Current trends in food allergy–induced anaphylaxis management at school

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Abstract

Objective

To review the evidence and current policies regarding the use of epinephrine at schools and child care centers

Data Sources and Study Selections

A narrative review was performed based on the result of conference proceedings of a group of interprofessional stakeholders who attended the USAnaphylaxis Summit 2017 presented by Allergy & Asthma Network.

Results

Anaphylaxis is a well-recognized medical emergency that requires prompt treatment with intramuscular epinephrine. Anaphylaxis can be associated with poor quality of life. There is renewed recent focus on anaphylaxis management in schools. This interest has been spurred by an increase in the number of children with food allergy who are attending school, 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. Stock epinephrine is now available in 49 states, with an increasing number of states instituting mandatory reporting for use of such devices. Nursing efforts are paramount to support and implement stock epinephrine programs. Many states do not have clarity on delegation of authority for who can administer stock epinephrine, and there is evidence of variability in storage of stock devices. Few states have outcomes data that support successful implementation of stock epinephrine programs.

Conclusion

Additional data are needed to demonstrate successful implementations of stock epinephrine programs and their outcomes. Such programs should include support for school nursing and clearer delineation of authority for medication administration as well as standards for where and how devices are stored.

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)

  • P.J. Turner et al.

    The emperor has no symptoms: the risks of a blanket approach to using epinephrine autoinjectors for all allergic reactions

    J Allergy Clin Immunol Pract

    (2016)
  • M.J. Greenhawt et al.

    We must create a national policy to protect and manage food allergic students at school

    Ann Allergy Asthma Immunol

    (2012)
  • L. DeSantiago-Cardenas et al.

    Emergency epinephrine use for food allergy reactions in Chicago Public Schools

    Am J Prev Med

    (2015)
  • M.A. Love et al.

    A law is not enough: geographical disparities in stock epinephrine access in Kansas

    J Allergy Clin Immunol

    (2016)
  • S.H. Sicherer et al.

    Section on allergy and immunology. Epinephrine for first-aid management of anaphylaxis

    Pediatrics

    (2017)
  • C.L. McIntyre et al.

    Administration of epinephrine for life-threatening allergic reactions in school settings

    Pediatrics

    (2005)
  • Virginia Allergy Death Index

    Allergy kills Virginia girl at school

  • L.R. Bacal

    The impact of food allergies on quality of life

    Pediatr Ann

    (2013)
  • M. Greenhawt

    Food allergy quality of life and living with food allergy

    Curr Opin Allergy Clin Immunol

    (2016)
  • T. Marrs et al.

    Why do few food-allergic adolescents treat anaphylaxis with adrenaline? reviewing a pressing issue

    Pediatr Allergy Immunol

    (2013)
  • L. Howe et al.

    What affects quality of life among caregivers of food-allergic children?

    Ann Allergy Asthma Immunol

    (2014)
  • A.J. Cummings et al.

    The psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families: a review

    Allergy

    (2010)
  • H.A. Sampson et al.

    Fatal and near-fatal anaphylactic reactions to food in children and adolescents

    N Engl J Med

    (1992)
  • R.S. Gupta et al.

    The prevalence, severity, and distribution of childhood food allergy in the United States

    Pediatrics

    (2011)
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      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

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      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.

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    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.

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