In this Chapter . . .
Goals of the guidelines are to assure students’ safety and rights, the safety of other students, and to offer safe services performed in accordance with nursing practice standards which include nursing care planning, delegation, training, and monitoring of direct service providers and unlicensed assistive personnel.
These guidelines will clearly identify roles and responsibilities of Sarasota County Core Team members consisting of, but not limited to: family, student, school RN, health room aides, food and nutrition staff, educational personnel, school administration, transportation and the physician. They will ensure that emergency medical services (EMS) are engaged immediately in the sequence that puts the safety of the child first.
These guidelines were developed through the collaborative efforts of the School Nurses of the Florida Department of Health in Sarasota County and the School Board of Sarasota County, the School Board of Sarasota County Food and Nutrition Services, and the Sarasota County School Health Advisory Board.
Life-threatening allergies and associated anaphylaxis are on the rise and are a growing public health concern in the United States. “Anaphylaxis refers to a collection of symptoms affecting multiple systems in the body. The most dangerous symptoms include breathing difficulties and a drop in blood pressure, or shock, which are potentially fatal. Common examples of potential life-threatening allergies are those to foods and stinging insects. Life-threatening allergic reactions may also occur to medications, latex rubber, in association with exercise” or may be of an unknown cause (idiopathic). (Position Statement from American Academy of Allergy, Asthma and Immunology (AAAAI) Board of Directors:” Anaphylaxis in Schools and Other Childcare Settings”-1998)
From 1997 to 2007, the prevalence of reported food allergy increased 18% among children. In 2007, approximately 3 million children in the US were reported to have food allergies with the highest incidence (approximately 6%) occurring in young children under the age of three. Eight foods account for 90 percent of all food-allergic reactions in the U.S.: milk, eggs, peanuts, tree nuts (e.g., walnuts, almonds, cashews, pistachios, and pecans), wheat, soy, fish, and shellfish. Food allergies are the leading cause of anaphylaxis outside of the hospital setting. (AAAAI- "Allergy Statistics"-2009)
Life-threatening allergies to the venom of stinging insects (honey bees, bumble bees, wasps, hornets, yellow jackets, and fire ants) occur in 0.4% to 0.8% of children.
(AAAAI-"Allergy Statistics" 2009). For drug allergies, penicillin is the most common allergy trigger. Latex allergy affects between 5-15% of the health care workers, but less than 1% of the general population. (AAAAI-"Allergy Statistics"-2009)
There is no cure for life-threatening allergies. The most important aspect of the management of children with life-threatening allergies is strict avoidance. School environments provide numerous opportunities for exposure to allergens (e.g. classrooms, recess, athletic events, parties, snacks, arts and crafts projects, incentives, buses). A school environment for a child diagnosed with a life-threatening allergy needs to be created to prevent exposure and to recognize and manage a reaction if exposure occurs.
“A combination of state and federal laws guarantee the access to education and to health and other support services that enable students with special health needs to attend school. Section 381.0056 F.S. mandates basic school health services for all students, s.1006.062 F.S. mandates assistance with medication and special procedures, and s.1002.20 (3)(i) F.S, the Kelsey Ryan Act, allows public school students with a history of life-threatening allergic reactions to carry an epinephrine auto-injector and self-administer epinephrine while in school, participating in school-sponsored activities or in transit to or from school or school-sponsored activities if the school has been provided with parental and physician authorization.” (Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act - May 2006)
“The school district determines whether students with life threatening allergies should receive services under Section 504 (Rehabilitation Act of 1973), Title 11 of the Americans with Disability Act (ADA), or the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA). If the district determines that the student should receive services under IDEIA, the school staff documents the related aids and services needed in the student’s IEP. If it is determined that the student is eligible under s. 504, the school staff develops a Section 504 Plan to document the related aids and services school district will provide. Attach the IHP developed by the school RN to either plan to document the healthcare services required by the student” (TAP, May 2006).
Note: IDEA was reauthorized, revised, and renamed in 2004. The Individuals with Disabilities Education Improvement Act of 2004 (IDEIA) became effective July 1, 2005.
“Nursing services in Florida and Florida schools are regulated by the provisions of The Nurse Practice Act, Chapter 464, F.S., which specifies nursing training and qualifications, practice parameters, guidelines for the legal use of health aides or unlicensed assistive personnel in care provision” (TAP, May 2006).
