Current trends in food allergy–induced anaphylaxis management at school
Introduction
Anaphylaxis is a life-threatening medical emergency that requires prompt treatment with intramuscular epinephrine.[1], [2], [3], [4] With an increase in the number of children at risk or having experienced anaphylaxis in schools, there is a renewed focus on the preparation of schools to treat such an event, given data that support up to 25% of first-time anaphylactic events occurring on school grounds and a well-publicized fatality that helped to initiate a movement for stock, undesignated, non–student-specific epinephrine.[5], [6] This review details key issues related to anaphylaxis management at school and specifically themes and discussions shared in a recent multidisciplinary summit on this subject.
Section snippets
Developmental and Social Perspectives of Anaphylaxis in the School Setting
A school-aged child with food allergy may refer to someone in kindergarten or in college. Accordingly, needs for these students with respect to anaphylaxis management differ. Anaphylaxis has a negative effect on the psychological well-being and quality of life (QoL) of both children and their families.7 As children with anaphylaxis age, they carry an additional, escalating burden of sharing the responsibility of managing their risk of exposure.8 Data are mixed about whether epinephrine
How are Schools Currently Managing Anaphylaxis?
According to nationally representative survey data, approximately 6 million US children (approximately 8%) have IgE-mediated food allergy, including 25% with peanut allergy and 30% with multiple food allergies.19 This amount roughly translates to 2 students per 25-person classroom, with this rate expected to increase. Peanut and tree nuts are frequently reported triggers of severe reactions. Data indicate that potentially 18% of children with food allergies have experienced an allergic reaction
Measuring Stock Epinephrine Outcomes
On November 13, 2013, President Obama signed the School Access to Emergency Epinephrine Act into law. Not even 5 years later, 49 of the 50 states now have either opt-in or mandated stock epinephrine legislation.21 Most states have passed laws that are opt-in policies at the school or district level to voluntarily stock epinephrine, without specifying how to prescribe, maintain, or pay for the device (although this may also lack clarity in states with a mandate law).21 Few successful program
Needs Assessment for Anaphylaxis Management in Schools
Given increasing recognition of anaphylaxis as a critical health issue, we must create more unified diagnostic criteria for anaphylaxis that all practitioners agree on and will have minimal interpretive variation. The 2006 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network guidelines were a first attempt at this, but there is a paucity of data that demonstrate what outcomes these criteria have influenced, including if these have increased timely
Conclusion
The rates of anaphylaxis have increased in the past several years. Consensus diagnostic criteria have existed since 2006, but there are no national-level data to support that these are associated with widespread implementation or understanding of what key outcomes such criteria have affected. Although now 49 states have stock epinephrine legislation, more data are needed to demonstrate that this program has been effectively implemented, demonstrate the outcomes of this program, and elucidate
References (48)
- et al.
2015 update of the evidence base: world Allergy Organization anaphylaxis guidelines
World Allergy Organ J
(2015) - et al.
Anaphylaxis: unique aspects of clinical diagnosis and management in infants (birth to age 2 years)
J Allergy Clin Immunol
(2015) - et al.
Second symposium on the definition and management of anaphylaxis: summary report–Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium
J Allergy Clin Immunol
(2006) - et al.
Mental health and quality-of-life concerns related to the burden of food allergy
Immunol Allergy Clin North Am
(2012) - et al.
The impact of childhood food allergy on quality of life
Ann Allergy Asthma Immunol
(2001) Food allergy quality of life
Ann Allergy Asthma Immunol
(2014)- et al.
Fatalities due to anaphylactic reactions to foods
J Allergy Clin Immunol
(2001) - et al.
Further fatalities caused by anaphylactic reactions to food, 2001–2006
J Allergy Clin Immunol
(2007) - et al.
Food allergy and food allergy attitudes among college students
J Allergy Clin Immunol
(2009) - et al.
Impact of school peanut-free policies on epinephrine administration
J Allergy Clin Immunol
(2017)
The emperor has no symptoms: the risks of a blanket approach to using epinephrine autoinjectors for all allergic reactions
J Allergy Clin Immunol Pract
We must create a national policy to protect and manage food allergic students at school
Ann Allergy Asthma Immunol
Emergency epinephrine use for food allergy reactions in Chicago Public Schools
Am J Prev Med
A law is not enough: geographical disparities in stock epinephrine access in Kansas
J Allergy Clin Immunol
Section on allergy and immunology. Epinephrine for first-aid management of anaphylaxis
Pediatrics
Administration of epinephrine for life-threatening allergic reactions in school settings
Pediatrics
Allergy kills Virginia girl at school
The impact of food allergies on quality of life
Pediatr Ann
Food allergy quality of life and living with food allergy
Curr Opin Allergy Clin Immunol
Why do few food-allergic adolescents treat anaphylaxis with adrenaline? reviewing a pressing issue
Pediatr Allergy Immunol
What affects quality of life among caregivers of food-allergic children?
Ann Allergy Asthma Immunol
The psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families: a review
Allergy
Fatal and near-fatal anaphylactic reactions to food in children and adolescents
N Engl J Med
The prevalence, severity, and distribution of childhood food allergy in the United States
Pediatrics
Cited by (20)
The Need for Required Stock Epinephrine in All Schools: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee
2023, Journal of Allergy and Clinical Immunology: In PracticeAnaphylaxis: a treatment adapted for every situation
2021, Revue Francaise d'AllergologiePrevention and management of allergic reactions to food in child care centers and schools: Practice guidelines
2021, Journal of Allergy and Clinical ImmunologyCitation Excerpt :Studies have found that school nurses and parents of children with allergy are generally supportive of stock autoinjector programs,101,155,158,212,213 although some parents have concerns about the adequacy of stock autoinjector coverage in large schools or those with multiple buildings.212 In contrast, some administrators, teachers, and other personnel are reluctant to implement stock autoinjector programs, due to concerns about increased responsibility or real or perceived legal liability.93,208,209,212,213 Research among school nurses suggests that equipping personnel on field trips and other off-site activities with stock autoinjectors tends to be less feasible and acceptable to personnel than stocking autoinjectors on site alone, due to cost and other barriers.158
Schoolchildren with chronic diseases; what are teachers worried about?
2020, Anales de PediatriaManaging Food Allergy in Schools During the COVID-19 Pandemic
2020, Journal of Allergy and Clinical Immunology: In PracticeNovel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change
2020, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :Furthermore, studies have suggested that food triggers are a negative predictor for biphasic reactions.28-30 The requirement to reflexively activate EMS after epinephrine use is, ironically, a noted barrier to epinephrine use to treat anaphylaxis.31 Decoupling the mandatory recommendation for immediate ED assessment after epinephrine treatment may help increase rates of appropriate epinephrine use in the community setting.
Disclosures: All authors received honorarium from the Allergy and Asthma Network for presenting at the 2017 USAnaphylaxis Summit.
Funding Sources: The USAnaphylaxis Summit, during which the material and topics contained within this review were presented, was sponsored by the Allergy and Asthma Network through an educational grant provided by Mylan Pharmaceutical.