An Abnormal Response to Normal Things Teachers have to be aware that allergies can kill. A growing number of children are at risk – and a well-prepared teacher can make all the difference.

By Wendy Harris

Brenda and Dan Hobbs knew from the beginning there was something unusual about their son David. As an infant, he reacted in dramatic ways to Brenda’s breast milk, depending on what she had eaten during the previous days. When he nursed, his skin would sometimes turn blotchy or be covered instantly with red dots.

So it was really no great surprise when an allergy specialist confirmed that David was highly allergic and – like many children with severe allergies – had asthma, a specific allergy to eggs and could be highly allergic to peanuts.

This last possibility was confirmed shortly afterwards when David was given a cookie by a generous bakery shop assistant. He took a bite and almost immediately started to gag and drool. Dan raced him to a hospital emergency ward where, as the child’s symptoms gradually faded, doctors corroborated Dan and Brenda’s worst fear – David had had an anaphylactic reaction to peanut butter in the cookie he was given.

Anaphylaxis, sometimes called allergic shock, is a severe allergic reaction that, if untreated, can lead to rapid death. Like less severe allergic reactions, it happens when the body’s immune system responds to harmless substances as though they were harmful invaders. But instead of developing a runny nose or a rash, anaphylactic sufferers respond with an extreme systemic reaction that may begin with itching, hives, vomiting, diarrhea and swelling. Within moments, the throat closes, choking off breathing and leading to unconsciousness and death.

ALLERGIC SHOCK

Food allergies are most likely to kill people if they have asthma or don’t get epinephrine quickly enough. Epinephrine, also known as adrenaline, is a hormone produced naturally by the body in response to stress and is the only drug that can stop anaphylaxis symptoms. It works on both the cardiovascular and the respiratory systems to constrict blood vessels and relax the muscles of the chest to improve breathing.

While peanuts are the leading cause of food-induced anaphylaxis, many potentially life-threatening foods are out there. Tree nuts, milk, eggs, wheat, seafood, soy and sesame have all been implicated. Besides food, other common culprits in triggering extreme allergic reactions are drugs, insect stings, latex, hormone supplements and even exercise.

With his condition confirmed, Dan and Brenda set about ordering a life for David that precluded his contact with peanuts or peanut products of any kind. That meant checking the labels of every item of food that came into the house, warning friends and family, eliminating many restaurants and bakeries, monitoring Halloween candy and watching David like a hawk until he was old enough to start assuming some of the responsibility for himself.

When he was very young, they taught David never to accept food from anyone before checking with his parents. They carefully outlined David’s allergy to playmates’ parents, explaining that even minute amounts of peanut butter or products could trigger a reaction. They even changed daycares when they grew concerned that other parents were not taking the allergy risk for David seriously enough.

EPIPENS

Most importantly, they kept an EpiPen in their medicine chest and bought David a fanny pack in which to carry another one. EpiPens are pre-measured doses of epinephrine which must be injected immediately at the first indication of anaphylaxis. Because it is usually injected directly into the thigh muscle, children as young as six or seven can be taught to administer the drug themselves. However, in an emergency, they may not have the presence of mind to do so.

Asthmatic children experiencing anaphylaxis are sometimes treated with asthma inhalers or antihistamines. While these drugs may be useful as adjuncts, they are not a substitute for epinephrine. Even if all symptoms appear to be resolved after an injection of epinephrine, a child should be monitored for at least four hours but preferably for up to 24 hours.

David ended up in a daycare where everyone was already aware of his allergies. It wasn’t really until he moved to a west end school in Grade 1 that his parents had to raise the issue. The principal there had already encountered some children with severe allergies and set up a special spot not too far from the main lunchroom for David and a few other allergic children to eat. And he assured Brenda and Dan that the school would do its utmost to keep David safe.

The principal’s assurances did not prevent David from having to endure the teasing of his less diplomatic classmates. Dan can remember times when David came home from school upset because his friends taunted him with either real or imaginary peanut butter sandwiches. "We had to make sure that the teacher was on board and that she recognized that this was the worst kind of bullying because, basically, they were threatening him with death."

GROWING PROBLEM

David’s story is not unique. According to Dr. Peter Vadas, head of the division of allergy and clinical immunology at Toronto’s St. Michael’s Hospital, the prevalence of allergies, including life-threatening ones like David’s, has doubled in the last 10 years. And there’s no slowdown in that escalation.

Dr. Vadas says the fact that the incidence of allergies is rising so dramatically in developed countries of the West is no accident. He says there is solid evidence showing that as our society becomes increasingly focused on

cleanliness, the human immune system has shifted away from fighting bacterial and viral infections and towards attacking foods that are usually benign.

On top of that, says Dr. Vadas, it is generally accepted that children’s early exposure to potential allergens can trigger future allergies. And more children are being exposed to the ubiquitous peanut at a younger age. Peanuts and their byproducts are everywhere – in foods, cosmetics and pharmaceuticals, and the shells are even used for stuffing bean-bag-type chairs.

