Food allergies in children and young adults may feel more like a
stigma than a chronic medical condition. For children with
diagnosed life threatening allergies, medical alert identification,
in the form of a bracelet, necklace, or belt loop tag, may promote
stereotyping or create a basis for teasing. On the other hand, it
can save valuable response time and better safeguard the child's
health.1
In recent years, the number of children requiring treatment for
severe allergic reactions and anaphylaxis continues to
increase.2 3 4 According to data collected by the
Centers for Disease Control and Prevention, hospital discharges for
juveniles with a diagnosis related to food allergy grew from 2,615
in 1998-2000 to 9,537 in 2004-2006.5 This increase in
severe reactions to foods has prompted parents and physicians to
better communicate with schools to best protect children from
accidental exposure to allergens.
Although proper medical diagnosis, allergy testing, and remedial
measures taken to avoid exposure to allergens - where at all
possible - is a primary line of defense against severe
reactions,6 an appropriate and timely response,
including access to epinephrine, are also critical tools in the
immediate treatment of anaphylaxis after allergen exposure has
occurred.
Appropriate and Rapid Identification of an Allergic
Reaction
There is no one symptom that defines anaphylaxis; rather,
anaphylaxis is a life-threatening reaction that may present with a
variety of symptoms.7 While loss of consciousness or
difficulty breathing may be fairly obvious, coughing, stomach
cramps or a runny nose may be less clear; however, all have the
potential of being a symptom of a life-threatening
reaction.8
Students with a diagnosis of asthma, for instance, are at
especially high risk both for suffering anaphylaxis and for
receiving delayed treatment because the reaction may be mistakenly
believed to be asthmatic.9 For these reasons it is
critical that all individuals responsible for the care of students
are informed about the potential seriousness of allergic symptoms
and do not delay in ensuring that the child receive treatment
promptly upon experiencing known symptoms.10
While some may consider "peanut free zones" in school cafeterias,
for example, to cause segregating and stigmatizing of children, it
may very well be a convenient and safe way to ensure that children
are removed from accidental exposure to allergens.
The commonwealth's leadership role in keeping school children
safe
The commonwealth is a recognized leader in efforts to protect
students with allergies in schools. It established the
Life-Threatening Food Allergies in Schools Task Force, made up of
parents, medical and nutrition experts, school officials and
representatives from leading allergy organizations. Massachusetts
has developed comprehensive guidelines for schools on how to plan
and respond to life threatening allergic reactions, laid out in the
publication, "Managing Life Threatening Food Allergies in
Schools."11
The commonwealth further allows pharmacies to sell
non-patient-specific stock supply epi-pens to schools, and
encourages having epi-pens in schools to treat
anaphylaxis.12 School nurses may train unlicensed
individuals to administer epinephrine to students with diagnosed
allergies.13 Schools also must permit students with
life-threatening allergies to carry and administer prescribed
epinephrine.14 Additionally, Massachusetts requires all
new bus drivers to receive training in epi-pen
administration.15
The commonwealth goes further and requires state school systems to
submit forms to the Massachusetts Department of Public Health each
time epinephrine is administered.16 Epinephrine
administrations in Massachusetts schools have increased from 127
administrations in 2003-2004 to 198 administrations in
2009-2010.17
Peanuts and tree nuts are consistently the most frequently
reported allergens.18 While all food allergies have the
potential to be life threatening, peanut and tree nut allergies are
of special concern because they are believed to be responsible for
92 percent of severe and fatal reactions.19 20
While a small number of students may react from coming in contact
with minute amounts of an allergen, such as breathing in airborne
peanut particles or coming in contact with peanut oil, most
individuals with peanut allergies only experience severe reactions
after consumption of a peanut product.21 The amount an
individual would have to consume to have a reaction varies, but can
be as small as 1/5000th of a teaspoon.22
In Massachusetts, the most common trigger for an allergic reaction
at school is food, believed to be the trigger for 43 to 46 percent
of reactions requiring epinephrine administration.23
However, in up to 46 percent of cases, the triggering allergen is
unknown. Further, in roughly 25 percent of cases, the individual
experiencing the reaction was unaware that he had an
allergy.24
Studies suggest that exposure to a food for the first time at
school is the trigger in 20 percent of anaphylactic episodes in
schools.25 Registered nurses reportedly administered
epinephrine in 87 to 92 percent of cases while other parties
reportedly administered it in 8 to 13 percent of
incidents.26
Although the objective is not to stigmatize or treat any
differently those students with known food allergies, school
districts should consider establishing seating arrangements in the
cafeteria and designated areas of allergy-free zones.
Additionally, school policies should address events in which
students bring foods to share into the classroom - such as class
parties and birthdays - as those foods, even if believed to not
contain the allergen, often present exposure risks for students
with severe allergies.27
Access and Administration of Epinephrine
Immediate access to epinephrine has been demonstrated to
significantly reduce fatalities from anaphylaxis.28 29
While ideally a licensed professional, such as a school nurse,
would be available to administer epinephrine, there should always
be multiple adults at a given site trained to administer
epinephrine.30 Adults responsible for the care of
children in an organized setting should be trained to administer
epinephrine.31
Epinephrine, in the form of an epi-pen, is easy to administer with
minimal training and is life-saving, and the administration in
response to a life threatening reaction is generally protected by
Good Samaritan laws.32 Delays in administration of
epinephrine are frequently the cause of deaths resulting from
allergic reactions.33
It may be reasonable to consider further extensions of the
Massachusetts "Good Samaritan" laws to explicitly exempt from
liability those persons who administer epinephrine to children in
good faith attempts to render emergency care; in much the same way
the commonwealth exempts those rendering CPR and defibrillation
services.34
While prevention is the most critical component of protecting
children with life threatening allergies, every reaction cannot be
accounted for. The relatively high number of students with no prior
knowledge or diagnoses of an allergy that experience severe
allergic reactions, along with the number of students with
allergies who have a severe reaction triggered by an unknown
allergen, emphasize the limitations of prevention and the
importance of on-site identification and response.35
Added state protections, for example, may be necessary to hold
harmless those individuals who respond by administering epinephrine
in good faith situations.
1. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools 49
(2002).
2. American Academy of Allergy, Asthma, and
Immunology. Allergy Statistics, (2010).
3. American Academy of Allergy, Asthma, and
Immunology. Allergy Statistics, (2010).
4. Amy M. Branum & Susan L. Lukacs, National
Center for Health Statistics, Food Allergy Among U.S. Children:
Trends in Prevalence and Hospitalizations, 10 NCHS Data Brief
1 (2008).
5. Amy M. Branum & Susan L. Lukacs, National
Center for Health Statistics, Food Allergy Among U.S. Children:
Trends in Prevalence and Hospitalizations, 10 NCHS Data Brief
1, 4 (2008).
6. Massachusetts Dep't of Education, Managing
Life Threatening Food Allergies in Schools 7 (2002).
7. American Academy of Allergy, Asthma, and
Immunology, Anaphylaxis(END ITALIC) (2013) available at
www.aaaai.org/conditions-and-treatments/allergies/anaphylaxis.aspx
(last visited April 1, 2013).
8. Massachusetts Dep't of Education, Managing
Life Threatening Food Allergies in Schools 6-7 (2002).
9. Massachusetts Dep't of Education, Managing
Life Threatening Food Allergies in Schools 7-8 (2002).
10. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools 7-8
(2002).
11. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools
(2002).
12. Mass. Dep't of Public Health, Advisory
Regarding Stock Supply of Non-Patient Specific Epinephrine for
Schools, (Feb. 14, 2012). ("The Board of Registration in
Pharmacy and the Drug Control Program strongly support all
prescriber and pharmacy efforts to provide stock epinephrine in a
pre-measured, auto injector device to Massachusetts public and
private schools to facilitate emergency treatment of anaphylaxis
reactions.")
13. 105 CMR 210.000 (2012).
14. Mass. Gen. Laws ch. 71 § 54(b) (2013).
15. Mass. Gen. Laws ch. 90 § 8(a) (2013).
16. 105 CMR 210.000 (2004); School Health Unit,
Mass. Dep't of Public Health, Report of Epinephrine
Administration (2010-2011) (2010); Asthma and Allergy
Foundation of America, Massachusetts State Honor Roll,
(2012) available at
www.aafa.org/display.cfm?ID=5&sub=105&cont=654 (last
visited Apr. 4, 2013).
17. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).
18. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).
19. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools 2
(2002).
20. American Academy of Allergy, Asthma, and
Immunology. Allergy Statistics, (2010).
21. Jill F. Kilanowski & Ann Salter,
Peanut Allergy in the School Environment Myths and Facts
(2007) available at www.netwellness.org/healthtopics/ch/peanut1.cfm
(last visited April 8, 2013).
22. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools 2
(2002).
23. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).
24. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).
25. NIAID-Sponsored Expert Panel, Guidelines
for the Diagnosis and Management of Food Allergy in the United
States: Diagnosis of IgE-Mediated Food Allergy, 126(6) The
Journal of Allergy and Clinical Immunology S1, S1-S68, (2010)
available at
www.jacionline.org/article/S0091-6749percent2810percent2901566-6/fulltext#sec4.2
(last visited Apr. 8, 2013).
26. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).
27. Scott H. Sicherer et al., Clinical Report
Management of Food Allergy in the School Setting, 126(6)
Pediatrics 1232, 1236 (2010); National School Boards Association,
Safe at School and Ready to Learn: A Comprehensive Policy for
Protecting Students with Life-Threatening Food Allergies
(2012); Massachusetts Dep't of Education, Managing Life
Threatening Food Allergies in Schools (2002).
28. The Food Allergy & Anaphylaxis Network,
Managing Food Allergies in the School Setting: Guidance for
Parents 1, 5 (2011).
29. National School Boards Association, Safe
at School and Ready to Learn: A Comprehensive Policy for Protecting
Students with Life-Threatening Food Allergies 7 (2012).
30. National School Boards Association, Safe
at School and Ready to Learn: A Comprehensive Policy for Protecting
Students with Life-Threatening Food Allergies 49 (2012).
31. National School Boards Association, Safe
at School and Ready to Learn: A Comprehensive Policy for Protecting
Students with Life-Threatening Food Allergies 30 (2012).
32. National School Boards Association, Safe
at School and Ready to Learn: A Comprehensive Policy for Protecting
Students with Life-Threatening Food Allergies 49 (2012).
33. Massachusetts Dep't of Education,
Managing Life Threatening Food Allergies in Schools 7-8
(2002).
34. Mass. Gen. Laws ch. 112 § 12(v).
35. School Health Unit, Mass. Dep't of Public
Health, Data Health Brief: Epinephrine Administration in
Schools 2003-2004 (2005); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2004-2005 (2006); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2005-2006 (2007); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2007-2008 (2009); School Health Unit, Mass. Dep't of
Public Health, Data Health Brief: Epinephrine Administration in
Schools 2009-2010 (2011).