For further clarification of the nurse’s role in delegation and supervision, see Chapter 64B9-14.001-003, Florida Administration Code (F.A.C.). This rule describes the “Delegation of Tasks or Activities” (Chapter 64B9-14.002, F.A.C.), and the “Delegation of Tasks Prohibited” (Chapter 64B9-12.003, F.A.C.). Internet sites for text of state and federal laws that apply to children with special health care needs are provided in the reference section of this document. (TAP, May 2006)
Allergic reactions begin when a predisposed student eats, inhales, or has contact with an allergen/protein that triggers an allergic response. The most common allergic response is when the immune system in the body responds by producing an antibody, IgE, to a particular allergen/protein. “The antibody circulates throughout the body sensitizing mast cells in the GI tract, lungs, etc. “ (FAAN, 2005) All of this happens the first time the student is exposed to the allergen/protein, but commonly there are no symptoms until the second exposure.
“The next time the student eats, touches or inhales the offending allergen/protein, the immune systems sensitized cells protect the body from the
“dangerous invader” by releasing histamine and other chemicals. As a result, the individual experiences symptoms of an allergic reaction.” (FAAN, 2005)
Even trace amounts of an allergen/protein can produce a reaction.
Symptoms that the student will experience depend on the location in the body in which the histamine is released. There is no way to predict how a reaction will develop. The severity of symptoms can change very rapidly and become a life- threatening reaction.
“Anaphylaxis is the potentially life-threatening medical condition occurring in allergic individuals after exposure to their specific allergens. Anaphylaxis refers to a collection of symptoms affecting multiple systems in the body. These symptoms may include one or more of the following” (FAAN, 2005):
Typical Allergy Symptoms
“The most dangerous and potentially fatal symptoms include breathing difficulties and a drop in blood pressure or shock. Common examples of potentially life-threatening allergies are those to food and stinging insects. Life-threatening allergic reactions may also occur to medications, latex rubber, in association with exercise, or may be of an unknown cause” (www.foodallergy.org/anaphylaxis.html).
“For some individuals, the reaction begins slowly and gradually gets worse, for others it develops more quickly and can become life threatening within a few minutes, which is why all reactions need to be taken seriously and treated promptly. Early administration of epinephrine is crucial to treating anaphylactic reactions. It is better to err on the side of caution, if in doubt give the epinephrine. (FAAN, 2005).
“Anaphylaxis can occur immediately or up to two hours following allergen exposure. In about a third of anaphylactic reactions, the initial symptoms are followed by a delayed wave of symptoms two to four hours later [and possibly longer].” “This combination of an early phase of symptoms followed by a late phase of symptoms is defined as a biphasic reaction. While the initial symptoms respond to epinephrine, the delayed biphasic response may not respond at all to epinephrine and may not be prevented by steroids. Therefore, it is imperative that following the administration of epinephrine the student be transported by emergency medical services to the nearest hospital emergency department even if the symptoms appear to have been resolved” (MaDOE, 2002).
How a Child Might Describe a Reaction
Children have unique ways of describing their experiences and perceptions, and allergic reactions are no exception. Precious time is lost when adults do not immediately recognize that a reaction is occurring or don’t understand what a child is telling them.
Some children, especially very young ones, put their hands in their mouths or pull or scratch at their tongues in response to a reaction. Also, children’s voices may change (e.g., become hoarse or squeaky), and they may slur their words.
The following are examples of the words a child might use to describe a reaction:
If you suspect that your child is having an allergic reaction, follow your doctor's instructions.
Copyright © 2010, The Food Allergy & Anaphylaxis Network
A food allergy can develop from any food. A food allergy is a medical condition involving the immune system. Food poisoning, food intolerance, food aversions, or phobias are commonly mistaken for but are not considered food allergies because there is no immune response. Eight foods account for 90 percent of all food –allergic reactions in the U.S.; milk, eggs, peanuts, tree nuts, (e.g., walnuts, almonds, cashews, pistachios, pecans), wheat, soy, fish, and shellfish. (www.foodallergy.org/section/common-food-allergens1)
“There is no cure or preventive medication available for food allergy. Avoidance of the food is the only way to prevent a reaction from occurring. (FAAN,2005)
“Most individuals who have experienced a food-allergic reaction knew what they were allergic to and unknowingly ate that food. In most cases, the allergy-causing food was an unexpected ingredient in another food. Another potentially serious cause of allergic reactions is cross contact from an allergy –causing food to a non allergy-causing food during food processing or preparation. “ (FAAN, 2005)
There is no way to predict how a reaction will develop. The severity of symptoms can change very rapidly and become a life-threatening reaction. Nevertheless with food allergies, “there are three specific pieces of a patient’s history that signify an increased risk for a severe reaction: a record of severe reactions in the past, an allergy to peanuts and or tree nuts, and the presence of asthma” (The Food Allergy & Anaphylaxis Network (FAAN) Food Allergy News Sample)
School environments provide numerous opportunities for exposure to food allergens (e.g. classrooms, recess, athletic events, parties, snacks, arts and crafts projects, incentives, buses). A school environment for a child diagnosed with a life- threatening allergy needs to be created to prevent exposure and to recognize and manage a reaction if exposure occurs.
