Food allergy and anaphylaxis in schools
-why the fuss?
Anaphylaxis is the most severe form allergy
Systemic anaphylaxis is characterised
by the presence of two or more of hives / throat swelling, acute
asthma, gastrointestinal symptoms and hypotension. Many will suffer
dangerous symptoms, such as as difficulty breathing or a drop
in blood pressure.
Anaphylaxis can be frightening
The impact and fear of anaphylaxis is best understood when
patients describe the event. Their words often include statements
of intense fear, that they felt they were going to die, an inability
to think clearly or call out for help, of the dread felt when
their child collapsed, unable to breathe. Patients with severe
allergies also live with the knowledge that there is a good chance
they will go through it all again when they least expect it.
Allergy is increasing
The frequency of hay fever, asthma and eczema has doubled
in every country in which it has been studied over the last 30
years. Recent studies suggest that the frequency of food allergy
is heading in the same direction.
Food and sting allergy is not rare
1 in 20 children have a transient allergy
to food, often resulting in mild contact hives or aggravated
eczema. Recent estimates of cows milk allergy, egg allergy and
peanut allergy in infancy are generally given as 1%, 1% and 2%,
respectively. Fortunately, life-threatening allergic reactions
are much less common but are certainly not rare. By contrast,
1 in 100 adults have food allergy of variable severity. Around
1 in 250 people of all ages are susceptible to serious allergic
reactions to stinging insects.
Anaphylaxis is not rare
Published studies suggest that new cases of anaphylaxis arise
at a rate of one case per 500 people per year. That equates to
over 1 new cases of serious allergic reactions in the Australian
Capital Territory each week.
Food and insect stings are the main triggers
The major food triggers in infants are peanut and tree nuts,
egg, cows milk, soy and sometimes seafood. By the time a child
gets to school age, many of these have resolved but reactions
to nuts and seafood usually persist. Adults can react to a more
diverse range of foods. Bites and stings by bees, wasps, "jumper
ants" (sometimes even ticks) can cause similar reactions.
Drug allergy is more of a problem in adults.
Anaphylaxis occurs at all ages
Anaphylaxis can occur at any age, but is most common in children
and young adults. A recent South Australian study of over 4000
school-aged children demonstrated that 1 in 170 children had suffered
an episode of anaphylaxis, and 1/6 episodes had occurred at school.
The majority had no emergency action plan or medication available
if they were re-exposed to their trigger, despite the fact that
these children spend over a third of their waking hours at school.
The implication is that on average, most child-care centres, preschools
and schools in will enrol child with anaphylaxis every couple
of years, if not more often.
Anaphylaxis kills around 10-20 Australians yearly
Even this may be an underestimate, as some post-mortem studies
have shown high levels of serum tryptase (a sensitive marker of
massive allergic reactions) in some cases of unexplained death.
Why the problem with nuts?
Not only are peanut and tree nuts the most common trigger
for food-induced anaphylaxis, but they are the most common explanation
for recurrent anaphylaxis. Nuts are hard to avoid because of their
widespread use, because allergy tends to persist (less than 1
in 5 resolve), and only small amounts are needed to trigger symptoms
(say, the size of a sesame seed). In published studies of death
from anaphylaxis, 90 % have been allergic to nuts, exposure has
been accidental and usually away from home (including school!)
and treatment with adrenaline (epinephrine) has been delayed or
not given at all.
Reducing the risk at school
Discussion about anaphylaxis often centres on the administration
of medication. While administration of life-saving medication
(like EpiPen) is an essential part
of management of patients with life-threatening allergies, it
is just as important to take steps to avoid potential triggers,
and to recognise signs of anaphylaxis when they do occur.
That is why the Canadian Society for Clinical Immunology and Allergy, the American Academy of Allergy, Asthma and Immunology and the Australasian Society for Clinical Immunology and Allergy have adopted Guidelines for the Prevention, Recognition and Management of Anaphylaxis in Childcare and Schools. The salient points are:
Duty of care in schools
Children spend over one third of their waking hours at school
and are dependent on care givers such as parents, child care workers
or teachers to provide a safe environment. Very young infants
at preschool and child care are probably at greatest risk, since
food allergy is more common in this group, because they are dependent
on care-givers to prepare and distribute food and more likely
to grab food or objects contaminated with food allergen. Education
Department guidelines generally emphasise the importance of providing
a safe environment for children at school. Sometimes this means
repairing broken play equipment, sometimes removing bee hives
and sometimes making recommendations about what foods should or
should not be brought to school. Some education department guidelines
also allow staff to administer First Aid and emergency medication
if required, including adrenaline
(EpiPen).
