Clinical Report—Management of Food Allergy in the School Setting Abstract

Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Management of Food Allergy in the School Setting Scott H. Sicherer, MD, Todd Mahr, MD, and THE SECTION abstract ON ALLERGY AND IMMUNOLOGY Food allergy is estimated to affect approximately 1 in 25 school-aged chil- KEY WORDS dren and is the most common trigger of anaphylaxis in this age group. food allergy, school, anaphylaxis School food-allergy management requires strategies to reduce the risk of ABBREVIATION IHCP—individualized health care plan ingestion of the allergen as well as procedures to recognize and treat This document is copyrighted and is property of the American allergic reactions and anaphylaxis. The role of the pediatrician or pediatric Academy of Pediatrics and its Board of Directors. All authors health care provider may include diagnosing and documenting a poten- have filed conflict of interest statements with the American tially life-threatening food allergy, prescribing self-injectable epinephrine, Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American helping the child learn how to store and use the medication in a responsi- Academy of Pediatrics has neither solicited nor accepted any ble manner, educating the parents of their responsibility to implement commercial involvement in the development of the content of prevention strategies within and outside the home environment, and work- this publication. ing with families, schools, and students in developing written plans to The guidance in this report does not indicate an exclusive reduce the risk of anaphylaxis and to implement emergency treatment in course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be the event of a reaction. This clinical report highlights the role of the pedi- appropriate. atrician and pediatric health care provider in managing students with food allergies. Pediatrics 2010;126:1232–1239 INTRODUCTION Anaphylaxis is a severe, potentially fatal, systemic allergic reaction that occurs suddenly after contact with an allergy-causing substance.1 Food allergy is a common cause of anaphylaxis.2 The Centers for Dis- ease Control and Prevention recently reported an 18% increase in food allergy among school-aged children from 1997 to 2007; 1 in 25 children 3 are now affected. Results of studies of children with food allergy indi- www.pediatrics.org/cgi/doi/10.1542/peds.2010-2575 cate that 16% to 18% have experienced a reaction in school.4,5 Allergic doi:10.1542/peds.2010-2575 reactions or treatment for anaphylaxis also occur in children whose All clinical reports from the American Academy of Pediatrics 5,6 allergy was previously undiagnosed (ϳ25% of cases of anaphylaxis). automatically expire 5 years after publication unless reaffirmed, Fatalities were noted to be overrepresented by children with peanut, revised, or retired at or before that time. tree nut, or milk allergy and among teenagers and those with underly- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). ing asthma. Preschool-aged children may experience food-induced Copyright © 2010 by the American Academy of Pediatrics anaphylaxis more often than older children, but the majority of food- allergic reactions in preschool- and school-aged children are not anaphylaxis,7,8 and deaths are rare.9 In case series of fatalities from food allergy among preschool- and school-aged children in the United States, 9 of 32 fatalities occurred in school and were associated primarily with significant delays in admin- istering epinephrine.10–12 The purpose of this clinical report is to highlight the pediatrician’s role in management of food allergy in the school setting and emphasize prevention and treatment of food-induced anaphylaxis.13 Management of infants, toddlers, and preschool-aged children who are cared for in myriad settings poses additional challenges (eg, infants may suck on 1232 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 25, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS shared toys, grab another infant’s bot- trigger a reaction. A child also may The following considerations may be tle, etc) that are beyond the scope of test strongly positive to a food with- helpful in developing emergency plans: this document. out a previous known ingestion; in ● The written treatment plan could in- this situation, the child may still be clude the child’s name, identifying DOCUMENTING FOOD ALLERGY at risk of anaphylaxis. Physician- information (child’s picture, if pro- (DIAGNOSIS) AND ASSESSING supervised oral food-challenge test- vided), specifics about the food al- RISKS ing, typically undertaken by an aller- lergies, symptoms and treatments, Before developing a management plan, gist, may be required to confirm or instructions to activate emergency it is important to ascertain, as best as refute a diagnosis when the history services, and contact information possible, whether a child has a poten- and