Additional considerations for Food Allergy Management in School include: (FAAN, Food Allergy News Sample)
Latex allergies are a reaction to the proteins in natural rubber latex, a milky sap produced by the Hevea Braziliensis rubber tree. There is an increased prevalence of latex allergies in children who have had multiple surgeries early in life and with healthcare workers.
Latex can result in an allergic reaction by direct contact with products containing latex such as balloons, elastic in clothes, rubber bands, pencil erasers, etc. Latex can also become airborne and cause respiratory symptoms. For example as latex gloves are used, the proteins in latex may be carried on cornstarch powders that are used as a lubricant on some gloves resulting in respiratory symptoms.
In most cases, latex allergy develops after repeated exposure to natural rubber latex products. Symptoms usually occur immediately following contact with latex. Allergic reactions can vary from mild to life threatening. There is no cure for latex allergy so avoidance of known latex allergens is the best method of treatment.
For lists of latex alternatives and latex-free products, visit the American Latex Allergy Association website at www.latexallergyresources.org. Another resource is the CDC Latex Allergy Hotline (1-800-356-4674 or www.cdc.gov/niosh/latexfs.html. To check out a product’s contents for sure, call the manufacturer.
Insect allergies involve an allergic reaction associated with the venom or toxin induced when bitten or stung by an insect. There are thousands of biting and stinging insects in our environment, however the insects most known to produce an anaphylactic reaction are fire ants, bumble bees, honey bees, wasps, yellow jackets and hornets (Selekman, 2006).
“To decrease the chance of insect stings, the following measures should be followed:
“Management and treatment of stinging insect anaphylaxis included prevention, immunotherapy, medic alert identification and epinephrine, if needed. “ (Selekman, 2006)
“Although rare, exercise can cause anaphylaxis. Oddly enough, it does not occur after every exercise session and in some cases, only occurs after eating certain foods before exercise. Food-associated exercise-induced anaphylaxis is caused by a combination of eating a particular food, often celery or wheat, plus exercise within an hour or two after eating.” (AAAAI, 2010)
Idiopathic Etiology (Unknown Cause)
This form of anaphylaxis involves an allergic reaction to an unknown substance or combination substances and/or environmental factors. The specific allergen has not been identified therefore planning is complicated. (Lechner and Grammer, 2010)
Sarasota County School District supports environmental policies that limit possible allergens in the facilities. The use of airborne sprays that propel possible allergens in the air should be eliminated in all areas in which students visit. Air fresheners, perfume, and deodorizers, especially of food origin are examples of products to avoid.
“It is most likely that, in the face of a natural disaster or emergency, all students will be sent home from school. However, in the event that environmental hazards exist that would prevent the student from leaving the school or that may precipitate an allergic episode, emergency medical services must be aware that environmentally fragile students with life-threatening allergies may be in the affected school. Every effort should be made to remove the student with life-threatening allergies safely, and ensure that emergency medications are available to the student” (TAP, 2006).
with a Life-threatening Allergy
Medically diagnosed life-threatening allergies are managed using a core team approach (see Student Life-Threatening Allergy Notification Flow Chart). The team’s goal is to ensure the safety and well being of the student. Upon identification of a student with a life-threatening allergy, members of the core team implement these guidelines and take responsibility for their role as outlined below. (The majority of the following information on Responsibilities of the Core Team was taken from the Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act - May 2006)
The physician/healthcare provider manages the medical care of the student with life threatening allergies. The physician should provide information and guidance to the school RN to use in developing the Individual Health Plan (IHP). Physicians should take into consideration the resources available in the school to assist students with their care. To safeguard student health, the physician should:
The school health policies should delineate roles that promote partnership between parents and the school. According to the School Health Services Act (Section 381.0056 F.S.), “School health services supplement, rather than replace, parental responsibility.”
