Anaphylaxis in schools and other child-care settings

Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

A survey of school's preparedness for managing anaphylaxis in pupils with food allergy

Allergic diseases are on the increase and can affect the child's well-being. The aim of this survey was to assess regional schools' preparedness in dealing with anaphylaxis following the publication of national and international guidelines for schools in 2014. The survey was developed in 2015 and distributed to schools in Cumbria, North West England, UK between 2015 and 2016. Only 47% of the respondents (95% CI, 39-57%) felt confident to manage anaphylaxis. Schools without allergic pupils were significantly less likely to have a standard management protocol in place for emergencies compared to those with allergic pupils (p < 0.001). The majority of the schools indicated that further training was needed (81% (95% CI, 74-88%).Conclusion: At the time of the survey, schools' preparedness in the region, did not meet safety standards recommended by national and international organisations. Although schools have shown eagerness in accessing training in the management of anaphylaxis, tailored training for schools is not yet widely available. There is now an urgent need to design feasible training strategies that create a safe environment for allergic pupils across all UK schools. What is Known: • One quarter of the severe allergic reactions take place for the first time while at school with some of them being fatal. • School staff is ill-prepared in the management of anaphylaxis. Access to formal training is not widely available. What is New: • School staff remains unconfident in managing the severe allergic child. Training in the management of anaphylaxis is scarce, and when available, it does not offer the required depth to cover the holistic needs of allergic pupils. • Schools would welcome generic adrenaline autoinjectors and a national policy with central funding which would describe step by step the necessary measures for the management of anaphylaxis.

Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan

Anaphylaxis is a potentially life-threatening, severe allergic reaction. The immediate assessment of patients having an allergic reaction and prompt administration of epinephrine, if criteria for anaphylaxis are met, promote optimal outcomes. National and international guidelines for the management of anaphylaxis, including those for management of allergic reactions at school, as well as several clinical reports from the American Academy of Pediatrics, recommend the provision of written emergency action plans to those at risk of anaphylaxis, in addition to the prescription of epinephrine autoinjectors. This clinical report provides information to help health care providers understand the role of a written, personalized allergy and anaphylaxis emergency plan to enhance the care of children at risk of allergic reactions, including anaphylaxis. This report offers a comprehensive written plan, with advice on individualizing instructions to suit specific patient circumstances.

Comparison of School Food Allergy Emergency Plans to the Food Allergy and Anaphylaxis Network’s Standard Plan

Eighty-four percent of children with food allergies have a reaction in school, and 25% of first food reactions occur in schools. An evaluation was conducted comparing food allergy emergency plans to the Food Allergy and Anaphylaxis Network’s (FAAN) Food Allergy Action Plan. Of the 94 respondents, 60 provided food allergy emergency plans for comparison. Although two-thirds used food allergy plans, only 15% used the current FAAN plan. Plans were missing essential components, including emergency contact information, medication administration instructions, and health history information. School nurses must adhere to current clinical guidelines to provide an accurate resource for personnel in charge of a food allergy reaction in school. Professional associations and state school health agencies must create and market a resource that provides easy, one-stop access to current best-practice guidelines and tool kits.

Epinephrine Use in Clinical Trials of Sublingual Immunotherapy Tablets

BACKGROUND

Allergy immunotherapy can result in systemic allergic reactions and even life-threatening anaphylaxis requiring epinephrine administration.

OBJECTIVE

The objective of this study was to describe epinephrine use in the clinical trial development programs of 3 rapidly dissolving sublingual immunotherapy tablets (SLIT-tablets; Merck & Co., Inc., Kenilworth, NJ/ALK, Hørsholm, Denmark/Torii Pharmaceutical Co., Ltd., Tokyo, Japan).

METHODS

Data on epinephrine use were collected from 13 timothy grass SLIT-tablet trials (MK-7243; ≤2800 bioequivalent allergen units/75,000 SQ-T dose, n = 2497; placebo, n = 2139), 5 short ragweed SLIT-tablet trials (MK-3641; ≤12 Amb a 1-U, n = 1725; placebo, n = 770), and 11 house dust mite (HDM) SLIT-tablet trials (MK-8237; ≤12 SQ-HDM; n = 3930; placebo, n = 2246).

RESULTS

In grass SLIT-tablet trials, epinephrine was used 13 times (grass SLIT-tablet, n = 10; placebo, n = 3). Eight administrations were for grass SLIT-tablet-related adverse events (AEs): 4 for systemic allergic reactions and 4 for local mouth and/or throat swelling. In ragweed SLIT-tablet trials, epinephrine was used 9 times in 8 subjects (ragweed SLIT-tablet, n = 7; placebo, n = 1 [2 administrations for protracted anaphylaxis]). Four administrations were for ragweed SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local mouth and/or pharynx/throat swelling. In HDM SLIT-tablet trials, epinephrine was administered 13 times (HDM SLIT-tablet, n = 8; placebo, n = 5). Four administrations were for HDM SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local events. Of the 16 epinephrine administrations for events related to SLIT-tablet treatment, 11 occurred within the first week of treatment (7 administrations on day 1) and 5 were subject self-administered.

