Critical Incidents LIFE THREATENING FOOD ALLERGIES (LTFA) Background A life threatening food allergy occurs when the body’s immune system has a hypersensitive reaction to a food allergen. After ingestion of the offending food, it is broken down in the gastrointestinal (GI) tract into degraded food proteins that cross the mucosal membrane exposing the proteins to the immune system. The immune system recognizes the protein as a foreign invader or allergen causing the production of the antibody, IgE (or immunoglobulin E). During an anaphylactic reaction, these allergens are recognized by IgE antibodies causing the release of inflammatory mediators such as histamine. An array of systemic symptoms develop that can result in death. Immediate recognition of symptoms, prompt intervention, and referral to emergency care are critical.
Food allergy symptoms do not manifest themselves the first time a child is exposed to the food allergen; however, during the initial exposure the body begins to produce IgE. After the second exposure to the food, the food proteins interact with the IgE and the body releases inflammatory mediators such as histamine. The child’s symptoms are indicative of where the inflammatory mediator release occurs. For example, if they are released into the skin, the student will experience hives, rash, itching, swelling and redness; if released into the respiratory tract, symptoms of tightness in the throat, shortness of breath, congestion, wheezing and cough will occur; and, if released into the GI tract, symptoms can appear as nausea, vomiting, discomfort, cramping and diarrhea.
The prevalence of food allergies is increasing and is currently estimated at 3 million children under the age of 18, which translates to 1 in every 13 children under the age of 18 – an average of two in every classroom. Food allergies account for 150-200 total deaths/year in the U.S. Most fatal food anaphylactic reactions are caused by peanuts and tree nuts. Death occurs more often when there is a delay in the administration of epinephrine.
Common allergens include peanut, tree nut, milk, egg, soy, wheat, fish and shellfish proteins. These foods account for 90% of food allergies. Children may outgrow some food allergies however, peanut and nut allergies tend to be lifelong. It is important to note that the severity of allergic reactions are not predictable, prevention is still the best intervention.
Reactions can occur through ingestion, contact and/or inhalation. The majority of anaphylactic reactions occur through ingestion Younger children are at increased risk because developmentally they are more likely to place their hands, toys or other objects into their mouth.Localized, skin reactions typically do not progress to anaphylaxis.
Oral allergy syndrome is a cross-sensitization reaction to food proteins. This occurs when someone is allergic to an environmental allergen such as pollen, and eats a raw fruit or vegetable. Similar proteins found in the fruit can cause symptoms which include itchy mouth, throat or lips, and irritation of gums, eyes, and nose. However, if the fruit or vegetable is cooked, the protein is denatured and there is no response. Avoidance of particular foods and use of antihistamines can be helpful in preventing and treating symptoms. If symptoms occur for the first time at school, evaluation is needed by a health care provider to differentiate oral allergy syndrome from early symptoms of anaphylaxis. It is possible, but rare, for oral allergy syndrome to change into a life threatening allergy.
Page 2, Life Threatening Food Allergies
The goal for any child with a chronic health condition is for them to enjoy normal life activities and to have excellent school attendance. Younger children must have adult assistance to restrict allergenic foods, but the goal for older children is to have them learn healthy self-care practices, understand their allergy, avoid allergenic food, and know what to do in the event of an allergic reaction.
Prevention is the most fundamental intervention for students with LTFA. Since food cannot be completely avoided during the school day, active and appropriate planning is important to reduce the risk of an accidental exposure. Certain situations and environments can increase the risk of exposure and subsequent reaction, such as riding the bus, some classroom activities, lunch, field trips, and specials classes such as art, music and PE. Regular staff should communicate student allergy information with unfamiliar or substitute staff. Recommendations to reduce the risk of exposure include cleaning food areas, substituting foods for those children with known allergies, reviewing all food labels for ingredients list and warnings regarding plant processing contaminants, and ensuring that teachers and parents of other students in the classroom are aware of food restrictions.
