergy.org/page/how-a-child-might-describe-a-reaction1
• The Food Allergy & Anaphylaxis Network (FAAN)” Food Allergy News Sample”
• The Food Allergy & Anaphylaxis Network (FAAN) “School Food Allergy Program.” August 2005)
• Greenberger, B, and  Greenberger E.” The Emotional Impact of Food Allergies.”  17th Annual Food Allergy Conference. April 2010.
• Lechner, K. and Grammer, L. “A Current Review of Idiopathic Anaphylaxis: Diagnosis” Retrieved July 30, 2010, from   www.medscape.com/viewarticle/460702_4
• Massachusetts DOE. “Managing Life-Threatening Food Allergies in Schools.” 2002. Retrieved July 30,2010 from   www.doe.mass.edu/cnp/allergy.pdf
• National Association of School Nurses. (June 2005). Position statement. “Epinephrine Use in Life-Threatening Emergencies,” Scarborough, MA.
• National Institute of Allergy and Infectious Disease,” Report of the NIH Expert Panel on Food Allergy Research.” March 13-14, 2006. Retrieved July 30, 2010, from  www.niaid.nih.gov/topics/foodAllergy/.../foodallergyexpertreport.pdf
• Selekman, J. Editor. (2006) “School Nursing: A Comprehensive Text.” Philadelphia: F.A.Davis Company.
• Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act -1002.20(3)(i),F.S., May 2006