Transcript Document

What do we know about
food allergies in the
school?
Christine Szychlinski, MS, APN, CPNP
Manager, Bunning Food Allergy Program at
Children’s Memorial Hospital Chicago, IL
Supported by the Food Allergy Initiative of Chicago
faiusa.org/Chicago
© 2010 Children’s Memorial Hospital
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Definition
Adverse reactions to foods are any abnormal reaction
associated with ingestion and can include intolerances
Food Allergy is different
Reaction mediated by the immune system which is rapid in
onset and involves allergic symptoms.
Any food allergy reaction can be life threatening
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Food allergy
 6% of young children in U.S.
– affects approximately 1 in 25 school-aged children
– 4% of adults in U.S.
 Increasing prevalence in U.S.
– 18% increase between 1997 and 2007
(http://cdc.gov/nchs/data/databriefs/db10.pdf)
 Leading cause of anaphylaxis treated in
emergency departments
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Common Allergens
Cow’s milk
Soy
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Egg white
Wheat
Peanut
Tree nuts
Fish
Shellfish
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Diagnosis
Diagnosis can be made with convincing clinical
history supported by testing and/or oral food
challenge.
Skin testing supports a reaction but has a 50% false
positive rate without a history
Blood based testing can provide a diagnosis with 95%
confidence with a very limited number of foods
– Milk, egg, peanut and walnut
– Cannot predict severity of reaction
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Treatment
There is no cure (yet) for food allergies.
The only current treatment is AVOIDANCE.
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Avoidance
Avoid exposure to allergen
 During school day
 While traveling to and from school
 During school-funded events
 While on field trips
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Avoidance
Other issues with avoidance include
 Cross-contamination
 Mislabeled foods/unlabeled foods
 Different practices
 Developmental readiness of child
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School is a high risk setting
Accidents happen at school and not always
where you may predict
 Telephone survey of 132 children indicated 58% had food
allergy reactions in the past 2 years
– 18% of reactions were in the school setting
(Sicherer S JACI 2003)
 Data collection over a 2 year time showed majority of
reactions occurred in the classroom
(McIntyre CL Pediatrics 2005)
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Impact on the school nurse
 Telephone survey of 400 school nurses
• 44% increase in food allergies
• >33% at least 10 students with food allergy
• 78% did staff training
• 74% did guideline development
» Weiss, C Jrnl of School Nurs 2004
 Need for standardized guidelines
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What are the risks associated with
food allergy reactions
 ANY FOOD can cause a fatal reaction in an allergic child
 Some risk factors for life threatening reactions
– a history of a life threatening reaction in the past
– asthma
– adolescent age group
– peanut and/or tree nut allergy
– DELAY IN GETTING EPINEPHRINE
(Bock A JACI 2001/2007)
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Managing Food Allergies in School
 Illinois School Code: each school board is required to
implement a policy for the management of students with
life-threatening food allergies by January 1, 2011
 Use the "Guidelines for Managing Life-threatening Food
Allergies in Illinois Schools“ to create school policies and
best practices
www.isbe.net
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Step one
 Identifying the child with food allergy
– each child identified by a parent as having food allergy must
have an Emergency Action Plan (EAP) signed by a licensed
health care provider (LHCP)
– The EAP includes the child’s allergy foods and what
medications should be used in an emergency situation
• The form available for use also contains parental
treatment authorization and other information necessary
for the school staff
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Emergency Action Plan (EAP):
Auto injectable Epinephrine
EAP provides:
 Permission to self-administer
 Medication authorization and dose
 Parent's consent for the school to administer medication
 A list of staff members trained
 Where auto-injectors stored (including a backup storage)
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Step two
 An Individualized Health Care Plan is created for the child
based on the recommendations of the LHCP
 Participants may include parents, school administration,
school health personnel, teachers, custodial staff, kitchen
staff, social work/special education
– The child’s day should be considered from the time they
arrive in school (or are on the school bus) until the time they
are returned to the care of their parents or guardians
– This should include after school activities and may need
to include activities that use school property that do not
directly involve the child
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How risky is the environment
 Studies have looked peanut allergen in the school and these
findings can help with decision making
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How does research help us in the
school setting
 How safe is the average school environment?
– Testing of 60 sites in 7 schools after routine cleaning had
one positive finding for peanut (Perry TT JACI 2004)
 How can you effectively remove peanut from hands?
– Most cleaning methods worked except
plain water and hand sanitizer
 How can you effectively remove peanut from surfaces?