CONCLUSIONS

Epinephrine administrations in response to SLIT-tablet-related reactions in clinical trials are uncommon, typically occur within the first week of treatment, and are rarely self-administered. All SLIT-tablet-related events treated with epinephrine were nonserious.

“Know before You Serve”

Given the potential severity of allergic reactions to certain foods, restaurant operators and staff need to know how to prevent guests from eating what could be fatal food. When the state of New Jersey enacted a law to create a fact sheet to explain safe handling of food allergens, a research team examined the information and communication challenges regarding food allergens— including knowing what foods cause the most trouble and how to avoid cross-contamination. The team then created a fact sheet that depicts the suspect foods and explains specifically how to avoid triggering food allergies in guests. This fact sheet will be displayed in all restaurants in the state.

Intention to prescribe self-injectable epinephrine: Are there differences depending on who assesses the patient post-reaction?

INTRODUCTION

Anaphylaxis is the most severe of all allergic reactions and can even prove fatal. There is limited evidence of a difference in prescribing patterns for self-injectable epinephrine (SIE) between general paediatricians and paediatricians with greater knowledge of allergology.

OBJECTIVES

Assess knowledge about prescribing SIE of a sample of primary care/hospital paediatricians and paediatricians with specialised knowledge of allergology through a questionnaire asking them about clinical cases of anaphylaxis in their daily paediatric practice.

MATERIALS AND METHODS

Participants were primary care and hospital paediatricians practicing in different regions of the province of Barcelona and paediatricians with specialised knowledge in the field of allergology from Spain.

RESULTS

A total of 183 paediatricians responded. Of that 59.6% were paediatricians with specialised knowledge of allergology. General paediatricians in most cases correctly prescribed SIE device (more than 70% answered correctly in five of the eight clinical cases). In the case of drug anaphylaxis, which is an avoidable allergen for which SIE is not indicated, 67.5% of general paediatricians would prescribe it. In the case of exercise-induced anaphylaxis there were also differences in the prescription of epinephrine by general paediatricians, with only 40% prescribing it.

CONCLUSIONS

In this study the percentage of SIE prescriptions would be higher than expected by general paediatricians, with no differences in the cases proposed between them and the paediatricians with better knowledge of allergology. Despite these results, it is important to insist on conducting education programmes and disseminating them to facilitate physicians' recognition and treatment of anaphylactic reactions.

A workshop with practical training for anaphylaxis management improves the self-efficacy of school personnel

BACKGROUND

School personnel are required to guarantee a secure school environment for children suffering from severe food allergies. We organized a workshop for school personnel to learn the appropriate management of anaphylaxis that included practical training with an adrenaline auto-injector (AAI). The objective of this study was to evaluate the workshop in terms of the improvement of self-efficacy (SE) of participants to deal with anaphylaxis.

METHODS

All 93 school nurses, 73 schoolteachers and 110 childcare workers participating in the study completed a questionnaire before and after the workshop. The SE of the participants was evaluated using an original 15-item questionnaire.

RESULTS

Before the workshop, the SE of school nurses was the highest among the profession groups, and being involved with children prescribed an AAI was a common factor associated with a high SE. After the workshop, the SE increased in all groups, but most apparently in school nurses and those involved with children prescribed an AAI. The presence of an emergency plan was positively associated with the SE of schoolteachers only after the workshop, even though no such association existed beforehand.

CONCLUSIONS

Practical instruction of school nurses and school personnel involved with children prescribed an AAI resulted in dramatic improvement of the SE. These people are expected to play a central role in the development of an anaphylaxis management plan in their schools.

Food allergy knowledge, perception of food allergy labeling, and level of dietary practice: A comparison between children with and without food allergy experience

BACKGROUND/OBJECTIVES

The prevalence of food allergies in Korean children aged 6 to 12 years increased from 10.9% in 1995 to 12.6% in 2012 according to nationwide population studies. Treatment for food allergies is avoidance of allergenic-related foods and epinephrine auto-injector (EPI) for accidental allergic reactions. This study compared knowledge and perception of food allergy labeling and dietary practices of students.

SUBJECTS/METHODS

The study was conducted with the fourth to sixth grade students from an elementary school in Yongin. A total of 437 response rate (95%) questionnaires were collected and statistically analyzed.

