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Aggressive allergy care in schools

How to prevent severe reactions and respond more effectively when they occur
Passion project: Students in Deerfield Public Schools in Illinois created a healthy and tasty snacks project, with a goal to reveal the guidelines of the district's Food Management Plan snack policy.
Passion project: Students in Deerfield Public Schools in Illinois created a healthy and tasty snacks project, with a goal to reveal the guidelines of the district's Food Management Plan snack policy.

Shortly after a teacher inadvertently gave almond biscotti to a student allergic to dairy and nuts, Deerfield Public Schools Superintendent Michael Lubelfeld convened the first of several meetings for parents of students with allergies.

The goal: Review current policies and identify ways to improve practices to keep students with allergies safe and to protect those students who might suddenly exhibit symptoms. “The biggest concern was the inconsistent procedures at our six schools for how to actually implement the existing policy,” Lubelfeld says.

The child suffered anaphylactic shock—which can cause a drop in blood pressure, difficulty breathing and even death—but was quickly given Benadryl and epinephrine and then taken to the hospital where the student made a full recovery.

Deerfield, in the Chicago suburbs, already had a food allergy management policy, but with life-threatening allergies skyrocketing, the district needed to do more, says Jenell Mroz, executive director for student services.

Allergy epidemic

No one knows why the number of students suffering more severe allergic reactions is increasing.

“We are in an epidemic of food allergies with 8 percent of children having at least one food allergy, 40 percent of whom have experienced a severe or life-threatening allergic reaction, and a third of kids with allergies having multiple food allergies,” says Gina Clowes, national director of training and outreach for Food Allergy Research & Education (FARE).

While people are most familiar with peanut allergies, eight food groups are responsible for 90 percent of severe allergic reactions in the United States: milk, eggs, fish, shellfish, wheat, soy, peanuts and tree nuts, according to the Centers for Disease Control and Prevention.

EpiPens for schools

Recent headlines about the steeply rising price of EpiPens have created an uproar among parents of children with severe allergies, but many schools can get the devices for free from Mylan's EpiPen4Schools program.

The initiative, created in 2012, provides four free EpiPens to schools in states with epinephrine laws and a valid school prescription for epinephrine. Schools can apply at www.epipen4schools.com.

    And districts need to be prepared to treat all students, not just those who have confirmed allergies. In 24 percent of cases where epinephrine was administered in school, the student did not have a previously known life-threatening allergy, according to a study by the American Academy of Pediatrics.

    Regulations & recommendations

    Laws and regulations vary state by state. Today 15 states have their own school food allergy management guidelines, says Clowes.

    Some districts, such as Deerfield, have been aggressive in establishing policies. Illinois recommended in 2010 that districts implement plans, but Deerfield went further. Working with an outside consultant from Mothers of Children Having Allergies, Deerfield’s procedures include:

    • Mandatory PD for all employees so they’ll recognize symptoms of anaphylaxis and know how to respond.
    • Restrictions on food in classrooms. At the K5 level, students’ snacks are limited to fruits and vegetables, and food is no longer used for parties and celebrations.
    • Stocking epinephrine in all schools. Deerfield participates in the EpiPen4Schools program (see sidebar on page 39). EpiPens not belonging to specific students are kept in the nurses’ offices in clearly marked boxes and are replaced annually, since they have a shelf life of up to roughly 18 months.

    In every state, students with life-threatening allergies are permitted to carry prescribed epinephrine with them at all times during school hours with proper consent. In the past, students had to go to the nurse when they required medication. In addition, several states mandate that districts stock epinephrine in all schools.

    Students with allergies typically have an independent health plan or an allergy action plan that clearly outlines what the student is allergic to, what the appropriate response is and what the treatment should be, says Beth Mattey, president of the school nurses association. Often, students with allergies qualify for accommodations under Section 504 of the federal Individuals with Disabilities Education Act.

    Apart from state laws, multiple resources help districts develop their own strategies. In 2013 the CDC published “Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs” in collaboration with FARE, the National Association of School Nurses and several government agencies.

    The 100-page document includes step-by-step instructions on how district leaders can create or improve food allergy plans. Also in 2013, President Barack Obama signed into law the School Access to Emergency Epinephrine Act.

    The law provides preferential funding for asthma grants to influence states to require that districts stock epinephrine and train staff to administer it.

    A priority, however, should be to prevent anaphylactic episodes from occurring in the first place, Mattey says. With strong policies and well-implemented procedures—similar to those established by Deerfield—district leaders are working hard to minimize risk.

    Keep food in the cafeteria

    In 2014, Clark County School District in Nevada—working with FARE and its own health and transportation departments—released a comprehensive manual for all staff and faculty members, says Lynn Row, the district’s director of health services.

