Community pediatricians, working in consultation with allergists, create a medical home that is the central focus of care for the child with life-threatening food allergies. They participate in coordinating mutual and critical collaborations within schools that support families and children. They can provide leadership and guidance to both families and schools to safeguard children and adolescents, thereby extending the medical home goals into the school setting.
Key points
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Community pediatricians participate in critical collaborations within schools that support families and children with food allergy and other potentially life-threatening allergies.
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Community pediatricians can provide leadership and guidance to both families and schools to safeguard children and adolescents with food allergy and other potentially life-threatening allergies, thereby extending the medical home goals into the school setting.
Introduction
Primary care pediatrician are the managers and facilitators of the patient-centered medical home and serve as the glue in a series of critical collaborations within schools that support the family and child with food allergy and other potentially life-threatening allergies. When primary care pediatricians include the school health professional team into a child’s overall medical plan for managing life-threatening food allergies and anaphylaxis, they can further the goals of the medical home. They can provide leadership and guidance to extend the medical home goals into the school setting, by educating the family to partner with their schools and encouraging the school to provide reasonable and effective accommodations, as per state or federal guidelines. In fact, the most effective management of life-threatening food allergies and anaphylaxis occurs when the medical home, the family home, and the educational home work together as a team for the benefit of the child or adolescent, ultimately affording the student the least restrictive environment with the greatest chance for safety and maximal opportunity to learn and thrive.
Families of children with food allergies are reliant on many individuals when it comes to the school community. The pediatrician and the pediatric allergist play a critical role in clearly defining the food allergy management strategies necessary for the child. They work with parents and schools to ensure that these important strategies are applied to the specific student while taking school resources and policies into account and collaborating with the school team. Pediatricians can coordinate and foster mutually beneficial relationships, a spirit of trust, and positive interactions among all stakeholders, especially the family. The school nurse, school physician, and others on the school health team are key members of the multidisciplinary school teams that include nutrition services, school administration, teachers, counselors, transportation directors, special subject areas, physical education teachers, and all others who interact with students.
The purpose of this article is two fold. The first is to guide community pediatricians by strengthening their understanding of essential principles and components in effective food allergy management in the school setting and to direct readers to additional resources to support this goal. The second is to empower pediatricians to be the stewards in collaborations that bridge the medical, family, and educational homes for the sake of children with food allergies and other potential life threatening allergies.
Food allergy management principles: the pillars of prevention and preparedness
Effective food allergy management is necessary at all times and in all situations. The pillars of food allergy management are prevention and emergency preparedness. Very small amounts of food allergen can cause anaphylaxis (severe, life-threatening, allergic reaction). To prevent accidental exposure, those responsible for students must effectively read labels, prevent ingestion of hidden ingredients, prevent cross-contact, use efficient cleaning strategies, and communicate clearly. It is equally necessary to be prepared for an allergic emergency. Adults who are responsible for students must be able to recognize an allergic reaction and have epinephrine (first-line treatment of choice for anaphylaxis) available. They must also know when and how to use it and know to contact emergency services immediately. These strategies are always necessary, and the school setting is no exception. Implementing solid food allergy management is challenging and takes knowledgeable administration, school nurses, school staff, and school community.
Prevention
It is important for pediatricians to understand the different routes of exposure and the risks of these exposures and apply this understanding to the school setting. Pediatricians should be aware of challenges and solutions as they apply to preventing accidental exposures in the school setting. Table 1 contains a list of potential routes of exposure, challenges to preventing these exposures, and solutions to these challenges. Pediatricians, as individuals and/or as American Academy of Pediatrics (AAP) Chapters, can provide guidance, such as school-related food allergy articles like as this current one and state and federal guidance documents, to those administrators in schools responsible for students with life-threatening food allergies on ways to try to prevent inadvertent exposure to food allergens. Pediatricians provide guidance for what parents expect from schools based on state and/or federal guidelines. Dietary guidance and medical orders for school diet restrictions can be challenging for both prescribers and school food services directors and staff. Under 7 CFR 15b.3, students with a disability that restricts their diet, which, according to the Americans with Disabilities Act (ADA) Amendments Act of 2008 ( http://www.eeoc.gov/laws/statutes/adaaa.cfm ) includes food allergy, are entitled to substitutions in lunches and after school snacks on a case-by-case basis. This occurs only when supported by a written statement of the need for substitutions from a licensed physician or, in some states, other state-allowed health care providers (US Department of Agriculture’s recent memo, SP32-2015, issued March 30, 2015: http://www.fns.usda.gov/nslp/policy ). The written statement must include recommended alternate foods, unless otherwise exempted by the Food and Nutrition Service ( www.fns.usda.gov/sites/default/files/special_dietary_needs.pdf ).