– Most cleaning methods worked except
dishwashing liquid
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(Perry TT JACI 2004)
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The environment
 Studies show that it is possible to keep a school environment
safe for food allergen if attention is paid to details
 Remembering:
– Allergen must be physically removed
– Plans in place to minimize cross contamination
– Use the right methods
– The developmental level of the child
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Airborne peanut
Airborne
 Activities included eating peanut products, open jars of
peanut butter, shelling peanuts and walking on the shells,
opening bags of unshelled peanuts while other had samples
collected via personal air monitors and area samples
– No detectable peanut allergen found
(Perry TT JACI 2004)
 Double blind placebo controlled randomized exposure to
peanut contact and inhalation
– No respiratory reactions
– 10/30 had contact reaction
(Simonte SJ JACI 2003)
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Prevent a Reaction:
So what do those studies tell us?
 Exposure to food allergens by touch or inhalation is unlikely
to cause a life-threatening reaction (Simonte SJ JACI 2003)
 However, risk of ingestion (and reaction) if child touches
allergen and then place fingers in or near mouth or nose
– Food allergy precautions cannot be one size fits all
– Younger children will require more safe guards
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FALCPA 2004
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What about food labeling
Do allergic consumers avoid those foods?
– Less likely to avoid in 2006 (75%) versus 2003 (85%)
– More avoid “may contain” than “shared facility”
Do foods with advisory labeling contain peanut?
– Detectable peanut protein in 10% of foods
– 7% with levels which could cause reaction
– “may contain” 2/51 “shared facility” 7/68
(Hefle SL JACI 2007)
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Food labeling
 Looked at foods with advisory labeling for milk, egg and
peanut and also similar foods with no allergen disclosure
– Peanut more likely to be found in a product with advisory
labeling (not milk or egg)
– Milk more likely to be found in products from small vs. large
manufacturers (not egg or peanut)
– 7 contaminated products without advisory labeling were
from 5 companies and only 1 large company
– Overall 5.1% of foods with advisory labels from small
companies tested positive and 0.75% from large companies
(Ford LS JACI 2010)
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What should happen in schools
 Read labels and strictly avoid
– allergens stated on ingredient list
– allergens stated on advisory statements
– foods not labeled
 Guidelines should acknowledge that food allergic families
have different practices
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Keys to allergen avoidance
 Control of environment
– Identify all food including food used in the curriculum
– Consistent cleaning practices
– Minimizing risk according to child’s developmental abilities
– Use of the EAP in the development of an IHCP
• Everyone involved with the child and the child’s
environment must be familiar with what is needed
• Keep in mind social consequences of food allergy and be
alert for bullying and increased risk of isolation
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Accidents happen
 It is estimated that a child will have an accidental ingestion of
one of their food allergens about every 5 years
– The setting for these accidents according to some studies
are allergens specific with milk being the most common
allergen accidentally ingested at home
– School is not an uncommon site for accidental ingestions
• Increased risk when routine is broken
– Some children may not recognize the early symptoms of an
allergic reaction
– Some children may be more fearful of admitting a mistake
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Reactions can include
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Allergic Reaction:
What a Child Might Say or Do
Say
Do
 “My tongue (or mouth) itches”
 Put their hands in
their mouths
 “My tongue is hot/burning”
 “My mouth feels funny”
 “There’s something stuck
in my throat”
 “It feels like there are bugs
in my ears”
 “This food is too spicy”
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 Pull or scratch at their tongues
 Drool
 Hoarse cry or voice
 Slur words
 Become unusually
clingy
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All staff must be able to recognize a
reaction
 Early recognition saves lives.
 Signs and symptoms can vary from mild to severe,
life-threatening and can change quickly.
 Those with more severe reactions respond to lower amounts.
(Wensing M JACI 2002)
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Recognize a reaction: Anaphylaxis
 The medical diagnosis for a severe reaction.
 Symptoms rapid in onset and severe.
 Involves the most dangerous symptoms including but
not limited to: breathing difficulties and a drop in blood
pressure (shock).
 Always a risk of death, even if treated appropriately.
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Allergic reaction: Respond
Follow the Food Allergy Emergency Action Plan
prescribed by licensed health care provider
Take all symptoms seriously
Do not delay in giving epinephrine when required
– Safe and simple to use
If epinephrine given, call 911
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Autoinjectable epinephrine
 Expiration date
 Must be readily available
 Call 911 after administering
 Train and retrain
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Managing Food Allergies in School:
Summary
Create a safe environment
 Prevent a reaction:
– Avoidance
– Know the IHCP for your student
 Recognize a reaction:
Know the signs and symptoms
 Respond to an allergic reaction:
– Know the EAP for your student. Respond quickly.
– Practice emergency response drills
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Thank you!
 Questions?
 Useful websites:
– www.foodallergyinitiative.org
– www.foodallergy.org
– www.childrensmemorial.org/FACE
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