For children to receive safe, consistent services while in school, it is important for parents and guardians to:
To remain active and healthy, the student with life-threatening allergies must assume some of the responsibilities in following the medical management plan designed by their health care provider as well as their IHP. Medication and supplies must be handled safely to prevent accidental injection of other students or staff. The student should:
The school RN functions under the scope of practice defined by Florida’s Nurse Practice Act. The functions of the school RN are:
Criteria for Safe Nursing Delegation
“The safety of the student is the primary consideration in the delivery of all health-related services provided in the school. The school RN is responsible for training and monitoring the individual designated to perform these services. Section 1006.062(1)(a), F.S. specifies that the school principal designates school staff to perform health services in the absence of the nurse. However, only the professional nurse may delegate the authority based upon nursing judgment and suitability of the individual to perform the task or activity to be delegated. Recognition of this distinction between designation to perform and delegation of nursing tasks is critical to the provision of safe care in the schools” (TAP, 2006).
Health room aides (HRA) perform under the administrative supervision of the School Principal and have the guidance and direction of the school RN for health related issues. The HRA performs services within the school health services program according to the written policies and procedures in the School Health Services Manual.
Food service staff members may play a critical role in providing an allergy safe environment for students.
Educational Personnel (teachers, aides, coaches, lunchroom aides; before & after school program staff)
The Principal or his/her designee should enforce district policies to assure implementation of the services needed for the student’s plan of care as follows:
The School Board of Sarasota County supports each student’s rights and seeks a balance for each student to support free choice in food selections and a safe environment for those students with life-threatening allergies. Efforts will be made to create a safe environment for the students to include environmental cleaning, safe zones in cafeteria areas and thoughtful and kind communication regarding possible limitation of offending allergens in the classroom during special snack times. Communication to classmates and their parents will be done after team review and consensus by the school RN, administration, teachers and student’s parents and will be worded to include consideration for all students.
(See sample letter - Foods to Avoid Bringing to School)
With the permission of the student and parents/guardians, the teacher or the school RN may educate the class about the special needs of an individual with life threatening allergies and use this as an opportunity to educate students regarding allergen avoidance and the need for immediate notification if a student is exposed to an allergen. Emphasize what the student can eat as well as what must be avoided. (See food allergy - sample lesson plan and food allergy - No Nuts Sign (additional signs are in Forms Chapter.
Be a PAL: Protect A Life™ From Food Allergies is an educational awareness program designed to help parents and educators teach students what food allergies are and how to help their friends who have food allergies. (See Food Allergy and Anaphylaxis Network-www.foodallergy.org/pal.html and food allergy-Be a PAL: Protect A Life™ From Food Allergies Poster.
“Chronic illness in children invariably poses many challenges to families. As children proceed through stages of cognitive, emotional and social development, their emotional responses and self-management strategies evolve.
If a life-threatening allergy is identified in a young child, the burden of prevention is initially fully upon parents. There may be an increase in anxiety around age 7 when a child’s cognitive development allows them to appreciate the possibility of serious reactions and as they move toward more independent functioning at school and with peers.
The transition from childhood to adolescence marks another time of increase risk. Although fatal food-allergy reactions are rare, they are most common among teenagers and young adults. This may be due to adolescents’ willingness to take risks, to faulty perceptions of risk, testing limits, or because they are more fearful of not fitting in socially than they are of having an allergic reaction. “(Greenberger, April 2010)
In addition, how other students react to the student who has a life threatening allergy impacts the child’s emotional health. “Beware of bullies who harass allergic students, threaten to make them eat an “unsafe “food” when there is a food allergy, or threaten them with any type of life-threatening allergen.” If there is a problem, such as harassment and bullying, it should be discussed with the guilty student and the parents as soon as possible. Be sure everyone understands this type of behavior is inappropriate” and follow the harassment/bullying procedure as per school guidelines. (FAAN,2005)
Because an anaphylactic reaction can occur at any time or anyplace, it is imperative that members of the core team are familiar with their roles/responsibilities and be comfortable with administering and/or supervising treatment.
The Epinephrine auto-injector is the treatment of choice for a life-threatening anaphylactic reaction. However, treatment when prescribed is always student specific. Some physicians are prescribing Benadryl (antihistamine) along with the auto-injector. The antihistamine in conjunction with the epinephrine may be given in an effort to decrease the symptoms and severity of the reaction. Antihistamines however should not be used in place of epinephrine. It is important that each member of the core team knows specifically what the treatment is for that particular student.
Once epinephrine is used, call EMS and “request an ambulance equipped with epinephrine and a responder trained to administer this medication” (FAAN, Food Allergy Action Plan) Send the used epinephrine auto-injector with the student to the Emergency Room.
