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Anaphylaxis: Preventing and Managing Allergic Reactions

16/05/24
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In this article we discuss some of the issues and strategies in relation to managing the risk of anaphylaxis in students.


What Is Anaphylaxis?

Anaphylaxis is the most severe form of allergic reaction and occurs when a susceptible person is exposed to an allergen, such as food, an insect sting or medication. Reactions can occur within minutes of exposure and progress rapidly over a period of up to two hours. Anaphylaxis is life threatening and always requires an emergency response.

Studies show increasing cases of anaphylaxis attacks in Australia, with anaphylaxis presentations to emergency departments in public hospitals increasing by 51 per cent in the five years to 2020.

 

Bullying and Anaphylaxis

The ubiquitous nature of food allergies has significant effects on students’ social and mental development. This is exacerbated by incidents of bullying. Peers or other students who bully can exploit the student’s weakness, threatening them with the allergen to cause psychological and/or physical harm. In extreme cases, this type of bullying can be fatal. Medical anthropologist Theresa MacPhail writes of a 12-year-old student with a dairy allergy who had cheese dip rubbed in her face, a young adult recalling being shooed away from a lunch table with a peanut butter sandwich, and a 13-year-old student from London with a dairy allergy who died in 2017 after someone flicked cheese onto his neck, and was given an EpiPen® at school that was a year out of date.

“Allergy bullying is symptomatic of a larger cultural problem, which is that children with allergies are still too often treated as a class apart,” Bee Wilson at The Guardian asserts. The more students with allergies feel unaccepted in the school community, the more likely they are to engage in potentially life-threatening behaviour, such as failing to carry their EpiPen®.

 

What Is an Adrenaline Injector?

Adrenaline injectors (EpiPen® or Anapen®) contain a single fixed dose of adrenaline. They are used for the emergency treatment of anaphylaxis.

 

What are ASCIA Action Plans?

Australian Society of Clinical Immunology and Allergy (ASCIA) Action Plans detail how to identify and manage a student’s allergic reaction and must be completed by the student’s doctor or nurse practitioner.

There are various types of ASCIA Action Plans that may be assigned to individual students:

  • Action Plan for Anaphylaxis (red) – this plan is for students who have been prescribed an adrenaline injector.
  • Action Plan for Allergic Reactions (green) – this plan is for students with confirmed allergy but who have not been prescribed an adrenaline injector.
  • Action Plan for Drug (medication) Allergy (dark green) – this plan is for students with confirmed medication allergies.
  • ASCIA First Aid Plan for Anaphylaxis (orange) – this plan is stored with general use adrenaline injectors.

For students with a red or green ASCIA Action Plan, schools should complete an individualised anaphylaxis care plan in consultation with the student’s parents/carers that includes the student’s ASCIA Action Plan.

 

How to Prevent and Manage Anaphylaxis at School

In November 2023, the National Allergy Council launched the Best Practice Guidelines for anaphylaxis prevention and management in schools (Best Practice Guidelines), an evidence-based guideline document to help schools across all states and territories of Australia reduce the risk of anaphylaxis, focusing on students. Schools should also have systems in place to manage allergies in relation to staff, volunteers and visitors.

The Best Practice Guidelines break down seven recommendations for preventing and managing anaphylaxis in relation to students, and strategies for their implementation.

 

  Recommendations Implementation Guide
Allergy aware approach

Banning foods or claiming to be ‘nut free’ are ineffective strategies for preventing or managing anaphylaxis in schools. Instead, an ‘allergy aware’ approach is recommended. Banning certain foods, such as peanuts, is not only difficult to enforce in a school setting, but gives students, staff and families a false sense of security. Students can also be allergic to staple foods such as wheat, egg, or cow’s milk which cannot be removed from school environments. Banning one food, such as peanuts, does not protect students with non-peanut allergies.

It is fundamental that staff know which students are at risk of anaphylaxis, and which allergens need to be managed within the school. Schools can minimise the risks identified by implementing appropriate strategies. For example, the school could introduce some food restrictions (this is different to ‘banning’ a food) such as asking families of young students not to pack sticky nut spreads or messy egg sandwiches in lunch boxes.