RESULTS

The prevalence of food allergy among respondents was 19.7%, and the most common food allergy-related symptoms were urticaria, followed by itching, vomiting and nausea. Food allergens, other than 12 statutory food allergens, included cheese, cucumber, kiwi, melon, clam, green tea, walnut, grape, apricot and pineapple. Children with and without food allergy experience had a similar level of knowledge on food allergies. Children with food allergy experience thought that food allergy-related labeling on school menus was not clear or informative.

CONCLUSION

To understand food allergies and prevent allergic reactions to school foodservice among children, schools must provide more concrete and customized food allergy education.

EAACI food allergy and anaphylaxis guidelines: managing patients with food allergy in the community

The European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines, managing patients with food allergy (FA) in the community, intend to provide guidance to reduce the risk of accidental allergic reactions to foods in the community. This document is intended to meet the needs of early-childhood and school settings as well as providers of non-prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast-food outlets) and targets the audience of individuals with FA, their families, patient organizations, the general public, policymakers, and allergists. Food allergy is the most common trigger of anaphylaxis in the community. Providing children and caregivers with comprehensive information on food allergen avoidance and prompt recognition and management of allergic reactions are of the utmost importance. Provision of adrenaline auto-injector devices and education on how and when to use these are essential components of a comprehensive management plan. Managing patients at risk of anaphylaxis raises many challenges, which are specific to the community. This includes the need to interact with third parties providing food (e.g., school teachers and restaurant staff) to avoid accidental exposure and to help individuals with FA to make safe and appropriate food choices. Education of individuals at risk and their families, their peers, school nurses and teachers as well as restaurant and other food retail staff can reduce the risk of severe/fatal reactions. Increased awareness among policymakers may improve decision-making on legislation at local and national level.

What do school personnel know, think and feel about food allergies?

Background

The incidence of food allergy is such that most schools will be attended by at least one food allergic child, obliging school personnel to cope with cases at risk of severe allergic reactions. Schools need to know about food allergy and anaphylaxis management to ensure the personal safety of an increasing number of students. The aim of this study was to investigate Italian school teachers and principals’ knowledge, perceptions and feelings concerning food allergy and anaphylaxis, to deeply understand how to effectively support schools to manage a severely allergic child. In addition a further assessment of the impact of multidisciplinary courses on participants was undertaken.

Methods

1184 school teachers and principals attended courses on food allergy and anaphylaxis management at school were questioned before and after their course. Descriptive and inferential statistics were used to analyze the resulting data.

Results

Participants tended to overestimate the prevalence of food allergy; 79.3% were able to identify the foods most likely involved and 90.8% knew the most frequent symptoms. 81.9% were familiar with the typical symptoms of anaphylaxis but, while the majority (65.4%) knew that “adrenaline” is the best medication for anaphylaxis, only 34.5% knew indications of using adrenaline in children. 48.5% thoroughly understood dietary exclusion. School personnel considered that food allergic students could have social difficulties (10.2%) and/or emotional consequences (37.2%) because of their condition. “Concern” was the emotion that most respondents (66.9%) associated with food allergy. At the end of the course, the number of correct answers to the test increased significantly.

Conclusions

Having adequately trained and cooperative school personnel is crucial to significantly reduce emergencies and fatal reactions. The results emphasize the need for specific educational interventions and improvements in school health policies to support schools to deal with allergic students ensuring their safety and psychological well-being.

Food Allergy Management in Elementary School

The prevalence of food allergies, with associated risk for anaphylaxis, has increasingly become a significant public health concern with copious and pervasive implications for patients, families, clinical health care professionals, researchers, and society at large. While potential treatments for food allergy are being explored through clinical research trials, there is currently no widespread scientifically proven cure available. Daily management of this atopic disorder consists of strict avoidance of the offending allergen. Subsequently, many families make concerted, burdensome efforts to create an allergen-controlled home environment. When children with food allergies start elementary school, this transition can be quite anxiety provoking for parents/caregivers. Schools may be perceived as allergen ubiquitous settings coupled with staff having varying awareness and training regarding food allergy and anaphylaxis. Clinical nurse educators, clinical nurse case managers, and other members of the primary care and/or specialty clinic teams can play a critical role in spanning the informational gap between clinic and school community. Ongoing collaboration between clinic team members with school nurse coordinators, school administrators, and other members of the school health services team may serve to minimize fragmentation of patient care, maximize ease of the child’s school entry transition, expand food allergy/anaphylaxis educational opportunities, and provide support to school nurse colleagues.

