Anaphylaxis a guide for teachers

The death of an Australian student due to anaphylaxis on a school camp is slowly resulting in State governments taking action to prevent more – potentially avoidable – fatalities.

Once upon a time, not all that long ago, anaphylaxis was a word few people knew and even fewer knew anything about. Anaphylaxis – or as it’s more commonly known, anaphylactic shock – was so rare that almost no one knew anyone who “had” it. If you did, it was usually an allergy to bee stings.

Now, the situation is dramatically different. The incidence of anaphylaxis due to allergies is on the rise. Our children may not know the term, but most of them know of classmates or friends who are not allowed to eat one food or another.

So what is it? The medical definition des-cribes anaphylaxis as a “sudden, severe and rapidly progressive allergic reaction to an allergen in a sensitised individual”.

Allergies to peanuts alone have become significantly more common worldwide and it is estimated that 2 per cent of students are peanut allergic. Reactions are also triggered by shellfish, egg, milk, insect stings, latex and medicines. In peanut–allergic children, half are likely to have experienced allergic symptoms by the age of two years; almost all would have experienced symptoms by the age of seven years.

If the prevalence in the western world is applied to Australia, most schools and licensed child-care premises have at least one child at risk of anaphylaxis and several others who are food allergic.

That suggests that a large number of the country’s teachers may be in a position that they are required to manage a child or children at risk of anaphylaxis. And school excursions are among the occasions when they may be the only adults in close range in any position to “manage” anything at all.

As was written in the Western Australian report Anaphylaxis: Meeting the challenge for Western Australian Children, “the unpredictable nature of anaphylaxis with rare but potentially life-threatening consequences leads to an expectation amongst parents of at-risk children, that child-care workers and teachers have the ability to protect their children and provide first aid in life-threatening emergencies”.

At the same time, though, the report points out, childcare workers and teachers can reasonably “have an expectation” that policies and practices will exist so they can “recognise and manage” the health needs of those children at risk.

Around the country, governments are starting to take heed and address the concerns of parents, school communities, health expert and – not least – students, who recognise that a reaction has potentially major social and psychological effects, not only on the allergic person but those who witness the reaction, and those who believe – rightly or wrongly – that they could have “done something”.

In NSW, Victoria and WA, governments have responded to a NSW coronial inquiry report into the death of Hamidur Rahman on an excursion in NSW in 2002. The coroner recommended that training in the area of allergy awareness should be implemented “immediately” in all public and private sector schools, for staff and students. Such training should include identifying students at risk, methods of allergy prevention and risk management, how to recognise anaphylaxis and how to provide emergency treatment, particularly in the use of the EpiPen, the injection that must be given as quickly as possible when symptoms of anaphylaxis are noted.

(Evidence suggests that early administration of the EpiPen means a child has a good chance of surviving; of the patients who have died from food related anaphylaxis, 84-91 per cent did not receive adrenaline within 15 minutes of the onset of symptoms.)

Other recommendations covered procedures that would ensure parents alerted schools, that schools maintained up-to-date records accessible by all staff, and that students also knew how to recognise an anaphylactic reaction.
Maria Said, president of Anaphylaxis Australia, says while South Australia and the ACT developed guidelines in the late 1990’s, NSW established guidelines after the death of Hamidur Rahman and since has revised those guidelines.

 In October 2006, then-Victorian Premier Steve Bracks announced that Victoria would be the first Australian State to mandate training for child-care workers, and kindergarten and school teachers to treat children with life-threatening allergies. And in October 2007, WA Premier Alan Carpenter agreed to act on all eight recommendations of the specially convened Anaphylaxis Expert Working Committee, among them the establishment of a training program for teachers and child-care workers to instruct them how to handle an allergy emergency.

But in Queensland, for instance, guidelines exist “on a website that not many people are aware of”; the government instructs principals to show a PowerPoint presentation to those staff members he or she believes should see it. If those particular staff members aren’t in the playground or on a camp when a student has a reaction, Ms Said points out, what then?

Similarly in Tasmania, where guidelines on a website suggest “relevant” teachers should be instructed; in South Australia, the first state to initiate action, in 1998, guidelines are currently being reviewed. But in the meantime, Ms Said, a reliance on the already under-resourced St John Ambulance and Red Cross for instructing school staff has led to “problems with access”.

“Different states are at different levels of acknowledging how widespread the allergy problem is, and how many people in their states are at risk,” Ms Said says. “There has been a sudden increase in the prevalence of food allergies, and we need resources to manage that in every state. The $6.6 million allocation in WA is an acknowledgement of the problem, but we need that in all states and around the country to ensure school staffs are informed and the risk to students is reduced.”

As to the reason for a “sudden increase” in food allergies – a trend so obvious that no one denies it – Ms Said says there are many theories but “no concrete answer”. One idea, the “hygiene hypothesis”, attributes the increase to the fact that children are not exposed to as many germs and bacteria as they used to be; another puts it down to children of today being exposed much earlier to a wider variety of foods.

Whatever the reason, she argues, the point is the same: training of teachers and other staff should occur so preventative measures can be implemented, symptoms are recognised early and action taken, and a management plan should be in place to cover emergency situations.

“This is even more crucial for a school camp,” Ms Said says. “Most people who die from anaphylaxis die away from home. But a lot of forward planning, with the parents’ involvement, can and should enable students at risk of an allergic reaction to attend camps with their peers.

“Planning should involve not just viewing a camp menu but talking to the chef or caterers. Mobile-phone access should be ascertained, and distances and routes to hospitals and medical personnel calculated.”

It may be, says Ms Said, that the answer is for a parent to attend the camp as a helper when children are young.
“Early planning and calculation of risk assessment will allow all concerned to develop a management plan so a student at risk of anaphylaxis can attend the camp. Parents, staff and doctors can talk about what can be done to minimise the risk of an emergency and action if such an emergency occurs,” she adds.

“Kids are tired on school camps, and teachers are tired as well. Preparation has to be done ahead of time, so that at all times, someone is responsible for that student or students, and that at any one time, the responsible person is aware of just that.”

What to do
The key is to avoid allergens – which, considering the widespread availability and varied forms in which peanuts alone may be obtained, is not as easy as it may sound.
But if the worst happens, it’s a matter of acting quickly. Symptoms of anaphylaxis include:

Mild to Moderate:
• Swelling of lips, face and/or eyes
• Hives or welts
• Abdominal pain, vomiting

Severe:
• Difficulty breathing or noisy breathing
• Swelling of the tongue
• Swelling/tightness in the throat
• Difficulty talking or a hoarse voice
• A wheeze or persistent cough
• Loss of consciousness or collapse
• Child becomes pale and floppy (particularly young children)

Adrenaline is the only medication that has been shown to be effective for the immediate treatment of anaphylaxis. In most cases – outside a hospital or clinic – a pre-filled auto-injector containing adrenaline, called an EpiPen, is used during the reaction. The EpiPen Junior is the version recommended for children weighing between 10 and 20 kg and the EpiPen for anyone weighing more than 20kg.

Evidence suggests that early administration of the EpiPen according to a person’s Anaphylaxis Action Plan (an individually tailored plan for instructions should symptoms occur, signed by the child’s doctor) means a child has a good chance of surviving. Once the EpiPen Is given, call 000 and organise ambulance transport to hospital for further treatment. Keep the person as calm as possible and in a lying position (if they have difficulty breathing, let them sit up). Do not stand them up.

Early detection and recognition of the signs and symptoms of anaphylaxis, by parents, carers and school staff is crucial in maximising the chances of prompt recovery and survival.