- Email: [email protected]
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
~
COMPREHENSIVE CARE IN THE ALLERGY/ASTHMA OFFICE
0889-8561/99 $8.00
+ .OO
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING Lori Jo Higgins, LPN
In the United States, asthma has an impact on 14 to 15 million people; nearly one third of those affected are children under the age of 18 years. In simple terms, 1 of 10 children has a ~ t h m aThe . ~ morbidity and mortality of asthma continue to increase, despite improved understanding of its pathophysiology and newer more effective medications. Allergies affect 41 million people, with 1% to 3% of the population having food allergies. With these numbers in mind, allergic emergencies such as acute asthma or anaphylaxis are serious situations that may occur in the school setting. Understanding what triggers an allergic emergency and recognition of early warning signs are important first steps. Appreciating the limitations on learning or participation in sports, identifying health risk factors that may be present in the school setting, and having wellinformed staff with a clear action plan are also crucial in the management of asthma, allergies, or anaphylaxis. TRIGGERS OF AN ALLERGIC EMERGENCY
There are many triggers of an allergic emergency depending on the child's situation. Food allergies probably represent the most severe and life-threatening reaction. Although any food may potentially cause an allergic reaction, certain foods such as eggs, peanuts, cow's milk, tree nuts, wheat, shellfish, soybeans, and fish are the most common. Stinging insects can also lead to severe life-threatening reactions. Environmental ~
From Northwest Asthma and Allergy Center, Seattle, Washington
IMMUNOLOGY AND ALLERGY CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 1 * FEBRUARY 1999
177
178
HIGGINS
allergens like tree, weed, and grass pollens; mold; dust mites; and animal dander can exacerbate allergic symptoms. A recent article examined cockroach exposure and found that children who were sensitive to this allergen were more likely to be hospitalized for their asthma! Other nonspecific irritants like cold air, exercise, viral infections, and exposure to fumes from cigarette smoke, dry board markers, chemical cleaners, paint, room deodorizers, and even cooking smells have also been noted to trigger a child’s asthma. Reactions can increase with repeated exposure to the allergens. WHAT OCCURS DURING AN ALLERGIC RESPONSE
Genetics and environmental exposures are important factors in the development of allergies. When an allergic person eats or breathes in an irritant, he or she is exposed to a specific protein. This protein then causes IgE antibodies to be produced, which bind to the mast cells that line the nose, lungs, skin, and digestive tract. When subsequent allergen exposure occurs, binding to IgE on the mast cells releases histamine, which then binds to receptors found in the nose, lungs, skin, stomach, and blood vessels. Other chemicals are also released in the allergic reaction, for example, leukotrienes, prostaglandins, and tryptase. Collectively, these chemicals cause dilation of blood vessels and leakage of fluid into the tissues. This, in turn, causes swelling around the nose, eyes, lungs, or skin, if systemic, this swelling may cause a drop in blood pressure. When it develops in the area of the nose or eyes, the reaction is called hay fever or allergic rhinitis. If the allergic event occurs in the lungs, it is called asthma. When an exposure causes a massive release of histamine throughout the body, it is called anaphylaxis (Fig. 1). WARNING SIGNS OF AN ALLERGIC EMERGENCY
The signs and symptoms of anaphylaxis include itching of the skin, hives, and swelling of the tissues or a feeling of warmth and flushing. Swelling of the tongue or throat can lead to airway compromise and needs immediate attention. Shortness of breath, wheezing, coughing, chest pain, and congestion are additional symptoms. Sneezing, nasal congestion, hoarseness, or a change in voice may also be present. Gastrointestional symptoms include nausea, vomiting, cramping, and diarrhea, often within 2 hours of ingestion of food. Finally, low blood pressure or an irregular and rapid heart beat and impending loss of consciousness are grave clinical signs. Sometimes, the earliest warning of anaphylaxis is a patient’s general feeling of unease that something serious has been initiated. Early warning signs of acute asthma are shortness of breath, wheezing, coughing, and chest tightness. Nasal congestion or red puffy eyes may also be present if the trigger was airborne.
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
Name: Doctor’s Name:
179
Phone #
What i s Anaphylaxis? Anaphylaxis is a very serious type of allergic reaction. It occurs when a person is exposed to an allergen (ie., an allergy causing substance) to which he or she has been previously sensitized. In anaphylaxis, cells in the immune system release large amounts of chemicals, including higamine, which cause blood vessels to dilate and leak fluid into surrounding tissues, thus producing swelling. Usually, anaphylaxis is a systemic reaction (ic., it affects the entire body). What Are the Common Causes of Anaphylaxis? 0 Insect stings: 0 Foods: 0 Medications: 0 Exercise: Exercise-induced anaphylaxis is rare and puzzling. It may be caused by warm temperatures, intense exercise, or a food eaten hours before. What Are the Symptoms of Anaphylaxis? Anaphylaxis causes different reactions in different people. Symptoms are usually severe and appear rapidly- within seconds or minutes-after exposure to an allergen; in a few cases, reactions have been delayed as long as 2 hours.
L7 Respiratory symptoms:Wheezing, shottness’of breath, cough, difficulty in swallowing 0 Gastrointestinal symptoms: Nausea, vomiting, cramps, diarrhea Skin symptoms: Itch, swelling, hives, red and blotchy areas 0 Cardiovascular symptoms:Feeling faint, irregular heart beat, shock How is Anaphylaxis Treated? Anaphylaxis is a medicel emergency that requires immediate attention. Treatment must be started before blood pressure and breathing problems become critical. The most important drug for the treatment of anaphylaxis is epinephrine. The sooner the reaction is treated the less severe it will be. Here are your individualized instructions for treating anaphylaxis:
CI Wear a Medic Alert bracelet. In the event of an emergency, others can help you if they know your allergies.