Anaphylaxis in children: current understanding and key issues in diagnosis and treatment

Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death. Since it is unpredictable and potentially fatal, prompt recognition and treatment are vital to maximize a positive outcome. The occurrence of anaphylaxis is increasing across all ages in the United States, with increased risk of worse outcome in teenagers/young adults and in those with comorbid conditions such as asthma. Gaps in the assessment of patient-specific risk factors, identification and prevention of triggers, recognition of signs/symptoms, and pharmacologic treatment of anaphylaxis have been identified at the physician and caregiver/patient level. A PubMed literature search (January 2000–December 2011) was conducted to identify publications on childhood anaphylaxis using the following terms: food allergy, food allergens, food hypersensitivity, epinephrine, epinephrine auto-injectors, anaphylactic triggers, and anaphylaxis. This review will critically appraise these key issues and highlight strategies that might result in improved management of anaphylaxis in children.

Prospective evaluation of an anaphylaxis education mini-handout: the AAAAI Anaphylaxis Wallet Card

BACKGROUND

Few anaphylaxis education materials have been prospectively evaluated in randomized controlled trials.

OBJECTIVE

Our objective was to evaluate the American Academy of Allergy, Asthma & Immunology Anaphylaxis Wallet Card (AAAAI-AWC) as an anaphylaxis education mini-handout for health care professionals.

METHODS

We performed a randomized controlled study of the AAAAI-AWC with residents in general pediatrics at Miami Children's Hospital. Participants in the intervention group completed a pretest about anaphylaxis, heard a 3-minute PowerPoint presentation based on the AAAAI-AWC, reviewed the AAAAI-AWC, and discussed it with the presenter. After this, participants took a post-test immediately and a follow-up test 4 weeks later. Participants in the control group took the pretest, were handed an AAAAI-AWC, studied it briefly, then took the post-test immediately and the follow-up test 4 weeks later.

RESULTS

Fifty-five residents participated. Regardless of the amount of time spent studying the AAAAI-AWC, when the pretests were compared with the post-tests and follow-up tests, residents in both the intervention and control groups were more likely to recognize anaphylaxis symptoms (P < .05), name asthma as the most common comorbid disease in children with fatal or near-fatal anaphylaxis (P < .05), and recall the names of epinephrine auto injectors (P < .05) and the epinephrine doses available in these auto injectors (P < .05). When the pretests were compared with the post-tests and the follow-up tests, residents in the intervention group were more likely than controls to identify the body organ systems involved in severe or fatal anaphylaxis correctly (P < .05).

CONCLUSION

The AAAAI-AWC is a practical, concise anaphylaxis education mini-handout for pediatric residents, a time-challenged group of health care professionals.

Management of anaphylaxis in schools: Evaluation of an epinephrine auto-injector (EpiPen®) use by school personnel and comparison of two approaches of soliciting participation

BACKGROUND

There has been no large study characterizing selection bias in allergy and evaluating school personnel's ability to use an epinephrine auto-injector (EpiPen®). Our objective was to determine if the consent process introduces selection bias by comparing 2 methods of soliciting participation of school personnel in a study evaluating their ability to demonstrate the EpiPen®.

METHODS

School personnel from randomly selected schools in Quebec were approached using a 1) partial or 2) full disclosure approach and were assessed on their ability to use the EpiPen® and identify anaphylaxis.

RESULTS

343 school personnel participated. In the full disclosure group, the participation rate was lower: 21.9% (95%CI, 19.0%-25.2%) versus 40.7% (95%CI, 36.1%-45.3%), but more participants achieved a perfect score: 26.3% (95%CI, 19.6%-33.9%) versus 15.8% (95%CI, 10.8%-21.8%), and identified 3 signs of anaphylaxis: 71.8% (95%CI, 64.0%-78.7%) versus 55.6% (95%CI, 48.2%-62.9%).

CONCLUSIONS

Selection bias is suspected as school personnel who were fully informed of the purpose of the assessment were less likely to participate; those who participated among the fully informed were more likely to earn perfect scores and identify anaphylaxis. As the process of consent can influence participation and bias outcomes, researchers and Ethics Boards need to consider conditions under which studies can proceed without full consent. Despite training, school personnel perform poorly when asked to demonstrate the EpiPen®.

Timing the transfer of responsibilities for anaphylaxis recognition and use of an epinephrine auto-injector from adults to children and teenagers: pediatric allergists' perspective

BACKGROUND

The optimal time for transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use from adults to children and teenagers has not yet been defined.

OBJECTIVE

To determine whether pediatric allergists have age-specific goals for beginning to transfer responsibilities for anaphylaxis recognition and epinephrine auto-injector use from parents and caregivers to children and teenagers at risk of anaphylaxis in the community.

METHODS

Members of the American Academy of Pediatrics Section on Allergy and Immunology (AAP-SOAI) were surveyed about when they typically begin to transfer these responsibilities from adults to children and teenagers.