Additionally, all health offices within MMSD have emergency epinephrine since 25% of children experience their first reaction at school. However, it is extremely important to obtain an individually prescribed epinephrine from every student with a known anaphylactic response to an allergen. Follow MMSD Guidelines for administering medications in the school setting and the Expanded Health Services Protocol for Emergency Treatment of Anaphylaxis.
Symptoms Allergic reactions to foods can vary from localized, mild to systemic, life-threatening reactions. A history of asthma is a risk factor for a more severe reaction. Symptoms may include all listed below or only one. Systemic symptoms that pose a risk for anaphylaxis usually occur within minutes to 2 hours after exposure and may appear in any order. The student may also experience a bi-phasic reaction, or “rebound effect” where the symptoms may appear to be resolved and reoccur hours later without any additional exposures.
Itching, sneezing, congestion, runny nose, red eyes, tearing
Itching, tingling, or swelling of lips, tongue, mouth
Hives, itchy rash, swelling of the face or extremities
Nausea, abdominal cramping, vomiting, diarrhea
Tightening of throat, hoarseness, hacking cough, difficulty swallowing, difficulty speaking, itchiness in ear canals, change of voice
Shortness of breath, repetitive coughing, wheezing, chest tightness
Common descriptions of symptoms by children include, (i) “It feels like something is poking my tongue”, (ii) “My tongue feels like there is hair on it”, (iii) There’s something stuck in my throat”, (iv) “My lips feel tight”. These comments are examples of what may be communicated.
Additionally, previous reactions do not predict future reactions. It is important to assess each student individually and review their School Emergency Plan-Food Allergy.
Page 3, Life Threatening Food Allergies
If a reaction occurs and epinephrine is administered, continued monitoring by health care providers is crucial in decreasing morbidity and mortality. The length of monitoring depends on the severity of the reaction and should be determined by hospital based providers.
Treatment Management Every allergic reaction has the potential for developing into a life-threatening event known as anaphylaxis. Anaphylaxis should always be considered a medical emergency as students can have the onset of symptoms within minutes, and if untreated, it can lead to collapse and death shortly thereafter.
When a student known to be at risk for anaphylaxis displays initial symptoms, health office staff need to implement the School Emergency Plan. Immediate intervention is essential. It will not harm the student if his/her prescribed medication is given even if anaphylaxis is not present. For students without a previously identified food allergy, who develop anaphylaxis symptoms at school, school nurses (if in the building) will provide treatment according to the Expanded Health Services Protocol for Emergency Treatment of Anaphylaxis.
Epinephrine is generally provided in an auto-injector (EpiPen® or EpiPen®Jr. depending on child’s weight). Epinephrine treats the rapidly advancing effects of the inflammatory mediators such as histamine in the body. When given intramuscularly (IM) in the outer thigh, the onset is rapid, but duration of action is 15-20 minutes. It must be given as soon as possible to treat and reverse symptoms while EMS is en route. Subsequent transport to a medical facility is imperative. Unfortunately, epinephrine and other treatments for food-induced anaphylaxis are not fail-safe; deaths can and do occur despite administration of emergency medications. The only truly effective treatment is absolute avoidance of the allergen.
Follow School Emergency Plan for students with known history of food allergies. Variations in individual treatments will be guided by specific health care provider orders.
b. Students with undiagnosed, but suspected serious allergic reactions should be referred to the school nurse (if in building) immediately for treatment. If the school nurse is not in the building, 911 should be called immediately.
2. Call 911 at the same time as treatment is initiated: The student should always be transported by EMS to an emergency room when epinephrine is given. Students should not be transported by their parent/guardian or by school staff alone if anaphylaxis is suspected or if epinephrine has been given.
3.Obtain the following information
a. Food ingested/contacted, onset, duration of symptoms and past occurrences.
b. General appearance, presence of hives, nausea, vomiting, gastrointestinal cramping or pain, tightening of throat, cough, difficulty speaking or swallowing,
Page 4, Life Threatening Food Allergies
shortness of breath, wheezing, and retractions or respiratory effort. Record vitals (pulse and respiratory rate).
