Allergy Handbook

Allergy and The Environment – An Arizona Handbook

The Arizona Allergy and Asthma Society is an organization comprised of board-certified and board-elligible Allergy/Immunology specialists in Arizona. One of our goals is to serve as a resource for allergy information to the Arizona public. This is achieved by providing Arizonians with the “Allergy and the Environment, An Arizona Handbook.” On online version of this handbook is available below.

School Environment

How can the school environment affect children’s allergies?

SCHOOL ALLERGIES

by Nabeeh N. Lahood, M.D. Leonard B. Schultz, M.D.

To appreciate the scope of allergic problems that children may experience during their school years, one must, first of all, realize that approximately one-third of a child’s life (up to eight hours a day) between the ages of six and eighteen is spent in the school environment. It is no wonder, then, that environmental exposures at school can profoundly influence the well-being (or lack thereof) of an allergic child.

Generally speaking, four categories of allergic problems can be distinguished.

Inhalant allergy. Probably the most common category, it can be exemplified by the Bermuda grass school yards common in Tucson and Phoenix. Bermuda pollen represents one of the prime allergenic exposures in both communities and, especially combined with other seasonal pollen exposures such as mulberry, olive tree, ragweed, and tumbleweeds, can wreak havoc on the recess and outdoor P.E. experience in spring and fall. In a somewhat narrower sense, exposure to furry pets during biology class or “show and tell” can have the same effect on a highly sensitive child.

Fortunately, recent advances in allergy treatment, both immunological and pharmacological, have provided physicians with a potent therapeutic armamentarium against the symptoms provoked by such exposure.

Food allergies. Particularly in the lower age groups, foods consumed at school, either by design or inadvertently, can provoke allergic symptoms – sometimes very severe ones, as in the case of a peanut sensitive individual. The school administrative staff should be informed if such a problem is known to exist and appropriate emergency medication such as injectable epinephrine (adrenaline) kept in the nurse’s office.

Exercise-induced bronchospasm (EIB). This is a much more common manifestation of allergy than has been thought in the past, and often goes unrecognized and undiagnosed. It consists of symptoms of coughing, wheezing, and shortness of breath during or after exercise, and it can lead, if untreated, to marked limitation of physical activity, both during recess and, more importantly, during physical education classes. This is all the more unfortunate because this distressing symptom can be both prevented and treated by the appropriate administration of a metered-dose inhaled medication (such as albuterol or cromolyn) prior to the anticipated exertion. Thus, any child with known EIB should have such an inhaler available for use prior to P.E. or recess.

Poor school performance. While both medical experience and common sense would teach that a child with constant nasal congestion, sneezing, and sinus pain could not function optimally in his or her school environment, only recently have physicians begun to recognize that the associated difficulty in sleeping, hearing problems, and general irritability can be significant contributors to poor school performance, emotional problems, and even the so-called Attention Deficit Disorder that seems to be increasing among school children. When allergy evaluation has revealed this possibility, subsequent allergy management has often resulted in significant improvement in these parameters.

Finally, if any or all of the above allergy categories are suspected, a comprehensive allergy evaluation should be considered.

Are inhaled medications appropriate in schools?

THE USE OF INHALED MEDICATIONS IN SCHOOL BY STUDENTS WITH ASTHMA

Position statement of the American Academy of Allergy and Immunology Committee on Drugs*

Students with asthma frequently have the sudden onset of asthma symptoms from a variety of causes, including exercise. In most cases, asthma can be prevented or treated by inhaled medications. For many students with asthma to function normally at school, these prescribed medications must be readily accessible to the individual. Students whose parents and physician judge that they have sufficient maturity to control the use of these inhaled medications should be allowed to retain these inhalers in their possession. School policies that require inhalers to be kept in school official’s or nurse’s offices result in an interference in the medical needs of the patient and may seriously delay treatment. Most students will not properly use their medications under these circumstances. School officials should discuss with parents or physicians of students with asthma any problems regarding appropriateness and responsibility of use of these medications. Otherwise, schools should cooperate in the best interest of the patient by permitting the student to have possession of their inhaled medication. There is no indication that these medications have any potential for abuse by students without asthma. Therefore, it should not be argued that this policy presents any danger to other students. It is reasonable to expect that the student requiring inhaled medication to be sufficiently responsible and discreet in its use to avoid drawing attention to treatment.

Therefore, we recommend that students with asthma be permitted to have in their possession inhaled medications for the treatment and the prevention of asthma symptoms when they are prescribed by that student’s physician.

* Reproduction from “The use of inhaled medications in school by students with asthma” (Committee on Drugs, American Academy of Allergy and Immunology, J. Allergy Clin. Immunol., 1989, 84(3):400) with permission from Mosby-Year Book, Inc.

How should schools handle children with allergies?