Prevention of Anaphylaxis Remember, prevention is the best treatment for anaphylaxis. Avoid substances and situations that are known to trigger extreme allergic reactions. Photocopy this action plan for your family, friends, coworkers, and school personnel. Prepare those around you so that they may help you in the event of an emergency.
Figure 1. Anaphylaxis action plan.
WHAT TO DO IF THESE SYMPTOMS ARE PRESENT
Preventing severe allergic and asthmatic reactions requires awareness and education on the part of the school personnel in identification of triggers, awareness of early warning signs and symptoms, and close communication with the student’s family and physician (see Appendix).
180
HIGGINS
Guidelines for the management of asthma and allergies in the school setting are provided in the display boxes on this page and on subsequent pages of this article. It is the physician’s responsibility to provide written permission forms that explain the use of medications during school hours and to determine whether a child should be allowed to carry his or her own medications for self-administration. In some cases, this may even be an issue that needs to be addressed with the school board if the school has a policy of “no drugs.” A written action plan on file for children with severe allergies, asthma, or food allergies is essential.2 Having identified personnel who are trained and prepared is the key.
Display Box 1. Actions for the Principal*
Involve your staff in the asthma management program. A school asthma management program is a cooperative effort that involves the student, parents, teachers, school staff, and physicians. Many members of the school staff can play a role in maintaining your school’s asthma management program, although the principal or the school nurse may be most instrumental in getting a program started. Take the steps listed below to help set up an asthma management program in your school. Develop a clear policy on taking medication during school hours. Work with parents, teachers, the school nurse (if available), and others to provide the most supportive policy that your school system allows so that the student can get the medication he/she needs. Designate one person on the school staff to be responsible for maintaining each student’s asthma action plan. Provide opportunities for staff to learn about asthma and allergies by setting up inservice courses. You may get assistance from your school nurse, or a local hospital or medical society. Other sources of information are the American Lung Association, Asthma and Allergy Foundation of America, National Jewish Center for Immunology and Respiratory Medicine, and the Mothers of Asthmatics. Establish an asthma resource file of pamphlets, brochures, and other publications for school personnel to provide an opportunity for the staff to get additional information about asthma. Many of the organizations cited above offer materials for this purpose. Make general information available to students as well. Schedule any extensive building repairs or cleaning to avoid exposing students to fumes, dust, and other irritants. When possible, try to schedule painting and major repairs during long vacations or the summer months. Support and encourage communication with parents to improve school health services. W o r n Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education, NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991
ALLERGIES AND ASTHMA IN THE SCHOOL SETTJNG
181
Display Box 2. Actions for the Classroom Teacher*
Know the early warning signs of an asthma episode. Have a copy of the asthma action plan in the classroom. Review it with the student and parents. Know what steps to take in case of an asthma episode. Develop a clear procedure with the student and parent for handling schoolwork missed due to asthma. Understand that a student with asthma may feel drowsy or tired, different from the other kids, anxious about access to medication, embarrassed about the disruption to school activities that an asthma episode causes, and/or withdrawn Help the student feel more comfortable by recognizing these feelings. Try to maintain confidentiality. Educate classmates about asthma so they will be more understanding. Know the possible side effects of asthma medications and how they may impact the student’s performance in the classroom. Refer any problem to the school nurse and parent(s). Common side effects of medicine that warrant referral are nervousness, nausea, jitteriness, hyperactivity, and drowsiness. Reduce known allergens in the classroom to help students who have allergies. Common allergens found in classrooms include chalk dust, animals, and strong odors (perfumes, paints). Encourage the student with asthma to participate fully in physical activities. Allow a student to engage in quiet activity if recovery from an acute episode precludes full participation. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of !&hools and Teaching, Office of Educational Research and Improvement (OEM), US Department of Education. NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991: with permission.
182
HIGGINS
Display Box 3. Actions for the School Nurse or Other Health Personnel*
Maintain the asthma action plan for every student with asthma. Include information on medications, dosages, triggers, and emergency procedures. Alert staff members about students with a history of asthma. Use the warning signs presented in the publication, Managing Asthma: A Guide for Schools, to help identify students with uncontrolled asthma. Provide this information to parents with the encouragement to see a physician. Assist with the administration of medication in accordance with school policy. Monitor response to treatment using a peak flow meter. Communicate with parents about acute episodes, if any, and about the student’s general progress in controlling asthma at school. Conduct inservices on asthma, and consult with staff to help develop appropriate school activities for students with asthma. Collaborate with the PTA to consider offering a family asthma education program in school. Consult organizations on the resource list in the publication, Managing Asthma: A Guide for Schools, for assistance. If there is not a nurse at your school, these tasks should be assigned to an appropriate staff member. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991; with permission.
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
183
Display Box 4. Actions for the Physical Education instructor and Coach*
Encourage exercise and participation in sports for students with asthma. When asthma is under good control, students with the disease are able to play most sports. A number of Olympic medalists have asthma. Appreciate that exercise can cause acute episodes for many students with asthma. Exercise in cold dry air and activities that require extended running appear to trigger asthma more readily than other forms of exercise. However, medicines can be taken before exertion to help avoid an episode. This preventive medicine enables most students with exercise-induced asthma to participate in any sport they choose. Warmup and cooldown activities appropriate for any exercise will also help the student with asthma. Support the student’s treatment plan if it requires premedication before exercise. Understand what to do if an asthma episode occurs during exercise. Have the child’s asthma action plan available. Encourage students with asthma to participate actively in sports but also recognize and respect their limits’. Permit less strenuous activities if a recent illness precludes full participation. Refer your questions about a student’s ability to fully participate in physical education to the parents and school nurse. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.