About a decade ago, the sudden surge in highly allergic children entering school systems across the province caught many educators off guard. At that time, few school boards had policies in place dealing specifically with anaphylactic children or children with other less lethal allergies.

Susan Yip, the past president of the Anaphylaxis Network of Canada, recalls that when her now 17-year-old son entered kindergarten, he was the first and only anaphylactic child the school of 600 had ever had. She talked to his teacher – who had never heard of life-threatening allergies – as well as to the principal and as many parents as she could to try to raise awareness so that her son’s daily environment wouldn’t kill him.

DOESN'T GO AWAY

"In the beginning, people thought I was talking about a little discomfort, a temporary problem," she says. "They didn’t realize these allergies are life threatening. They kill and they don’t go away and they’re forever."

That climate of ignorance has changed substantially during the last 10 years. Awareness was sadly raised by several tragedies. The Ontario Coroner’s Office reported seven deaths of school-aged children from allergic reactions to peanuts, tree nuts and sesame seeds between 1986 and 1991. More recent figures for anaphylactic deaths are not available, but a registry is currently being established in Ontario.

In 1994, a student on a field trip to Algonquin Park died from trace amounts of peanut butter which had been transferred to a jam jar. That same summer, a child attending camp in Montreal died after eating a cheese sandwich that had been stored in the same bag as a peanut butter sandwich. The amounts of peanut butter that killed these children can be measured on the head of a pin. Some children are so sensitive that even the smell of peanut butter can cause problems.

Health Canada recognized the growing magnitude of the problem and published Anaphylaxis: A Handbook for School Boards in 1996 in both English and French. It was sent to every school board in Canada and to many in the United States and has served as the foundation for many of the policies and procedures now in place.

The anaphylaxis handbook details what school boards and individual schools can do to protect their children. It suggests that schools develop policies in three general areas:

• communicating with and educating the entire school community, including parents, teachers and students,
   about who the anaphylactic children are, how to prevent exposure and how to use EpiPens in an emergency

• avoiding the main allergens – primarily peanuts – at the same time as seeking to strike a balance between the
   rights of all students to eat what they like and the allergic child’s right to a safe school environment

• developing emergency response procedures based on treatment protocols prescribed by the child’s doctor
   in case of accidental exposure – usually, an immediate epinephrine injection, a fast trip to a hospital and
   follow-up epinephrine every 10 to 15 minutes if breathing difficulties persist.

DIFFERENT RESPONSES

During the years since the handbook was released, schools and school boards have responded in different ways, depending on the needs of the individual students.

Diana Rawsthorn, principal at Earl Kitchener School, has about 390 students, four of whom have severe peanut allergies. Protecting those children, she says, is a shared responsibility borne by all the teachers, parents and students. And while Rawsthorn says she would never declare her school "peanut or nut-free," she has requested that parents not send peanut butter sandwiches to protect her allergic students.

"We’ve tried to educate the community and engage their support... In the end, the kids are the best police of it. They understand what things are dangerous... Children have come to me and said ‘My mother’s packed a peanut butter sandwich. What should I do?’"

As the parent of three children without allergies, Justine Elliott says communication with Earl Kitchener’s staff has been key in her agreement not to send peanut butter to school. She says armed with the understanding of how deadly the peanut allergy is, she wouldn’t ever consider it. "People’s reluctance to comply is really based on ignorance," she says.

FULL PROGRAM

In Barrie, Lou Brandes, principal of Ferndale Woods Elementary School, a K-8 school with 900 students, has gone a few steps further to protect the eight children who have peanut allergies there. Early in the fall for the past four years, Mr. Brandes has sent home

newsletters requesting that parents not send any foods with peanut products to school. At the same time, he calls assemblies and mounts a full education program for the students, with guest speakers and videos, and kids do a range of activities surrounding the subject.

"At the beginning, there was a lot of resistance (to not sending peanut butter and jelly sandwiches to school). That’s when we decided to educate the kids. We only got complaints the first year. Kids are really our best ambassadors for this... We call it reducing the risk, with the understanding that we can’t guarantee a peanut-free environment."

Suzanne Stiegelbauer, co-ordinator of the pre-service elementary teacher education program at Ontario Institute for Studies in Education at the University of Toronto, says while there is no specific training about children with allergies for teachers, it should be addressed during their practicums.

"It’s an experiential thing," says Stiegelbauer. "As always, they need to be aware of the issues relative to their profession and relative to a safe environment. As teachers, they’re going to run into all kinds of situations, including children with allergies. They’ll need to know what to do."

The cornerstone of anaphylaxis prevention is to avoid the offending substance. As an alternative to food bans, which can provoke not only divisiveness in the school community but create a dangerous false sense of security, parents should be told about the life and death seriousness of the allergies in the school.

Children should be taught never to share food or food containers. Allergic children should eat, if possible, in a segregated setting to minimize the risk of contact, and eat only food that has been sent from home. Food for special celebrations like Halloween, Christmas or children’s birthdays should be scrupulously monitored or, if necessary, avoided by the allergic child.

