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Anaphylaxis

Limestone Learning Foundation
Health Issues Handbook - Anaphylaxis

This handbook is an official guideline issued under:

Administrative Procedure 140: Safe Environments

Table of Contents

Awareness

Anaphylaxis - sometimes called “allergic shock” or “generalized allergic reaction” - is a term that describes acute, life threatening, severe allergic reaction to a food, drug or other substance (i.e. bee venom) that if untreated, can lead rapidly to death. The most common allergies are peanut, nut, milk, egg, soya, fish, shellfish, sesame seeds, mustard seeds,latex, medications, exercise and idiopathic allergies (from other unknown sources) are possible too. Anaphylaxis occurs when the body's immune system reacts to harmless substances as though they were harmful invaders. It is an explosive overreaction of the body's defense system to a foreign matter. However, instead of developing the familiar runny nose or rash, sufferers of anaphylaxis respond with an extreme body reaction, characterized by swelling, severe breathing trouble, sometimes cramps, vomiting and diarrhea, and ultimately circulatory collapse. The reaction may begin with itching, hives, swelling of the lips, eyes or face, possibly including vomiting and diarrhea; within moments, the throat may begin to close, choking off breathing, followed by circulatory collapse, unconsciousness and death. Therefore, there is a need for prompt administration of epinephrine at the onset of the reaction.

What An Anaphylactic Reaction Looks Like
An anaphylactic reaction can begin within seconds of exposure or after several hours. Any combination of the following symptoms may signal the onset of a reaction:
  • Intense sense of impending doom
  • Overwhelming panic
  • Hives, swelling, blotchy redness
  • Itching of eyes, lips and/or tongue (or any part of the body)
  • Swelling (of any body parts, especially eyes, lips, face, tongue, hands)
  • Change of voice
  • Red watery eyes
  • Runny nose or nasal stuffiness
  • Stomach ache or cramps
  • Coughing
  • Wheezing
  • Throat tightness or closing
  • Difficulty swallowing
  • Vomiting or nausea, diarrhea
  • Difficulty breathing
  • Rapid, weak pulse
  • Change of colour, paleness, sweatiness
  • Weakness
  • Dizziness
  • Sudden unsteadiness, fainting, loss of consciousness
  • Irregular or laboured breathing or breathing stops
*Many of these symptoms can result from conditions other than anaphylaxis, but in a person at risk of anaphylaxis, they should not be ignored.

Symptoms may vary with each individual, depending upon the specific food and quantity ingested, and may be only one or any combination of the symptoms above. Time from onset of first symptoms to death can be in as little as a few minutes, if the reaction is not treated immediately. Even when symptoms have subsided after initial treatment, they can return within eight to forty-eight hours after the first exposure.

Management and Prevention

Avoidance of a specific allergen is the cornerstone of management in preventing anaphylaxis. To do so, planning and education are the keys to successful management of life-threatening allergies.

The goal of the board’s administrative procedures is to provide a safe environment for children with life-threatening allergies, but it is not possible to reduce the risk to zero. However, a list of suggestions Practical Strategies for Avoidance: Minimizing the Risk at School (p. 26) will allow the anaphylactic child to attend school with relative confidence. Policies and procedures need to be flexible enough to allow schools and classrooms to adapt to the needs of individual children and the allergens which trigger reactions, as well as the organizational and physical environments in different schools. It should also be noted that precautions may vary depending on the properties of the allergen. It is impractical to achieve complete avoidance of all allergenic foods, as there can be many hidden or accidentally introduced sources. However it is definitely possible to reduce children’s exposure to allergenic foods within the school setting.

All of the following recommendations should be considered in the context of the anaphylactic child’s age and maturity. As children mature, they should be expected to take increasing personal responsibility for avoidance of their specific allergens. This being said, an anaphylactic individual at any age, should never be expected to self-inject. Innovative ways to minimize the risk of exposure without depriving the anaphylactic child of normal peer interactions or placing unreasonable restrictions on the activities of other children in the school may be found. Please see Practical Strategies for Avoidance: Minimizing the Risk at School.

Ensuring the safety of anaphylactic children in a school setting depends on the co-operation of the entire school community. To minimize risk of exposure, and to ensure a rapid response to an emergency, parents, students and school personnel must all understand and fulfill their responsibilities.

Responsibilities

A) Responsibilities of the Limestone District School Board
The Limestone District School Board has developed Administrative Procedure 315: The Safety of Anaphylactic Students to comply with Bill 3: Sabrina's Law, Ontario January 2006. HR - Academic and HR- Support Staff will ensure that appropriate training for occasional staff has been completed.

B) Responsibilities of Tri-Board Transportation
With the cooperation of the school principal or designate, Tri-Board Transportation Services will communicate with its contracting companies and DSB owned busses that an anaphylactic student is on the bus. Tri-Board Transportation Services will be responsible for the training of the personnel under their supervision. Bus drivers must be provided with the student's Emergency Medical Alert Form (from the school).

C) Responsibilities of the Parents of an Anaphylactic Child
The parent(s)/guardian(s) of the allergic student shall inform the school of their child's allergies and comply with the Limestone District School Board Administrative Procedures - AP 210 Safe Environments, AP-314 The Administration of Medication and/or Medical Procedures to Students, and AP 315 The Safety of Anaphylactic Students by providing the school, (before the child's first day of attendance), with the following:

Required:
  • A completed and signed by physician, Authorization and Request for Administration of Prescribed Medication/Medical Procedures (LDSB - AP Form 314-A1).
  • A completed and signed by parent, Authorization and Request Form for the Administration of Prescribed Medication (LDSB - AP Form 314-A2).
  • A completed and signed by parent, The Administration of Medication and/or Medical Procedures to Students (LDSB - AP Form 314-B1).
  • Photos of the student for Emergency Medical Alert Form, (LDSB - AP 314-D3)
  • (The above information and documentation will assist the school in developing an Emergency Medical Alert Form for your child.)
  • Epinephrine, and/or any other required medication plus a second/backup dose of epinephrine to be available in case of locational or functional problems and/or expiration. Medic Alert identification (e.g. bracelet, necklace, watch) for their child, to be worn at all times.
  • Up to date emergency contact information and telephone numbers. This will assist in reviewing and updating the school emergency plan as needed.
Strongly Recommended:
  • Provide support to the school and teachers as requested.
  • Provide information about anaphylaxis ie symptoms of past reactions, and avoidance strategies for student safety.
  • Assist in school communication plans.
  • Attempt to attend all out-of-school field trips with the anaphylactic child if possible, or provide a knowledgeable adult friend or relative to do so.
  • Be willing to provide "safe" foods or alternative foods for special occasions.
  • Welcome other parents' calls with questions about safe foods.
    • Teach their child:
- to recognize the first symptoms of an anaphylactic reaction, and to stop and alert a trusted individual, whether sure or unsure a reaction is occurring;
- to communicate clearly when he or she feels a reaction starting, or is concerned it could be starting ie "I am ..." "I think I am ... " ;
- to know where medication is kept, and who can get it, as well as give it (medication may be carried in a fanny-pack, pocket, backpack, or commercially available belt for carrying epinephrine)
- not to share snacks, lunches or drinks, and understand that the "air space" over their food should be free from other food and drinks;
- to understand the importance of hand-washing/cleaning, before and after meals (especially during off site trips etc. -consider hand washing/cleaning or carry hand wipes NB: Sanitary gel is not effective);
- to take as much responsibility as possible for his/her own safety.