| Type of Exposure | Relevant Concepts/Facts/Studies | Practical Challenges | Practical Interventions (See CDC, NSBA and/or State Guidelines) |
|---|---|---|---|
| Oral exposure | Unable to visualize allergens; they can be hidden ingredients Labels and ingredients can change without warning Items with advisory labels can contain allergens Trace amounts can cause severe allergic reactions Allergens can be detectable in saliva Cross-contact of food allergen can occur from one surface to another, food to food, and with transfer of saliva. If a person is then exposed to these allergens, especially by mouth, it may be enough of an exposure to cause a serious allergic reaction | Without labels, it is impossible to know avoidance practices of those responsible for preparation of foods brought in to school Classroom celebrations are common source of outside food and high risk for cross-contact In schools, most allergic reactions that occur start in classroom Resources and manpower in schools to read labels vary among schools | If food is not from home then all labels must be accurately read by an assigned reader Classrooms should have safe nonperishable snack or celebration items available if needed Cafeterias should prepublish menus and offer meal options without known allergens Food allergic children who are eating from the cafeteria should be assisted in selection of safe food No sharing of food, drinks, and utensils anywhere No unlabeled food in classroom or cafeteria Nonfood celebrations and rewards are optimal/safest |
| Additional consideration for preschool/early elementary | |||
| Young children can pass saliva to each other via developmentally appropriate exploration In some schools, children eat in their classrooms/learning environments Supervision during meal/snack time depends on resources and staff | If meal/snack is in the learning environment, then effective strategies must be in place to clean and prevent accidental exposure/cross-contact In some cases, food-free classrooms or selective allergen restriction (lower age groups) may be appropriate and practical if label reading is not possible | ||
| Additional consideration for adolescent/teenage students | |||
| Older students under less supervision and more reliant on self-management Increased risk taking, peer pressure, bullying, kissing with salivary exchange | Periodic check ins to ensure continued self-management and safety from bullying Discussion of intimate kissing and allergen exposure and evidence-based preventive measures | ||
| Skin exposure | Isolated skin contact on intact skin did not cause severe or systemic reactions in 2 small studies, although skin reactions did occur Soap and water and commercial hand wipes are effective in cleaning hands; alcohol- and nonalcohol-based hand sanitizers are not Soap and water, commercial cleaners, and commercial wipes were effective in cleaning table tops Young children frequently place their hands and objects in their mouth (age 1–2 y, 80×/h; age 2–5 y, 40×/h) Adults touch their eyes, nose, and mouth regularly (15×/h) | Hand washing in young grades can take 20–30 min Resources and manpower available to clean allergens and prevent cross-contact varies school by school and classroom by classroom Some nonedible items contain some food allergens; finger paint, play dough, shaving cream, paste, bean bags, furniture, pet food, bird feed, as well as others Skin exposure can result in mucosal exposure in adults and children | Hand washing with soap/water or wipes before and after eating is optimal Appropriate cleaning of eating areas decreases risk Curricular activities can be food free, or comparable, but alternate activities can be provided for children with life-threatening food allergies. Attention to avoid allergens with crafts/lessons/pets is optimal Establish a cleaning protocol to avoid cross-contact |
| Additional consideration for preschool/early elementary | |||
| Skin exposure that can quickly turn into mucosal exposure or oral ingestion Less effective cleaning skills (hands or eating surfaces) | In some cases, food-free classrooms or selective allergen restriction in lower age groups may be appropriate and practical Adult supervision of hand cleaning is optimal Adults have responsibility for cleaning surfaces, toys | ||
| Inhalation exposure | Aerosolized proteins in cooking are the most common cause of allergic reactions by inhalation. Odors are caused by volatile organic compounds, not protein, and odors alone do not cause allergic reactions Inhaling proteins can cause allergic reactions. There have been deaths associated with the inhalation of actively cooked foods | Experiments involving burning/heating of allergens create risk Some field trips are in areas where foods are actively cooked or aerosolized Some activities involve using food powders or grinding/crushing fresh foods | Use caution with cooking foods, flours, powders, and other small particles of food that can go up in the air Avoid food in curricular science experiments or classroom activities. All field trips to have prior assessment from school nurse to determine need for special accommodations |
Preparedness and Emergency Response
Despite everyone’s best efforts to prevent exposures to allergens through avoidance, exposures can and do occur. Therefore, it is equally necessary for schools to be prepared for allergic emergencies. The pediatrician or allergist should provide schools with an emergency care plan that includes a list of specific food and other triggers to avoid and emergency medical orders for epinephrine in the event of anaphylaxis. Alternately, physicians may write these orders as a prescription for school nurses who create the emergency care plan (ECP).
Anaphylaxis Emergency Care Plans
ECPs are a collaborative effort of the medical, family, and school homes. They are created by the pediatrician, allergist, and/or school nurse and serve as simplified criteria to assist parents, school personnel, and anyone caring for a child with life-threatening allergies to identify signs and symptoms of anaphylaxis and treat appropriately with epinephrine. It should be understandable to an unlicensed assistive personnel or other laypersons that epinephrine is the treatment of choice for anaphylaxis and administering other medications, like antihistamines, should never delay treatment with epinephrine. It is also helpful to address the potential need for a second dose of epinephrine and the need to be evaluated in the emergency room.
In all cases of life-threatening food allergy, unlicensed persons who function as a supervisor of a child or adolescent with a life-threatening food allergy at any time during the school day need to be willing and trained to carry out the ECP. This is a document created by the prescriber and/or the school nurse based on the provider’s written medical orders, providing in simple language directions to unlicensed staff on what to do in an emergency. The format is typically “If you see this…then do this….” Emergency contact information and a photo of the student usually accompany the action plan. The Centers for Disease Control and Prevention (CDC) recommends that the ECP includes information about signs and symptoms of an allergic reaction, how to respond, and what medications should be given. There are multiple templates available from the American Academy of Allergy, Asthma and Immunology, AAP, as well as other respected sources.
Leadership
Ultimately, pediatricians and allergists can educate, support, and empower parents to ensure that sound school policies and protocols exist and that there is clear leadership when it comes to the management of life-threatening allergies. They can guide administrators to understand that all school staff responsible for a student with a food allergy must be educated and prepared to recognize and play their specific role in an allergic emergency during a regular school day, as well as during other school situations, such as extended sheltering in place, emergency evacuations, lockdowns, and on day or extended field trips. Table 2 contain strategies to prepare for allergic emergencies in those with known and unknown allergic conditions.
| Strategies in Place for Known History of Food Allergy | Strategies in Place for Unknown Food Allergy (Approximately 25% of Epinephrine Administrations) |
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| Strategies in Place for All Students and Staff (with Known and Unknown History of Life-Threatening Allergies) | |
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