testing is not sufficient to diag- (see Appendix). nose the food allergy. Caution must tially life-threatening food allergy. It is ● The parent should be given a pre- be exercised in making a diagnosis beyond the scope of this report to scription for self-injectable epi- of a life-threatening food allergy, be- present all of the factors that might be nephrine devices to be used at cause treatment and food-allergen considered in rendering a diagnosis, school in addition to ones for use at avoidance require significant ef- although comprehensive reviews are home. It may be useful to prescribe 14 forts for everyone involved. available, as are national guidelines additional autoinjectors for school: (www.niaid.nih.gov/topics/foodAllergy/ ● Although subsequent reactions are (1) one to be carried by the child in a clinical/Pages/default.aspx). The pedi- not necessarily more severe than dedicated pack that is either on his atrician may wish to work with a pedi- initial reactions, they may be. For or her person (if it is judged reason- atric allergist but should be aware of example, initial mild reactions to able for the specific child and is in several key observations: peanut may be followed by more accord with local regulations) or in ● Any food may elicit a reaction; how- severe reactions on subsequent possession of the supervising adult ever, most significant reactions in exposures.16,17 and (2) other(s) to be kept in the children are attributable to peanut, ● Clinical factors such as a history of health office, should the self-carried tree nuts (eg, walnut, cashew, etc), asthma, previous reactions to trace pack be misplaced or an additional milk, fish, shellfish, egg, soy, and exposures, and allergies to foods dose be needed. The second-dose wheat. Sesame and other seeds mentioned previously are poten- feature of some types of self- have been reported as potent aller- tial risk factors for fatal injectors requires handling of a gens as well.15 Fatalities in school- anaphylaxis.10–12,18 used needle; although access to the aged children in the United States second dose is appropriate in some have primarily been attributed to NOTIFICATION OF THE SCHOOL, settings by licensed personnel, peanuts, tree nuts, milk, and sea- PRESCRIPTION OF EPINEPHRINE, these types of injectors should be food,10–12 but as stated previously, AND DEVELOPMENT OF A disposed of after the first dose to anaphylaxis and death are rare in PERSONALIZED EMERGENCY reduce the risk of needle-stick in- school-aged children. ACTION PLAN jury in the school setting (if a sec- ● Confirmation of a clinical history The family must notify the school about ond dose is needed, another unit (eg, urticaria, wheezing shortly af- the child’s potentially life-threatening should be used). ter ingestion) by laboratory tests food allergy. The family may notify the ● Before creating an action plan, the (eg, allergy skin-prick tests or food- school by providing a written “emer- pediatrician may determine if there specific serum immunoglobulin E gency action plan” or “food-allergy ac- is a licensed health care profes- [IgE] testing) is a typical modality tion plan” (see Appendix for a list of sional who will be assisting the for securing a diagnosis. However, resources). It is recognized that multi- child. When there is not, and only a although increasingly large skin ple forms of plans are in use and that nonlicensed assistive person is tests and increasing levels of food- development of a more universal plan available, the action plan should be specific IgE antibodies correlate would streamline care. The physician/ as simple as possible. For example, with increasing risk of a true al- family may also need to provide the whereas a licensed health profes- lergy, these tests do not, in isolation, school with a list of foods to be avoided sional may be able to administer an diagnose an allergy, nor do they ac- and possible substitutions. Physician- antihistamine and observe for pro- curately reflect severity of an al- recommended substitutions may be gression of symptoms before ad- lergy or the dose of food that might required for school food programs. ministering epinephrine, a nonli- PEDIATRICS Volume 126, Number 6, December 2010 1233 Downloaded from www.aappublications.org/news by guest on September 25, 2021 censed professional should not be toms (eg, paleness, blue skin tone, a school physician, a standard expected to make a medical or nurs- decreased consciousness/confu- anaphylaxis-management protocol ing assessment. Instead, the advice sion, poor pulses, etc) or if there is could be developed in consultation may be to give the epinephrine via progression of symptoms or in- with local public health profession- autoinjector and call for activation volvement of more than 1 organ sys- als, community health center staff, of emergency medical services tem (eg, more than a few hives).

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