4. Inform parents/guardians and health care provider.
Inform nurse and principal whenever rescue squad is called.
2. Chart in electronic health record.
3. Arrange for replacement EpiPen® and antihistamine for individual students as soon as possible.
4. Report incident to Health Services Coordinator.
5. Conduct post event debriefing following all allergen exposures and/or rescue medication administrations. Review school response with school staff members who were involved in providing care and provide suggestions for emergency response improvement.
Protocol Since there is no cure for food allergies, avoidance of the specific allergen is the cornerstone of management in preventing anaphylaxis. As the school nurse, it is recommended that you obtain or coordinate the following items: 1. Student History
a. Before the School Emergency Plan is put in place and/or any accommodations are made at school, the school nurse meets with parents and completes the Life Threatening Allergy Health History Form and Food Questionnaire –Appendix A. The nurse will also obtain and review medical orders. If a student needs specific accommodations, it is recommended the nurse have the parents/guardians sign a Medical Release of Information Formor bring in written medical documentation of LTFA..
a. The school nurses documents information about the child’s LTFA in Infinite Campus (IC). See IC manual.
3. Forms and letters
School Emergency Plan. The school nurse makes sure that a student with a medically documented food allergy or who is prescribed epinephrine has a School Emergency Plan. The recommended plan is the School Emergency Plan – Insect Sting/Food Allergy Form (Appendix B)which has been developed and approved by area allergy specialists. For students whose healthcare providers complete the School Emergency Plan – Insect Sting/Food Allergy, the Medication Consent Form and the Practitioner Order for Medication
Page 5, Life Threatening Food Allergies
Administration do not need to be completed for the medications listed on that form. A copy of the School Emergency Plan should be filed in the health office, provided to appropriate school staff, and brought on all field trips.
b. Food Substitutions. The nurse notifies parents that if a student with LTFA eats school breakfast and/or lunch, the Food Service Medical Statement for Food Allergies or Disabilities (Appendix C) needs to be filled out by the provider and faxed to the Food Services Manager (fax #204-0376).
c. Classroom Parent/Guardian Letters - The school nurse/principal notifies teachers that they must send a Classroom Parent/Guardian Letter to all parents/guardians in their classroom informing them that there is a student with a serious food allergy in their child’s classroom. (See Health Services website for various letters).
a. Every student with a life threatening food allergy should have emergency medications in the health office. Some students may carry emergency medications with them. Epinephrine should be kept in an UNlocked container/cabinet and its location should be easily accessible. Medication expiration dates should be checked every three months.
5. Student Self-Care
The nurse should assess the student’s knowledge of his or her life threatening food allergy and self-care capability. If the student, parent/ guardian, and health care provider agree to allow the student to carry and use the epinephrine auto-injector while at school, Parent and Health Care Provider Medication Form or the School Emergency Plan – Food Allergy is completed.
The school nurse reviews and completes the Contract for Self-Administration of Epinephrine Auto-Injector – Appendix D. It may be important for the nurse to consult with the health care provider if self-care capability is questioned or noncompliance is an issue. An additional epi-pen is also recommended for the health office if the student carries his or her own epi-pen in the event the student does not have the epi-pen available when needed.
6. Staff training
School Staff. All staff should receive basic knowledge about life threatening food allergies. The handout, Basic Allergy Knowledge and Response to Anaphylaxis: Answers to Frequently Asked Questions by Staff – Appendix E, can be shared with staff. In elementary and middle school, discuss with principal about presenting information about life threatening food allergies at the beginning of the year staff meeting. This can include the following information:
The definition of food allergy and anaphylaxis
A list of major allergens
Signs and symptoms of food allergy and anaphylaxis reviewed
Treatment of life threatening food allergies
Best practices for preventing exposure to food allergies
Page 6, Life Threatening Food Allergies
Staff with Frequent Contact with a Student with Food Allergies. The nurse informs teachers about the following information:
Students in their classroom with LTFA and their School Emergency Plan Food Allergy Information Sheets (Appendix E is a 2-page handout for staff about food allergies; Appendix F is a handout with specifics on how to have a food allergy-free classroom; Appendix G is a sample sign for a nut-free classroom, other signs for classrooms with allergy restrictions can be found in the virtual file cabinet at MMSD; and, Appendix H is a hand out describing school’s roles and responsibilities).