 

Schools can also implement an allergy aware approach by informing all students about allergies and therefore how they can keep their friends safe. Students can be educated to not share food with one another and to wash their hands after they eat.

 

Staff can also implement procedures at meal and snack times, ensuring the supervision of children, and that children with allergies receive the right food.

Anaphylaxis management policy and plans

Schools should have a detailed, site-specific anaphylaxis management policy to help guide practice and ensure that everyone understands how the school plans to manage anaphylaxis. This policy needs to consider risk management plans, risk minimisation strategies, a communication plan, and emergency response plans. The anaphylaxis management policy should be reviewed and updated at least every two years. It should be site-specific to make sure it is appropriate for the individual school and setting. It is recommended that, like a fire drill, the emergency response plans are practised at least once a year.
Allergy documentation

Parents/carers of students with allergies should provide the school with the student’s ASCIA Action Plan, and provide an updated ASCIA Action Plan if there is a change in the student’s allergy.

 

Where necessary, schools should consult with the student’s parent/carer to complete an individualised anaphylaxis care plan, featuring suitable risk minimisation strategies to manage the student’s allergies.

As outlined above, there are different types of ASCIA Action Plans, however, students with allergies to dust mites, mould or grasses do not require an ASCIA Action Plan as these allergens do not trigger anaphylaxis.

 

ASCIA Action Plans do not expire. The date of review is a guide for students to see their doctor.
Emergency response

Schools must be prepared to respond appropriately to an anaphylaxis emergency, even for students not previously identified as being at risk of anaphylaxis. In an anaphylaxis emergency, the ASCIA Action Plan or ASCIA First Aid Plan should be followed. After an adrenaline injector has been administered, these ASCIA Plans direct school staff to call an ambulance to transport the student to a hospital for at least four hours of medical monitoring and must not allow the student to stand or walk while waiting for the ambulance to arrive, even if they appear well. For further information on anaphylaxis positioning, visit the National Allergy Council’s online resource.

 

A procedure should be in place within the school to regularly check (for example, once per term) the expiry date of adrenaline injectors, both general and prescribed. Dr Katie Frith at Sydney Children’s Hospital encourages her patients to hold onto expired adrenaline injectors, as the pandemic saw a national shortage of supplies. Dr Frith says “it is important that you have access to an in-date injector, but the adrenaline doesn't lose its potency completely, so it is good to have it as a backup.”

Adrenaline is the first line treatment for anaphylaxis; therefore, it is crucial the student receives adrenaline as quickly as possible. Students experiencing anaphylaxis are not expected to be fully responsible for self-administration of an adrenaline injector, instead, staff should follow ASCIA Action Plan procedures in an emergency.

 

If in doubt, ALWAYS administer the adrenaline injector FIRST, and then other medication (as outlined in the ASCIA Action Plan).

 

In Australia, EpiPen® and Anapen® are authorised adrenaline injectors. Schools should ensure that staff are trained in how to administer both devices, as the Anapen® was only introduced to Australia in September 2021.

 

Once a student’s adrenaline injector has been used, the student’s parents/carers must replace it as soon as possible. Additionally, if a general use adrenaline injector has been used, the school must replace it as soon as possible.
Staff training All staff (including casual, relief and part-time staff) should undertake anaphylaxis training at least every two years and refresher training at least twice a year. Training should be consistent with the recommendations outlined in the Best Practice Guidelines. Training can be taken in-person or online (see, for example, ASCIA anaphylaxis e-training for schools, which takes about one hour to complete, and has state-specific versions for Queensland, Victoria and Western Australia). ASCIA also offers refresher training, a free course which takes about 10 to 15 minutes to complete.
Community and student education

Schools should communicate with their school community about anaphylaxis management and the school’s current anaphylaxis management policies. Age-appropriate student education programs should also be implemented.