RESULTS

Eighty-eight allergists responded to the survey, 97.7% of whom provided service to children and teenagers with food allergies. Few allergists expected to begin transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use to children younger than 9 to 11 years. By the time their patients reached age 12 to 14 years, however, most allergists expected them to be able to describe some anaphylaxis symptoms (95.4%), demonstrate how to use an epinephrine auto-injector trainer (93.1%), begin carrying self-injectable epinephrine (88.2%), recognize the need for epinephrine (88.1%), learn to self-inject epinephrine (84.5%), and be able to self-inject epinephrine (78.6%) (cumulative data). The allergists rated the following as "very important" readiness factors for beginning to transfer responsibilities: medical history, developmental level, and ability to demonstrate auto-injector technique.

CONCLUSION

Most pediatric allergists expected that by age 12 to 14 years, their patients should begin to share responsibilities with adults for anaphylaxis recognition and epinephrine auto-injector use; however, they individualized the timing based on assessment of patient readiness factors.

Comparing school environments with and without legislation for the prevention and management of anaphylaxis

BACKGROUND

  School personnel in contact with students with life-threatening allergies often lack necessary supports, creating a potentially dangerous situation. Sabrina's Law, the first legislation in the world designed to protect such children, requires all Ontario public schools to have a plan to protect children at risk. Although it has captured international attention, the differences a legislative approach makes have not been identified. Our study compared the approaches to anaphylaxis prevention and management in schools with and without legislation.

METHODS

  Legislated (Ontario) and nonlegislated (Alberta, British Columbia, Newfoundland and Labrador, and Quebec) environments were compared. School board anaphylaxis policies were assessed for consistency with Canadian anaphylaxis guidelines. Parents of at-risk children and school personnel were surveyed to determine their perspectives on school practices. School personnel's EpiPen5 technique was assessed.

RESULTS

  Consistency of school board policies with anaphylaxis guidelines was significantly better in a legislated environment (P=0.009). Parents in a legislated environment reported more comprehensive anaphylaxis emergency forms (P<0.001), while school personnel in nonlegislated environments reported more comprehensive forms (P=0.004). Despite school personnel in both environments receiving EpiPen5 training (>80%), suboptimal technique was commonly observed. However, school personnel in the legislated environment had better technique (P<0.001).

CONCLUSION

  Our results suggest that school boards in legislated environments have made greater efforts to support students at risk for anaphylaxis compared to nonlegislated environments. However, significant gaps exist in both environments, especially with respect to EpiPen5 administration, content, and distribution of anaphylaxis emergency forms, and awareness of school procedures by school personnel and parents.

Presence of food allergy emergency action plans in Mississippi

BACKGROUND

Multiple national, state, and local organizations recommend that emergency action plans (EAPs) direct therapy of allergic reactions in schoolchildren.

OBJECTIVE

To investigate the school nurse's perception of food allergies and the presence of EAPs for food allergic students in Mississippi.

METHODS

An investigator-developed food allergy survey was offered to all Mississippi public school nurses in 2008 and 2009.

RESULTS

The survey had a combined response rate of 29% (194/659) for the 2 years of the study. In both years, most participating school nurses had at least 1 food allergic student at their school (mean [SD], 11 [10] students per school). In 2008, 30% (28/93) of the school nurses reported that food allergy EAPs were present for all of their food allergic students, whereas 29% (27/93) of school nurses had 0% to 10% of their known food allergic students on EAPs. Similarly, in 2009, 37% (34/93) of school nurses reported all of their food allergic students possessed a food allergy EAP, whereas 26% (24/93) of school nurses had 0% to 10% of their known food allergic students on EAPs. In 2008, students were more likely to have food EAPs if the nurse received information on food allergies from parents or a physician or if the student attended a school in an urban area. However in 2009, only if the nurse received information from a physician were they more likely to have an EAP for their students.

CONCLUSION

Although numerous organizations recommend food allergy EAPs for allergic students, our study highlights their inconsistent use in Mississippi.

Management of food allergy in the school setting

Food allergy is estimated to affect approximately 1 in 25 school-aged children and is the most common trigger of anaphylaxis in this age group. School food-allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric health care provider may include diagnosing and documenting a potentially life-threatening food allergy, prescribing self-injectable epinephrine, helping the child learn how to store and use the medication in a responsible manner, educating the parents of their responsibility to implement prevention strategies within and outside the home environment, and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and pediatric health care provider in managing students with food allergies.

Food allergy education for school nurses: a needs assessment survey by the consortium of food allergy research

Food allergy is increasing in school-age children. School nurses are a primary health care resource for children with food allergy and must be prepared to manage allergen avoidance and respond in the event of an allergic reaction. An anonymous survey was administered to school nurses attending their association meetings to determine their educational needs regarding children with food allergy. With 199 school nurses responding, their self-reported proficiency for critical areas of food allergy knowledge and management varied, with weaknesses identified particularly for emergency plan development, staff education, delegation, developing guidelines for banning foods and planning school trips. Nurses reported a high interest in obtaining educational materials in these areas and prefer video and Internet resources that could be promoted through professional organizations.