D) Responsibilities of the School Principal
Required:
  • Ensure that upon registration all parents/guardians and/or pupils be asked to supply information on life-threatening allergies School Registration Form
  • Ensure that a School Emergency Response Plan (AP 140-A), Medical Safety Plan and an Emergency Medical Alert Form (AP 314-D3)for each anaphylactic student be developed which outlines the sequence of actions that should occur subsequent to an emergency situation on Board property.
  • Ensure all required forms from Limestone District School Board Administrative Procedures 140, 210, 314 and 315 are completed and filed in the student's OSR.
  • Develop and maintain an ORANGE file for each anaphylactic student in the main office visible and accessible to all. It must include the School Emergency Response Plan(AP 140-A), the Medical Safety Plan and the Emergency Medical Alert Form (AP 314-D3 with the student's photo) and Epi-pen. A 911 script could be included as well. NOTE: All emergency contact information must be kept up to date by the parent(s)/guardian(s).
  • Ensure a copy of the Emergency Medical Alert Form (AP 314-D3) is posted in the office(s), staff rooms(s), and other strategic area(s) in the school and is provided to the classroom teacher(s), bus driver(s), and others as per the Distribution List on the bottom of the form.
  • Store auto-injectors, labelled with the student's name, in safe, unlocked and easily accessible locations (ref: ORANGE file) known to all staff even if child carries it on their person (i.e. fanny pack).
  • Check, on a regular basis, that expiration dates are valid on auto-injector kits or other stored medication.
  • Establish safe procedures to reduce risk and avoid anaphylaxis in classrooms, common areas, cafeterias, field trips, sports events and other extra-curricular activities, including snack and lunch periods. See Practical Strategies for Avoidance: Minimizing the Risk at School.
  • Ensure all teachers and school staff including office staff, educational assistants, custodians, bus drivers, yard duty supervisors and cafeteria staff receive Anaphylaxis Training (Awareness, Avoidance and Action) including the use of an auto-injector. Training may be provided by Public Health or included in First Aid Certification Courses. See www.eworkshop.on.ca/allergies for more information.
  • Principals shall forward a copy of the Sabrina's Law Training Confirmation (AP 315-A & -B) for both academic and support staff to the appropriate superintendent by September 30 of each school year.
  • Implement an emergency drill taught and practice by the principal, teachers, school staff, volunteers and appropriate parents, regarding the correct procedures to be followed in the event of an emergency. The risk of death has been shown to be greater when such a system is not in place. This is no different from fire drills. Lives are at stake.
  • Ensure that all occasional staff - teacher, EA, office staff, custodian, bus driver and any other staff who would be part of the student's Emergency Response Team are informed of the presence of an anaphylactic child, and have been adequately trained to deal with an emergency.
  • A Principal Checklist for the above tasks is available as AP 315- C
Strongly Recommended:
  • Work as closely as possible with the parents of an anaphylactic child.
  • Notify the school community of the anaphylactic child, the allergens, ways to help protect and the treatment. The principal shall ensure that all student contacts are aware of a particular student's allergy by sending a Letter of Awareness to other parents.
  • Take precautions when housing a class with an anaphylactic child in a portable that may not be equipped with running water necessary for washing/cleaning hands and desks.
E) Responsibilities of the Anaphylactic Student's Teachers
Required:
  • Understand the 3 A's (Awareness, Avoidance and Action) and receive annual Anaphylaxis Training.
  • Review all emergency procedures and be sure the teacher can recognize symptoms and knows when and how to administer medications.
  • Keep information about the anaphylactic student in an organized, prominent and accessible format so an occasional teacher(s) will be immediately aware of it.
  • Share info with other teachers (such as art, music, physed or drama) so they know who the student is and what safeguards are necessary.
  • Follow the school procedures for increasing awareness and reducing risk for anaphylaxis in classrooms and common areas. Consider times when food and drinks (including all classroom activities, special events, crafts, science projects, cooking etc.) are available in the classroom. Consider Avoidance when planning for fund raising and celebrations. Include in Medical Safety Plan.
  • Examine all classroom activities, events and trips, crafts, science projects, cooking, etc. for possible allergens, food or otherwise, and replace with alternatives.
  • Discuss the Emergency Response Plan (AP 140-A) for any off-site activity (eg. field trips, sports events) with the parent(s)/guardian(s) and the student to ensure that avoidance strategies and action plans are in place. Epinephrine MUST be taken. ( Check for 911 availability, distance away from closest hospital, does cell phone work ? and who has one ? emergency vehicle, wet wipes and ensure supervision with meals and set up check-in times)
  • Support preventative measures for the anaphylactic student such as: He/she eats and/or drinks only what he/she brings from home and follows the rule, “NO EPINEPHRINE, NO FOOD, NO BEVERAGE.”
Strongly Recommended:
  • Use the parent's expertise in food allergies.
  • Facilitate communication with other parents.
  • Discuss anaphylaxis with the class, in age-appropriate terms.
  • Encourage and reinforce washing/cleaning of hands before and after meals. This will not only help avoid cross-contamination from snacks or other class foods, but it will also help reduce the spread of germs.
  • Examine seating arrangement for anaphylactic student, so that his/her desk is kept clean from food allergens. Seat away from garbage and food storage areas. Washing common tables after meals may be necessary, starting with a clean cloth or paper towel.
  • Discourage students from sharing lunches,trading snacks and cross-contaminating "safe" meals and drinks (ie unsafe food in student's air space or flicking food items).
F) Responsibilities of Anaphylactic Students
  • Take as much responsibility as possible for avoiding allergens. As age appropriate, teach friends how they can help and to recognize symptoms and what to do in an emergency.
  • Eat only food and drinks brought from home.
  • Take responsibility for checking labels and monitoring intake (older students).
  • Wash/clean hands before and after eating.
  • Learn to recognize symptoms of an anaphylactic reaction and promptly inform an adult, as soon as an accidental exposure occurs or symptoms appear.
  • Know where their medication is kept at all times and know where epi-pens are located in the school. Wear an Epi-pen as age appropriate.
  • Know how to use their auto-injector.
  • Live by the rule – “NO EPINEPHRINE, NO FOOD, NO BEVERAGE” Share your situation with close friends
  • Wear Medic-alert identification
G) Responsibilities of All Students
  • Learn to recognize symptoms of anaphylactic reaction, the importance of seeking help immediately, and how they can help keep their friend safe.
  • Avoid sharing food, especially with anaphylactic children.
  • Follow school procedures about keeping allergens out of the classroom and washing/cleaning hands. No food or beverages on the playground, on the buses or in common areas.
H) Responsibilities of Public Health/Unit Staff
  • Upon request, consult with and provide information to parents, students and school personnel.
  • Participate in planning the school response to an emergency.
  • Provide in-service and auto-injector training for school staff as time permits.
  • Provide resources (e.g. video and fact sheets) for teachers to use.