Display Box 5. Actions for the Guidance Counselor*
Help all school personnel understand that asthma is not an emotional or psychological disease-it is not ”all in the child’s head.” Strong emotions such as laughing or crying can trigger an acute episode because this irritates and constricts the sensitive airways of a person with asthma. Recognize that learning to cope with asthma, as with any chronic illness, can be difficult. Teachers may notice low self-esteem, withdrawal from activities, discouragement over the steps needed to control asthma, or difficulty making up schoolwork. Special counseling with the student and/or parents may help the student handle problems more effectively. “FromManaging Asthma: A Guide for Schools. National Heart, Lung and Blood Instutite (NHLBI), National Institutes of Health US, Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.
184
HIGGINS
Neither the parent nor the physician has direct authority at school; thus, the training of the identified staff should include how to administer nebulized medication, use of a metered dose inhaler, and administration of epinephrine. A further tool that can be useful in determining decreased lung function in asthma is the peak flow meter. By regular monitoring of an asthmatic’s lung function with this small handheld device, the staff can have increased confidence when assessing that child’s need for medication; after administration, such monitoring can assist in determining if further medical assistance is required. The peak flow meter is like a thermometer for the lungs. Through regular monitoring, each person obtains a “personal best” number. This number is the best that a given individual is able to blow into the meter in 1 second. Once the number is acquired, simple calculation of 80% and 50% of that number becomes the “watch” areas of that person’s lung function. Monitoring is set up like a stoplight, with 80% to 100% being the “green” zone. When lung function is in this range, daily medications are all that is required. The ”yellow” zone falls between 80% and 50% of the personal best number. When an asthmatic is in this area, use of a ”reliever” medication (e.g., albuterol) is indicated based on the physician’s plan. ”Red” zone readings on the meter indicate an acute need for assistance in breathing and must be aCted on immediately according to the action plan agreed on by the parent and physician. The Committee on School Health of the American Academy of Pediatrics has suggested that two or more members of the staff be designated and trained in the recognition and treatment of anaphylaxis, including the use of subcutaneous injection of epinephrine.2 Ideally, schools that have a full-time nurse or health clinic should provide training in recognition of allergic emergencies. Unfortunately, more school districts are having to cut back on finances; as a result, a person with no medical background may be required to perform medical treatments. The Food Allergy Network has a videotape and informational materials available for schools that wish to provide more education regarding food allergies. INFLUENCE ON PARTICIPATION IN SCHOOL ACTIVITIES Ideally, the goal for any child with asthma or allergies is full participation in sports. This is evidenced by the number of asthmatic Olympic athletes who, despite their medical conditions, achieve sports greatness. If personnel cannot be properly educated about symptom recognition and relied on to use good judgment or if the current status of a child’s asthma is not well managed, some limits may be temporarily placed on exercise, however. Efforts to prevent exercise-induced asthma require communication with the school coach and allowance of premedication on the part of the student athlete under a physician’s guidance. Often, coaches or teachers notice children who have increased coughing, wheezing, or shortness of
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
185
breath during or after exercise. By receiving education in symptom recognition of the signs of asthma, they may even prompt a visit to the physician for clarification and possible asthma diagnosis. It is the goal that children with asthma and allergies should be able to fully participate in all school activities. INFLUENCE ON LEARNING Many factors can affect the ability of a student with asthma or allergies to learn. For instance, poorly managed asthma or allergies and medication side effects can result in a poor attention span or loss of concentration. Inadequate rest, hearing loss due to clogged ears, headache, fatigue, hyperactivity, or excessive itching of the skin can also affect a student's ability to learn. With good communication between the school, parent(s), and physician, medications can be adjusted or revised, resulting in optimal control of the disease while limiting side effects and maximizing the student's ability to learn. IDENTIFYING HEALTH RISKS Each school offers its own list of factors that may place students at risk. These can vary based on the age of the building and the type of heating and ventilation systems. For children with food allergies, meal preparation and notification are important. The food service staff need to have a clear understanding that possible cross-contamination or misidentification could lead to adverse anaphylaxic events. Food-allergic children might be accommodated in an "allergy-free" eating space in the school lunchroom. The choice of carpeting as the desired flooring for schoolrooms and whether or not animals are allowed in the classrooms should be considered. Accordingly, it is prudent for school personnel and parents to work closely together in identifying factors that may affect the child. It is the parent's responsibility to communicate with the physician about any factors found in the classroom or school activities that are affecting the child's health. The United States Environmental Protection Agency Indoor Environmental Division has published a resource kit for school personnel calIed Tools for Schools, which covers some of these issue^.^ The National Heart, Blood, and Lung Institute also has published Managing Asthma: A Guide for Schools, which equips each member of the school staff with a clear outline and set of guidelines to follow.6 The American Lung Association offers a student education program entitled "Open Airways" to assist children in the management of asthma. ACTION PLAN(S) There are several excellent action care plans available, including one published by the Asthma and Allergy Foundation of America, the "Student Asthma Action Card" (Fig. 2): It may be obtained free of charge by contacting the Asthma and Allergy Foundation of America.