Ethical principles as a guide in implementing policies for the management of food allergies in schools

Food allergy in children is a growing public health problem that carries a significant risk of anaphylaxis such that schools and child care facilities have enacted emergency preparedness policies for anaphylaxis and methods to prevent the inadvertent consumption of allergens. However, studies indicate that many facilities are poorly prepared to handle the advent of anaphylaxis and policies for the prevention of allergen exposure are missing essential components. Furthermore, certain policies are inappropriate because they are blatantly discriminatory. This article aims to provide further guidance for school health officials involved in creating food allergy policies. By structuring policies around ethical principles of confidentiality and anonymity, fairness, avoiding stigmatization, and empowerment, policy makers gain another method to support better policy making. The main ethical principles discussed are adapted from key values in the bioethics and public health ethics literatures and will be framed within the specific context of food allergy policies for schools.

Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization

Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The Committee strongly believes that epinephrine is currently underutilized and often dosed suboptimally to treat anaphylaxis, is under-prescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate i.m. doses.

New visions for anaphylaxis: an iPAC summary and future trends

Anaphylaxis is an increasing emergency in Western countries, especially in children. In the last decade, efforts have been attempted to widely understand anaphylaxis from several angles but at present, there are still numerous issues to be clarified and tackled for its earlier identification. The discrepancies in the operational definitions and diagnostic criteria of anaphylaxis represent one of the most controversial issues in casting light upon its epidemiology. Furthermore, the lack of reliable markers of the disease hampers its diagnosis. Further basic and clinical research is urgently needed to confirm the recent promising results derived from studies on animal models, and to clarify the key role of selected mediators and markers in the different steps of the reaction, in its severity and in the recurrences. The underuse of adrenaline is another important issue, as available data demonstrate physicians' preference for steroids and anti-histamines despite the current lack of evidence of their effectiveness. In the near future, the management of anaphylaxis will be strongly influenced by the development of a stepwise approach, as well as by the creation of a system improving transmission of good quality data between the emergency room, the allergist and the family doctor. This process will certainly be enhanced by the establishment of a network of Centres of Excellence collaborating for high quality research and care and involved in the dissemination of new knowledge at a primary care level. This review will seek to briefly overview our current knowledge and highlight the key questions that need to be addressed in the next decade to improve clinical care to children and will focus on the epidemiology of anaphylaxis, the identification of individuals at risk of anaphylaxis, the special issues related to infants, community management of children at risk of anaphylaxis and school related issues.

Self-injectable epinephrine for allergic emergencies

Anaphylaxis is a severe, life-threatening systemic reaction that can affect all ages. Epinephrine is frequently cited as the first-line and single most important agent in the treatment of severe allergic emergencies. Prompt administration of self-injectable epinephrine by patients and caretakers remains a key component in effective out-of-hospital management. This article will review the technique for self-injectable epinephrine administration in allergic emergencies, including discussion of the available dosages and formulations, indications, as well as other issues related to its use.

The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology

Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.

Anaphylaxis: evidence-based long-term risk reduction in the community

Anaphylaxis occurs frequently in the community, and it can be fatal in community settings. Risk assessment and risk reduction should ideally be coordinated by an allergy/immunology specialist and focus on: (1) prevention of subsequent anaphylaxis episodes, (2) emergency preparedness, and (3) anaphylaxis education. Preventive strategies should include trigger avoidance, specific preventive measures, and optimal management of comorbidities. Despite best efforts to avoid anaphylaxis triggers they can be encountered inadvertently, and anaphylaxis episodes can and do recur. Risk reduction therefore also focuses on emergency preparedness: carrying self-injectable epinephrine, having a personalized Anaphylaxis Emergency Action Plan, and wearing accurate medical identification. Anaphylaxis education should involve not only at-risk individuals and their families, but also health care professionals and the general public.

Managing children with food allergies in childcare and school

In the past decade the rise in life-threatening allergic reactions to foods in young children has necessitated increased interaction among personnel in the psychosocial, medical, and educational arenas regarding the multifaceted aspects of this concerning problem. Schools and childcare facilities are vital venues for the continued growth and development of children outside the home. However, these facilities offer unique challenges to caring for the food-allergic child, requiring that the medical, educational, and caretaking communities work in unison to provide the safest environment for all children. Despite the potential obstacles, these settings offer a tremendous opportunity for the development and implementation of strategies to provide for proper identification of children at risk, to increase awareness and prevention, and for the provision of optimal treatment of food-related anaphylactic reactions occurring outside the home.