Emergency Treatment

Emergency Treatment - Anaphylaxis A.C.T. (Administer, Call, Transport)

A

Administer epinephrine (i.e. EpiPen®, Twin-Ject) at the first indication of a reaction. Lay individual down and elevate feet.

To Inoculate:
1.
Remove EpiPen from case.
2.
Pull off BLUE safety cap.
3.
Anchor child's leg firmly to avoid pulling away and disengaging needle from child's thigh, to ensure injecting the child's thigh.
4.
Firmly push down on OUTER MID THIGH of child's leg with the orange tip end of the needle until click is heard.
5.
Continue to hold child's leg firmly to avoid disengagement of needle.
6.
Wait for drug (fluid) to enter body for 10 seconds. (Count one-one thousand, two-one thousand etc.)
7.
Massage area for 10 seconds.

Ensure second EpiPen is on hand in the event a second dose is required.
9.
If symptoms do not improve or if symptoms reoccur, administer a second Epinephrine after an approximate duration of 5-10 minutes or sooner. “Signs that the reaction is not under control are that the patient's breathing becomes more laboured or there is a decreased level of consciousness.” Anaphylaxis in Schools & Other Settings p. 10 # 4 (This Handbook was distributed to every school Principal by the Ontario Ministry of Education, February 8, 2006)

Also:

• If food or drink is suspect, rinse out the mouth.
• If inhaled reliever medication is available, give it.
• Keep individual lying down on his/her back with feet elevated until emergency help arrives - do not allow the individual to sit up.
Note:

• Epinephrine must be administered promptly at the first warning symptoms, such as itching or swelling of the lips or mouth, tightening of the throat or nausea, sudden breathing difficulty (mouth drawn downwards in corners) and before respiratory distress, stridor or wheezing occur.
• Although epinephrine devices are designed for self-injection, it is dangerous to assume that any person, of any age, will be able to self-inject if the reaction is proceeding rapidly.
• In other words, if there is any reason to suspect an anaphylactic reaction is taking place, and if epinephrine has been prescribed as the treatment protocol, care givers should not hesitate to administer the medication.

C

Call 911 or local emergency number.
Advise dispatcher that a child is having an anaphylactic reaction.

• Ask for an ambulance and ETA (estimated time of arrival). Identify yourself, give the child's name. IF the ETA is too long and you are going to meet the ambulance enroute, give the name of the hospital that you are on your way to.

• Indicate child's doctor's name. Give used auto-injector to ambulance personnel.

• If school is in a rural area, or ambulatory service advises you that the ambulance is too far away, plan to meet ambulance enroute. Give description of transport vehicle, make, colour, licence, driver's name, and route to the hospital. Take along additional Epinephrine. See Driving Crew*

• Indicate whether the driver does have or does not have Epinephrine with them.

• Tell them you will have four way flashers and headlights on and will honk horn upon sighting ambulance.

T

Transport the child to hospital by ambulance, or transport the child and meet the ambulance enroute to the hospital, or transport the child directly to hospital immediately. Go to the hospital even if symptoms subside. Take along additional Epinephrine.


• If transporting child directly to the hospital or meeting ambulance en route, a minimum of two adults are required (driver and child first-aider).

• Administer additional dosages of epinephrine every 5-10 minutes or sooner as required en route if symptoms do not improve or if symptoms reoccur. See Part A of this section # 8

 

About Epinephrine

Despite best avoidance efforts, accidents can and do happen. Treatment protocols, including the use of an epinephrine auto-injector must be provided by a physician. All persons at risk of anaphylaxis and their relatives, caregivers, and school personnel must be prepared to respond in
emergency situations. Accidents are seldom predictable. Being prepared for the unexpected is always necessary.

Epinephrine - also known as synthetic adrenaline - is the drug form of a hormone that the body produces naturally. Epinephrine is the only treatment or drug or choice to treat anaphylaxis and as a result is widely prescribed for those at risk of anaphylaxis. All efforts should be directed toward its immediate use. Epinephrine is not a guarantee in halting a reaction; avoidance is always the key to managing anaphylaxis. Individuals at risk of anaphylaxis are instructed to carry it with them at all times when age appropriate.

Sometimes people who have severe allergies also have asthma. Epinephrine can be used to treat potentially life-threatening allergic reactions and severe asthma attacks.

Epinephrine helps to reverse symptoms of an allergic reaction by opening the airways, improving blood pressure and accelerating heart rate. There are currently two epinephrine auto-injectors available in North America: EpiPen and Twinjet. Both products come in two dosages or strengths - 0.15 mg and 0.3 mg - which are prescribed based on weight.

"Individuals at risk of anaphylaxis will not always have predictable symptoms during an allergic reaction. Reports have shown that warning signs are not always present before serious reactions occur. P. 9 Emergency Protocol - About Epinephrine Anaphylaxis in Schools & Other Settings,
CSACI 2005 Recognizing potential symptoms is vital.

Principals must ensure that all staff, entrusted with the care of students have received Anaphylaxis Training including the use of an auto-injector device. Procedures for awareness, avoidance and action i.e. treating anaphylaxis need to be in place and understood. In addition at least 2 staff members or 20% of staff (whichever is greater) and all members of the emergency response team must be trained as First Responders in basic first aid and resusitative techniques. See AP-140, Safe Environments.

