Anaphylaxis in schools

What is anaphylaxis?

Anaphylaxis is the name given to a severe allergic reaction. Allergies to peanuts and tree nuts are the most common trigger for such reactions, but a number of other allergens can cause anaphylaxis, including egg, milk, fish, sesame, soya, penicillin, latex, kiwi fruit and insect stings. It can be life-threatening if it is not treated quickly with adrenaline. However, experts agree that it is very definitely manageable with precautionary procedures and support from school staff.

The number of children at risk of anaphylaxis is on the increase. One in 70 children in the UK is allergic to peanuts, and the number of those affected by other anaphylaxis-related allergens appears to be rising. Such children are not ill in the usual sense of the word, but otherwise healthy children who may become very unwell if they come into contact with a certain food or substance.

The symptoms can vary considerably. The milder reactions can involve itchiness or swelling in the mouth, an uncomfortable skin rash, sickness or nausea. Serious symptoms include a severe drop in blood pressure, in which the person affected becomes weak and debilitated, severe asthma, or swelling which causes the throat to close.

Other symptoms which may be present during anaphylaxis are:

flushing of the skin
hives
mounting fearfulness
difficulty in swallowing or speaking
changes in heart rate
stomach pain
collapse and unconsciousness.

Anaphylaxis is treated with adrenaline – also known as epinephrine. This is available on prescription in the form of pre-loaded adrenaline auto-injectors or ‘pens’, the most common being the EpiPen. In the event of a severe allergic reaction, the adrenaline should be injected into the muscle of the upper outer thigh, and an ambulance should be called. Milder reactions are sometimes treated with an antihistamine such as Piriton. In any case, careful vigilance should be maintained, as mild symptoms are often the sign that a serious reaction is imminent.

Supporting students at risk of severe allergic reactions

Drawing up individual health care plans

It is recognised that the risks for allergic children are reduced where an individual health care plan is in place. The plan should be drawn up and agreed between the child’s parents, the school and the consulting doctor. The plan should identify individual symptoms and triggers, day-to-day management, arrangements for medical emergencies, including support from school staff, type of prescribed medicine and its location(s), food management and precautionary measures. Contact details for family and GP/clinic should also be included. All care plans should be reviewed on a regular basis to ensure that that they are still relevant to the needs of the child. Model care plans for children at risk of anaphylaxis can be downloaded from the Anaphylaxis Campaign.

Access to Medication

As part of its overall medicines policy, the school needs to establish viable procedures for dealing with incidents of anaphylaxis quickly and effectively, in order to minimise harm and distress to the child concerned. Part of this protocol will relate to the storage of medicines for use in treating anaphylaxis. Given the imperative for speedy administration in an emergency situation, it would clearly be unacceptable to hold supplies of the child’s adrenaline in a locked cupboard some distance from the child’s classroom. Where children are old enough to be able to carry their adrenaline with them, access will be straightforward; however, there should always be a spare set held by the school in a place known to, and accessible by, all staff. Alternative arrangements will need to be made where the child is not thought to be able to look after their own medication; however, the DfE recommends that wherever the school might store adrenaline pens, they should not be locked away, in order to avoid precious time being lost in the event of an emergency.

Decisions as to the specific arrangements for any individual child at risk of a severe allergic reaction, including how many pens the school should store and their location(s), will result from discussions between the head teacher, the parents of the child concerned and the medical staff involved. When such details have been agreed they should be clearly stated in the child’s individual care plan, and made available to all staff.

The law allows schools in the UK to keep spare adrenaline auto-injectors (EpiPens) for emergency use. The Human Medicines Act was amended in 2017 to allow schools to buy these items from a pharmaceutical supplier, without prescription, for use in emergencies, where a child’s adrenaline pen isn’t readily accessible, is out-of-date, faulty or the child requires an additional dose following the administration of their own auto-injector. It is not compulsory for schools to hold a spare.

Administration of medicines

Another vital component of the school’s medicines policy will be that of key personnel involved in the administration of any medicines to students. It should be remembered that teachers’ conditions of service do not include any legal or contractual obligation to administer medicine or to supervise a pupil taking medicine. Contracts of employment for support staff may include such a role.

Teachers who do volunteer to administer medicines should not agree to do so without first receiving appropriate information and training. In cases of accident and emergency, teachers must, of course, always be prepared to help as they and other school staff in charge of pupils have their general legal duty of care to act as any reasonably prudent parent would. In such emergencies, however, teachers should do no more than is obviously necessary and appropriate to relieve extreme distress or prevent further and otherwise irreparable harm. Qualified medical treatment should be secured in emergencies at the earliest opportunity.