186
HIGGINS
Name:
Grade:-
Teacher:
Room:
ParenUCuardian Name:
P h (H)
-
AF:
ID Photo
P h (W)
Address: ParentlGuardian Name:
PhtH) Ph: (W)
Address: Emergency Phone Contact # I Name
Relationship
Phone
Relationship
Phone
Emergency Phone Contact t 2 Name Physician Student Sees for Asthma:
Ph
Other Physician:
Ph
DAILY ASTHMA MANAGEMENT PLAN Identify the things wbirh .start an asthma episode (Check each that appliesto the student.) 0 Exercise
0 Strongodorsorfuma
0 Respiratory infections 0 Change in temperature
0 Chalkdust
0 Animals
0 Carpetsintheroom poiimr
D Food
0 Molds
0 Other
Comments
Control of SchoolEnvironment (List any cnvironmental control measures, pre-medications, and/or dietary restrictions that the student needs to pment an asthma episode.)
~~
Peak plow Monitoriag Personal Best Peak Flow number: Monitoring 'Emes:
DdyMcdicptionPlan Name
Amomt
When to Use
1. 2.
3. 4.
Figure 2. See legend on opposite page
Another good source is the National Lung, Heart, and Blood Institute, which has care plans, educational pieces, and handouts available in its publication entitled, Teach Your Patients About Asthma: A Clinician's Guide.7 The important thing to remember is that whatever action plan is chosen, it should include the following: causes of the reaction, who to
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
187
EMERGENCYPLW Emergencyaction is necessary when the student has symptomssuch as
-.
or has a peak Bow reading of Steps t o take during an asthma episode: I. Give medicationsas lited below.
2. Have student return to classroom if 3. Contact parent if Seek emergencymedical care if the student has any of the following: V No improvement 15-20 minutes aher initial treatment with medication and a relativecannot be reached. V Peakflowof
4.
V Hard time breathing with:
- Chest and neck pulled in with breathing
/ F 7 k I i S m f & T
E ~ ~ m m HELP c r Now!
Child is hunched over Child is struggling to breathe V Trouble walkingor talking
-
V Stops playing and can't start activity again
V Lips or fingernails are gray or blue *
Emergency Asthma Media~tiom Amount
Naate
When to Usc
1. 2.
3. 4.
COMMENTS / SPECIAL hS"RUCn0NS
FORINHALED MEDICATIONS in the proper way to use hidher medications. It is my should be allowed to carry and use that mediition
I have instructed prohioaal opinion that by himherself.
0 It is my professionalopinionthat
Parent Signature
should not carry hdber inhaled medication by hidhemelf.
Date
Figure 2. Student asthma action card endorsed by the NationalAsthma Education Program. (From the Asthma and Allergy Foundation of America, Washington, DC; with permission.)
188
HIGGINS
contact in a emergency, what the physician has outlined to do until medical help arrives, and customization of the plan to each student’s needs. By forming a partnership between the family, student, school personnel, and physician, allergic and asthmatic episodes can be effectively managed in the school setting. References 1. American Academy of Asthma, Allergy, and Immunology, Asthma and Allergy Alliance: Anaphylaxis Action Plan, Publication No. 1993 2. American Academy of Pediahics, Committee on School Health: Guidelines for urgent care at school. Pediatrics 86:999-1000, 1990 3. Asthma and Allergy Foundation of America: Student Asthma Action Card 4. Current estimates from National Health Interview Survey, 1994. Vital Health Stat 10:94, 1995 5. Furukawa C T Allergy, Asthma, and Immunology from Infancy to Adulthood, ed 3. Philadelphia, WB Saunders, 1996, pp 761-768 6. National Lung, Heart, and Blood Institute (NLHBI), United States Department of Health and Human Services, National Asthma Education and Prevention Program: Managing Asthma: A Guide for Schools, NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991 7. National Lung, Heart, and Blood Institute (NLHBI),United States Department of Health and Human Services, National Asthma Education and Prevention Program: NIH Publication No. 92-2737. Bethesda, MD, National Institutes of Health, 1992 8. Rosenstreich DL, Eggleston P, Cattan M, et ak The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med 3361356-1363, 1997 9. United States Environmental Protection Agency Indoor Environmental Division: Tools for Schools, Publication No. 402-K-001
Address reprint requests to Lon Jo Higgins, LPN Northwest Asthma and Allergy Center 4540 Sand Point Way NE Seattle, WA 98105
APPENDIX
Resources Available to Schools To Help Manage Asthma* For more information contact: The National Asthma Education Program Information Center 4733 Bethesda Ave. Suite 530 Bethesda, MD 20814-4820 (301) 951-3260 The following organizations can provide additional materials and additional information about asthma: Asthma and Allergy Foundation of America National Headquarters 1717 Massachusetts Ave., NW Suite 305 Washington, DC 20036 1-800-727-8462 American Lung Association (Call your local Lung Association) National Jewish Center for Immunology and Respiratory Medicine 1400 Jackson St. Denver, CO 80206 1-800-222-5864 American Academy of Allergy and Immunology 611 East Well St. Milwaukee, WI 53202 1-800-822-2762 National Allergy and Asthma Network/ Mothers of Asthmatics 3554 Chain Bridge Road Suite 200 Fairfax, VA 22030 1-800-878-4403 American College of Allergy & Immunology 800 East Northwest Hwy. Suite 1080 Palatine, IL 60067 1-800-842-7777 *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education, NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.)
