When my eldest son started pre-school, the highly regulated environment provided me with confidence in its ability to reduce risk and respond to an instance of food-related anaphylaxis. The pre-school teachers knew exactly what role they had to play in the response plan. The less regulated primary school environment highlighted, to me, the importance of preventing, planning and responding to anaphylaxis in the school setting.
Severe food allergies are a part of everyday life and severe peanut allergies affect between 0.25% and 3% of children. Peanuts and tree nuts are the most common foods associated with food related anaphylaxis and death during childhood, with one EpiPen being given to every 544 children under the age of 10 years. The number of children affected, and the potential severity of anaphylaxis, emphasises the importance of having a well-planned prevention strategy for food related anaphylaxis at school.
There are a number of guidelines that are currently available (listed in Further Reading) which describe fundamental principles such as communication, information sharing and responsibilities of school staff and parents/carers of the students. These generic documents alone however, are insufficient for schools.
Instead, schools need to develop their own specific anaphylaxis management plan (in the form of protocols/detailed plans) which takes into account the size of the school, the staff and the available facilities. School specific management plans should detail step-by-step processes for all school staff responding to a case of anaphylaxis.
Management plans that cover prevention and responding to food related anaphylaxis provide the opportunity to ensure that all necessary support is in place throughout the school. Staff and school communities can feel increasingly confident in the school’s ability to deal with incidents involving anaphylaxis. Also, such procedures will put in place safer working conditions that are consistent with relevant state occupational health and safety legislation.
Preventing an event generally involves targeting it from a number of angles. Preventing anaphylaxis is no different. This involves identifying and targeting the groups of individuals who may be responsible for preventing and responding to anaphylaxis: that is, parents, the school itself and the wider school community.
Parents play a vital role in preventing anaphylaxis by providing the school with all the necessary documentation and medical information about their child’s condition. It is the responsibility of parents to provide medically-approved instructions to the school once their child has been diagnosed with a severe food allergy. Parents are also responsible for providing an unexpired EpiPen while their child is at school as well as educating their child(ren) about general avoidance measures such as never sharing food with other children.
One of the major components of any prevention strategy is awareness by the wider community in which a child exists. Within the school setting, the community can be represented by the other parents and students at the school. Anaphylaxis should not be an issue about privacy. Rather, the more people who are aware of the child’s allergic condition, the safer the child’s environment.
Initiatives that will increase community awareness can be taken by the school or parents. These may include some or all of the following:
• Education about anaphylaxis should routinely take place in situations where parents attend general information sessions about the school;
• Distributing letters to parents identifying students in the class who have been diagnosed with food-related anaphylaxis. They also present ideal opportunities in which to request parents of other students to refrain from taking, for example, peanut products to school (my experience is that almost all parents are happy to comply);
• Providing safe catering for birthday parties by including food alternatives for children with food-related anaphylaxis. Also, parents of the affected child could provide safe alternative suggestions for food;
• Placing a photograph of each student who is diagnosed with a severe allergy near the medication in the classroom. Medication should be centrally located in a bag/cupboard. Students should always have their personal EpiPen close by;
• Ensuring that any replacement teacher is aware of the bag/cupboard, its contents, children with severe allergies and relevant procedures to be implemented, if necessary; and
• Schools providing parents of children with severe allergies, information about products such as the ‘Medic Alert’ bracelet or disc. Vinyl name stickers (for books and accessories taken to school) are now available with a ‘no peanut’ symbol (see Further Reading).
School responsibilities: reducing risk
The school’s responsibility in preventing anaphylaxis can be best described as a two tier system. The first tier involves implementing school-wide strategies that minimise a child’s risk of coming into contact with peanuts at school. This can be achieved in a number of ways i.e. increasing community awareness (discussed above) and minimising the risk of exposure to peanuts.
Some schools have decided to become ‘peanut free zones’, which means that foods containing peanuts cannot be brought from home or sold in the school canteen. This approach could minimise, but does not eliminate, the risk of peanut related anaphylaxis occurring at school. Notably, peanut free schools are not endorsed by organisations such as the Australian Society of Clinical Immunology and Allergy (ASCIA) (perhaps because of the practical difficulty of monitoring what children bring to school), whereas peanut free canteens are recommended, as the products sold can be easily managed.
