Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Management of 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 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 , 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 . 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 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 ana- phylaxis,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 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 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- 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). The or school-of-medicine faculty. immediately. treatment plans (see Appendix) list Additional information about adminis- ● There is no diagnostic test for ana- key additional symptoms not stated tration of medications in schools is ad- in this report. phylaxis, and specific symptoms dressed in a policy statement from the may vary. A recent report suggested ● Anaphylaxis may occur without American Academy of Pediatrics titled that anaphylaxis is likely to be oc- urticaria.10 “Guidance for the Administration of curring if any of the following 3 sit- ● Dosing of self-injectable epineph- Medication in School.”23 The diagnosis, uations are observed1: rine (either 0.15 or 0.3 mg) has been treatment plan, and prescriptions 1. acute onset (minutes to several reviewed in a previous clinical re- should be reviewed periodically and hours from exposure) of symptoms port.19 Briefly, the manufacturer updated at least yearly. Pediatricians with involvement of the skin and/or recommends switching to the should remind parents to be cognizant mucosal tissue (eg, generalized 0.3-mg dose at 66 lb, but because of expiration dates on epinephrine au- hives, pruritus or flushing, swollen that results in underdosing as chil- toinjectors and to be alerted to proper lips/tongue/uvula) and signs or dren approach this weight, consid- temperature storage requirements. eration should be given to pre- symptoms of either respiratory ● It may be advisable to inject epi- scribing the 0.3-mg dose at approx- compromise (eg, dyspnea, wheeze/ nephrine at the time of first imately 55 lb. bronchospasm, stridor, reduced symptoms if an allergen was in- peak expiratory flow, hypoxemia) ● Symptoms of anaphylaxis may ini- gested that previously caused and/or reduced blood pressure or tially respond to treatment but re- anaphylaxis.24 cur (biphasic response) with possi- associated symptoms of end-organ ● It may be advisable to inject epi- bly more severe manifestations.10 dysfunction (eg, hypotonia [col- nephrine before symptoms if an al- lapse], syncope, incontinence); or Therefore, emergency plans should lergen was ingested that previously include activation of emergency 2. 2 or more of the following that oc- medical services and transport to a caused anaphylaxis with cardiovas- cur rapidly after exposure to a 24 facility at which additional observa- cular collapse. likely allergen for that patient: in- tion and care can be administered ● Emergency action plans can be indi- volvement of the skin/mucosal in the ensuing hours whenever a vidualized according to the child’s tissue; respiratory compromise; significant allergic reaction is be- history as well as the abilities of the reduced blood pressure or lieved to have occurred. A second responsible adult. associated symptoms; or persis- dose of epinephrine is recommend- ● tent symp- Physicians are encouraged to edu- ed20–22 in 5 to 20 minutes if signifi- toms (eg, crampy abdominal pain, cate parents/school caregivers cant symptoms progress or are not vomiting); or that: responding to the first dose. 3. reduced blood pressure after expo- ● antihistamines are adjunctive ● Because 25% of anaphylaxis in sure to a known allergen for that therapies to treat an allergic re- schools occurs without a previous action but cannot be depended on patient (minutes to several hours). 6 diagnosis, a prescription for unas- to treat anaphylaxis; ● In the context of a possible allergen signed epinephrine for general use, ● ingestion, a simple means to impart consistent with district regulations inhaled bronchodilators may be instructions regarding when epi- and state laws, should be consid- given for respiratory reactions nephrine should be administered is ered, especially in schools with but must not be depended on to to suggest that it be injected for sig- nurses. A standard anaphylaxis- treat anaphylaxis; nificant respiratory (eg, tightness of management protocol should be de- ● medication should not be ex- the throat, hacking cough, hoarse- veloped by the school health ser- posed to extremes in tempera- ness, shortness of breath, wheez- vices staff and the consulting school ture, and expired units should be ing, etc) or cardiovascular symp- physician. In districts without replaced; and