189
COMPREHENSIVE CARE IN THE ALLERGY/ASTHMA OFFICE
0889-8561/99 $8.00
+ .OO
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING Lori Jo Higgins, LPN
In the United States, asthma has an impact on 14 to 15 million people; nearly one third of those affected are children under the age of 18 years. In simple terms, 1 of 10 children has a ~ t h m aThe . ~ morbidity and mortality of asthma continue to increase, despite improved understanding of its pathophysiology and newer more effective medications. Allergies affect 41 million people, with 1% to 3% of the population having food allergies. With these numbers in mind, allergic emergencies such as acute asthma or anaphylaxis are serious situations that may occur in the school setting. Understanding what triggers an allergic emergency and recognition of early warning signs are important first steps. Appreciating the limitations on learning or participation in sports, identifying health risk factors that may be present in the school setting, and having wellinformed staff with a clear action plan are also crucial in the management of asthma, allergies, or anaphylaxis. TRIGGERS OF AN ALLERGIC EMERGENCY
There are many triggers of an allergic emergency depending on the child's situation. Food allergies probably represent the most severe and life-threatening reaction. Although any food may potentially cause an allergic reaction, certain foods such as eggs, peanuts, cow's milk, tree nuts, wheat, shellfish, soybeans, and fish are the most common. Stinging insects can also lead to severe life-threatening reactions. Environmental ~
From Northwest Asthma and Allergy Center, Seattle, Washington
IMMUNOLOGY AND ALLERGY CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 1 * FEBRUARY 1999
177
178
HIGGINS
allergens like tree, weed, and grass pollens; mold; dust mites; and animal dander can exacerbate allergic symptoms. A recent article examined cockroach exposure and found that children who were sensitive to this allergen were more likely to be hospitalized for their asthma! Other nonspecific irritants like cold air, exercise, viral infections, and exposure to fumes from cigarette smoke, dry board markers, chemical cleaners, paint, room deodorizers, and even cooking smells have also been noted to trigger a child’s asthma. Reactions can increase with repeated exposure to the allergens. WHAT OCCURS DURING AN ALLERGIC RESPONSE
Genetics and environmental exposures are important factors in the development of allergies. When an allergic person eats or breathes in an irritant, he or she is exposed to a specific protein. This protein then causes IgE antibodies to be produced, which bind to the mast cells that line the nose, lungs, skin, and digestive tract. When subsequent allergen exposure occurs, binding to IgE on the mast cells releases histamine, which then binds to receptors found in the nose, lungs, skin, stomach, and blood vessels. Other chemicals are also released in the allergic reaction, for example, leukotrienes, prostaglandins, and tryptase. Collectively, these chemicals cause dilation of blood vessels and leakage of fluid into the tissues. This, in turn, causes swelling around the nose, eyes, lungs, or skin, if systemic, this swelling may cause a drop in blood pressure. When it develops in the area of the nose or eyes, the reaction is called hay fever or allergic rhinitis. If the allergic event occurs in the lungs, it is called asthma. When an exposure causes a massive release of histamine throughout the body, it is called anaphylaxis (Fig. 1). WARNING SIGNS OF AN ALLERGIC EMERGENCY
The signs and symptoms of anaphylaxis include itching of the skin, hives, and swelling of the tissues or a feeling of warmth and flushing. Swelling of the tongue or throat can lead to airway compromise and needs immediate attention. Shortness of breath, wheezing, coughing, chest pain, and congestion are additional symptoms. Sneezing, nasal congestion, hoarseness, or a change in voice may also be present. Gastrointestional symptoms include nausea, vomiting, cramping, and diarrhea, often within 2 hours of ingestion of food. Finally, low blood pressure or an irregular and rapid heart beat and impending loss of consciousness are grave clinical signs. Sometimes, the earliest warning of anaphylaxis is a patient’s general feeling of unease that something serious has been initiated. Early warning signs of acute asthma are shortness of breath, wheezing, coughing, and chest tightness. Nasal congestion or red puffy eyes may also be present if the trigger was airborne.
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
Name: Doctor’s Name:
179
Phone #
What i s Anaphylaxis? Anaphylaxis is a very serious type of allergic reaction. It occurs when a person is exposed to an allergen (ie., an allergy causing substance) to which he or she has been previously sensitized. In anaphylaxis, cells in the immune system release large amounts of chemicals, including higamine, which cause blood vessels to dilate and leak fluid into surrounding tissues, thus producing swelling. Usually, anaphylaxis is a systemic reaction (ic., it affects the entire body). What Are the Common Causes of Anaphylaxis? 0 Insect stings: 0 Foods: 0 Medications: 0 Exercise: Exercise-induced anaphylaxis is rare and puzzling. It may be caused by warm temperatures, intense exercise, or a food eaten hours before. What Are the Symptoms of Anaphylaxis? Anaphylaxis causes different reactions in different people. Symptoms are usually severe and appear rapidly- within seconds or minutes-after exposure to an allergen; in a few cases, reactions have been delayed as long as 2 hours.
L7 Respiratory symptoms:Wheezing, shottness’of breath, cough, difficulty in swallowing 0 Gastrointestinal symptoms: Nausea, vomiting, cramps, diarrhea Skin symptoms: Itch, swelling, hives, red and blotchy areas 0 Cardiovascular symptoms:Feeling faint, irregular heart beat, shock How is Anaphylaxis Treated? Anaphylaxis is a medicel emergency that requires immediate attention. Treatment must be started before blood pressure and breathing problems become critical. The most important drug for the treatment of anaphylaxis is epinephrine. The sooner the reaction is treated the less severe it will be. Here are your individualized instructions for treating anaphylaxis:
CI Wear a Medic Alert bracelet. In the event of an emergency, others can help you if they know your allergies.
