Policy Content Requirements (1) Distinguishing between building wide, classroom, and individual approaches to allergy prevention and management;

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1 Prevention and Response Allergy Prevention and Response Policy Required July 8, 2009, Governor Jay Nixon signed House Bill 992 into law The new law requires school districts to adopt a policy protecting children with allergies, particularly those with life threatening food allergies All school districts must finalize a policy by July 1, 2011 Policy Content Requirements (1) Distinguishing between building wide, classroom, and individual approaches to allergy prevention and management; (2) Providing an age appropriate response to building level and classroom level allergy education and prevention; (3) Describing the role of both certificated and non certificated school staff in determining how to manage an allergy problem, whether it is through a plan prepared for a student under Section 504 of the Rehabilitation Act of 1973 for a student with an allergy that has been determined to be a disability, an individualized health plan for a student who has allergies that are not disabling, or other allergy management plans;

2 Policy Content (Continued) (4) Describing the role of other students and parents in cooperating to prevent and mitigate allergies; (5) Addressing confidentiality issues involved with sharing medical information, including specifying when parental permission is required to make medical information available; and (6) Coordinating with the school health advisory council, local health authorities, and other appropriate entities to ensure efficient promulgation of accurate information and to ensure that existing school safety and environmental policies do not conflict. The department of elementary and secondary education shall, in cooperation with any appropriate professional association, develop a model policy or policies by July 1, A Model Policy ( Missouri Schools are committed to providing a safe and nurturing environment for students. Missouri Department of Elementary and Secondary Education (DESE) Missouri Department of Health and Senior Services (DHSS) Focus on prevention, education, awareness, communication, and emergency response Missouri School Allergy Management Program

3 St. Louis Children s Hospital Advisory Board St. Louis Children s School Allergy Program Advisory Board Meet several times per year Have 5 pilot schools School Allergy Program Manual School Allergy Program Tool Kit Food Allergy Management and Education Program(FAME) School Nurse Resources Missouri DHSS Website: /presentations.php Allergy Management Manual Sample forms and policies School Faculty and Staff Training PowerPoint Teaching materials for Administrators and Teachers St. Louis Children s Hospital FAME Tool Kit Role of the School Nurse Detailed health history and family concerns Medication orders signed by the medical provider and parent/guardian Individualized Healthcare Plan (IHP) Action Plan and/or Emergency Plan Alert Faculty and Staff Faculty/Staff Training Student s environment modifications Collaboration with parent/guardian, teachers, and healthcare providers

4 Allergy Management Overview Allergy and Anaphylaxis Overview Intake Information Allergy Exposure Prevention Emergency Response Faculty/Staff Allergy Education Prevention Response Intake Process Parent Partnership One of the most vital participants in the care of the student with a severe allergy is the parent/guardian. Most parents have had to work tirelessly to ensure that every new situation is not a potentially fatal experience for their child. Understandably, many parents of students with severe allergies experience a high level of anxiety in new situations.

5 Parent Partnership In advance of the student entering school, the school nurse should collaborate with the parent/guardian to facilitate completion of the following familial responsibilities: Health history Medications : Obtain necessary signed medication permission forms Delivery of medications to school in appropriate original pharmacy containers; and Emergency Action Plan (have the parent/guardian sign the plan, giving written permission to share the student s health information with the staff on a need to know basis). Intake Forms Health inventory and history Physician medical statement and Medication orders Food Allergy Action Plan USDA Form for food substitution Avoidance of exposure to allergens is the key to preventing an allergic reaction

6 Interdisciplinary Collaboration It is best, when able, to plan as a team that includes: Student School District Administration School Building Administration School Medical Director Coaches, Athletic Director, Afterschool Employees, Volunteers Teachers School Nurse Food Service Personnel Transportation Personnel Other School Personnel Prevention Avoidance of exposure to allergens is the key to preventing an allergic reaction. The school nurse will develop an Individualized Healthcare Plan (IHP) based on each child s unique needs and treatment. The school nurse will develop an Emergency Action Plan (EAP). The IHP will provide specific prevention steps for the individual child and the EAP will provide student specific symptoms to observe. Students with food allergies and anaphylaxis must not be excluded from school activities and the IHP and EAP will provide steps to keep the student safe. Classroom Accommodations Through awareness, prevention, and education, the teacher can keep the classroom as allergen safe as possible Consider allergens that might be included in instructional materials (science supplies, art project materials, etc.) that may contain food items. The school nurse and classroom teacher(s) can meet to discuss a student s allergies, potential symptoms of reaction, and immediate response. With parent permission, a letter can be sent home alerting all parents that there is a student (do not identify the student by name) with significant allergies in their child s classroom The teacher can encourage hand washing before and after eating or activities involving food. The teacher can provide age appropriate student instruction in food allergy awareness