THE TREATMENT IN SCHOOL OF CHILDREN WHO HAVE FOOD ALLERGIES

Committee report from the Adverse Reactions to Food Committee Of the American Academy of Allergy and Immunology*

Although the exact prevalence of food allergy in school-age children is unknown, conservative estimates suggest that at least one food-allergic student attends most schools (1). The symptoms and signs attributable to allergic reactions to foods vary among affected individuals, but commonly involve the gastrointestinal tract and/or the skin, less frequently involve the respiratory tract, and rarely involve the cardiovascular system (2). Although most of these reactions are self-limited and/or respond to appropriate early medical intervention, fatal anaphylactic reactions to foods is exquisitely sensitized individuals have been documented (3). Simply stated, the key to the prevention of allergic reactions to foods is antigen avoidance, that is, ensuring that the food-allergic child is not exposed to an offending food. Attainment of this goal often prove more elusive in practice than might theoretically be predicted and requires the development of a heightened awareness of the potential risks associated with allergic reactions to foods and increased commitment and cooperation among several parties, including teachers, physicians, parents, and sensitized children.

If, while these children are at school, all children with food allergies ate only foods carefully prepared at home, it would theoretically be possible to prevent food- induced reactions. However, many children with food allergies prefer to consume meals in the school cafeteria, share or swap foods with classmates, or participate in classroom activities that involve the ingestion of various snacks. Since it is impossible for parents to inspect everything eaten by their children at school, instruction of these children concerning which foods are safe and which foods must be avoided is important. Physicians should review potential sources of inadvertent exposure to offending foods with their parents and their parents, when this is necessary, should teach their children how to read labels. In turn, parents need to inform the appropriate teachers about their children’s sensitivities. Bracelets or necklaces identifying the children as having food allergies should be worn to school. Cooperation among parents and teachers about providing safe snacks for the food- allergic child at classroom activities without drawing undue attention to the child is sometimes necessary. The unambiguous advance listing of ingredients used in the preparation of foods served in the school cafeteria provides the food-sensitive child, either alone or with the aid of a responsible adult, the information needed to select a safe meal. In addition, steps should be taken in the kitchen of the school cafeteria to avoid inadvertent contamination of non-allergenic foods with allergenic foods by preparing these foods with separate utensils.

* Reproduced from “The treatment in school of children who have food allergies” (Committee report from the Adverse Reactions to Food Committee of the American Academy of Allergy and Immunology, J. Allergy Clin. Immunol., 1991, 87(3):749-51) with permission from Mosby-Year Book, Inc.

Unfortunately, long-term studies of food-allergic subjects suggest that the frequency of adverse reactions resulting from the accidental ingestion of offending foods by allergic individuals is alarming. For example, in one study, 16 of 32 peanut-sensitive individuals contacted had experienced an accidental ingestion within the previous year. (4). Clearly, discussion between teachers, physicians, parents, and food-allergic children concerning the prevention of reactions should also include both a review of symptoms and signs that might aid in early recognition of a reaction and a detailed treatment plan. A study reviewing seven cases of fatal allergic reactions to foods revealed that the ingestion of milligram to gram (5000 mg equals 5 grams or 1 teaspoon) amounts of food allergen by exquisitely sensitized individuals may prove fatal and raised important points regarding the treatment of individuals during allergic reactions to foods (3). The rapidity with which life-threatening reactions developed in these individuals suggests that the availability and early appropriate administration of epinephrine followed by immediate transport to an emergency room is indicated at the first sign of a severe allergic reaction. Parents, food-allergic children who are old enough to be trained, and school nurses or another designated responsible individual, such as the child’s teacher, need to be trained to recognize the symptoms of impending anaphylaxis and promptly institute the proper therapy, including the oral administration of an appropriate dose of antihistamine and the early use of aqueous epinephrine by injection. It is strongly recommended that aqueous epinephrine in a form that can easily be administered by injection (EpiPen Jr. and EpiPen; Center Laboratories Division, Port Washington, N.Y.; Ana-Kit; Hollister-Stier Laboratories, Spokane, Wash.) be available and that a responsible individual be designated to administer the injection in the event of an allergic reaction to a food. The dosages and indications for the use of other medications, such as antihistamines and/or inhalers needed for the treatment of bronchospasm, should be clearly delineated (Fig. 1). Furthermore, a plan for safe transport of a food-allergic child during a reaction to the closest medical facility capable of treating anaphylaxis should be developed.

REFERENCES

1. Anderson JA, Sogn DD, eds. American Academy of Allergy and Immunology and the National Institute of Allergy and Infectious Diseases: Adverse reactions to foods. (Washington D.C.: U.S. Government Printing Office. Publication no. 0170- 44-0045-1), 1984.

2. Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlled food food challenge (DBPCFC) as an office procedure: a manual. J Allergy Clin Immunol 1988; 82:986-97.

3. Yunginger JW, Sweeney KG, Sturner WQ, et al. Fatal food-induced anaphylaxis. JAMA 1988; 260:1450.

4. Bock SA, Atkins FM. The natural history of peanut allergy. J Allergy Clin Immunol 1989; 83:900-4.

Allergy and the Environment