Although the management of life threatening allergies in Massachusetts’ schools has greatly improved, there remain ongoing challenges.

Physicians’ ordering Benadryl: Epinephrine is the first line treatment of anaphylaxis. This must be reflected in allergy action plans. Antihistamines are second line and if used, should only be used in conjunction with epinephrine in the treatment of anaphylaxis.
Antihistamines are slow to act (30-60 minutes), have no effect on platelet activating factor, leukotrienes, prostoglandins, or other mediators, and are ineffective for GI, respiratory, and circulatory symptoms. . Additionally, there is no high quality evidence either for or against the use of H1-antihistamines in anaphylaxis as per a recent Cochrane Review.

Students who like peanut-butter and those allergic to it: Schools need to develop strong communication systems with all families to advise them of the prevention strategies for students with LTAs. Additionally they need to be aware of the potential divisiveness of this issue and help bridge the gap between the families of the food allergic and those without allergies (Of note is that the policies concomitant to wellness and obesity prevention are actually assisting in making the food allergy environment safer.)

Peanut free schools: An ongoing controversy is the issue of peanut-free schools versus allergy aware zones. Stating a school is peanut free tends to give a false security. Many Massachusetts schools have allergy aware zones or tables with strict policies.
An additional consideration is the importance of a child’s participation in food allergy management that will help them develop skills that they will inevitably need when they leave their school.

Teaching unlicensed personnel: A wide range of school personnel need education about the issues relating to food allergies, as well as training to administer the epinephrine by auto-injector should an unintended exposure occur; these staff may include teachers, athletics personnel, administrators and school bus drivers.

Education regarding biphasic reactions and the potential need for additional epinephrine: Some episodes of anaphylaxis may be biphasic, where there is a return of anaphylaxis after the resolution of symptoms. It is difficult to predict which patients may experience a biphasic reaction, but there seems to be increased likelihood with increased severity, higher epinephrine requirements, and in cases where there was a delayed administration of epinephrine. . Taking the biphasic reaction into account, students should be taken by ambulance to the emergency department and observed for a minimum of four to six hours, with longer observation times and hospital admissions for severe symptoms . In addition to the potential for a biphasic reaction, episodes of anaphylaxis may require more than one dose of epinephrine, supporting recommendations to have two doses available

Massachusetts has accrued valuable information and has developed a well thought out and ever evolving set of guidelines that has improved the management of life threatening allergies in school. It is our hope that Massachusetts’ experience may be used as a building block or guide for new and changing policies nation wide, and used as a guide to assist pediatricians in their collaboration with schools.