This document provides information for school nurses on food allergies, including an overview of common food allergies, signs and symptoms of anaphylaxis, emergency treatment of anaphylaxis with epinephrine, and developing a food allergy action plan and management plan for students with food allergies. It also discusses a case example of a fatal food-induced anaphylaxis and risk factors. The goal is to educate nurses on recognizing and treating allergic reactions and ensuring safe participation of students with food allergies in all school activities.

1. Food Allergy Primer
for School Nurses
Stacy K. Silvers, M.D.
Robert W. Sugerman, M.D.
DallasAllergyImmunology Associates

2. Learning Objectives
• Recognize signs and symptoms of anaphylaxis
• Understand acute management of anaphylaxis
• Discuss long term preventive approaches for
individuals at risk for anaphylaxis

3. Case Illustration
An 8 year old boy with known history of
peanut allergy and asthma complains of a
burning sensation in the mouth and throat
several minutes after eating a snack of jelly
beans, potato chips and lemonade at school.
He is sent to the nurse’s office, where he
complains of abdominal pain and vomits.
The child’s mother is called to come get him.

4. Case Illustration (continued)
The child is noted to be hypotensive and
wheezing upon arrival to the pediatrician’s
office 30 min later. SC epinephrine, Benadryl,
nebulized albuterol and IV NS fluid bolus are
given promptly and 911 is called. The child
develops asystole en route to the hospital and
expires in the emergency department 90 min
later in spite of aggressive resuscitation
efforts.

6. Prevalence of Food Allergy
• 25-30% of parents believe their children
have at least one food allergy
• Prevalence of immune mediated adverse
reactions to foods (food allergy) in children
is approximately 4-6%
• Prevalence of food allergy in adults is 1-2%

7. Food Allergy vs. Intolerance
• Food allergy is an adverse response
mediated by an immunologic mechanism
– May be triggered by minuscule quantities
– Potentially life threatening

8. Food Allergy Examples
• Anaphylactic shock due to peanut
– IgE mediated immediate hypersensitivity
• Acute milk / soy protein enterocolitis
– Lymphocyte mediated hypersensitivity
• Atopic dermatitis
– IgE and lymphocyte mediated responses
• Celiac disease (gluten sensitive enteropathy)
– Anti-gliadin antibody

10. Food Allergy vs. Intolerance
• Food intolerance is an adverse response
mediated by a non-immunologic mechanism
– Often more “dose dependent” compared to
allergic reactions
– Effects are frequently annoying but never life-threatening

11. Food Intolerance Examples
• Taste preferences
– Regular vs. chocolate milk
• Lactose intolerance
– Lack of a digestive enzyme
• Migraine headaches
– Pharmacologic effect of vasoactive amines

12. Most Common Allergenic Foods
The “Big 8”:
•Milk
•Egg
•Wheat
•Soy
•Peanut
•Tree nuts
•Fish & shellfish

13. Relevant Proteins
• Milk: casein, whey, lactalbumin, lactoglobulin,
sodium caseinate, milk solids, caramel flavoring,
“natural flavorings”, “dairy free” creamers, “KD”
• Egg: ovalbumin, ovomucoid, egg substitutes,
mayonnaise, meringue
• Soy: soy sauce, tofu, miso, hydrolyzed vegetable
protein, textured vegetable protein (TVP), “natural
flavorings”, meat substitutes, milk substitutes

14. Food Allergen Labeling &
Consumer Protection Act (2004)
• Ingredient labels must list presence of
allergenic food proteins in plain English
• Some manufacturers have added
precautionary statements:
– “may contain . . .”
– “manufactured in a facility that processes. . .”

15. Approach to Diagnosis
• Detailed history of adverse reactions
– What, when, where, how much & how severe
• Allergy testing
– Percutaneous skin testing - commercial extracts
or fresh ingredients
– ImmunoCAP IgE antibodies
– Patch testing – for eosinophilic esophagitis
– Open, single blind & double blind placebo
controlled food challenges

16. Case Illustration Revisited

17. Food Anaphylaxis Fatality
Statistics (U.S.)
• 150 food anaphylaxis fatalities annually
• 90% of fatal reactions begin in a public
setting (e.g., schools, restaurants)
• 70-80% of fatalities involve nuts (peanuts or
tree nuts)

18. Most Common Hiding Places
• Cookies
• Candies
• Snack foods
• Cereals
• Restaurants
• Ice cream parlors
• School classrooms

19. Recipe for Disaster:
Risk Factors for Fatal Anaphylaxis
• Peanut / tree nut allergy
• History of asthma
• Delay in administering epinephrine

20. Be Prepared for Allergic Reactions
• Accidents are never planned
• Keys to being prepared:
Knowing how to recognize symptoms and
administer medications quickly
A written Food Allergy Action Plan
Epinephrine must be immediately available

21. Signs & Symptoms of Anaphylaxis
Trouble swallowing
Shortness of breath
Repetitive coughing
Voice change
Nausea & vomiting
Diarrhea
Abdominal cramping
Swelling
Hives
Eczema
Itchy red rash
Drop in blood pressure
Loss of consciousness

23. Epinephrine Autoinjectors
EpiPen® and Auvi-Q® are both reliable products
Standard doses: 0.15 mg and 0.3 mg

24. EpiPen®
Instructions
Epipen is a registered trademark Online video at w owf Dewy P.ehaprmipaceeuntic.aclsom

25. Auvi-Q® Instructions
Online video at www.auvi-q.com

26. The Food Allergy Plan
The plan to manage a student’s food allergies
should take into account:
• Unique needs of the child
• School environment and personnel resources
• Goal of equal participation in all school-related
activities

27. The Food Allergy Plan
Developing the plan is a team effort involving:
• School staff
• Child’s family (parents/guardians)
• Child’s physician
• The child who has allergies, as age-appropriate

28. School’s Responsibility
• Create an environment where all children,
including those with food allergies, will be safe
• Employ prevention and avoidance strategies
• Be prepared to handle allergic reactions
• Address bullying

29. Family’s Responsibility
• Provide written medical documentation
• Work with the school to develop a plan
• Provide properly labeled medications and replace
after use or when expired
• Keep emergency contact information up-to-date
• Teach child age appropriate self-management skills

30. Food Allergy Rules to Live By
• Be careful and prepared, not fearful
• Have a Food Allergy Emergency Action Plan
at school
• Always have 2 epinephrine injectors on hand
• 3-4 hours of E.R. observation after giving
epinephrine to watch for late phase response

31. Food Allergy Resources
•Food Allergy Research & Education (FARE):
www.foodallergy.org
•Allergy & Asthma Network/Mothers of
Asthmatics: www.aanma.org
•American Academy of Allergy, Asthma &
Immunology: www.aaaai.org
•American College of Allergy, Asthma &
Immunology: www.aacai.org