Snack and lunchroom procedures
Classroom Parent/Guardian Letter
c. Medication Administration Training. The school nurse assists with the following trainings:
i. DPI approved medication training
ii. Yearly skills training
d. Student education and bullying prevention. Nurse and/or teacher present materials in classroom about LTFAs. Educating classmates helps to avoid isolating, stigmatizing, or harassment of students with LTFAs. Staff enforces rules about bullying/threats.
e. Fieldtrips. If going on a fieldtrip with a student who has a known history of anaphylaxis, at least one staff member trained in medication administration should be available to the student, along with the medication. Have a cell phone available in case of an emergency. No food should be eaten on buses.
7. Food Services staff
a. Nurses inform and train cafeteria staff about students with LTFAs.
b. Nurse informs staff about cleaning protocols.
8. Parent/Guardian Information
a. 504 plan
School staff is required to inform families that their child may qualify for a 504 plan if they have a food allergy. Not all children will need 504 accommodations, but families should be given the choice of whether or not to pursue a 504 plan. Provide families with the brochure Section 504 Parents’ Rights (found at the MMSD Educational Services website).
Section 504 is a federal law which prohibits discrimination on the basis of an individual's disability. Its purpose is to ensure that students with disabilities are not denied access to educational programs and opportunities on the basis of their disability. A disability is defined as a physical or mental impairment that substantially limits one or more of the major life activities of the individual. A sample 504 plan can be found on Health Services website.
Page 7, Life Threatening Food Allergies
For up to date information about the 504 process and required forms, access the MMSD Educational Services website. b. Bus Transportation.
Bus questions need to be directed to the bus company providing services for MMSD. Bus carriers are responsible for providing basic first aid training for all drivers and attendants, including information about allergic reactions and the administration of epinephrine auto-injectors.
c. Cafeteria set-up and classroom snack procedures.
Parent Food Allergy Information Sheets
Food Allergy Management Plan Roles and Responsibilities (Appendix H).
Food Allergies in the School, Frequently Asked Questions: A Parent’s Guide (Appendix I)
9. Cleaning Protocols
a. Soap and water or disposable wipes are the most effective methods of removing food proteins from surfaces or hands. Unless otherwise requested and documented from a provider, special cleanings are not recommended.
b. To avoid food protein contamination, allergy-free lunch tables should be cleaned with separate supplies from regular lunch tables.
If desired school nurse may complete the School Nurse Checklist for Life Threatening Food Allergies (LTFA) (Appendix J) for students with complex or multiple food allergies.
Resources and References: National Association of School Nurses: http://www.nasn.org/ToolsResources/FoodAllergyandAnaphylaxis The School Food Allergy Program: www.foodallergy.org Safe at School and Ready to Learn: http://www.nsba.org/foodallergyguide.pdf 2011 Wisconsin Act 85
Administration of Drugs to Pupils (Third Edition) (February 2012) Wisconsin Department of Instruction: http://dpi.state.wi.us/sspw/pdf/sndrugscomplete.pdf
Page 8, Life Threatening Food Allergies
Appendices Sting/Food Allergy Health History Form and Food Questionnaire
(Appendix A) School Emergency Plan – Insect Sting/Food Allergy
(Appendix B) Medical Statement For Children with Food Allergies
(Appendix C) Contract for Self-Administration of Epi-Pen
(Appendix D) Basic Allergy Knowledge and Response to Anaphylaxis