1. Managing Severe Allergies within Schools
Introduce yourself and where you are from.
The aim of the training is to provide you with up to date information about managing severe allergies in schools. With particular emphasis on Allergen avoidance, Early recognition of symptoms and Crisis Management
You currently have …………… pupils in the school who are at risk of a severe allergic reaction, otherwise known as anaphylaxis, and later on we’ll talk specifically about their allergies, and how they can be managed.
To begin with though I’m going to run through what anaphylaxis is, symptoms, causes, treatments, everyday management and emergency procedures, and then we’re going to have a practical session with the trainer pens. If you have any questions please ask as we go along. (or if you prefer “please can you save any questions until the end”)
Please note the devices we will be practicing with do not contain adrenaline or have needles in them.

2. What is Anaphylaxis?
Anaphylaxis is a severe systemic allergic reaction.
At the extreme end of the allergic spectrum.
The whole body is affected usually within minutes of exposure to the allergen.
It can take seconds or several hours.
Read the slide and move on to next one.

3. Definition of Anaphylaxis
Anaphylaxis involves one or both of two features: -
Respiratory difficulty (swelling of the airway or asthma).
Hypotension (fainting, collapse or unconsciousness).
Allergic reactions can produce many unpleasant symptoms, but very few are likely to be described as anaphylaxis. This definition helps to explain the differences. (Ewan 1998)

4. What exactly is going on?
An anaphylaxis reaction is caused by the sudden release of chemical substances, including histamine, from cells in the blood and tissues where they are stored.
The release is triggered by the reaction between allergic antibodies (IgE) and the allergen.
Varying sensitivity with individuals
The patient would have been exposed to the allergen previously (that’s the thing they’re allergic to) and on that occasion the body wrongly perceived the allergen as a threat and started to make antibodies against it. So the next time the body is exposed, it over reacts and the symptoms we’ve just discussed occur.
For some people very small amounts can trigger a reaction.
This can be from – Eating,
Touching
Inhalation
The child or their parents will know how careful they have to be, so talk to them about how sensitive they are.

5. Common causes Peanuts Tree nuts Milk Egg Sesame Fish Shellfish Wasp
Bee
Latex
Penicillin
Blood products
Drugs
Kiwi
You may wish to talk in more detail about foods or substances which a child in the school is allergic to. Please use the information sheets at the back of the pack.
Anything which contains protein could cause an allergic reaction however most people react to a fairly small group of things. The most common causes are listed above.

6. What are the symptoms? Minor allergic reaction
Feeling hot / flushing
Itching
“Nettle sting-like” rash / welts / hives (urticaria)
Red, itchy watery eyes
Itchy, runny or congested nose or sneezing
Swelling: face, lips, eyes, hands
Tummy pain
Vomiting or diarrhoea
Metallic (funny) taste in the mouth

7. Action Minor allergic reaction
Stay with pupil and call for help
Send for emergency medication and emergency protocol
Give prescribed antihistamine medication
If asthmatic, give 4 – 10 puffs of reliever inhaler (blue)
Contact parent or carer

8. What are the symptoms? Severe anaphylactic reactions
Difficulty breathing, wheeze, breathlessness, chest tightness, persistent cough
Difficulty talking, change in voice, hoarseness
Swelling, tightness, itchiness of the throat
Swollen tongue
Impaired circulation – pale clammy skin, blue colour of lips and around mouth, decreased level of consciousness
Sense of impending doom
Becoming pale/floppy
Absent or very weak pulse
Collapse and unconsciousness
Often the first symptoms are swelling around the mouth and tongue. This can rapidly lead on to difficulty in swallowing of speaking.
Alterations in the heart rate, usually this means a very rapid perhaps thready pulse, which doesn’t settle with resting, but there can also be an irregular pulse rate.
Urticaria, sometimes known as hives or nettle rash developing anywhere on the body, there can also be a complete body flush when the patient can go pinky red all over.
Abdominal cramps and nausea, also diarrhoea and vomiting. This is a sign of another system of the body becoming affected. Though not potentially life threatening these symptoms may well be seen alongside some of the others.
Sudden feeling of weakness, or dizziness, this is caused by the blood pressure dropping, and it’s really important to get the patient laying down to preserve their blood pressure. You might also want to raise their legs onto a chair which can also help. (Pumphrey 2003) If you do lay them down, make sure that you turn their head to the side, this helps prevent aspiration if they vomit. If vomiting looks likely they should lay on their side.
Some patients report a sense of doom, they get a feeling that something terrible is about to happen.
Difficulty breathing which can be caused by severe asthma or throat swelling, and collapse and unconsciousness can follow.
You don’t have to tick these off before giving treatment or seeking help if several of these symptoms are present, get help immediately.