What can be done?
School-based educational training programmes have been established
in the USA and Great Britain. A similar programme in South Australia
is sponsored by the Department of Health, and the Department of
Education, Training and Employment. When a school is notified
that a child has suffered from anaphylaxis, the entire staff is
trained (not just a First Aid officer) in the recognition and
management of anaphylaxis by the Australian Red Cross and St John
Ambulance Australia. This successful programme has trained over
1000 teachers and child care workers in South Australia in the
last three years.
What's happening in Canberra?
An educational programme on Anaphylaxis Prevention and Management
has been developed in association with the Australian Red Cross
and St John Ambulance Australia in the Australian Capital Territory.
First Aid Trainers from Australian Red Cross and St John Ambulance
conduct sessions. Bookings by child-care centres, preschools and
schools can be made with either St John Ambulance Australia First
Aid Training (Tel 02 6282 2399) or Australian Red Cross First
Aid Training (Tel 02 6206 6099). Similar programmes are under
development or consideration elsewhere in Australia.
Anaphylaxis FactsAnaphylaxis occurs in approximately 1 in 200 school age children. 1 in 6 episodes of anaphylaxis occur at school. Children spend over one third of their waking hours at school. They are totally dependent on care-givers to administer First Aid in an emergency. Studies of fatal anaphylaxis have demonstrated that patients who die from anaphylaxis have generally been exposed to their trigger unknowingly, away from home & essential treatment has been delayed. 10 to 20 Australians die from anaphylaxis each year. Adrenaline (epinephrine) is the only medication shown to be of benefit in treating anaphylaxis. It is considered to be a First Aid treatment for anaphylaxis by many professional international immunology/allergy societies. Current ACT Department of Education and Community Services policies allow staff to administer emergency medication if required. Successful anaphylaxis education programs have been established in the USA, Great Britain and South Australia. |
| PATIENT SUPPORT GROUPS | Food Allergy Network (USA) |
| FACTS (Food Anaphylaxis in Children, Training and Support, Australia) | |
| The Anaphylaxis Campaign (UK) | |
| Peanut Allergy Site (USA) | |
| PROFESSIONAL MEDICAL SITES | ASCIA Education Resources (Australasian Society of Clinical Immunology & Allergy) |
| National Jewish & Medical Research Center (Anaphylaxis Section; USA) | |
| Canadian Information Handbook on Anaphylactic Shock (downloadable pdf file; Canada) | |
| Food Allergy Site (Switzerland) | |
| POSITION STATEMENTS | Guidelines for the prevention, recognition and management of anaphylaxis in child care and school sites. A Position Statement of the Australasian Society for Clinical Immunology and Allergy (ASCIA) (web link to this ASCIA document) |
| Anaphylaxis in schools and other child-care settings. Position Statement of the American Academy of Allergy, Asthma and Clinical Immunology (AAAAI) (web link to this document) | |
| The Use of Epinephrine in the Treatment of Anaphylaxis. Position Statement of the American Academy of Allergy, Asthma and Clinical Immunology (web link to this document) | |
| EDUCATIONAL ARTICLES | Tips to Remember: Food Allergy (AAAAI) (web link to this information) |
| Tips to Remember: Stinging insect allergy (AAAAI) (web link to this information) | |
| Anaphylaxis (Australasian Society for Clinical Immunology and Allergy) (web link to this information) | |
| Tips to Remember: What is anaphylaxis? (AAAAI) (web link to this information) |
ACT Department of Education School Health Policies and on admininstration of medication
| PROFESSIONAL ARTICLES | Stinging Insect Allergy (web link to MJA article) |
| Prof M Fisher. Treatment of Anaphylaxis (web link to BMJ article) | |
| Ewan PW. ABC of Allergies: Anaphylaxis. BMJ 1998; 316: 1442-45.(Web link to BMJ article) | |
| Administration of medicines in school: who is responsible? BMJ 1998; 316: 1591-3. (web link) | |
| Australian Venom Research Unit, University of Melbourne |
| COMMERCIAL SITES (information provided but not necessarily endorsed by this web site) | Allergypack Web site selling "Pen Pals" for carrying Epipen devices (web link) |
| Protectube Web site selling a protective carrying case for Epipen (web link) | |
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