Prevention of Anaphylaxis Remember, prevention is the best treatment for anaphylaxis. Avoid substances and situations that are known to trigger extreme allergic reactions. Photocopy this action plan for your family, friends, coworkers, and school personnel. Prepare those around you so that they may help you in the event of an emergency.
Figure 1. Anaphylaxis action plan.
WHAT TO DO IF THESE SYMPTOMS ARE PRESENT
Preventing severe allergic and asthmatic reactions requires awareness and education on the part of the school personnel in identification of triggers, awareness of early warning signs and symptoms, and close communication with the student’s family and physician (see Appendix).
180
HIGGINS
Guidelines for the management of asthma and allergies in the school setting are provided in the display boxes on this page and on subsequent pages of this article. It is the physician’s responsibility to provide written permission forms that explain the use of medications during school hours and to determine whether a child should be allowed to carry his or her own medications for self-administration. In some cases, this may even be an issue that needs to be addressed with the school board if the school has a policy of “no drugs.” A written action plan on file for children with severe allergies, asthma, or food allergies is essential.2 Having identified personnel who are trained and prepared is the key.
Display Box 1. Actions for the Principal*
Involve your staff in the asthma management program. A school asthma management program is a cooperative effort that involves the student, parents, teachers, school staff, and physicians. Many members of the school staff can play a role in maintaining your school’s asthma management program, although the principal or the school nurse may be most instrumental in getting a program started. Take the steps listed below to help set up an asthma management program in your school. Develop a clear policy on taking medication during school hours. Work with parents, teachers, the school nurse (if available), and others to provide the most supportive policy that your school system allows so that the student can get the medication he/she needs. Designate one person on the school staff to be responsible for maintaining each student’s asthma action plan. Provide opportunities for staff to learn about asthma and allergies by setting up inservice courses. You may get assistance from your school nurse, or a local hospital or medical society. Other sources of information are the American Lung Association, Asthma and Allergy Foundation of America, National Jewish Center for Immunology and Respiratory Medicine, and the Mothers of Asthmatics. Establish an asthma resource file of pamphlets, brochures, and other publications for school personnel to provide an opportunity for the staff to get additional information about asthma. Many of the organizations cited above offer materials for this purpose. Make general information available to students as well. Schedule any extensive building repairs or cleaning to avoid exposing students to fumes, dust, and other irritants. When possible, try to schedule painting and major repairs during long vacations or the summer months. Support and encourage communication with parents to improve school health services. W o r n Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education, NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991
ALLERGIES AND ASTHMA IN THE SCHOOL SETTJNG
181
Display Box 2. Actions for the Classroom Teacher*
Know the early warning signs of an asthma episode. Have a copy of the asthma action plan in the classroom. Review it with the student and parents. Know what steps to take in case of an asthma episode. Develop a clear procedure with the student and parent for handling schoolwork missed due to asthma. Understand that a student with asthma may feel drowsy or tired, different from the other kids, anxious about access to medication, embarrassed about the disruption to school activities that an asthma episode causes, and/or withdrawn Help the student feel more comfortable by recognizing these feelings. Try to maintain confidentiality. Educate classmates about asthma so they will be more understanding. Know the possible side effects of asthma medications and how they may impact the student’s performance in the classroom. Refer any problem to the school nurse and parent(s). Common side effects of medicine that warrant referral are nervousness, nausea, jitteriness, hyperactivity, and drowsiness. Reduce known allergens in the classroom to help students who have allergies. Common allergens found in classrooms include chalk dust, animals, and strong odors (perfumes, paints). Encourage the student with asthma to participate fully in physical activities. Allow a student to engage in quiet activity if recovery from an acute episode precludes full participation. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of !&hools and Teaching, Office of Educational Research and Improvement (OEM), US Department of Education. NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991: with permission.
182
HIGGINS
Display Box 3. Actions for the School Nurse or Other Health Personnel*
Maintain the asthma action plan for every student with asthma. Include information on medications, dosages, triggers, and emergency procedures. Alert staff members about students with a history of asthma. Use the warning signs presented in the publication, Managing Asthma: A Guide for Schools, to help identify students with uncontrolled asthma. Provide this information to parents with the encouragement to see a physician. Assist with the administration of medication in accordance with school policy. Monitor response to treatment using a peak flow meter. Communicate with parents about acute episodes, if any, and about the student’s general progress in controlling asthma at school. Conduct inservices on asthma, and consult with staff to help develop appropriate school activities for students with asthma. Collaborate with the PTA to consider offering a family asthma education program in school. Consult organizations on the resource list in the publication, Managing Asthma: A Guide for Schools, for assistance. If there is not a nurse at your school, these tasks should be assigned to an appropriate staff member. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650, Bethesda, MD, National Institutes of Health, 1991; with permission.
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
183
Display Box 4. Actions for the Physical Education instructor and Coach*
Encourage exercise and participation in sports for students with asthma. When asthma is under good control, students with the disease are able to play most sports. A number of Olympic medalists have asthma. Appreciate that exercise can cause acute episodes for many students with asthma. Exercise in cold dry air and activities that require extended running appear to trigger asthma more readily than other forms of exercise. However, medicines can be taken before exertion to help avoid an episode. This preventive medicine enables most students with exercise-induced asthma to participate in any sport they choose. Warmup and cooldown activities appropriate for any exercise will also help the student with asthma. Support the student’s treatment plan if it requires premedication before exercise. Understand what to do if an asthma episode occurs during exercise. Have the child’s asthma action plan available. Encourage students with asthma to participate actively in sports but also recognize and respect their limits’. Permit less strenuous activities if a recent illness precludes full participation. Refer your questions about a student’s ability to fully participate in physical education to the parents and school nurse. *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.