9. Action Severe anaphylactic reaction
If child’s airway is open and child is breathing:
Send for emergency medication and care plan
Administer EipPen and record time
Dial 999 and request paramedic ambulance
Keep child in lying down position unless breathing difficulties
If child has breathing difficulties then keep in sitting position
If no improvement in 5 minutes give 2nd epipen
Contact parents and continue observation until professional help arrives

12. Types of Reaction
Uni-phasic – rapidly developing severe reaction involving the airway or circulation.
Bi-phasic – early oral and abdominal symptoms, then a symptom-free period of 1-2 hours, then increasing symptoms involving breathing and circulation.
Uni-phasic meaning one phase, the reaction comes on rapidly but once treated the symptoms go away and don’t return. However a few people experience Bi-phasic reactions. Two phases. About 6% of children have a bi-phasic reaction. (Lees and Greenes 2000) There could be all the symptoms we’ve just discussed immediately and then a rest period when everything appears to have gone away, (this could be after using emergency treatment.) Then the symptoms come back after a couple of hours and they can be very serious.
Is for this reason that anyone who has an allergic reaction of this kind must go to hospital and they must be monitored for between 4-6 hours to ensure they’re not having a bi-phasic reaction.
It’s likely medical staff will give additional medication to prevent any recurrence whilst the patient is being monitored in hospital.
The patient or their family will also need to ensure that they have spare or replacement emergency medicine before leaving the hospital

13. Treatments Adrenaline is the mainstay of treatment:-
Reverses swelling.
Relieves asthma.
Constricts the blood vessels.
Stimulates the heartbeats.
A safe drug if given correctly
Antihistamines – useful for minor allergic reactions or if reaction coming on more slowly
Asthma inhalers
As these reactions come on so quickly there is often not enough time for antihistamine tablets or syrup to work. Antihistamines take at least 15 minutes to start working. An injection of adrenaline (otherwise known as Epinephrine) works within seconds. It reverses the swelling around the airway so that the child can breathe, and it relieves asthma symptoms too. The allergic reaction causes the blood vessels to leak fluid which causes the blood pressure to drop. The adrenaline constricts the blood vessels which helps to stabilise the blood pressure, and it stimulates the heart beats.
Adrenaline is a very safe drug if it is given correctly. It is a hormone normally produced by the body, but in a crisis the body can’t produce enough. When we hear stories of people dying from severe allergic reactions it is almost always because adrenaline wasn’t given or there was a delay in giving it.
Antihistamines may be useful if the reaction is coming on slowly, and asthma inhalers may also help.
Incidentally children with asthma as well as severe allergies are far more at risk of a severe reaction than allergic children who do not have asthma. (Sampson et al 1992)

14. Devices Epipen Auto injector: - Adult dose 0.3mgs Child dose 0.15mgs
2year shelf life
Can be given through light clothing
The child dose is suitable for children who weigh between 15kgs and 30kgs.(which is 4.73 stones) This means that by the time a child has reached 4 and a half stone they should be on the adult dose.
You may wish to demonstrate the trainer pen here.

15. Devices Anapen auto injector: - Adult dose 0.3mgs Child dose 0.15mgs
18 – 24 month shelf life
The trainer device is grey in colour
The real devices are bright yellow or bright green.

16. Devices Jext auto injector:- Adult dose 0.3mgs Child dose 0.15mgs
Shelf life of 24 months
Can be given through clothing (including denim)

17. Storage Accessible. Avoid extremes of temperature. Clearly labelled.
In date.
The auto injector devices should always be accessible, so never stored in a locked cupboard or room. All the staff should know where it is stored so that it can be collected quickly and taken to the child.
The devices are designed to be stored at room temperature. They are stable up to 40 degrees C. They’re not meant to be stored in the fridge, or in bright sunlight. If a child carries one in his rucksack this should not be left leaning against a radiator in the winter on left on a window sill in the summer.
They should be clearly labelled with the child’ name, and should be in date. They have a 2 year shelf life so this can be overlooked. I recommend that parents should check the devices termly to make sure they remain in date and that they have not changed in appearance. The Epipens are designed to be stored in the light sensitive container which helps to preserve them. Sometimes there can be several dates on the device. The expiry date is the date on the pen itself and not the one on the dispensers label.

18. Management in schools Allergen avoidance.
Early recognition of symptoms.
Crisis management.
Managing severe allergies in schools can be divided into 3 areas. Allergen avoidance, early recognition of symptoms and crisis management.