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● epinephrine is generally safe (ie, suming local and state agencies AVOIDANCE STRATEGIES when in doubt, inject), and par- allow it) (to make these deci- Avoidance strategies must be practi- ents/school caregivers should be sions, student, parent/guardian, cal and focus on policies to avoid in- advised about common adverse ef- and school and community fac- gestion of the allergen, the primary fects of epinephrine (eg, tremor, tors may be assessed [see: www. route that can result in anaphylaxis. tachycardia, flushing/paleness). nhlbi.nih.gov/health/prof/lung/ There have been no controlled studies ● In some adults experiencing ana- asthma/emer_med.htm]; how- to evaluate the effectiveness of poten- phylaxis who were raised from the ever, designated adults [eg, li- tial avoidance strategies. Knowledge supine to the upright position dur- censed provider or a lay desig- about risks primarily come from ob- ing transport to a hospital, death oc- nee] should be additionally servational studies and self-report. curred suddenly, presumably from responsible for treatment. be- Avoidance strategies appropriate for a “empty-ventricle syndrome” caused cause the student may not be de- specific child may vary on the basis of by blood pooling in the legs during pended on for or be capable of the nature of the allergy, circum- anaphylactic .25 The implica- self-administration). stances unique to the particular insti- tions of this observation for chil- ● Pediatricians can encourage par- tution, age of the child, and the child’s dren, who more typically succumb ents to request to meet with key developmental stage and disposition. to respiratory insufficiency during school staff members who have re- anaphylaxis and who may vomit dur- sponsibility for the care of their BEST-PRACTICE STRATEGIES ing anaphylaxis, are not known. Nev- child and to work cooperatively with The following points may be helpful in ertheless, caregivers should be ad- schools to ensure their child’s instructing families and schools about vised that individuals with severe safety. Key staff members may in- avoidance strategies. anaphylaxis who may benefit from clude the directors of transporta- ● Studies of skin contact and inhala- being in a supine position with legs tion and food service, the building tion of peanut-butter vapors by chil- raised should remain in that posi- administrator, school nurse, class- dren with peanut allergy failed to in- tion and be transported that way by room teacher, and director of duce any systemic reactions.27,28 emergency personnel until ad- health services. Pediatricians can vanced care can be accessed (eg, Lack of a reaction from these casual provide resources for parents to additional medications and intrave- exposures is not unexpected, be- give to school officials to help them nous fluids). cause penetration to the systemic develop food-allergy management circulation by skin contact is un- ● Physicians are encouraged to edu- protocols at the school board of di- likely, and peanut-butter vapors do cate families and the student, as ap- rectors’ level. Pediatricians can also not contain protein. Although these propriate for age (or arrange for serve as a resource to school well- findings suggest that such expo- education): ness committees or councils and to sures are of low risk, concern re- ● about how to administer self- boards of education to help them in mains for young children transfer- injectable epinephrine and edu- developing safe policies, regula- ring skin contact to their mouths. cate others, because mistakes tions, and procedures for children ● Case reports and controlled studies are common26; with food allergies. in which foods are vaporized ● to consider obtaining medical ● Pediatricians (and allergists) are through heating have shown that re- identification jewelry; encouraged to counsel parents actions, primarily respiratory, can ● about the importance of avoid- about the level of exposure that be elicited.29 These observations ance strategies (eg, no food- might be dangerous for a specific support limiting exposure to aller- sharing), to notify an adult of any child, such as ingestion versus inha- gens being cooked (eg, in science/ symptoms or if they may have lation versus touching food resi- craft projects). eaten an unsafe food, and when dues, so that parents are appropri- ● Reports that focused on reactions to use self-injectable epineph- ately vigilant without becoming to peanut in schools from noninges- rine; and needlessly hypervigilant about tion exposures primarily identified ● to determine if carrying/self- avoidance strategies, particularly craft projects with peanut butter as administration of self-injectable because they might affect schools a cause of mostly mild reactions.5 epinephrine is appropriate (as- or neighbors. This observation supports not using

PEDIATRICS Volume 126, Number 6, December 2010 1235 Downloaded from www.aappublications.org/news by guest on September 25, 2021 food allergens in craft or cooking share with classmates for celebra- or emergency medical order so that projects. tory functions and offer acceptable the school nurse can develop an indi- ● A study showed that peanut can be alternative options for purchase vidualized health care plan (IHCP). The cleaned from the hands of adults by through school food services. emergency action or care plan is a using running water and soap or ● Several professional organizations document created by the pediatrician commercial wipes but not antibac- (see Appendix) have advocated pro- or school nurse on the basis of medi- terial gels alone.30 In addition, pea- cedures to reduce the risk of acci- cal orders from the pediatrician that is nut was cleaned easily from sur- dental allergen ingestion that are written in simple lay terms for the non- faces by using soap, wet wipes, and responsive to previously published licensed staff members who may have commercial wipes but not dish- observations regarding circum- a supervisory role for a child at any washing alone. Results of stances leading to allergic reac- time before, during, or after the school threshold studies indicated a wide tions.4,5 These procedures include