Emergency First Aid for Anaphylactic Reaction
Adrenaclick® Auto-Injector EpiPen® Auto-Injector Twinject® Auto-Injector Auvi-Q Auto-Injector
The IHP will include age appropriate accommodations for the student medically approved per the Medication /Treatment Authorization Form to have epinephrine administered or self-administered in accordance with the Kelsey Ryan Act. The school RN in conjunction with school administrator and teacher will assess ability to perform self-administration, maturity level to function in an emergency, past life-threatening allergy episode and history of action taken by the student. Once safety and performance of the student has been assessed, the student can carry epinephrine in a rigid container attached to the student’s body. A second dose of medication is encouraged to be available at the school in case the student forgets it.
“The auto-injector is a disposable drug delivery system with a concealed needle that is spring activated. The active ingredient is epinephrine, the treatment of choice in allergic emergencies (anaphylactic reactions) because it quickly constricts blood vessels, relaxes smooth muscles in the lungs to improve breathing, stimulates the heartbeat and works to reverse hives and swelling around the face and lips.” (http://www.epipen.com)
Initial symptoms of anaphylaxis may represent a potentially fatal outcome and should be treated as a medical emergency, whether the symptoms occur gradually or suddenly. Even mild symptoms may intensify rapidly, triggering severe and possibly fatal shock. Usually, symptoms occur immediately following the sting or bite; death may occur within minutes. Symptoms, which often vary according to individual response, include the following:
These symptoms may escalate swiftly to anaphylactic shock characterized by cyanosis, reduced blood pressure, collapse, incontinence, and unconsciousness. Epinephrine given after the onset of low blood pressure may not prevent death.” (http://www.foodallergy.org: Information About Anaphylaxis)
Do not hesitate to use the auto-injector if you suspect a
serious allergic reaction, "err on the side of caution” (FAAN, 2005)
Epinephrine is available by prescription only. Epinephrine needs to be stored in a dark place at room temperature (59-86 degrees Fahrenheit). Exposure to light and extreme temperatures may inactivate the medication. Check the medication color (it should be clear) and expiration date. Notify the student’s parents when a replacement is needed. (FAAN, 2005)
Adrenaclick Training and Instructions: www.adrenaclick.com
American Academy of Allergy, Asthma and Immunology (AAAAI) Board of Directors: Position statement: Anaphylaxis in Schools and Other Childcare Settings”-1998)
American Academy of Allergy, Asthma and Immunology (AAAAI) “Allergy Statistics - 2009”. Retrieved July 30, 2010 from www.aaaai.org/media/statistics/allergy-statistics.asp
American Academy of Allergy, Asthma and Immunology (AAAAI) “Patients & Consumers Center: Tips to Remember: What is Anaphylaxis” Retrieved July 30, 2010 from www.aaaai.org/patients/publicedmat/tips/whatisanaphylaxis.stm
EpiPen Training and Instructions: www.epipen.com
Food Allergy and Anaphylaxis Network (FAAN). How A Child Might Describe A Reaction. Retrieved July 30,2010 from http://www.foodallergy.org/page/how-a-child-might-describe-a-reaction1
The Food Allergy & Anaphylaxis Network (FAAN)” Food Allergy News Sample”
The Food Allergy & Anaphylaxis Network (FAAN) “School Food Allergy Program.” August 2005)
Greenberger, B and Greenberger E.” The Emotional Impact of Food Allergies.” 17th Annual Food Allergy Conference. April 2010.
Lechner, K. and Grammer, L. “A Current Review of Idiopathic Anaphylaxis: Diagnosis” Retrieved July 30, 2010 from www.medscape.com/viewarticle/460702_4
Massachusetts DOE. “Managing Life Threatening Food Allergies in Schools.” 2002. Retrieved July 30,2010 from www.doe.mass.edu/cnp/allergy.pdf
National Association of School Nurses. (June 2005). Position statement. “Epinephrine Use in Life-Threatening Emergencies,” Scarborough, MA.
National Institute of Allergy and Infectious Disease,” Report of the NIH Expert Panel on Food Allergy Research.” March 13-14, 2006. Retrieved July 30, 2010 from www.niaid.nih.gov/topics/foodAllergy/.../foodallergyexpertreport.pdf
Selekman, J. Editor. (2006) “School Nursing: A Comprehensive Text.” Philadelphia: F.A.Davis Company.
Technical Assistance Paper (TAP): Implementing the Kelsey Ryan Act -1002.20(3)(i),F.S., May 2006
Last updated: 07/25/12