19. Allergen avoidance Know the child, and their allergies.
Be allergy aware and risk assess.
Special occasions.
School trips.
Cookery lessons, science experiments.
School pets, bird tables.
If you have a child in your care who has a severe allergy, please get to know the child. Find out what they’re allergic to and what things they need to avoid. These children and their families become experts at this so speak to the child or his parent. This will help you to make informed decisions and avoid unnecessary exposure to the child’s allergen. These children are usually very normal children except for their allergy, so it’s important that they join in as many activities as possible Schools should carry out a risk assessment around location and activities the child is involved in, particularly trips away, cookery and science experiments and mealtimes.
Allergy awareness - Allergens can turn up unexpectedly. For example. Trees in the school grounds with walnuts on. Cereal cartons which contained crunchy nut cornflakes.
Special occasions like Christmas are often more risky times because different foods may be brought into school.
School trips can be hazardous when the child is being taken out of the normal environment. Again talk to the parents about this to help identify any risks and conduct a risk assessment.
Cookery lessons and science experiments may be hazardous so plan ahead and talk to the pupil or parents well in advance. It’s also a good idea to avoid using home economics rooms as form rooms for food allergic pupils.
Does the school have a bird table or a furry pet? Birds are often fed on peanuts or nut feeders. ..and small furry animals are often fed on nut and seed based foods
See Questions and Answers pages and factsheets at the back of the pack for further ideas on avoiding allergens in schools.

20. Crisis Management Alleviating fear Indemnity insurance.
Individual protocols.
There can be a lot of fear about managing this condition.
Children may be frightened because they know how serious it could be.
Parent’s because they worry about someone else caring for the child, and whether they will spot the early signs and act quickly, and school staff may well be nervous about whether they will be able to spot early signs too. Many people are worried about giving someone an injection.
Hopefully this training will allay any fears you have, but please asked if you have any particular concerns or questions.
Indemnity insurance- Most LEA’s are happy to indemnify staff to give emergency tretment as long as the staff have received regular high quality training. This should be provided at least annually.
Each child should have an individual protocol about how to manage their allergy.
This should be developed and agreed by the child’s doctor, the parents and the school, and is designed to make management clear and simple.There is also a lower risk of repeated reactions when a protocol or management plan is used. (Ewan & Clark 2005)
*(Look at specific protocols for children in the school)

21. Who’s responsible for what?
Written consent.
Provide school with full information.
Ensure medicine is in date.
Written consent? - It’s the schools responsibility to ensure that written consent has been obtained from the parents to administer emergency treatment should it be needed. (Managing Medicines in Schools,2005 DoH/DfSE)
Full information - sounds obvious, but the parents have a responsibility to ensure that the school have been given full information about their child’s condition. There have been cases of parents not informing the school of their child’s allergies, instead the child carries an Epipen in their rucksack in secret.
The parents also have a responsibility to ensure that any medication is in date. We recommend that parents should check the medication at least once each term.

22. A few things to think about!
“ Will a supply teacher know who I am?”
Kissing can seriously damage your health!
Other training needs? e.g. Breakfast and after school clubs, school discos, sports clubs. School visitors, bus drivers/escorts. Mid-day supervisors, catering staff.
Many children worry that supply teachers will not know who they are and will not know what to do.
If you have regular supply teachers it’s worth asking them to attend your annual training sessions, if not then you should consider how you can ensure that they’ll know which child has severe allergies and what to do.
Kissing! This can be a huge issue for allergic teenagers. Suddenly instead of just considering what they are eating the allergic teenager needs to consider what their boyfriend or girlfriend is eating too. There have been a number of nasty reactions after kissing.
It may be appropriate to mention here that Alcohol and drug taking can speed up a reaction and lower inhibitions, they may also impair judgement in realising that they are having an allergic reaction.
And consider the other training needs within the school. If the allergic children are attending these other clubs or groups then those staff also need training.

23. Want more information? Contact the Anaphylaxis Campaign
Tel:
Schools pack
Video/DVD
Managing Medicines in Schools and Early Years Settings. DH/DfES.
If you would like more information, this can be obtained by contacting the Anaphylaxis Campaign by phone or on their 2 websites. They can also provide additional information about managing allergies in schools, and have an excellent video/DVD which can also be helpful for training purposes.
There is also a new document published in March 2005 by the Department of Health and the Department of Skills and Education called ‘Managing Medicines in Schools and Early Years Setting’. It has a section all about severe allergies and is worth reading.