day. The IHCP is a nursing document range of doses of peanut that elicit strict “no food-sharing” policies; created by a school nurse with input objective symptoms, but the lower use of commercially prepared and from the pediatrician’s orders that range seems to be 10 to 100 mg, on labeled, individually wrapped food contains a complete school manage- average. More typical eliciting items; education of those providing ment plan with preventive procedures doses are one-half to one whole pea- foods regarding safe and unsafe for day-to-day management in the nut kernel.31 These observations in- foods and label-reading; education school. The following information dicate that standard cleaning and of cafeteria/food service staff; a should be considered: lack of visible contamination should ready supply of safe alternative ● The student’s IHCP is typically devel- suffice for most children with pea- snacks; and policies of no eating on oped by the school nurse in collabo- nut allergies. the school bus and having a means ration with the family, physician, ● On the basis of the aforementioned of communication on the bus. Avoid- and other school personnel. Gen- studies, allergen avoidance might ance strategies and emergency eral recommendations for materi- vary depending on the age of the management must also be commu- als to be included in the IHCP are children, and more supervision, nicated to personnel who may not included in various state guidelines cleaning, and containment of the al- have primary responsibilities for (see Appendix). The IHCP should be lergen are needed for younger chil- the student, such as coaches, spe- revised according to the child’s dren. Care must be taken not to os- cialty teachers (art, music, etc), needs on the basis of age and devel- tracize or physically separate the substitute teachers, field trip per- opmental stages. child with food allergies. For sonnel, etc. These individuals also ● Schools may establish a core team example, an “allergen-aware” table require training in the use of epi- responsible for food-allergy man- should include the child’s friends nephrine autoinjectors, familiarity agement and actions, to ensure that who are eating safe meals. Experts with the food-allergy action plan, reasonable and nondiscriminatory have not espoused blanket “bans” and indicators for activating the avoidance plans are in place, that a emergency medical response on foods,32 particularly because food-allergy treatment plan is re- peanut butter, milk, egg, and other system. viewed and practiced periodically, common allergens may be a protein ● School food services leadership that people are designated and staple of another child’s diet. In rare should be involved in district policy trained to recognize and treat ana- instances, individual schools or development and assist in the edu- phylaxis, etc (also see Appendix). classrooms might pursue these op- cation of cafeteria/food service The pediatrician should be familiar tions. For example, removal of staff at the individual school level. with these responsibilities and may highly allergenic foods from the vi- wish to provide education on these cinity of kindergarten-aged children SCHOOL TREATMENT GUIDANCE/ procedures, particularly when the or children with significant develop- DEVELOPMENT OF THE plans are part of the student’s IHCP. mental disabilities might be war- INDIVIDUALIZED HEALTH CARE The pediatrician/family may also de- ranted when transfer of the aller- PLAN termine if a full-time registered gen among the children is likely. The pediatrician may submit a written nurse is present in the student’s Schools may wish to ban children emergency action plan, emergency school during all school hours and from bringing food from home to care plan, or food-allergy action plan advocate for delegation of nursing

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services in that school when the that facilitate carrying medications certified allergist-immunologist to se- school nurse is not present. If there (eg, large pockets, larger purses, cure a diagnosis and provide directed is a before- and/or after-school pro- book bags, etc). treatments and advice is recommend- gram, the parent should be aware of ● Harassment or bullying of students ed.34 It is important that there be close the process for ensuring access to because of their food allergy must communication between the pediatri- epinephrine and allergen reduction be taken seriously. Students should cian and allergist for diagnosis and during this out-of-school time. be encouraged to report such be- management. Partnerships with stu- ● Results of several studies support haviors, and the school should ad- dents, families, school nurses, school the notion that epinephrine may be dress the situation with quick and physicians, and school staff are impor- needed in locations outside of the decisive antibullying policies. tant for individualizing effective and practical care plans. school cafeteria, that significant de- ● The legal rights of children with life- lays in administration are associ- threatening food allergies are pro- LEAD AUTHORS ated with fatalities (eg, Ͼ20 tected under several laws. If a stu- Scott H. Sicherer, MD minutes after symptoms), and dent qualifies for special education Todd A. Mahr, MD prompt administration is advanta- services under the Individuals With SECTION ON ALLERGY AND geous.6,8,10–12 To ensure access to Disabilities Education Act and also IMMUNOLOGY EXECUTIVE COMMITTEE, epinephrine within several