How to Use Epinephrine (Epi-Pen)

Information about the use of Epinephrine

Epinephrine may be supplied as an

a) EpiPen®
b) EpiPen Jr.®
c) TwinJect
d) TwinJect Jr.

Expiration dates need to be checked regularly. Auto-injectors should be stored at 25*C (77*F). (On a field trips the permitted range is 15* to 30*C ( 59*F to 86*F))

A Junior EpiPen® with .15 mg of epinephrine, should be provided if the student weighs 15 - 30 kg (33 - 66 lbs), to ensure the proper dosage is administered. The student’s weight is be recorded on the Emergency Medical Alert Form. (AP-314-F-D3) An adult EpiPen with .3 mg of epinephrine should be provided if the student weighs 30 kg (66 lbs) or more.

The following is a synopsis of the training that would be provided to staff in First Aid Certification. This section is not meant to replace the training sessions.

When injecting an auto-injector, ensure the proper end is placed on the thigh. Many incidents were reported where thumbs were accidentally injected rather than the anaphylactic individual. Arrows pointing toward the tip of the auto-injector have been added right next to the instructions that read, “Place tip against outer thigh. This will assist new users in properly administering the auto-injector.

When injecting, remember to hold the auto-injector against the body for a full ten seconds, to allow complete dissemination of the medication. The anaphylactic student's leg may have to be held firmly to avoid disengaging him/her from the auto-injector. It is normal to see some liquid left in the used auto-injector. The statement “1.7 ml. of liquid will remain after activation” was added to avoid confusion. The complete dose of epinephrine will have been injected if it was held in place for ten seconds. Massage the area for 10 seconds after injection.

It is not uncommon for individuals to be fearful of using the auto-injector the first time, if up until then they have only practised with the trainer. There is confusion from first time auto-injector users about not hearing the “click” on the real auto-injector, as one hears when using the trainer.

The actual auto-injector does not have a “click” but one can feel the device activate. On Epi-Pens an orange sheath surrounds an exposed needle. On TwinJects, the exposed needle will need to be bent backwards on a hard surface if the second dose is needed.


It is recommended that the used auto-injector be disposed of at your local Health Unit, at your own pharmacy, or at the Hazardous Waste Depot, rather than a trash container at home or school. It may be helpful to take it to the Hospital Emergency Room to show what was given.

ALL individuals receiving emergency epinephrine must be transported to hospital immediately. Further treatments may be required and therefore observation in a hospital setting is necessary.

Additional epinephrine must be available during transport and may be administered after 10 to 15 minutes, should symptoms not subside or in fact, reoccur.
About Auto-Injectors

An auto-injector administers epinephrine (also known as synthetic adrenaline)—the medication recognized by healthcare professionals as the only treatment of choice for severe allergic reactions.

Auto-injectors are simple and ready to use.
The labels on EpiPen and TwinJect Auto-Injectors provide quick, simple directions. The carrying case provides built-in protection to promote safety. Epinephrine has been used to treat severe allergic emergencies for over 30 years.

People can reduce the risks associated with a severe allergic emergency by:

  • Carrying an auto-injector at all times
  • Use auto-injector at the earliest sign of a reaction
Make sure you are prepared wherever you go by having an auto-injector in all key locations, including:

  • Home (on every floor)
  • Work (office and briefcase)
  • School and/or day care (backpack, classroom and school office)
  • Gym class
  • In transit (purse, briefcase, and luggage)
Are there different doses of EpiPen?
Yes. There are 2 dosage strengths: EpiPen (0.3 mg) and EpiPen Jr. (0.15 mg). EpiPen should be used for adults and children weighing 30 kg or more. EpiPen Jr. should be used for children weighing 15 kg to 30 kg.
How do I use EpiPen and EpiPen Jr. Auto-Injectors?
EpiPen can be administered in 2 simple steps:
epipen
Step 1

Remove the yellow or green cap from the storage tube

Grasp the Auto-Injector with the black tip pointing down

Pull off the grey safety cap
epipen
Step 2

Place black tip against mid-outer thigh and press firmly until the Auto-Injector activates.

Hold while counting for several seconds, then remove.

Massage the injected area for 10 seconds
Seek medical attention immediately.
Either call 911 or have someone take you to the emergency room.

What should I do after I use EpiPen?
Carefully place any used Auto-Injectors, needle first, back into the storage tubes. Screw the caps back on the storage tubes tightly.
It is important that you call 911 or have someone take you to the emergency room because the effects of epinephrine can wear off and there is a chance of a second reaction. You should also stay within close proximity to a hospital or where you can easily call 911 for the next 48 hours.
Give any used Auto-Injectors in their storage tubes to emergency responders or emergency room personnel.
You should also try to stay warm and avoid unnecessary movement.
Twinject Auto-Injector
STEP 1 - MAKE SURE THAT THE MEDICINE IS READY

Look at TwinjectTM 0.3 mg or TwinjectTM 0.15 mg regularly. It may not work if medicine looks cloudy (has particles), pinkish, or more than slightly yellow, or if the expiration date has passed.

In the event of a life-threatening allergic reaction, you should use an out of date product, if that is all you have.

Do NOT remove the GREEN or the RED cap until you are ready to use.
STEP 2 - FIRST DOSE
1.
PULL of Green end Cap to see a GREY cap
Never put thumb, finger, or hand over the GREY cap.
first dose
first dose
2.
PULL off RED end cap.
3.
Place GREY cap against mid-thigh (can go through clothes).
4.
Press down fromly until auto-injector activates - hold while slowly counting to ten.
5.
Remove auto-injector and check the GREY cap; it needle is exposed, you received the dose. If not, repeat #3 and #4 under step 2. Prepare for second dose.

Get emergency medical help right away
STEP 3 - PREPARE FOR A SECOND DOSE
1.
Unscrew and remove GREY cap. Beware of exposed needle.
needle
second dose
2.
Holding BLUE hub at needle base, remove syringe from barrel.
3.
Slide YELLOW (Twinject 0.3 mg) or ORANGE (Twinject 0.15 mg) collar off plunger.
4.
PAUSE HERE. If symptoms have not improved in approximately 10 minutes since first injection, proceed with Step 4.
STEP 4 - INJECT SECOND DOSE
1.
Insert needle into mid-thigh.
inject second dose
2.
Push plunger down completely.
Get emergency medical help right away.
SYRINGE DISPOSAL
Re-insert syringe, needle first, into blue case. Return it to your physician or pharmacist for proper disposal. Do not throw away in trash.