Any teacher volunteering to administer medicine to a child in the event of an emergency should be provided with comprehensive training from local health services. During such training, staff should have the opportunity to practise with trainer injection devices. Adrenaline pens are straightforward to use and very safe – it is not possible to give too large a dose, and the needle is not seen until after it has been withdrawn following the injection. In cases of doubt it is better to give the injection than to hold back.

Schools should ensure that their school medicines policy gives details of who is appropriately trained, and how they can be contacted. It is important that there is somebody available at all times with the training to administer such medication, as in such circumstances speed of response is of the essence. It is advisable to have several people trained in this way, to ensure that cover is available in the event of staff absence. This would be even more important in a large or split site school, where a trained member of staff would need to be able to intervene without precious minutes being lost in getting from one part of the school to another.

Checklist for responding to emergency situations

All schools must have a clear emergency procedure for cases of anaphylaxis, which should include arrangements for:

summoning an ambulance in an emergency
treating the child if necessary whilst waiting for the ambulance to arrive
where to find the adrenaline, ie in a known, accessible location and not locked away
who should administer the adrenaline and how they can be contacted swiftly in an emergency
who else must be contacted in an emergency.

These procedures should be agreed with the appropriate parties and clearly set out in the child’s individual care plan.

Remember that even if the child is only displaying mild symptoms, care should be taken to remain very vigilant as these signs might be the precursor to a more serious attack. The serious signs to watch out for can be summarised in the form of the following questions:

Is the child having marked difficulty in breathing or swallowing?
Does the child appear suddenly weak or debilitated?
Is there are steady deterioration?

If the answer to any of these questions is yes, adrenaline should be administered without delay and an ambulance must be called.

Other considerations

There are a number of day-to-day considerations which schools may need to address in supporting children at risk of severe allergic reactions.

Food and other potential allergens

Discussion with parents should inform the best approach for the individual child. While a school may be happy that they can provide safe lunches for the child concerned, it might well be that parents prefer the element of control they can retain in providing a packed lunch.

Where packed lunches are taken, it is important that children do not share food with one another in case the allergic child unwittingly eats something containing an allergen. The area should be clean, with spillages quickly attended to, and all children should wash their hands before and after eating.

The Anaphylaxis Campaign does not consider it good practice to segregate children at risk of anaphylaxis from their peers at mealtimes, as it could lead to stigmatisation of the child concerned. However, schools should try to be responsive to parents’ anxieties, for example, by seating children eating particular foods such as peanut butter away from a child with a severe nut allergy.

Similarly, prohibitions on specific foods such as ‘nut bans’ which have been introduced by some schools are not seen as the best way forward; allergic children should be able to develop an awareness of dealing with risks which prepares them for life outside the school environment.

Cookery lessons should be given careful thought, particularly with regard to the selection of ingredients and cleaning procedures.

Where children have an allergy to school pets, the level of risk should be discussed with parents and appropriate action taken where necessary.

School trips and visits

Allergic children should have the opportunity to fully participate in all aspects of school life. Where a school trip is proposed, the child’s needs should be fully incorporated into the planning process, and parents consulted to ensure they are happy with the arrangements. Clearly, at least one member of staff accompanying the party should be trained in administering adrenaline, and the location of any adrenaline pen(s) checked and confirmed prior to departure. The issue of food during the trip will also need to be addressed.

Sporting activities

Where an allergic child is involved in a fixture at another school, the PE teacher should be fully aware of the child’s condition. A member of staff trained in adrenaline administration must accompany the team and staff at the other school need to be appropriately briefed.

Checklist for NEU safety representatives

Check that your school has incorporated the treatment of anaphylaxis into its school medicines policy, and that sufficient staff are trained in administering adrenaline.
Ensure that school staff are fully aware of the identity of children at risk of severe allergic reactions, and are able to recognise symptoms of anaphylaxis. They should also know what action to take if a child exhibits a reaction, including the identity and whereabouts of staff trained to administer adrenaline and the procedure to be followed in the event of an emergency.
Comprehensive and regularly updated individual health care plans should be available for each child at risk of a severe allergic reaction within the school. Such plans should be easily accessible to staff, for example posted in the staff room. It is often helpful to affix a recent photograph of the child to the plan – especially in larger schools – to aid identification.
Check that the school has made appropriate provision in respect of the other considerations mentioned in this briefing, such as food issues and the implications for school trips and sporting activities.