Medical anthropologist Theresa MacPhail states that “looking after children with food allergies is something that requires collective action,” therefore, it is important that schools regularly communicate with the school’s community. This can be done at the start of each year to remind parents that students with severe allergies attend the school. Communicating more than once each year is encouraged, such as through a notice in the school newsletter or in parent information sessions.

 

Educating students about the seriousness of food allergies may help prevent bullying and ensure that students can look out for the signs of an anaphylaxis emergency among their friends and know to alert staff if this occurs. Student education about food allergies can be incorporated into health classes and other class activities, such as story time for younger students.
Post-incident management and incident reporting

All allergic reactions (where there is risk of anaphylaxis) should be reported to the relevant organisation, typically the state or territory education department.

 

After an incident, schools should hold debriefing meetings to discuss the incident for emotional processing and to identify areas of improvements. Support (such as in the form of counselling) should be offered to affected students and staff.

 

Also, after an anaphylaxis incident, the student’s individualised anaphylaxis care plan should be reviewed and updated if required.

Australia does not have a nationally centralised system for collecting standardised anaphylaxis data, so data should instead be reported at a jurisdictional level. Allergy Aware’s incident reporting template for schools can be used by schools to identify potential risks and implement appropriate risk minimisation strategies.

 

If a packaged food or food provided by the school has caused an allergic reaction, it should be reported to state or territory’s health department, in accordance with Allergy and Anaphylaxis Australia’s Report a Reaction flowchart.

 

How to Prevent and Manage Anaphylaxis in Off-site Settings

Site-specific risk management plans and emergency response plans should be developed for off-site activities, such as excursions and school camps. Schools should also develop communication plans to alert parents/carers of students with allergies about the activities that the students will engage in and that may present a risk. When embarking on an excursion or school camp, the school must take to the off-site setting for each student with allergy:

  • adrenaline injectors (two are recommended)
  • the individual anaphylaxis care plan
  • the ASCIA Action Plan
  • a means of contacting emergency assistance e.g. a mobile phone if on a bushwalk.

When participating in day and overnight excursions and camps, all staff present must be aware if there is a student at risk of anaphylaxis, and a sufficient number of staff members on the excursion must be trained in preventing, recognising and treating anaphylaxis, including administering adrenaline injectors.

For day excursions, parents/carers of younger children may wish to accompany their child on excursions to help manage the prevention of anaphylaxis. Staff and students should be alert to consuming food on buses that may contain allergens.

When participating in school camps and overnight excursions, students with allergies’ ASCIA Action Plans should be provided to the campsite, with parental consent, at least three weeks before the camp. Any additional information relating to students with food allergies must be provided to the camp food service provider at least two weeks before the camp. It is crucial that the school, the parent/carer and the camp food service provider communicate about food provision prior to the camp to ensure that the student’s food allergies can be accommodated while on camp, especially for students with multiple allergies. Schools should provide parents/carers with the camp food service provider’s contact details to facilitate this liaising. Non-food allergies must also be considered, such as exposure to ticks on camp sites.

 

Additional Requirements for Victorian Schools

Schools in Victoria have a legal requirement to comply with Ministerial Order No. 706 Anaphylaxis Management in Victorian schools and school boarding premises (Ministerial Order No. 706) by having a policy and procedures in place for students at risk of anaphylaxis. Specific requirements of Ministerial Order No. 706 can be met by following these Anaphylaxis Guidelines. These guidelines recommend that the principal nominates at least one staff member as the Anaphylaxis Supervisor, who will undertake the appropriate training to be able to verify the correct use of adrenaline autoinjectors, lead the twice-yearly briefings on the school’s anaphylaxis management policy and brief all volunteers, casual relief staff and new staff on preventing and managing anaphylaxis.

Additionally, Victorian schools must develop individual anaphylaxis management plans for students with anaphylaxis. The Anaphylaxis Supervisor will work with the student, parents/carers and principal to develop, implement and review each individual anaphylaxis management plan. The Ministerial Order No. 706 also requires the principal to complete an annual Risk Management Checklist to monitor the school’s obligations.

 

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About the Author

Alice Knox

Alice Knox is a Content Services Assistant at Ideagen. She is currently a student at the University of Sydney.

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