Display Box 5. Actions for the Guidance Counselor*
Help all school personnel understand that asthma is not an emotional or psychological disease-it is not ”all in the child’s head.” Strong emotions such as laughing or crying can trigger an acute episode because this irritates and constricts the sensitive airways of a person with asthma. Recognize that learning to cope with asthma, as with any chronic illness, can be difficult. Teachers may notice low self-esteem, withdrawal from activities, discouragement over the steps needed to control asthma, or difficulty making up schoolwork. Special counseling with the student and/or parents may help the student handle problems more effectively. “FromManaging Asthma: A Guide for Schools. National Heart, Lung and Blood Instutite (NHLBI), National Institutes of Health US, Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education. NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.
184
HIGGINS
Neither the parent nor the physician has direct authority at school; thus, the training of the identified staff should include how to administer nebulized medication, use of a metered dose inhaler, and administration of epinephrine. A further tool that can be useful in determining decreased lung function in asthma is the peak flow meter. By regular monitoring of an asthmatic’s lung function with this small handheld device, the staff can have increased confidence when assessing that child’s need for medication; after administration, such monitoring can assist in determining if further medical assistance is required. The peak flow meter is like a thermometer for the lungs. Through regular monitoring, each person obtains a “personal best” number. This number is the best that a given individual is able to blow into the meter in 1 second. Once the number is acquired, simple calculation of 80% and 50% of that number becomes the “watch” areas of that person’s lung function. Monitoring is set up like a stoplight, with 80% to 100% being the “green” zone. When lung function is in this range, daily medications are all that is required. The ”yellow” zone falls between 80% and 50% of the personal best number. When an asthmatic is in this area, use of a ”reliever” medication (e.g., albuterol) is indicated based on the physician’s plan. ”Red” zone readings on the meter indicate an acute need for assistance in breathing and must be aCted on immediately according to the action plan agreed on by the parent and physician. The Committee on School Health of the American Academy of Pediatrics has suggested that two or more members of the staff be designated and trained in the recognition and treatment of anaphylaxis, including the use of subcutaneous injection of epinephrine.2 Ideally, schools that have a full-time nurse or health clinic should provide training in recognition of allergic emergencies. Unfortunately, more school districts are having to cut back on finances; as a result, a person with no medical background may be required to perform medical treatments. The Food Allergy Network has a videotape and informational materials available for schools that wish to provide more education regarding food allergies. INFLUENCE ON PARTICIPATION IN SCHOOL ACTIVITIES Ideally, the goal for any child with asthma or allergies is full participation in sports. This is evidenced by the number of asthmatic Olympic athletes who, despite their medical conditions, achieve sports greatness. If personnel cannot be properly educated about symptom recognition and relied on to use good judgment or if the current status of a child’s asthma is not well managed, some limits may be temporarily placed on exercise, however. Efforts to prevent exercise-induced asthma require communication with the school coach and allowance of premedication on the part of the student athlete under a physician’s guidance. Often, coaches or teachers notice children who have increased coughing, wheezing, or shortness of
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
185
breath during or after exercise. By receiving education in symptom recognition of the signs of asthma, they may even prompt a visit to the physician for clarification and possible asthma diagnosis. It is the goal that children with asthma and allergies should be able to fully participate in all school activities. INFLUENCE ON LEARNING Many factors can affect the ability of a student with asthma or allergies to learn. For instance, poorly managed asthma or allergies and medication side effects can result in a poor attention span or loss of concentration. Inadequate rest, hearing loss due to clogged ears, headache, fatigue, hyperactivity, or excessive itching of the skin can also affect a student's ability to learn. With good communication between the school, parent(s), and physician, medications can be adjusted or revised, resulting in optimal control of the disease while limiting side effects and maximizing the student's ability to learn. IDENTIFYING HEALTH RISKS Each school offers its own list of factors that may place students at risk. These can vary based on the age of the building and the type of heating and ventilation systems. For children with food allergies, meal preparation and notification are important. The food service staff need to have a clear understanding that possible cross-contamination or misidentification could lead to adverse anaphylaxic events. Food-allergic children might be accommodated in an "allergy-free" eating space in the school lunchroom. The choice of carpeting as the desired flooring for schoolrooms and whether or not animals are allowed in the classrooms should be considered. Accordingly, it is prudent for school personnel and parents to work closely together in identifying factors that may affect the child. It is the parent's responsibility to communicate with the physician about any factors found in the classroom or school activities that are affecting the child's health. The United States Environmental Protection Agency Indoor Environmental Division has published a resource kit for school personnel calIed Tools for Schools, which covers some of these issue^.^ The National Heart, Blood, and Lung Institute also has published Managing Asthma: A Guide for Schools, which equips each member of the school staff with a clear outline and set of guidelines to follow.6 The American Lung Association offers a student education program entitled "Open Airways" to assist children in the management of asthma. ACTION PLAN(S) There are several excellent action care plans available, including one published by the Asthma and Allergy Foundation of America, the "Student Asthma Action Card" (Fig. 2): It may be obtained free of charge by contacting the Asthma and Allergy Foundation of America.