7 Cafeteria Accommodations The Food Service Director, in collaboration with the school nurse, cafeteria manager, and parent/guardian can make the cafeteria environment as safe as possible for a student with a severe allergy. Decisions should be made on a district level as to whether or not to serve foods with allergens, and what steps can be taken to reduce the chance of a student experiencing an accidental exposure. Considerations should include: Emergency Action Plan (EAP) Safe Food Handling Environmental Accommodations including allergen safe zones and procedures for prevention of cross contamination Food Label Reading Education Proper Food Labeling in Cafeteria lines Field Trip Planning Before leaving for a field trip, appropriate school personnel should: Collaborate with the school nurse before planning a field trip to avoid high risk destinations; Ensure the epinephrine auto injector and instructions are taken on the trip Identify a staff member who has been trained to recognize symptoms of an allergic reaction, trained to administer epinephrine and trained in emergency procedures to accompany the student on the trip; Consider all eating situations and plan for prevention of exposure to life threatening foods, insect exposure, and the presence of latex; Package meals to avoid cross contamination; A cell phone or other means of communication should be available if emergency help is required; Invite parents to accompany their child; Consider ways to wash hands before and after eating, or bring disposable wipes. Field Trip Planning Care should be taken when planning the field trip that the environment the student will be in is not compromising, (i.e., a student with a milk allergy attending a field trip at a petting farm with milk ingredients in the food for the animals, or balloons present for a student with a latex allergy). The student s Emergency Action Plan and medications can be given to a designated individual (parent/guardian or an employee designated by the school district) who is familiar with the student s health needs and will be directly available to the student.

8 Emergency Response Know where it is Know what it says Follow it immediately Steps to Take in the Event of an Allergic Reaction If a student displays signs and symptoms of an allergic reaction and/or reports an exposure to their allergen, school personnel should immediately implement the school s policy on allergy anaphylaxis which should require that immediate action be taken: Notify the school nurse (if available) and initiate the Emergency Action Plan; Locate the student s epinephrine immediately; Implement the student s Emergency Action Plan; including timely administration of epinephrine if needed and Call 911 if epinephrine has been administered.

9 Important Considerations Know your school s emergency procedures and protocols in advance of an emergency and be prepared to follow them; In the presence of symptoms, GIVE EPI PEN WITHOUT DELAY! Do not wait! Note time administered; Use a calm and reassuring voice with the student and do not leave him/her unattended; Do not attempt to stand the student up or ask them to walk around (this may increase the danger to the student in the event of a reaction) Emergency Medication Epinephrine Brand names include, but are not limited to EpiPen, EpiPen Jr, and Twinject auto injectors. Epinephrine may need to be given again after the initial effects wear off, potentially in fifteen to twenty minutes. A school nurse who does not work in an area where emergency medical services (EMS) can respond within that window of time, may need to have additional epinephrine available to use as needed. Many ambulances don t carry epinephrine the school may need to request Advanced Life Support for EMS to respond with epinephrine. Emergency Medication Antihistamine Diphenhydramine hydrochloride Brand name includes: Benadryl Cetirizine Brand name includes: Zyrtec May cause drowsiness, nausea, dryness of the mouth. NOTE: Antihistamines should not be the only medication given in anaphylaxis since epinephrine is the drug of choice. There is no contraindication to give epinephrine for anaphylaxis along with an oral antihistamine.

10 What does your faculty and staff need to know? See the Missouri DHSS Website for a Training PowerPoint for your faculty and staff: tions.php Education Components Overview Prevention Response Allergy Information Food Allergy in children has risen 18% in 10 years. Hospitalization due to food allergies has tripled in 10 years. Individuals with asthma in addition to food allergies may be at increased risk for having a life threatening anaphylactic reaction. Teens with food allergy and asthma appear to be at the highest risk for a reaction, because they are more likely to take risks when away from home, are less likely to carry medications, and may ignore or not recognize symptoms. 16% to 18% of children with food allergy experience a reaction at school with 79% of these reactions having occurred in the classroom, only 12% in the cafeteria. (Branum AM, Lukacs SL. Food allergy among U.S. children: trends in prevalence and hospitalizations. US Department of Health and Human Services. NCHS Data Brief NO. 10. October 2008.)

