OBJECTIVES OF SESSION

1. GUIDELINES FOR MANAGEMENT OF ANAPHYLAXIS IN EDUCATIONAL ESTABLISHMENTS DOH /Education AuthorityRevised February 2018

2. OBJECTIVES OF SESSION • Update your knowledge on anaphylaxis • Be aware of the emergency treatment prescribed for children with this condition • Practise the correct technique for Adrenaline auto-injector administration • Be aware of the roles and responsibilities of parents, school, pupils, and school health team

3. WHAT IS ANAPHYLAXIS? • Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing life-threating problems involving the airway and /or breathing and /or circulation. In most cases, there are associated skin and mucosal changes

4. Why does anaphylaxis occur? The body’s immune system reacts inappropriately in response to the presence of a food or substance that it wrongly perceives to be a threat. (Anaphylaxis Campaign 2016)

5. COMMON CAUSES • Milk (2nd most common) • Latex • Penicillin • Blood Products • Aeroallergens • Non steroidal anti-inflammatory • Kiwi • Bee • Drugs • Peach • Peanuts • Tree nuts • Wasp • Egg • Sesame • Fish • Shellfish • Soya beans

6. Children at increased risk • Little contact with other young children • Link with lack of vitamin D • Atopic parents • Atopic siblings • Mum smokes • Male • Born by caesarean • Formula fed • Early / late weaning

7. What increases the risk of a severe reaction? • Exercise • Heat • Poorly controlled asthma • The amount of allergen taken • Infection • Emotional stress • Alcohol • Suffering from aeroallergens e.g. hay fever

8. TYPES OF REACTION • Uni-phasic – rapidly developing severe reaction involving the airway or circulation. • Bi-phasic – early oral and abdominal symptoms, then a symptom-free period of 1 – 2 hours, then increasing symptoms involving breathing and circulation.

9. MINOR REACTION • Feeling hot or generalised flushing of the skin • Intense itching and rapid development of a nettle like rash • Burning sensation of lip and /or metallic taste in mouth • Red, itchy, watery, swollen eyes or swollen lips or face • Vomiting and diarrhoea with abdominal pain • Itchy, runny or congested nose and / or sneezing • Dizziness and feeling faint/pallor – may indicate severe reaction in the very young.

10. TREATMENT FOR MINOR REACTION ANTIHISTAMINE AND INHALERS • Follow the child’s individual care plan. Administer the prescribed antihistamine and/or inhaler • Sit/lie child down to avoid injury if they faint, if wheezy raise head and shoulders slightly • Record the time given and stay with the child • Contact parent.

11. SEVERE REACTION • Difficulty in breathing / noisy breathing, wheeze or stridor • Swelling of mouth / tongue or feeling of tightness or lump in throat • Decreased level of consciousness • Collapse, lack of breathing • Absent or very weak pulse

12. TREATMENT OF SEVERE REACTION • Give prescribed Adrenaline auto-injector & record time • If unconscious but breathing place in recovery position • Call paramedic ambulance 999 and state clearly person suffering from anaphylaxis • Contact parent / carer (contact numbers given over) • If no improvement within 5 minutes give second Adrenaline auto-injector & record time • If no signs of life commence CPR (cardiopulmonary resuscitation) and continue until professional help arrives • IF IN DOUBT GIVE ADRENALINE AUTO-INJECTOR • If Adrenaline auto-injector is given the child MUST go to hospital for observation even if they have made a full recovery

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17. Adrenaline auto-injector Adrenaline is life saving and must be used promptly in anaphylaxis. Delaying the giving of adrenaline can result in sudden deterioration and death .

18. The effects of Adrenaline • An adrenaline auto-injector is prescribed according to the child’s weight to deliver a single dose of adrenaline to reverse the symptoms of anaphylaxis • Acts quickly to reduce swelling • Relieves wheeziness • Improves blood pressure • The only medicine which stops the production of the chemicals which make symptoms worse

19. Reasons given for failing to use the Adrenaline auto-injector • Thought unnecessary (54%) • Unsure if it was necessary (19%) • Already called an ambulance (8%) • Device not available (5%) • Too scared to use it (2.5%) • Not trained (2.5%) • Attended A&E (1.5%) • Device was out of date (1%)

20. STORAGE OF EMERGENCY BOX • Accessible at all times during the school day – NOT in a locked room or cupboard. • Contains completed care plan with medication in date. • Clearly labelled with child’s name and passport photo for clear identification. • Avoid extremes of temperature

21. ROLES AND RESPONSIBILITIES The Child’s Parent • Will ensure the school are notified if their child requires an Adrenaline auto-injector and when no longer allergic to particular foodsor substances • Parent will attend school meeting with School Nurse, Principal and young person if age appropriate, to complete Adrenaline auto-injector care plan. • Will accept responsibility for maintaining and replacing, in school, two up to date Adrenaline auto-injectors. • The parent should inform the school and school nurse if any change in child’s prescription .

22. It is the duty of the parent to check the expiry date of the Adrenaline auto-injectors. The parent should return out of date Adrenaline auto-injectors to pharmacy for disposal • Will discuss with the school arrangements for lunch and snacks. • Will regularly remind the child of the need to refuse any food items offered by others. • Will remove all medication at the end of the school year and return to school in September. • Adrenaline auto-injectors can be registered “on-line” to receive expiry date alert Apps, are available to download.