    Clark County schools, with over 320,000 students in 356 schools, outlined procedures and guidelines on topics such as:

    • Recognizing common signs of anaphylaxis, including difficulty breathing, hives and stomach cramps
    • Choosing field trips that limit exposure to allergens and identifying a chaperone responsible for a student’s welfare
    • Cleaning tables with school-approved products and designating cleaning equipment for use only with allergen-safe tables

    The manual includes extensive checklists for school personnel so, for example, custodians know how to properly wipe down computer keyboards that are used by students with allergies, bus drivers keep their vehicles food-free, and teachers initiate an emergency response in case of a reaction.

    Clark County and Deerfield require all employees to watch an educational video on anaphylaxis and epinephrine. Unless they have witnessed anaphylaxis first-hand, some adults may not realize how dangerous allergies can be, says Mroz of Deerfield.

    More districts are reducing or eliminating food outside the cafeteria. Parents often feel a “right” to celebrate their children’s birthdays with candy and cupcakes in class, says Clowes of FARE. “These other parents don’t live in a food allergy world,” she says. “They don’t imagine that a chewy candy contains milk or licorice contains wheat.”

    How to modify menus

    Today, most districts, such as Minneapolis Public Schools, have shifted to peanut-free menus in their cafeterias.

    Depending upon the number of students with allergies, each building principal, nurse and food service manager determines how to establish a table that’s safe for students with allergies but doesn’t make them feel singled out, says Nan Miller, Minneapolis’ policy development specialist.

    For example, a table might be designated for those who eat school lunches, since students with allergies will likely have bought from the modified menus, she says, and a large number of students participate in the school lunch program.

    While peanut-free food service addresses just one type of allergen, students with other allergies typically have meals modified according to their 504 plans. Software alerts K8 food service workers in Sacramento USD when a student with allergies goes through the meal line. And a red flag alerts servers of what foods are off limits, says Diana Flores, Sacramento’s nutrition supervisor.

    Sacramento serves more than 300 modified diets, up from about 200 just a few years ago, adds Melissa Peacock, area supervisor for nutrition services.

    Deerfield doesn’t restrict food in the cafeteria, but works directly with families to decide how they want to manage lunchtime, says Mroz, the district’s executive director of student services.

    Tips to establish food allergy plan

    • Be transparent and welcome stakeholders to planning meetings. Include representatives from a cross section of groups including teachers, parents and community members.
    • Use an outside expert to facilitate meetings. Deerfield Public Schools worked with Denise Bunning of MOCHAllergies.org. Clark County School District worked with Food Allergy Research & Education.
    • Continual communication is essential.
    • Know your state’s laws and guidelines regarding food allergies.

    Source: Michael Lubelfeld and Jenell Mroz of Deerfield Public Schools

    A school might use color-coded trays to ensure that foods don’t cross-contaminate, or students who want to sit with friends who have allergies must agree not to bring the allergen in their lunches, she adds.

    When there’s no nurse

    The school nurse plays an integral role in ensuring policies are carried out, says Mattey. Nurses educate and work with parents, pediatricians, classroom teachers and principals to ensure that everyone understands the students’ health plans and emergency procedures, she says.

    In part due to funding concerns, many districts have cut back or even eliminated nurses in every school. Less than half the country’s schools have full-time nurses and 85 percent have nurses for just 30 hours per week, Mattey says.

    In schools without a nurse, unlicensed personnel can be trained by the district nurse to care for students with allergies. But Mattey says that strategy may be insufficient in the event of an emergency.

    Inclusion as important as safety

    It’s not enough to just keep students safe, says FARE’s Clowes. They need to have the same access to school activities as their peers. For example, sending a child with peanut allergy to the library while the class makes birdfeeders with peanut butter is not okay, says Clowes.

    Districts also need to be aware of a possible backlash against students with allergies, Clowes says. “You can’t have one classroom in a grade without parties and the other three with because of one student with allergies,” she says. “The more you do with guidelines and policies across the board, the less you have to do individually.”

    FARE has had reports of students having allergens smeared on their lockers or backpacks or waved in their faces, says Clowes. It’s humiliating and it’s dangerous, she adds. Better training of school personnel will help minimize such incidents against students.

    It’s a fine line between educating people and protecting the privacy of students, says Clowes. Although a child may choose to disclose allergies to friends or classmates, encouraging this as a means to a safer environment is not appropriate.

    Parents must discuss their child's medical condition with school officials but they should not be forced to share this information with classroom parents in order to get needed accommodations.

    “No child or parent should have to disclose private medical information to have safe access to activities,” Clowes says. “That’s the job of the administration and the teachers and school officials.”

    Resources

    Emily Rogan is a freelance writer in New York.