11 Food Allergy Overview Approximately five to six percent of the pediatric population has had an occurrence of food allergy, with eight foods accounting for 90% of allergic reactions. Currently there is no cure for food allergies and strict avoidance is the only way to prevent a reaction. Most common food allergens: Peanuts Shellfish Fish Tree nuts (i.e. walnuts, cashews, pecans, etc.) Eggs Milk Soy Wheat Food Allergies Food allergy is an exaggerated response by the immune system to a food that the body mistakenly identifies as being harmful. Once the immune system decides that a particular food is harmful, it produces specific antibodies to that particular food. The next time the individual eats that food, the immune system releases moderate to massive amounts of chemicals, including histamine, to protect the body. These chemicals trigger a cascade of allergic symptoms that can affect the respiratory system, gastrointestinal tract, skin, and cardiovascular system. A reaction can occur within minutes to hours after ingestion. Symptoms can be mild to life threatening (anaphylaxis). The specific symptoms that the student will experience depend on the location in the body in which the histamine is released. Insect Sting Allergies Insect allergy is an under reported event that occurs every year to many adults and children. Most stings are caused by yellow jackets, paper wasps, and hornets. Some students have true allergies to insect stings that can lead to life threatening systemic reactions. Prompt identification of the insect and timely management of the reaction are needed Insect avoidance is advised for students and staff at risk for anaphylaxis. Some precautions schools should follow include: 1) insect nests should be removed on or near school property, 2) garbage should be properly stored in well covered containers 3) eating areas should be restricted to inside school buildings for students and staff at risk.

12 Signs and Symptoms Hives Itching (of any part of body) Swelling (of any body parts) Red, watery eyes Runny nose Vomiting Diarrhea Stomach cramps Change of voice Coughing Wheezing Throat tightness or closing Difficulty swallowing Difficulty breathing Sense of doom Dizziness Fainting or loss of consciousness Change of skin color Prevention Do not allow food in instructional areas unless approved by parent of child with food allergy. Consider art and science materials, including pet foods. Promote hand washing before and after eating. Read food labels every time food is served. Always contact the parent of a child with an allergy if there is any question about safety take no chances! Consider talking with the parent of the child with an allergy to send home a letter to parents in the class. Be sure to take Emergency Action Plan and Medication on field trips. Recognition Know the signs and symptoms specific to each child as listed on their Emergency Action Plan (EAP). Do not ignore odd symptoms or behaviors that may indicate an allergic reaction. Always consider possible allergy if any different symptoms appear in a child with allergies. Food is the leading cause of anaphylaxis in children. Children who have asthma and food allergies are at a greater risk for anaphylaxis and may often react more quickly requiring aggressive and prompt treatment.

13 Steps to Take If a student displays signs and symptoms of an allergic reaction and/or reports an exposure to their allergen, school personnel should immediately implement the school s policy on allergy anaphylaxis which should require that immediate action be taken: Notify the school nurse (if available) and initiate the Emergency Action Plan; Locate the student s epinephrine immediately; Implement the student s Emergency Action Plan; including timely administration of epinephrine if needed, and Call 911 if epinephrine has been administered. Act Quickly! Do Not Delay! Epinephrine is the medication of choice for the treatment of acute anaphylaxis. Delay of or failure to administer Epinephrine may contribute to a fatal outcome. When in doubt, use the EpiPen. The side effects of the EpiPen could include fast heart beat, jittery feeling, and other cardiovascular symptoms. The life saving benefit of Epinephrine outweighs the risks of side effects in an anaphylactic reaction. Call 911 anytime Epinephrine is administered. Teachers Checklist Adopted from FAAN Teacher s Checklist Be familiar with your school s emergency procedures. Know how to recognize the symptoms of an allergic reaction and what to do if a reaction occurs. Be sure to notify substitute teachers and aides about students food allergies. Avoid using food in your lesson plans, such as math lessons and art projects. Don t use food as an incentive or reward. Minimize the use of food in class parties or celebrations. Develop a plan for communicating with parents about issues that might affect their child s food allergies. Consider food allergies when planning for field trips, and be sure to include the school nurse and parents early in the planning process. Check the ingredient labels on pet food, if your classroom has a pet. to get you started/checklist.pdf

14 Students Can Be Safe and Healthy Students with life threatening allergies can be kept safe at school. Careful planning and prevention can greatly reduce the risk of students experiencing anaphylaxis, or a lifethreatening allergic reaction at school. It is important for school staff to know their role in prevention, recognition, and response in caring for students with an allergy. School Community Education The team consists of the parent, student, principal, school nurse, classroom teacher, food service kitchen manager, and other involved school staff working together to create the safest learning environment for the student. Each team member has specific responsibilities for creating a safe learning environment. Please see the Missouri School Allergy Management Program Manual for a complete listing of policies and procedures including roles and responsibilities.