Navigating the updated anaphylaxis parameters

: Anaphylaxis, an acute and potentially lethal multi-system clinical syndrome resulting from the sudden, systemic degranulation of mast cells and basophils, occurs in a variety of clinical scenarios and is almost unavoidable inmedical practice. Healthcare professionalsmust be able to recognize its features, treat an episode promptly and appropriately, and be able to provide recommendations to prevent future episodes. Epinephrine, administered immediately, is the drug of choice for acute anaphylaxis. The discussion provides an overview of one set of evidence-based and consensus parameters for the diagnosis and management of anaphylaxis.

Self-injectable epinephrine for first-aid management of anaphylaxis

Anaphylaxis is a severe, potentially fatal systemic allergic reaction that is rapid in onset and may cause death. Epinephrine is the primary medical therapy, and it must be administered promptly. This clinical report focuses on practical issues concerning the administration of self-injectable epinephrine for first-aid treatment of anaphylaxis in the community. The recommended epinephrine dose for anaphylaxis in children, based primarily on anecdotal evidence, is 0.01 mg/kg, up to 0.30 mg. Intramuscular injection of epinephrine into the lateral thigh (vastus lateralis) is the preferred route for therapy in first-aid treatment. Epinephrine autoinjectors are currently available in only 2 fixed doses: 0.15 and 0.30 mg. On the basis of current, albeit limited, data, it seems reasonable to recommend autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children who weigh 10 to 25 kg (22-55 lb) and autoinjectors with 0.30 mg of epinephrine for those who weigh approximately 25 kg (55 lb) or more; however, specific clinical circumstances must be considered in these decisions. This report also describes several quandaries in regard to management, including the selection of dose, indications for prescribing an autoinjector, and decisions regarding when to inject epinephrine. Effective care for individuals at risk of anaphylaxis requires a comprehensive management approach involving families, allergic children, schools, camps, and other youth organizations. Risk reduction entails confirmation of the trigger, discussion of avoidance of the relevant allergen, a written individualized emergency anaphylaxis action plan, and education of supervising adults with regard to recognition and treatment of anaphylaxis.

Mixed-up nuts: identification of peanuts and tree nuts by children

BACKGROUND

Peanuts and tree nuts frequently cause severe allergic reactions. Nut avoidance is the key treatment, and accurate identification of nuts is essential for successful avoidance.

OBJECTIVES

To determine the age at which nut-allergic and nonallergic children can accurately identify various nuts and whether nut-allergic children can identify nuts they should avoid.

METHODS

A "nut box" was constructed containing samples of 11 common nuts and pine nuts. Nut-allergic and nonallergic children were asked to identify the nuts, and their responses were compared and correlated by age. Nut-allergic children were asked to identify the nut(s) that they should not eat.

RESULTS

One hundred children (37 allergic and 63 nonallergic) were enrolled. The mean number of nuts correctly identified was only 2.7 per child and increased with age, but there was large variation. Fifty-nine children identified 2 or fewer nuts. Peanuts in the shell were identified most often (89% of children), followed by peanuts out of the shell (52%). Other nuts were identified less commonly, ranging from 32% for pistachios to 0% for Brazil nuts. Nut-allergic children were not better able to correctly identify tree nuts and were less able in the case of peanuts. Of the nut-allergic children, 10 (27%) could not identify the peanut or tree nut to which they were allergic.

CONCLUSIONS

In general, children, including those who are allergic to nuts, can identify few nuts. This lack of recognition could put them at increased risk for unintentional ingestion. As part of an overall educational plan, nut-allergic children should be taught not only to avoid but also to identify the nut to which they are allergic.

Anaphylaxis, killer allergy: long-term management in the community

Traditionally, physicians are trained to diagnose and treat anaphylaxis as an acute emergency in a health care setting. In addition to this crucial and time-honored role, we should be cognizant of our wider responsibility to (1) provide a risk assessment for individuals with anaphylaxis, (2) prevent future anaphylaxis episodes by developing long-term personalized risk reduction strategies for affected individuals, and (3) emphasize anaphylaxis education. Risk assessment should include verification of the trigger factor or factors for the anaphylaxis episode by obtaining a comprehensive history and performing relevant investigations, including allergen skin tests and measurement of allergen-specific IgE in serum. In addition, the potential effect of comorbidities and concurrently administered medications on the recognition and emergency treatment of subsequent episodes should be determined. Risk reduction strategies should be personalized to include information about avoidance of specific triggers and initiation of relevant specific preventive treatment (eg, venom immunotherapy). At-risk individuals should be coached in the use of self-injectable epinephrine and equipped with an anaphylaxis emergency action plan and with accurate medical identification. Anaphylaxis education should be provided for these individuals, their families and caregivers, health care professionals, and the general public. Further development of an optimal diagnostic test for anaphylaxis and of tests and algorithms to predict future risk and prevent fatality are urgently needed.