WASH HANDS

Frequent handwashing should be encouraged. Students and staff who have eaten peanut butter and haven’t washed their hands can leave residue on school bus handles and seats, desks and chairs, toys, balls, skipping rope handles, markers or pencils and computer keys.

What is clear is that while schools and teachers can plan, take action and hope for the best, they must at all times be prepared for the worst. All teachers should be made aware of which children are at risk and trained to administer epinephrine. Identification sheets with the child’s name, photograph, specific allergy or allergies, early warning signs and specific medical treatments can either be posted – with permission of both parents and child – or readily available. Medication should be clearly labeled and easily accessed during an emergency – not in a locked cabinet.

According to Anaphylaxis: A Handbook for School Boards, there are no contraindications to the use of epinephrine for a life-threatening allergic reaction. In other words, if there is any reason to suspect an anaphylactic reaction is taking place, and if epinephrine has been prescribed as the treatment protocol, caregivers should not hesitate to administer the medication.

LEGAL RESPONSIBILITY

Moreover, according to Cynthia Peterson, who researched the legal context for the Ontario Public School Teachers’ Federation in 1996, teachers have a legal responsibility to provide a level of care and supervision that could be reasonably expected of a prudent parent. That legal duty extends to not only protecting a child from exposure to allergens but also administering emergency medication during a crisis.

This level of care and supervision is all well and good for younger children. But once they hit puberty and start looking for ways to take risks and perhaps rebel a bit, the careful child may transform into a teen who flirts with dangerous foods.

Vivien Goss is a high school geography teacher at Langstaff Secondary School in Richmond Hill who has a nine-year old anaphylactic son. She says she is concerned not only about her son on his direct path to teenagehood but also about the students she teaches daily.

Goss says policies are necessarily focused on children in elementary schools. In high school, where children and their peers haven’t necessarily known each other their whole lives, those same policies become vaguer and must be refocused to apply to teens.

When a vulnerable student enters high school, parents should let the school know that their child has a life-threatening allergy. Students should also consider wearing a MedicAlert bracelet identifying their allergies and symptoms.

Most critical of all, students should carry an accessible EpiPen with them at all times and the teacher should be made aware of where it is.

MANY TRIGGERS

Of course, not all allergies are deadly. Allergies are, after all, an abnormal response to normal substances. The substances in the classroom environment can be anything from scented markers, stickers, molds or mildew, carpets, chalk dust, animals, paint fumes, dust, pollen, perfume and a variety of foods. The non-fatal responses can range from sniffling, coughing, puffy eyes, skin rashes or eczema, itchiness, irritability, headaches, disruptive behaviour, abdominal cramps and vomiting.

Some doctors have suggested that antihistamines used to treat milder allergies may have an adverse affect on a child’s ability to learn or on behaviour because the drugs affect the central nervous system. The anti-asthma drug theophylline has been correlated with reports of inattentiveness, hyperactivity, irritability, drowsiness and withdrawal behaviour and may be a contributor to learning disabilities. Corticosteroids, which are also commonly prescribed, can have similar effects.

It is estimated that about one in five of the general population suffers from some type of allergy. Asthma, which often goes hand in hand with allergies of all kinds, is one of the most common chronic illnesses of childhood. Many of the symptoms of asthma and other allergies can be considerably reduced by limiting exposure to allergens and irritants.

That’s where people like Chris Broadbent, health and safety manager for the Toronto District School Board, play a huge role. Broadbent regularly does battle with a host of indoor allergens that could have a negative impact on learning in the classroom. During the spring, he says, there was extensive flooding which meant that carpets had to be removed and replaced with vinyl flooring to prevent the widespread growth of mildew and molds. In Toronto, where growing student populations have caused the proliferation of portable classrooms, that problem is particularly acute. Broadbent says that many portables have had to be closed because of mold infestation.

The concern for clean, allergen-free air extends to what sorts of maintenance and cleaning products are used in the schools. Broadbent says he is bombarded by people selling "everything from snake oil to a cure-all for everything" and is constantly sifting through the information to come up with environmentally and allergy-friendly products.

Meanwhile, David Hobbs is now 12 years old and heading off to University of Toronto Schools for Grade 7 this year. Once again, his parents will have to raise the alarm to make sure the awareness level about deadly allergies is high. Since his brush with death as a toddler, David has had no anaphylactic episodes. But he must always be vigilant and always be prepared.

"It doesn’t get in the way of my life," he says philosophically. "It just sets me apart as an individual... All my friends are always really careful. The only time I feel ostracized is when I ostracize myself to protect myself... I guess I’ll always have to be careful."

Anaphylaxis: A Handbook for School Boards can be ordered from the Canadian School Boards Association in Ottawa at 613-235-3724. Some web sites that may be helpful: Anaphylaxis Network of Canada: www.anaphylaxis.org; Allergy Asthma & Immunology Society of Ontario: www.allergyasthma.on.ca; Allergy Asthma Information Association; www.nuconnexions.com. Lou Brandes, principal of Ferndale Woods PS in Barrie, is happy to make the resources he uses available to anyone interested. He can be reached at 705-733-5636 or by fax at 705-733-0723.