Source: Twinject, autoinjector, epinephrine inhection (USP1:1000), www.twinject.ca

Sources of Available Information

Educational material is available from several associations:

Limestone District School Board

Limestone District School Board Administrative Procedures Manual
"Anaphylaxis at a Glance"
“Anaphylaxis - The Bigger Picture, You have an Anaphylactic Child in Your School or Classroom.”
Health Issues Handbook Revised January 2011.

Anaphlyaxis in Schools & Other Settings

This resource kit was distributed to all schools in Ontario by the Ministry of Education in February 2006. It contains a handbook, Anaphylaxis in Schools & Other Settings, posters and training pens. The handbook provides educators with the Consensus Statement from the Canadian Society of allery and Clinical Immunology. Concise information about Awareness (Understanding Anaphylaxis), Avoidance (Avoidance Stategies), and Action (General Recommendations, Training and Communication) are of importance to school administrators as are the Appendices.

Anaphylaxis Canada www.anaphylaxis.com (866) 785-5660

Anaphylaxis Canada provides information specifically on anaphylaxis. They provide a newsletter with membership, support research and offer various products, videos, books, allergy awareness posters for schools, allergy information cards, etc.

The Allergy/Asthma Information Association. www.aaia.ca Ontario (888) 250-2298 Canada (800) 611 7011

AAIA provides information on allergies, asthma and anaphylaxis. Trained community volunteers, a help-line and many useful tools and products (quarterly newsletter with membership, videos and books) are available. Anaphylaxisis and Asthma Reference Kits are available for training purposes ( 32 pages of information, 18 pages of overheads, an EpiPen trainer and poster)

The Food Allergy Network in Fairfax, Virginia. www.foodallergy.org (800) 929-4040

FAN provides newsletters and various products.

KFL&A Public Health, Kingston, Ontario http://www.kflapublichealth.ca/ (613) 549-1232 ext. 102

Offers anaphylaxis and Anaphylaxis and EpiPen® training for teachers as well as resources (e.g. videos) for students.

The Lung Association in Kingston, Ontario (613) 545-3462

Canadian Medic-Alert Foundation www.medicalert.ca (416) 696-0267 or (800) 668-1507

Ontario Physical and Health Education Research www.ophea.net

An excellent article called "How Sabrina's Law applied to Outdoor Education and Field Trips OE & FT is attached (page 257)

Allergic Living Magazine
(888) 771-7747 www.allergicliving.com
-insert pamphlet "Food Allergy"

Practical Strategies for Avoidance

Avoidance is the cornerstone of preventing an allergic reaction. Much can be done to reduce the risk when avoidance strategies are developed. General recommendations for food allergens and insect stings as well as additional strategies for avoiding specific food allergens are provided below.

Food Allergens

For food-allergic individuals, the key to remaining safe is avoidance of the food allergen. It must be stressed that very small or minute amounts of certain foods can cause severe reactions when ingested. This may happen if people at risk touch an allergenic substance and then subsequently put their hand to their mouth or eye. Even a very small amount "hidden" in a food or a trace amount of an allergen transferred to a serving utensil has the potential to cause a severe allergic reaction. For foods such as fish and shellfish, egg and milk, vapour or steam containing proteins emitted from cooking these foods have been shown to trigger asthmatic reactions and even anaphylaxis.

While it is difficult to completely eliminate all allergenic ingredients due to hidden or accidentally introduced sources, it is possible and extremely important to reduce the risk of exposure to them. Effective ingredient label reading, special precautions for food preparation, proper hand washing, and cleaning go a long way toward reducing the risk of an accidental exposure.

Parents of food-allergic children are often concerned that the odour or smell of a particular food such as peanut butter will cause a life-threatening or anaphylactic reaction. Inhalation of airborne peanut protein can cause allergic reactions. The odour alone (without airborne proteins) has not been known to cause an anaphylactic reaction. Direct ingestion of an allergy-causing food poses the greatest risk for the sensitized individual. The following guidelines are recommended to reduce the risk of exposure for people with food allergy:
  • Adult supervision of young children while eating is strongly recommended.
  • Individuals with food allergy should not trade or share food, food utensils, or food containers.They should also place meals on a napkin or personal placemat. Young children should eat in the same location while at school. Air space above meals should be kept free and clear.
  • Parents should work closely with foodservice staff to ensure that food being served during lunch and snack programs is appropriate. Food-allergic children should only eat food which parents have approved if there is any uncertainty.
  • The use of food in crafts and cooking classes may need to be modified or restricted depending on the allergies of the children. Non-food items such as stickers and pencils should be considered for some class and school celebrations where young children are involved. If teachers have a system in place to reward students, they should consider non-food items for extra time for a special activity.
  • Ingredients of food brought in for special events by the school community, served in school cafeterias, or provided by catering companies should be clearly identified. Parents of food-allergic children should be consulted when food is involved in class activities. Food should not be left out where young children with food allergies can help themselves.
  • All children should be encouraged to comply with a "no eating" rule during daily travel on school buses.
  • All children should wash their hands before and after eating.
  • Surfaces such as tables, toys, etc. should be carefully cleaned of contaminating foods.
  • Insect Stings
The risk of insect stings is higher in the warmer months. General guidelines to reduce the risk of exposure to insect stings include:

i. Keep garbage cans covered with tightly fitted lids in outdoor play areas. Consider restricting eating areas to designated locations inside the school building during daily routines. This allows for closer supervision, avoids school yard cleanup, and helps reduce the revalence of stinging insects.

ii. Have insect nests professionally relocated or destroyed, as appropriate.

iii. People who are allergic to stinging insects should:
  • Carry an epinephrine auto-injector with them during insect season (varies by region).
  • Stay away from areas where stinging insects gather such as gardens, hedges, fruit trees, and garbage cans.
  • Wear light colours and avoid loose flowing garments or hair that could entrap an insect (tie hair back).
  • Wear shoes instead of sandals during the warm weather; do not go barefoot.
  • Avoid highly fragrant varieties of products such as perfumes, colognes, suntan lotions, cosmetics, hair sprays or deodorants which attract insects.
  • Drink from cups or use a straw rather than beverage cans or bottles where insects can hide. Use a straw if drinking beverages outdoors.
  • Consult with an allergist to determine if they are a candidate for venom immunotherapy (de-sensitizations program).
Other Allergens

Reactions to medication, exercise and latex are rare in school settings. Care of children with these allergies should be individualized based on discussions amongst the parents, physicians, and school personnel. The emergency protocol, as described earlier in this document, would apply.
Avoidance Strategies for Specific Food Allergens