Administration of epinephrine for life-threatening allergic reactions in school settings

OBJECTIVE

Although the potential for life-threatening allergic reactions in children is a significant health concern for schools, there is little information about the circumstances surrounding anaphylactic events that occur in schools. The objectives of this study were to determine the incidence of anaphylaxis in schools, describe the circumstances around anaphylactic events, assess practices that are used to manage students with life-threatening allergies, and identify opportunities for improvement.

METHODS

A total of 109 school districts in Massachusetts completed an Epinephrine Administration Form whenever epinephrine was administered at school. Data were collected from September 2001 to August 2003.

RESULTS

Forty-eight school districts reported a total of 115 administrations of epinephrine during the 2-year reporting period. In 24% of the cases, the individual was not known to have a life-threatening allergy. Almost one third (31%) of the students who received epinephrine had allergies to multiple substances, and one quarter (25%) had an allergy to peanuts or tree nuts only. Twenty-two (19%) cases occurred outside the school building on the playground, traveling to and from school, or on field trips. The administration of epinephrine most often occurred in the health office by a registered nurse. The average time from onset of symptoms to administration of epinephrine was 10 minutes. In 92% of the cases, the student was transported to a medical facility via the emergency medical system.

CONCLUSIONS

Anaphylactic reactions in schools, although not frequent, are not uncommon events. A systematic review of anaphylactic events that required epinephrine administration identified opportunities for improvement in the treatment of students with life-threatening allergies.

Anaphylactic reactions in children--a questionnaire-based survey in Germany

BACKGROUND

Severe anaphylactic reactions are medical emergencies requiring immediate recognition and treatment. Despite this, little is known on their clinical features, especially in infants and children.

OBJECTIVE

To evaluate trigger factors, patterns of clinical reaction, site of occurrence and treatment modalities of reported reaction in infants and children below 12 years of age in Germany.

METHODS

Paediatricians throughout Germany were asked by questionnaire to report accidental anaphylactic reactions over the previous 12 months. Severity of reported reactions was classified in grades I-IV according to reported symptoms.

RESULTS

Hundred and three cases of anaphylaxis were evaluated. Median age was 5 years, 58% were boys. Site of occurrence was the child's home in the majority of cases (58%). Foods were the most common causative allergen (57%), followed by insect stings (13%) and immunotherapy (SIT) (12%); in 8% anaphylactic agent was unknown. Among foods, peanuts and tree nuts were the most frequent allergens (20% of food allergens in each case). Severe reactions with cardiovascular involvement occurred in 24% of cases. No fatal reaction was observed. Recurrent episodes of anaphylaxis were reported in 27% of cases, half of these caused by the same allergen again. For treatment, 20% of children received adrenaline, in 8% of cases intravenously. Thirty-six per cent of patients with grade-IV reactions received adrenaline, 24% intravenously. In 17% of all children an adrenaline self-injector was prescribed after the episode.

CONCLUSION

Our data: (i) shows an uncertainty of physicians in diagnosing anaphylaxis, (ii) reveals remarkable under-treatment of the majority of children with anaphylaxis, (iii) reflects the need for guidelines and training for physicians in managing children with anaphylaxis and (iv) should encourage the development of self-management programmes for patients and families.

Seafood allergy: lessons from clinical symptoms, immunological mechanisms and molecular biology

Food allergy consists of a wide range of disorders that result from adverse immune responses to dietary antigens. Manifestations of allergic response includes acute, potentially fatal anaphylactic reactions and a variety of chronic diseases that mainly affect the gastrointestinal tract, skin, and respiratory tract. Tools for clinical diagnosis and management, which have not changed much in the past two decades, include the clinical history, tests for specific IgE antibody to suspected foods, elimination diets, oral food challenges, and provision of medications such as epinephrine for emergency treatment. On the other hand, recent immunological and molecular biological research have enhanced our understanding of the mechanisms of these disorders and revealed the identities of many food allergens. Here, we will discuss seafood allergies with respect to the clinical manifestations, diagnosis, immunological mechanisms, and molecular biology of seafood allergens. Furthermore, potential applications and future directions in the clinical management of seafood allergies are discussed.

Use of alpha-agonists for management of anaphylaxis occurring under anaesthesia: case studies and review

Anaphylaxis is an uncommon but serious complication of anaesthesia. Most current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of cardiovascular collapse. We present two cases of anaphylaxis under anaesthesia where return of spontaneous circulation was refractory to epinephrine, but occurred following the administration of the alpha-agonist metaraminol. Potential advantages and disadvantages of using epinephrine in this setting, the role of alpha-agonists and some potential mechanisms accounting for their role in successful management are reviewed.