186
HIGGINS
Name:
Grade:-
Teacher:
Room:
ParenUCuardian Name:
P h (H)
-
AF:
ID Photo
P h (W)
Address: ParentlGuardian Name:
PhtH) Ph: (W)
Address: Emergency Phone Contact # I Name
Relationship
Phone
Relationship
Phone
Emergency Phone Contact t 2 Name Physician Student Sees for Asthma:
Ph
Other Physician:
Ph
DAILY ASTHMA MANAGEMENT PLAN Identify the things wbirh .start an asthma episode (Check each that appliesto the student.) 0 Exercise
0 Strongodorsorfuma
0 Respiratory infections 0 Change in temperature
0 Chalkdust
0 Animals
0 Carpetsintheroom poiimr
D Food
0 Molds
0 Other
Comments
Control of SchoolEnvironment (List any cnvironmental control measures, pre-medications, and/or dietary restrictions that the student needs to pment an asthma episode.)
~~
Peak plow Monitoriag Personal Best Peak Flow number: Monitoring 'Emes:
DdyMcdicptionPlan Name
Amomt
When to Use
1. 2.
3. 4.
Figure 2. See legend on opposite page
Another good source is the National Lung, Heart, and Blood Institute, which has care plans, educational pieces, and handouts available in its publication entitled, Teach Your Patients About Asthma: A Clinician's Guide.7 The important thing to remember is that whatever action plan is chosen, it should include the following: causes of the reaction, who to
ALLERGIES AND ASTHMA IN THE SCHOOL SETTING
187
EMERGENCYPLW Emergencyaction is necessary when the student has symptomssuch as
-.
or has a peak Bow reading of Steps t o take during an asthma episode: I. Give medicationsas lited below.
2. Have student return to classroom if 3. Contact parent if Seek emergencymedical care if the student has any of the following: V No improvement 15-20 minutes aher initial treatment with medication and a relativecannot be reached. V Peakflowof
4.
V Hard time breathing with:
- Chest and neck pulled in with breathing
/ F 7 k I i S m f & T
E ~ ~ m m HELP c r Now!
Child is hunched over Child is struggling to breathe V Trouble walkingor talking
-
V Stops playing and can't start activity again
V Lips or fingernails are gray or blue *
Emergency Asthma Media~tiom Amount
Naate
When to Usc
1. 2.
3. 4.
COMMENTS / SPECIAL hS"RUCn0NS
FORINHALED MEDICATIONS in the proper way to use hidher medications. It is my should be allowed to carry and use that mediition
I have instructed prohioaal opinion that by himherself.
0 It is my professionalopinionthat
Parent Signature
should not carry hdber inhaled medication by hidhemelf.
Date
Figure 2. Student asthma action card endorsed by the NationalAsthma Education Program. (From the Asthma and Allergy Foundation of America, Washington, DC; with permission.)
188
HIGGINS
contact in a emergency, what the physician has outlined to do until medical help arrives, and customization of the plan to each student’s needs. By forming a partnership between the family, student, school personnel, and physician, allergic and asthmatic episodes can be effectively managed in the school setting. References 1. American Academy of Asthma, Allergy, and Immunology, Asthma and Allergy Alliance: Anaphylaxis Action Plan, Publication No. 1993 2. American Academy of Pediahics, Committee on School Health: Guidelines for urgent care at school. Pediatrics 86:999-1000, 1990 3. Asthma and Allergy Foundation of America: Student Asthma Action Card 4. Current estimates from National Health Interview Survey, 1994. Vital Health Stat 10:94, 1995 5. Furukawa C T Allergy, Asthma, and Immunology from Infancy to Adulthood, ed 3. Philadelphia, WB Saunders, 1996, pp 761-768 6. National Lung, Heart, and Blood Institute (NLHBI), United States Department of Health and Human Services, National Asthma Education and Prevention Program: Managing Asthma: A Guide for Schools, NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991 7. National Lung, Heart, and Blood Institute (NLHBI),United States Department of Health and Human Services, National Asthma Education and Prevention Program: NIH Publication No. 92-2737. Bethesda, MD, National Institutes of Health, 1992 8. Rosenstreich DL, Eggleston P, Cattan M, et ak The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med 3361356-1363, 1997 9. United States Environmental Protection Agency Indoor Environmental Division: Tools for Schools, Publication No. 402-K-001
Address reprint requests to Lon Jo Higgins, LPN Northwest Asthma and Allergy Center 4540 Sand Point Way NE Seattle, WA 98105
APPENDIX
Resources Available to Schools To Help Manage Asthma* For more information contact: The National Asthma Education Program Information Center 4733 Bethesda Ave. Suite 530 Bethesda, MD 20814-4820 (301) 951-3260 The following organizations can provide additional materials and additional information about asthma: Asthma and Allergy Foundation of America National Headquarters 1717 Massachusetts Ave., NW Suite 305 Washington, DC 20036 1-800-727-8462 American Lung Association (Call your local Lung Association) National Jewish Center for Immunology and Respiratory Medicine 1400 Jackson St. Denver, CO 80206 1-800-222-5864 American Academy of Allergy and Immunology 611 East Well St. Milwaukee, WI 53202 1-800-822-2762 National Allergy and Asthma Network/ Mothers of Asthmatics 3554 Chain Bridge Road Suite 200 Fairfax, VA 22030 1-800-878-4403 American College of Allergy & Immunology 800 East Northwest Hwy. Suite 1080 Palatine, IL 60067 1-800-842-7777 *From Managing Asthma: A Guide for Schools. National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health, US Department of Health and Human Services, and the Fund for the Improvement and Reform of Schools and Teaching, Office of Educational Research and Improvement (OERI), US Department of Education, NIH Publication No. 91-2650. Bethesda, MD, National Institutes of Health, 1991; with permission.)
189