Guidelines for Managing Food Allergies in School

Food allergy affects approximately 1 in 25 school-aged children and is a common trigger of anaphylaxis, a severe, potentially fatal, systemic allergic reaction. In a new report, the American Academy of Pediatrics provides guidance on managing food allergies at school and on the prevention and treatment of food-induced anaphylaxis.

Published in Pediatrics, the report includes guidance for pediatricians on diagnosing and documenting a potentially life-threatening food allergy; prescribing self-injectable epinephrine; helping the child learn how to store and use the medication in a responsible manner; and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction.

For children with potentially life-threatening food allergies, it is critical that families and physicians develop a personalized emergency action plan that provides the school with a list of foods to be avoided and possible substitutions.

In developing emergency plans, the AAP offers the following guidelines:

• The written treatment plan could include the child’s name, identifying information, specifics about the food allergies, symptoms and treatments, instructions to activate emergency services, and contact information
• Parents should be given a prescription for self-injectable epinephrine devices to be used at school in addition to ones for use at home.
• Before creating an action plan, the pediatrician may determine if there is a licensed health care professional who will be assisting the child. When there is not, and only a non-licensed assistive person is available, the action plan should be as simple as possible.
• In the context of a possible allergen ingestion, a simple means to impart instructions regarding when epinephrine should be administered is to suggest that it be injected for significant respiratory or cardiovascular symptoms or if there is progression of symptoms or involvement of more than 1 organ system.
• Anaphylaxis may occur without urticaria.
• Dosing of self-injectable epinephrine (either 0.15 or 0.3 mg) has been reviewed in a previous clinical report. Briefly, the manufacturer recommends switching to the 0.3-mg dose at 66 lb, but because that results in underdosing as children approach this weight, consideration should be given to prescribing the 0.3-mg dose at approximately 55 lb.
• Symptoms of anaphylaxis may initially respond to treatment but recur with possibly more severe manifestations. Plans should include activation of emergency medical services and transport to a facility at which additional observation and care can be administered in the ensuing hours whenever a significant allergic reaction is believed to have occurred. A second dose of epinephrine is recommended in 5 to 20 minutes if significant symptoms progress or are not responding to the first dose.
• Because 25% of anaphylaxis in schools occurs without a previous diagnosis, a prescription for unassigned epinephrine for general use should be considered, especially in schools with nurses.
• It may be advisable to inject epinephrine at the time of first symptoms if an allergen was ingested that previously caused anaphylaxis.
• It may be advisable to inject epinephrine before symptoms if an allergen was ingested that previously caused anaphylaxis with cardiovascular collapse.
• Emergency action plans can be individualized according to the child’s history as well as the abilities of the responsible adult.
• Physicians are encouraged to educate parents/school caregivers that: antihistamines are adjunctive therapies to treat an allergic reaction but cannot be depended on to treat anaphylaxis; inhaled bronchodilators may be given for respiratory reactions but must not be depended on to treat anaphylaxis; medication should not be exposed to extremes in temperature, and expired units should be replaced; and andepinephrine is generally safe, and parents/school caregivers should be advised about common adverse effects of epinephrine.

Finally, the report stresses that close communication between the pediatrician and allergist is a critical component for diagnosis and management of children with allergies. “Partnerships with students, families, school nurses, school physicians, and school staff are important for individualizing effective and practical care plans,” wrote the authors.

To access the Pediatrics study, click here.