23. The school • The school principal/or designated teacher will notify the school nurse on becoming aware of a pupil requiring an Adrenaline auto-injector device in school, where no care plan is in place. • The principal or designated teacher will create awareness of pupil’s allergic condition. Staff should be aware of those trained in the management of anaphylaxis in school. • The principal or designated teacher will identify adequate numbers of appropriate staff to attend training. • School should raise awareness with all staff regarding any activities which can place the child at risk. • School should make arrangements for safe handling and availability of Adrenaline auto-injector for pupils leaving the school building on school trips/swimming/sports activities etc

24. Principal/designated teacher to attend the school meeting with school nurse, parent and young person, if age appropriate, to devise and complete the care plan. • Will agree with the parents and if necessary school meals staff on the provision of school meals/snacks etc in attempting to minimise risk. • Will ensure safe storage of, and easy access to, the two auto-injectors devices. All school staff must be aware of where these are stored. • It is the duty of the parent to check the expiry date of Adrenaline auto-injectors, however schools must be aware of auto-injector expiry dates to ensure they are in date at all times in school. • Following an anaphylactic incident, a review/debriefing with school staff and school nurse must take place within one week of the incident.

25. DOH Guidance on the use of Adrenaline Auto-injectors (AAIs) in schools From 1 October 2017 the Human Medicines (Amendment) Regulations 2017 will allow all schools in the UK to buy adrenaline auto-injectors (AAI) devices without a prescription, for emergency use in children who are at risk of anaphylaxis but whose own device is not available or not working. Schools are not required to hold spare AAI(s) – this is a discretionary change enabling schools to do this if they wish. The guidance attached is an addendum to Supporting Pupils with Medication Needs. It is non-statutory and has been developed to capture the good practice which schools should observe in using spare AAIs. Schools may wish to use this as the basis of any protocol or policy. The school’s spare AAI(s) should only be used on pupils: • where both medical authorisation and written parental consent have been provided for the spare AAI to be used on them, and • whose own prescribed AAI(s) cannot be administered correctly and without delay.

26. The Pupil (depending on age of child) • Post primary pupils may be responsible for carrying their own Adrenaline auto-injectors WITH THEM AT ALL TIMES especially when away from main building e.g. sports fields/school trips • Pupils should be advised to ensure they are safe and responsible at all times with their Adrenaline auto-injector. • Will be aware of the risk of food sharing • Advised to wear medical identifier • Report the onset of symptoms to a responsible member of staff

27. School Health Team • Provide centralised awareness training on the recognition and treatment of anaphylaxis in partnership with Education Authority and give advice and support to school staff. • School Nurse will arrange with school, parents and young person, if age appropriate, to attend meeting in the school to devise and complete the Adrenaline auto-injector care plan. • School Nurse will outline the responsibilities within this presentation. A copy of this presentation can be obtained on line from Education Authority’s website. • Participate in any debriefing session/follow up of major or minor incident

32. Frequently asked questions • In an emergency can I use another pupil’s Adrenaline auto-injector? We would recommend that all schools take advantage of the new legislation and purchase a spare adrenaline auto-injector, and ensure all children with allergies have a BSACI care plan giving consent for the spare device to be used. If there was an emergency situation in which the only device available belonged to another pupil we would recommend 999 is called first and permission to use the device is asked for. It would be imperative to ensure the other pupil obtains a replacement device as soon as possible. (anaphylaxis.org.uk accessed February 2018)

33. In a school population of teachers, pupils and school assistants what is the recommended ratio of staff to pupils that should have attended an anaphylaxis awareness session and how often should the school attend ? It is difficult to suggest a precise ratio as this will vary depending on the school size and other factors. The regularity of training and how many staff is likely to be dictated in the schools professional indemnity insurance, however we would recommend key members of staff such as the allergic pupil’s teacher, the school nurse if there is one on site, and at least two other full time staff members have received full anaphylaxis training. (anaphylaxis.org.uk accessed February 2018)

34. What do we do with used Adrenaline auto-injector? Send to Emergency Department with child in the ambulance. School must follow up replacement autoinjector with parents prior to child returning to school (anaphylaxis.org.uk accessed February 2018)

35. Can we be a ‘nut free’ school? Generally speaking the Anaphylaxis Campaign would not necessarily support ‘peanut bans’ in all schools, as they are very difficult to enforce, and other allergens such as milk can cause equally severe reactions. Research also suggests that there are not fewer reactions in ‘nut free’ schools.  Schools do however have a duty of care to all pupils, so need to have procedures in place to minimise the risk of a reaction occurring in a food-allergic child. Schools may wish to write to parents requesting that they do not give their children food to bring to school that contains relevant allergens, and asking for their cooperation in making life safe for allergic children. (anaphylaxis.org.uk accessed February 2018)

36. What will happen if I give Adrenaline and the child is not having a reaction If you suspect a child is having a severe allergic reaction we would always recommend administering their adrenaline device. If they are not having a reaction and adrenaline is given the heartbeat could increase and the child may have palpitations for a few minutes. There should be no serious side effects unless the child has coexisting heart problems. The child should still be taken to A&E for ongoing assessment. (anaphylaxis.org.uk accessed February 2018)

37. And finally • Updated your knowledge and skills • Be aware of the emergency treatment prescribed for children with this condition • Practise the correct technique for Adrenaline auto-injector administration • Be clear of roles and responsibilities of all involved.

38. WANT MORE INFORMATION? • www.anaphylaxis.org.uk • www.allergyinschools.org.uk • www.allergyuk.org • www.cateringforallergy.org.uk • Schools pack • Video/DVD • Supporting pupils with medication needs DHSSPS/DOE (2008) • www.health-ni.gov.uk ref HSS(MD) 21/2017 Guidance on the use of Adrenaline auto-injectors (AAIs) in schools

39. Contact telephone numbers for school nursing • Armagh 028 3741 2510 • Banbridge & Dromore 028 4066 2866 • Dungannon 028 8771 3027 • Kilkeel 028 4176 0829 • Newry 028 3083 4309 • Craigavon Area 028 3756 1025

40. Thank you for your time. Any questions?