Canteens are an important part of a school and should be considered as an important part of the prevention process by contributing to the overall risk reduction strategy. Suggestions for achieving this might include:
• Placing a list (including photographs) of all children who are known to have severe food-related allergies in the canteen;
• Clear labelling of food related allergies on the lunch-order bag; and
• Flagging products with known allergens on the canteen list.
School responsibilities: responding to anaphylaxis
The second tier involves the responsibility that lies with the school in responding to a case of anaphylaxis. This can best be determined by assessing how well a school, as a whole, is prepared for such a situation.
A detailed management plan, which is specific to the school, will assist to instil confidence in staff and increase the chances of a best possible outcome. A last minute search for a mobile phone, an EpiPen that is not easily accessible, a phone that has not been recharged or expired medication can contribute to delays, furthering the panic and increasing the risk of a fatality. Teachers, who are generally not medically trained, should be provided with as many clear guidelines and given the confidence of a plan that maximises a positive outcome for the student.
Responses must therefore be carefully considered and individually tailored for each school. They may include some or all of the following:
• EpiPen training for staff represents a fundamental component to the response process, and for this reason, it is imperative that staff undertake regular training in small groups;
• Implementing a school response which involves a number of staff members and the sharing of responsibility (including administration staff). For example, response plans should allocate responsibility to staff guiding the paramedics to the student, to call the parents and (if applicable) contact the first aid officer to offer additional support to the student and teacher;
• Mobile phones and/or landline telephones must always be available for a teacher’s use in the classroom;
• Teachers who are on yard duty should carry a ‘back up’ EpiPen (a generic EpiPen that is not prescribed to any student) and a charged mobile phone. Once the student is identified, the teacher can administer the (back-up) EpiPen. The staff member should also make the 000 call (advising that a student has experienced anaphylaxis/severe allergic reaction) and advise reception of the situation;
• A ‘unique’ telephone number could be used to call reception, avoiding being placed on hold (as is the case with some schools); and
• Any medically qualified staff member/first aid officer should always be accessible via mobile phone to other staff members including reception staff.
Other situations the school should consider include children attending before and after school care. As the school is ultimately responsible, it must ensure it is satisfied that staff has been adequately trained, even if this responsibility has been contracted to an external organisation.
Additionally, children attending day excursions present another situation where planning is important. Medication and instructions must remain with the students at all times. A precautionary measure such as taking a minimum of two EpiPens on an excursion is suggested. If one EpiPen is misfired, a back-up EpiPen is available. Also, food taken on excursions must be clearly marked with the student’s name and kept separately from other food taken on the excursion. Clearly, there must be no sharing of food.
A ‘feedback loop’ can be implemented for the purposes of learning from experience. After such an event, the staff members involved should, even with successful outcomes, assess procedures and identify areas for improvement.
This article is designed to make a number of suggestions to assist schools in preventing and responding to anaphylaxis. It is up to the individual schools to take the initiative to develop their own management plan. It is also important not to forget that two of the three deaths in the past five years have occurred within the school camp setting. It is therefore also important to develop formal management/response plans extending to camps and, most notably, those held in remote areas. In the short term, anaphylaxis management protocols in the school setting must not be overlooked as the first step in a vital process which helps maintain a high standard of child safety.
Anaphylaxis guidelines: A resource for managing severe allergies in Victorian government schools (Victorian based document): http://www.eduweb.vic.gov.au/edulibrary/public/stuman/wellbeing/Anaphylaxis_guidelines-v1.01b.pdf
Anaphylaxis:Guidelines for schools (NSW based document): http://www.schools.nsw.edu.au/media/downloads/schoolsweb/studentsupport/studenthealth/aguidelines_v2.pdf
Australasian Society of Clinical Immunology and Allergy (ASCIA): http://www.allergy.org.au/aer/infobulletins/posters/Anaphylaxis_plan_(child)_Au.pdf
Food Allergy and Anaphylaxis Network
http://www.foodallergy.org/school/childdescribe.pdf (anaphylaxis in a child’s language)
Guidelines for managing food allergies at camps: http://www.foodallergy.org/downloads/CampGuidelines.pdf
Medic Alert bracelet: http://www.medicalert.com.au/
Lillian De Bortoli is a mother of three children with her eldest son being diagnosed with a severe peanut allergy and asthma. She works at Monash University and has completed a Master of Social Work research degree analysing the public health framework as a basis for preventing child abuse.