minutes, has food allergies, the food allergy 2008–2009 school plans should consider allow- should be addressed in the stu- Scott H. Sicherer, MD, Chair ing the student to self-carry, if al- Sami L. Bahna, MD dent’s individualized education Bradley E. Chipps, MD lowed and age appropriate, and/or plan. Section 504 of the Rehabilita- Mary Beth Fasano, MD storing epinephrine in secure tion Act of 1973 may also be used to Mitchell R. Lester, MD and readily accessible locations. Todd A. Mahr, MD document specific management Elizabeth C. Matsui, MD, Section Outreach Chair Prompt access to a reliable source plans and provides legal recourse Frank S. Virant, MD of autoinjectable epinephrine is for students and their families if Paul V. Williams, MD, Immediate Past Chair critical. To ensure medication secu- they and the school are unable to CONSULTING AUTHOR rity and safety and provide for come to terms on health care plans Anne Muñoz-Furlong, BA – Founder, Food timely treatment, procedures through normal channels. In some Allergy & Anaphylaxis Network should be established that specify schools, Section 504 plans may not STAFF where the medication will be be necessary if the written emer- Debra L. Burrowes, MHA stored, who is responsible for the gency action plan and/or IHCP pro- [email protected] medication, who regularly monitors vide the necessary procedures for Comments on this clinical report were and replaces outdated medication, safety. The Americans With Disabili- solicited from committees, sections, and who will carry the medication ties Act also protects children with and councils of the AAP; 5 responded. for field trips. life-threatening food allergies who Additional comments were sought ● The adolescent age group seems to attend schools that do not receive from the Centers for Disease Control be at the highest risk of fatal food- federal funding. and Prevention, National Association induced anaphylaxis.10–12 Special at- ● After a reaction has occurred, it is of State School Nurse Consultants, Na- tention for this group should in- important to review policies and tional Association of School Nurses, clude education of the adolescent procedures among the school staff, and Food Allergy & Anaphylaxis Net- and his or her peers to reduce risk- the child’s health care provider, work. For recommendations for which taking and to encourage carrying parents, and the child. high levels of evidence are absent, the and using medications when need- expert opinions and suggestions of the ed.33 Education should be provided SUMMARY members of the Section on Allergy and to staff, including coaches, trainers, The pediatrician plays an important Immunology and other groups and au- and after-school advisors. Affected role in contributing to the manage- thorities consulted were taken into students should be permitted to ment of school-aged children with food consideration in developing this clini- wear/carry clothing/bags/purses allergies. Consultation with a board- cal report.

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APPENDIX RESOURCES Example of an emergency treatment plan www.foodallergy.org/downloads/FAAP.pdf Overview of school guidelines endorsed by professional organizations www.foodallergy.org/school/schoolguidelines.pdf Examples of state school programs Arizona www.azdhs.gov/phs/oeh/fses/pdf/allergies1007.pdf Connecticut www.sde.ct.gov/sde/lib/sde/PDF/deps/student/health/Food_Allergies.pdf Maryland www.marylandpublicschools.org/nr/rdonlyres/6561b955-9b4a-4924-90ae-f95662804d90/21182/ anaphylaxisstateguidelines_final082809.pdf Massachusetts www.doe.mass.edu/cnp/allergy.pdf Mississippi www.healthyschoolsms.org/health_services/documents/GuidelinesforManagingFoodAllergies.pdf New Jersey www.nj.gov/education/students/safety/health/services/allergies.pdf New York www.schoolhealthservices.org/uploads/Anaphylaxis%20Final%206-25-08.pdf Tennessee http://health.state.tn.us/Downloads/HealthySchoolsGuidelines.pdf Vermont http://education.vermont.gov/new/pdfdoc/pgm_health_services/food_allergies_manual_0608.pdf Washington www.k12.wa.us/HealthServices/publications/09-0009.aspx West Virginia http://wvde.state.wv.us/osshp/main/documents/GuidelinesforAllergiesintheSchoolSetting-Final2.doc Centers for Disease Control and Prevention information for school food allergy www.cdc.gov/Healthyyouth/foodallergies/index.htm

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/126/6/1232 References This article cites 34 articles, 6 of which you can access for free at: http://pediatrics.aappublications.org/content/126/6/1232#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Community Pediatrics http://www.aappublications.org/cgi/collection/community_pediatrics _sub School Health http://www.aappublications.org/cgi/collection/school_health_sub Current Policy http://www.aappublications.org/cgi/collection/current_policy Section on Allergy and Immunology http://www.aappublications.org/cgi/collection/section_on_allergy_an d_immunology Allergy/Immunology http://www.aappublications.org/cgi/collection/allergy:immunology_s ub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 25, 2021 Management of Food Allergy in the School Setting Scott H. Sicherer, Todd Mahr and the Section on Allergy and Immunology Pediatrics 2010;126;1232 DOI: 10.1542/peds.2010-2575 originally published online November 29, 2010;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/126/6/1232

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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