Avoidance of Food Allergens

While research efforts are underway worldwide to better understand food allergy, a cure has not been found. Currently, physicians cannot safely determine which patients may be at risk for a mild or moderate allergic reaction and which patients might go on to develop a severe or potentially fatal allergic reaction to a food. A very small or minute amount of a food allergen can trigger an allergic reaction if ingested. Therefore, avoidance of an allergenic substance is the only way to prevent an allergic reaction. For many people at risk of food anaphylaxis, a lifelong avoidance diet will be necessary.
It is difficult to imagine how daily life in impacted when basic safety depends on avoiding a food which has the potential to cause a life-threatening allergic reaction. Consider how many times a day the average person eats something. For the majority of people, this is done without thought. For those at risk for a life-threatening or anaphylactic reaction, however, nothing can be taken for granted. Every bite counts.
Individuals at risk of food anaphylaxis must take ownership for their own safety. This involves sticking to basic rules such as:
  • Washing hands before and after eating
  • Eating only foods which are safe. Food-allergic individuals should always read food labels and avoid high risk foods such as bulk foods and foods which are known to often contain an allergenic substance (e.g. peanuts/nuts in ice cream, baked goods, or ethnic foods.)
  • Inquiring about the preparation of foods outside of the home.
  • Learning how to use an auto-injector and teaching others to assist them in an emergency
  • Carrying life-saving medication (an epinephrine auto-injector) with them at all times and wearing medical identification, such as a MedicAlert bracelet.
  • Refraining from eating if they do not have their auto-injector
Note: It is prudent for parents of young children (especially in high-risk families with a history of allergy) to try new goods at home before they are introduced in a day care or other setting.
Awareness and support from others in the community can help to create safer environments for individuals at risk of anaphylaxis. Ways to reduce the risk of accidental exposure include:
  • Washing hands and mouth after eating
  • Taking precautions to minimize the risk of cross-contamination in food preparation.
  • Reading food labels and asking food-allergic individuals about their specific needs.
  • Not sharing food with friends who have good allergy or pressuring them into accepting a food they do not want.
  • Properly cleaning surfaces and disposing of food items after meals and snacks
  • Ensuring that young children have adult supervision while they are eating.
Where younger children are involved, some food restrictions or special measures may be developed. Special accommodations should be handled on an individual basis. Parents of food allergic children and school staff are encouraged to work collaboratively to develop strategies which are both realistic and reasonable for their environments.

Many school principals ask the entire school community to read food labels and to not send in products with an allergenic substance such as peanuts. It is important to note that food restrictions alone do not take the place of effective risk reduction strategies. The emphasis should be on preventing an allergic emergency through education, awareness, and training and being prepared to respond during an emergency.

Parents of young food-allergic children should condition them to not accept foods which parents have not approved. They should also ask school staff not to offer food to their children without their prior approval. People who do not have a food allergy may not understand ingredient labeling practices. Assumptions about goods can put allergic individuals at risk. Therefore, parents should reach food-allergic children to stick to strict safety rules (not sharing or accepting food, carrying epinephrine, etc.) even in schools which have implemented a restriction on products with peanuts and nuts. Schools can be expected to create an 'allergy aware' environment. It is unrealistic, however, to expect an 'allergen-free' environment.

The following sections provide information about the most common food allergens in the school setting as well as examples of ways in which they are being managed in the school environment.

Avoidance of Peanut

Recent studies suggest that peanut allergy among North American children has doubled in the past decade. 1,2 A study conducted in Montreal schools estimated the prevalence of peanut allergy to be 1.34 to 1.5%.2

Peanut allergy requires stringent avoidance and management plans as it is one of the most common food allergies in children, adolescents, and adults. 3 Reactions to peanuts are often more severe than to other foods. Peanut has been a leading cause of severe, life-threatening, and even fatal allergic reactions. 4,5

Despite appropriate counseling on peanut avoidance, the majority of subjects followed up for 5 years experienced adverse reactions from accidental peanut exposure. 6 Very minute quantities of peanut, when ingested, can result in a life-threatening reaction.
In the high school environment, teens at risk of anaphylaxis must adhere to key safety rules. When food is concerned (any food ), this involves reading food labels carefully and taking special precautions such as asking food service staff about the preparation and handling of food in the cafeteria, if they purchase their lunch at school. Students with food allergy should eat with a friend and advice others quickly if they feel they are having an allergic reaction. They should not eat if they do not have their epinephrine auto-injector with them.

Food Service companies have a responsibility to train their staff to understand the risk of cross-contamination in the purchasing, preparation, and handling of food items. Food Service staff should participate in regular school staff training on anaphylaxis management; they must be aware of students at risk for food allergy.

Avoidance of Milk and Egg

While many young children outgrow an allergy to milk and egg within the first decade of life, some will continue to remain at risk of anaphylaxis, and should therefore follow key safety rules such as carrying epinephrine at all times. Anaphylactic reactions to milk and egg can occur when relatively small quantities are ingested. Therefore, the allergic child must avoid all traces of milk and egg.

Under proposed new labeling regulations in Canada, all traces of milk, egg and other major allergens will be listed on processed food. Currently, however, there can be legally undeclared ingredients. In addition, common names for milk and egg may not be noted, e.g. casein (milk). This can make avoidance of these allergens particularly challenging.

Elementary schools have adopted different strategies to reduce the risk of exposure for milk and egg-allergic children.

Milk
  • Some schools ask families not to send milk products in classes where there are milk-allergicchildren.
  • Some schools have milk programs but classes with milk-allergic children do not participate
  • Some schools allow milk products in classrooms where there are milk-allergic children and have implemented practices to reduce risk:
  • Children are given straws to put in bevel-topped milk containers (distributed through milk programs) and are taught to close the top once the straw is inserted.
  • Children who bring milk from home are asked to bring it in a plastic bottle with a straw
  • Children at risk for milk allergy sit at a table where spillable milk products are not being consumed. Alternatively, they sit at the same table but not directly beside classmates who have spillable milk products, e.g. milk, yogurt
  • On pizza days some parents of milk-allergic children take their kids home for lunch (where they have this option); others send their child with an alternative lunch so that they can still participate; others ask that their child eat in a pizza-free classroom. Special care should be taken to ensure that children properly wash their hands and mouths after pizza lunches and that all surfaces are properly cleaned.
Egg
  • In classrooms where there are young egg-allergic children, parents and staff have worked to reduce the risk of accidental exposure by:
  • Avoiding egg in cooking classes or egg shells in craft activities. (This includes both egg whites and yolks, either cooked or raw.) Some food products which may contain egg protein are: bread brushed with egg white, deli meats with egg, drinks such as orange julep, and egg substitutes. Non-food items which may contain egg protein include: egg tempera paints, cosmetics, and shampoo.
  • Selecting activities which do not involve the use of real egg for special activities, e.g. Easter egg decorating or hunts with wooden or plastic eggs.
  • Seating children with egg allergy away from those who bring eggs for lunch or snack (e.g. hard-boiled, egg salad sandwiches) or whose food may contain egg (e.g. mayonnaise)
  • Asking children to enjoy eggs and egg salad at home.
Individuals with egg allergy are advised to consult with their allergist about drugs (such as anesthetics) and vaccines or flu shots which may have egg protein.

