Legal and Practical Strategies for Managing Food Allergies Christina Eldredge MD, Medical College of Wisconsin Brenda White, Archdiocese of Milwaukee Linda Joyner, St. Mary School, Menomonee Falls

Objectives Discuss why school management is important Define and discuss signs and symptoms of anaphylaxis and food allergy Updates on new Epinephrine Auto- injector options Update on new law & guidelines

Food Allergy Basics Increasing in prevalence Most recent study 8% children have a reported food allergy1 1/3 have had a severe reaction No cure Abnormal immune reaction by the body to a food protein When food eaten, the body’s immune system abnormally thinks the food is bad and “attacks” with histamine and other chemicals² Treatment is avoidance of food allergen & plan for accidental exposure (action plan) 1. Gupta, 2011 2. FAAN slides

Most Common Food Allergies Milk Peanut Fish Soy Wheat Shellfish Egg Tree nuts

Why is food allergy important? Can be potentially life threatening Anaphylaxis: “serious allergic reaction rapid in onset and may cause death”¹ Many food allergy reactions occur in school² Approximately 25% of first time food allergy reactions occur in school Teachers the primary first responders² 1 Sampson 2006 2.US Peanut and Tree Nut Registry

School Deficiencies Two Main Deficiencies: Inadequate food allergy management plans Recognizing reactions and prompt treatment (epinephrine) *Young, 2009

Signs and Symptoms Cutaneous (Skin) >90% Hives / Swelling 85 – 90% Flush 45 – 55% Pruritus 2 – 5% Respiratory (breathing) 40 – 60% Shortness of breath / Wheezing 45 – 50% Upper Airway Swelling 50 – 60% Runny nose 15 – 20% Dizziness, Loss of Consciousness, Low Blood Pressure 30 – 35% Abdominal Involvement 25 – 30% Seizures 1 – 2%

Severe Reactions or Anaphylaxis Fatal and near fatal reactions to food are usually unpredictable Delay in treatment a factor Treatment: Epinephrine auto-injector Often accidental, peanuts/tree nuts usually worse Jr 33-66 lbs, >66 adult dose

Where do school reactions occur? Peanut/tree reactions* Classroom Craft projects Birthday celebrations Cafeteria Playground Field trips *US Peanut and Tree Nut Registry Not cafeteria, field trip case wrong lunch

Federal and State Laws Section 504 prohibits a private school from discriminating against an individual because of a disability. Wisconsin Statute 118.29 requires the administration of medication by trained staff. Wisconsin Act 239 governs the use of stock epi pens in schools.

School Policy and Guidance School administrators and school personnel must receive medication training in accordance with DPI regulations. No medication will be administered by school personnel without the Medication Consent Form and the Physician Order for Medication Administration Form being filled out and returned to the individual(s) administering the medication and/or the School Nurse.

Self Carry Policy and Guidance Students may carry certain emergency prescription medications, such as asthma inhalers, glucagon, and EpiPens. Students in grades K-12 may self-administer while at school only under the supervision of trained school staff/ volunteers. Must have a release form completed and signed by the student’s physician, parent/legal guardian, principal, and homeroom teacher (refer to Form 5140.2c) The parent must provide to the school a copy of a health care plan (refer to Form 5140.2d) for a student who requires an emergency prescription medication.

Wisconsin Act 239 The governing body of a school may adopt a plan for students with life threatening allergies. A physician, NP, or PA may prescribe epinephrine auto-injectors in the name of a school with a plan. Designated, trained school personnel may administer Epipen to pupils with prescription and pupils believed to be experiencing anaphylaxis in accordance with a standing protocol from a physician, APNP, or physician assistant. Must call 911 after Epipen injection. http://docs.legis.wisconsin.gov/2013/related/acts/239

Federal Legislation School Access to Emergency Epinephrine Act, President Obama signed on November 13, 2013. “Encourages states to adopt laws requiring schools to have on hand “stock” epinephrine auto-injectors.” http://www.foodallergy.org/advocacy/epinephrine/map

School Plan Develop a local plan for management of students with life threatening allergies Epinephrine training for staff and volunteers Accessible action plans for each student Review and retention of student health records Storage of medication Self carry policies No-food sharing policies (bus, classroom, cafeteria) Hand-washing and cleaning protocols Classroom protocols (snacks, projects, rewards) Field trips

Google Forms

Other Possibilities… Annual coaches training Flipping staff meetings/PD modules ???

FARE: Food Allergy Research & Education http://www.foodallergy.org/ http://www.foodallergy.org/section/video-gallery http://www.slideshare.net/FoodAllergy/food- allergies-for-adults

References: 1. Branum AM, Lukacs SL. Food allergy among U.S. children: trends in prevalence and hospitalizations. NCHS Data Brief. Oct 2008(10):1-8. 2. Food Allergy and Anaphylaxis Network. 2011; http://www.foodallergy.org/. Accessed August 17th, 2011. 3. Hay GH, Harper TB, 3rd, Moore TG. Assuring the safety of severely food allergic children in school. J Sch Health. Nov 2006;76(9):479- 481. 4. Sicherer SH, Mahr T. Management of food allergy in the school setting. Pediatrics. Dec 2010;126(6):1232-1239. 5. Young MC, Munoz-Furlong A, Sicherer SH. Management of food allergies in schools: a perspective for allergists. J Allergy Clin Immunol. Aug 2009;124(2):175-182, 182 e171-174; quiz 183-174. 6. Shah E, Pongracic J. Food-induced anaphylaxis: who, what, why, and where? Pediatr Ann. Aug 2008;37(8):536-541. 7. Rhim GS, McMorris MS. School readiness for children with food allergies. Ann Allergy Asthma Immunol. Feb 2001;86(2):172-176. 8. Pulcini JM, Marshall GD, Jr., Naveed A. Presence of food allergy emergency action plans in Mississippi. Ann Allergy Asthma Immunol. Aug 2011;107(2):127-132.

References: 9. Pulcini JM, Sease KK, Marshall GD. Disparity between the presence and absence of food allergy action plans in one school district. Allergy Asthma Proc. Mar 2010;31(2):141-146. 10. Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. Dec 2010;126(6 Suppl):S1-58. 11. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. Dec 2009;124(6):1549-1555. 12. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. Aug 6 1992;327(6):380-384. 13. Jarvinen KM. Food-induced anaphylaxis. Curr Opin Allergy Clin Immunol. Jun 2011;11(3):255-261. 14. Clark S, Espinola J, Rudders SA, Banerji A, Camargo CA, Jr. Frequency of US emergency department visits for food-related acute allergic reactions. The Journal of allergy and clinical immunology. Mar 2011;127(3):682-683. 15. Ford LS, Taylor SL, Pacenza R, Niemann LM, Lambrecht DM, Sicherer SH. Food allergen advisory labeling and product contamination with egg, milk, and peanut. J Allergy Clin Immunol. Aug 2010;126(2):384-385. 16. Avery NJ, King RM, Knight S, Hourihane JO. Assessment of quality of life in children with peanut allergy. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. Oct 2003;14(5):378-382.  17. Sampson HA. Anaphylaxis and emergency treatment. Pediatrics. Jun 2003;111(6 Pt 3):1601-1608.