15 Role of the School Administrator Assist the school team in prevention, care, and management of students with life threatening allergies. Support and oversee faculty, staff, students, and parent/guardian in implementing all aspects of the management plan. Provide input to school district administration in the development and implementation of related policies and procedures. Ensure implementation of policies and plan, with training and education by a registered professional nurse for all involved faculty and staff regarding: Anaphylaxis and reactions to food, insect stings, medications, or latex; Risk reduction strategies; Emergency procedures; and How to administer epinephrine auto injector in an emergency. Role of the Student Will not trade food with others. Will not eat anything with unknown ingredients or known to contain any allergen. Will be proactive in the care and management of their food allergies and reactions based on their developmental level. Will notify an adult immediately if they eat something they believe may contain the food to which they are allergic. Role of the Parent Notify the school of the child s allergies. Work with the school team to develop a plan that accommodates the child s needs throughout the school Provide written medical documentation, instructions, photo, and medications as directed by a physician, using the Food Allergy Action Plan as a guide. Provide properly labeled medications and replace medications after use or upon expiration. Educate the child in the self management of their food allergy including: safe and unsafe foods strategies for avoiding exposure to unsafe foods symptoms of allergic reactions how and when to tell an adult they may be having an allergy related problem how to read food labels (age appropriate) Review policies/procedures with the school staff, the child s physician, and the child (if age appropriate) after a reaction has occurred. Provide emergency contact information.

16 Role of Food Service Work with school nurse, parent, and administration to determine food allergens on the menu and appropriate prevention measures. Develop protocols for cleaning and sanitation to avoid crosscontamination. Maintain current contact information from manufacturers for food products (Consumer Hotline). Order non latex gloves. Avoid use of latex gloves. Set up policies for cafeteria to follow regarding students with food allergies. Provide Label Reading Education including Allergen Labeling Education regarding the Food Allergen Labeling and Consumer Protection Act (FALCPA). Provide food substitutions in accordance with USDA guidelines Provide allergen aware or allergen safe zones according to district policy Role of Coaches, Athletic Director, After School Employees, and Volunteers Keep a copy of the ECP and student s photograph for all students with lifethreatening allergies. All school sponsored after school activities should be consistent with school policies and procedures regarding life threatening allergies. Participate in training and implementing the emergency action plan. Ensure that emergency communication equipment is always available. Clearly identify who is trained and responsible for administering the epinephrine auto injector (EpiPen). Know how to access EMS if an allergic reaction is suspected, following district policies: Call 911 and request Advanced Life Support. Implement other school board approved emergency procedures. Consider the presence of allergens involved in after school activities and modify as needed. Role of Transportation Personnel Bus drivers should have access to the Emergency Action Plan of each student they transport with a life threatening allergy. Arrangements should be made to provide a safe environment for the student with allergies on the bus: Maintain school district policy of no food or eating allowed on school buses. Student may require dedicated seating; and Careful attention to cleaning, including seat and handrails. Training may be provided by the school nurse for school bus drivers, monitors, and attendants on managing life threatening allergies. Provide functioning emergency communication device (ie.,cell phone, walkietalkie, two way radio) to all bus drivers. Provide school Transportation Director with list of students with lifethreatening allergies by bus/van number. Train bus drivers in district s protocols and procedures for activating the EMS system: Call 911 and request Advanced Life Support. Implement other school board approved emergency procedures. Inform substitute bus drivers of students with life threatening allergies. Implement a policy of non consumption of food or beverages on school buses.

17 Online Resources FAAN Back to School Tool Kit: to school toolkit FAAN School Guidelines for Managing Students with Food Allergies: anaphylaxis networkguidelines/schoolguidelines.pdf FAAN Food Allergy Action Plan: CDC National Center for Chronic Disease Prevention and Health Promotion: References Liberty Public School District Life Threatening Allergy Policy and Guidelines: /104_CareerEducation/ContinuingEducation/Webinars/FoodAlle rgywebinar Allergy_policy_guidelines.pdf?n=9295 Spokane Public School District: wse.asp?a=383&bmdrn=2000&bcob=0&c=55889 New York State School Health Services: s%20final% pdf School Nutrition Association Webinar Series: References The Food Allergy and Anaphylaxis Network (FAAN) , American Academy of Allergy, Asthma and Immunology. (AAAAI). National Association of School Nurses. Asthma & Allergy Foundation of America.