Avoidance of Fish and Shellfish

Fish and shellfish allergies can be severe and life-threatening; therefore, strict avoidance must be practiced. Individuals with a specific shellfish allergy are advised to consult with their allergist about possible sensitivity to other species of shellfish. The same would be true for fish allergy. The risk of accidental exposure through cross-contamination in the stage and handling of fish or shellfish could be high. Fish- and shellfish-allergic consumers should look for 'may contain' warnings on food ingredients labels and be especially careful when purchasing fresh fish or shellfish, which is often stored in a common area in grocery stores. It is important to note that exposure to airborne fish particles have been known to cause an allergic reaction.

Casual Contact with Food Allergens

A recent U.S. study7 explored the commonly held beliefs that peanut odour and skin contact with peanut products pose a significant risk to peanut-allergic individuals. Many people believe that the mere presence of peanut products can contaminate the surrounding airborne environment, making an area unsafe for a peanut-allergic child.

Allergic reactions to foods such as peanut butter are triggered by specific food proteins. Food odour is caused by chemicals called pyrazines. Smelling peanut butter odour (pyrazines) is different from inhaling airborne peanut particles (proteins) which might occur from the mass shelling of peanuts in a poorly ventilated area. Peanut-allergic people may feel unwell if they smell peanut butter, but this is likely due to a strong (and understandable) psychological aversion. Inhaling airborne peanut particles can cause allergic reactions with symptoms such as rashes, runny nose, itchy eyes, and occasionally wheezing or difficulty breathing, but anaphylaxis is thought to be unlikely. Some people worry that just touching small amounts of peanut butter will result in a significant or life-threatening allergic reacion. The researchers noted that a very small amount of peanut butter induced only a local reaction when touched; however, the same amount could cause anaphylaxis should it be unintentionally transferred to the mouth.

While the researchers hope that their study will allay concerns about casual exposure to peanut, they advise continued caution: " Indeed, trace quantities of peanut can induce reactions when ingested, and intimate kissing, although perhaps considered casual contact, is also akin to ingestion." They add: "Specifically, on the basis of this study alone, we would not recommend changing any school policies that protect children with peanut allergy." The researchers also stressed that they did not study effects of having a large amount of peanut or peanut butter in the room and that further investigation would be required.

Foods with "May Contain" Warnings

While it is the responsibility of allergic consumers to always read food labels, confusion can be created by strong brand awareness and unfamiliarity with food labeling regulations. Here are some examples which consumers need to be aware of:
  • Some popular brands which are widely recognized as being safe for allergic consumers may be used in other products which may contain peanuts/nuts (e.g. peanut-free chocolate in ice cream which has a 'may contain' warning).
  • An allergen-free claim on certain products may be specific to only one size or format of the brand, not to all products using the same brand name. In some cases, the brand name has been used in new products which contain the allergen.
  • Product formulations (recipes) may change and ingredients of a particular brand may not be the same in all formats or all sizes. For example, a regular size candy bar may be considered to be free of an allergen such as peanut; however, the snack size version could have a 'may contain peanuts' warning. This could be due to the risk of cross-contamination if the product is run on the same equipment as products which contain peanut. Products may also be produced in a different format or in a different production factory.
  • Food labeling standards in other countries may not be the same as Canada's. Imported products may pose a risk to allergic consumers. Researchers found that 31% of imported chocolate bars from Eastern Europe without a precautionary label actually contained detectable levels of peanut protein.8
Food-allergic individuals and those who buy on their behalf must read food ingredient labels every time they purchase a product.

Food-allergic consumers are encouraged to read food ingredient labels three times: once when purchasing an item, a second time when putting the product away, and a third time just before serving.

Cleaning Surfaces

A recent U.S. study suggests that liquid or bar soap and antibacterial wipes can effectively remove peanut butter residue from hands. However, anti-bacterial hand sanitizers and water alone are not as effective.9 In the same study, researchers found that common household cleaning products such as Formula 409 (Clorox), Lysol sanitizing wipes, and Target brand cleaner with bleach were effective in removing residual peanut allergens from surfaces. Not all products may be available in Canada, but the research suggests that comparable products would work equally well. Dish soap did not effectively remove residue of peanut butter from surfaces.9 It is important to start cleaning with a clean cloth or paper towel at the anaphylactic student's desk.

Food Lists

Many schools provide a list of 'safe foods' to all families to help them comply with a 'no peanut or nut' request. While this is well-intended, schools and food-allergic consumers are encouraged to use them as a guideline only. Many of these lists could be inaccurate or outdated.

Parents of children with food allergy should teach them to always read food ingredients labels and not to accept or share foods which the parents have not approved, even in so-called 'peanut free' schools. It is unrealistic to expect others who are not affected by food allergies to understand the details required to properly read a food label. Others may not recognize alternate names for foods (e.g. casein = milk), and assume that a product is okay is there is no 'may contain' warning (which is voluntarily put on by manufacturers).

How Sabrina's Law Applies to Outdoor Education and Field Trips

By Cindy Paskey

 

children climbing stairsSabrina's Law, An Act to Protect Anaphylactic Pupils, came into effect on January 1, 2006 with the purpose of protecting students at risk of anaphylaxis.

Anaphylaxis is a severe, potentially life-threatening allergic reaction to any stimulus. Reactions are characterized by sudden onset, and involve one or more body systems with multiple symptoms. Allergens are the stimulus, or substances, that cause allergic reactions.

The most common anaphylaxis triggers are foods and insect stings, followed by medications, latex and on rare occasions even exercise. In Canada, the most common food allergens are peanut, tree nuts (e.g. almond, cashew, pistachio, walnut), milk, egg, fish, shellfish, and to a lesser extent, sesame seeds, mustard seeds, soy and wheat, as well as the food additive, sulphites.

