Standard Anaphylaxis Action Plans are a MUST

Your Allergy Advocacy Association was concerned to find out there is not a standard Anaphylaxis Action Plan form used by doctors to communicate with a child’s school. We were also surprised to learn that many pediatricians as well as allergists are recommending that Benadryl be administered first for any signs of an allergic reaction, serious or not. We interviewed school nurses as well as allergists for their opinion on the matter and uncovered a lot of issues with how schools are being informed about allergies in children.

Standard Anaphylaxis Action Plans are a MUST
for ALL NYS Central School Districts!

Action Plan sign

By Suzanne Driscoll March 15th, 2019

How to communicate effectively with your child’s school regarding life-threatening allergies remains a challenge for many parents. In addition to the school nurse and classroom teacher, there are coaches, after school activity leaders, bus drivers and substitute teachers who must be informed on what to do in an anaphylaxis emergency. Instructions from doctors range from information on an annual school physical form to specific orders and action plans. Even then nurses are often left guessing if the allergy is mild with a slight rash resulting—or is life-threatening.

The Allergy and Asthma Network developed an excellent form to give to all school and summer camp personnel called an Anaphylaxis Action Plan. (See below.) It clearly states that epinephrine should be administered FIRST for any signs of a severe allergic reaction. Your Allergy Advocacy Association became aware of this form and others like it at a recent conference and decided to ask school nurses whether a form such as this is ever used, and if not, how do they learn about a child’s allergies and what to do in an emergency. We were concerned to find out that many pediatricians as well as allergists are indicating that Benadryl be given first, even when signs of anaphylaxis are present.

“If I know a child is experiencing anaphylaxis, I administer epinephrine,” says nurse Danielle Andolina at Pittsford Mendon High School. If an Anaphylaxis Plan or doctor’s orders states they should be given Benadryl first, I administer both.”

Andolina’s bigger issue is with the annual physical examination forms completed by the student’s doctor. “Many times they don’t even mention the child has a severe food or other allergy. I have to rely on my memory to review the files from previous years. I’m sure the parents aren’t even aware this has been left out on the form, so they should be careful to review everything before turning it in to the school.”

Dr. Kirsi Jarvinen-Seppo, Director of the Center for Food Allergy at the UR Medical Center, is in strong favor of the Anaphylaxis Action Plan developed by the Allergy and Asthma Network. “It clearly outlines that epinephrine needs to be administered first for anaphylaxis. I would certainly go by this, and many allergists use this resource. The problem comes when schools demand their own anaphylaxis plan to be used that states one order of meds for allergic reactions irrespective of the symptoms. I am not sure what would be the best way to go about this, but standardization of Emergency Action Plans would be hugely beneficial.”

Dr. Theresa Bingemann of Rochester Regional Health holds a slightly different point of view. A Clinical Associate Professor of Pediatrics and Medicine at the University of Rochester School of Medicine, she agrees that epinephrine is indeed the first line treatment for anaphylaxis, “but I do not disagree with having Benadryl on an action plan. For a child with mild symptoms, such as a few localized hives, this is not inappropriate.”

Dr. Bingemann believes that epinephrine should not be administered in the absence of symptoms. “But if the child has a rapidly progressing reaction, two body symptoms, or symptoms suggestive of anaphylaxis, then epi is appropriate. There is a concern that if we remove Benadryl from all action plans that kids may not report symptoms as they do not want to be ‘poked.’ Also, if epi is used for ‘everything’ this may dramatically increase cost of care and lead to more unnecessary trips to the emergency room.”

Lynne Muth of BOCES is a registered nurse providing services to Rochester City School students. She reports that she has never seen an Anaphylaxis Action Plan in the Rochester schools, “but we do get doctors’ orders. Fifty to seventy percent of them say to use Benadryl first and that really angers me. They might list two or three things a child is allergic to and we have to guess which are mild allergies and which are life-threatening. But if we see any signs of possible anaphylaxis we administer epinephrine first. Benadryl only reacts to one little histamine while epi reacts to everything. Why would you put anybody at that risk?”

Muth has an interesting idea for how doctors could be educated to recommend epinephrine first rather than Benadryl. “Perhaps the epinephrine pharmaceutical company sales representatives could emphasize how important it is to administer epi first.” She would also like to see a standard form of Anaphylaxis Action Plans that clearly state epinephrine be administered first for any signs of anaphylaxis.

Meanwhile the bottom line is this: parents should closely review the annual physical and any other forms and instructions given by your doctor to the school. Make sure the child’s allergies are clearly defined and not leaving the nurse to guess if it is a mild food intolerance or a life-threatening allergy. Specific actions to take and what medicines to administer in an emergency should match what you have discussed and agreed upon with your doctor. As an extra precaution, take it upon yourself to tell coaches, school bus drivers and after school activity leaders about your child’s allergies and what to do in an emergency. This is particularly important if the nurse is not present during after school hours.

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Download a PDF copy of the Anaphylaxis Action Plan from AAN, then scroll downward to nearly the bottom of the page.

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