Sabrina's Law outlines specific requirements for Ontario school boards and school principals. All boards are required to have an anaphylaxis policy that sets minimum standards for managing anaphylaxis in school settings. For boards that already have comprehensive policies, a review and minor adjustments will be all that are necessary to ensure compliance.
The bill requires principals to implement strategies that are consistent with board policy. These include a process to identify at-risk students and to develop individual plans for them, strategies to reduce risk, a school-wide communication plan and regular training for all employees and others who are in regular contact with at-risk students. The individual student plans should identify student's allergen(s) and the emergency protocol to be followed in the event of a reaction.

Parents and students must also be accountable by ensuring schools are provided with up-to-date medical and emergency information and epinephrine auto-injectors. Students themselves must learn how to self protect in age-appropriate ways. For example, young children are taught to ask a trusted adult about food ingredients before eating food that is not from home. Before entering high school, these students must be able to read food ingredients for themselves. As always, individual levels of ability and maturity must be accounted for when setting these expectations.

School boards will determine how training will be provided, and by whom. Such training should provide an understanding of anaphylaxis, familiarity with the signs and symptoms of a life threatening reaction, knowledge of emergency response, and familiarity with students at risk of severe allergic reactions. Ideally, everyone should practise how to give an epinephrine auto-injector with training devices.

There are two different auto-injectors on the market: EpiPen® and Twinject®. Both types contain life saving medication, epinephrine, also known as adrenaline. It needs to be given early in the course of a reaction and is administered by needle injected into the muscle on the outer side of the thigh. In normally healthy individuals, epinephrine will not cause harm if given unnecessarily. During a reaction, individuals may not be able to give themselves epinephrine. Assistance from others is crucial.

Since life threatening allergic reactions are unpredictable and can progress quickly, early symptoms should never be ignored. They may appear alone or in any combination, regardless of the trigger. Symptoms may include:

Skin: hives, swelling, itching, warmth, redness, rash

Respiratory (breathing): wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, runny/itchy nose, watery eyes, sneezing, trouble swallowing

Gastrointestinal: nausea, pain/cramps, vomiting, diarrhea

Cardiovascular: pale/blue colour, weak pulse, passing out, dizzy/lightheaded/shock

Other: anxiety, feeling of “impending doom”, headache, uterine cramps

Medical research has lead experts to recommend the emergency protocol below in response to severe, potentially life threatening allergic reactions. The acronym ACT serves as a reminder of the steps to follow:

Administer epinephrine auto-injector – EpiPen® or Twinject®
Call 911
Transfer care to emergency responders and ensure transport to hospital

checkmark Administer a 2nd auto-injector if life threatening symptoms (breathing, consciousness) do not subside.

People living with life threatening allergies must always be prepared for the unexpected. How can you help to ensure that practical risk reduction measures are in place during field trips and outdoor education? While your School Board Safety Guidelines should always be followed, listed below are tips to implement that will help keep allergic students safe. Insect sting allergies, in particular, are managed differently in outdoor compared to classroom settings.
checkmark Think ahead! Know the students at risk and their allergens. Know the type of auto-injector the student carries, either EpiPen® or Twinject®.
checkmark Be observant and alert to potential risks.
checkmark Canvass school property and activity areas for stinging insect nests. Arrange for their professional removal.
checkmark Ensure proper training of people who will supervise – know the emergency protocol; practice with training device.
checkmark Ensure quick access to an auto-injector.
checkmark Know the location and ensure easy access to second back-up auto-injector.
checkmark Establish a buddy system.
checkmark Ensure an emergency communication system is in place – walkie talkies or cell phone.
checkmark Ensure that parents/guardians have provided required medical information that is up-to-date, with appropriate consents for emergency response and emergency contact information.
checkmark Keep student's medical information with you while on field trips.
checkmark Know the location of the nearest medical facility.
checkmark Know your location so you are able to correctly inform 911 responders.
checkmark Enforce a ‘no eating' rule on buses. On long trips, enforce restrictions on allergen-containing foods.
checkmark Check, in advance, about food ingredients from food service providers.

Allergic students must always be mindful of their allergies. They should
checkmark Carry at least one epinephrine auto-injector, as age appropriate. Generally age 6 or 7. Otherwise, a supervising adult should carry the medication.
checkmark Wear medical identification, e.g. MedicAlert.
checkmark Inform others if he/she suspects a reaction is happening.
checkmark Ensure that asthma is well controlled.

Self protection requires allergic students to practice avoidance strategies and avoid risk taking behaviour. For food, this includes:
checkmark Hand washing before and after eating.
checkmark Avoid putting food directly on surfaces. Use a napkin or place mat.
checkmark Check ingredients before eating. If in doubt, do without.
x mark Do not trade or share food, utensils or food containers.
x mark Avoid eating if auto-injector is not readily available.

Students at risk of insect sting reactions should be encouraged to:
checkmark Wear closed shoes.
checkmark Wear light colours.
checkmark Wear long hair tied back.
checkmark Keep away from areas where stinging insects gather, such as gardens, hedges, fruit trees, garbage cans.
checkmark Keep food covered.
checkmark Drink from covered cups or straws.
checkmark Stay with a buddy while outdoors.
x mark Avoid wearing scented products.
x mark Avoid loose flowing garments.

As always, different challenges to student safety arise because of differences between elementary and high school settings.The higher degree of elementary level supervision helps to protect young children who are more apt to engage in hand to mouth behaviour and are generally more trusting of statements made by others which might lead to sharing food.
The physical setting in middle and high school is larger, there is a greater number of students and student class locations change because of rotary. Vending machines and cafeterias are more prevalent. Students are more likely to be involved in extra-curricular activities outside of normal school hours and do not want to be ‘singled out' because of their allergy.

Sabrina's Law makes it clear that anaphylaxis management at school is a shared responsibility. The law provides a foundation for collaboration among school boards, principals, parents, at-risk students and the broader school community. Student safety is enhanced while roles and expectations are identified.

By ensuring that you know the students at risk of an allergic reaction, that auto-injectors are readily available in an unlocked location and by practicing emergency drills you should be able to provide prompt and effective emergency response in the case of a reaction. The end result is saving lives!

Ophea's Asthma Education Initiative provides a wide variety of asthma/allergy and anaphylaxis education materials.
Other web-based and print resources are available from:
Cindy Paskey volunteers for Anaphylaxis Canada, AAIA (Asthma Allergy Information Association, and a Niagara-area nonprofit anaphylaxis group, NASK (Niagara Anaphylaxis Support and Knowledge). She advocates for anaphylaxis awareness as an educator, writer and consultant.

The Limestone District School Board is situated on traditional territories of the Anishinaabe & Haudenosaunee.