New District Policy to Always give Epinehprine

[Curry]

I have a preschooler with numerous food and environmental allergies ranging from mild to severe.  I am in Washington state and have been researching the schools and their polices for DS2 who will be entering kindergarten next year.  I was surprised to find out that the school his brother goes to and that district has a policy to ALWAYS give epi no matter the severity of the reaction if that child has an epi order.  The basis for this is that the school does not always have a nurse or even a health tech their so it has been determined that a nurse may not delegate the assessment of the severity of an allergic reaction to a 'lay' person and the decision to give benadryl or benadryl and epi.  This seems based on WA state guidelines http://www.foodallergy.org/files/Wash_State_Anaphylaxis_Guidelines.pdf . 

I am all for my child getting epi should he need it and erring on the side of caution.  However, I am uncomfortable with the idea of him getting epi for a mild reaction.   Most of his reactions have been mild and I am worried about the psychological effect of him getting epi when it's not need and of other possible adverse reactions. 

I am new here so if this has been discussed before please link me to the thread. 

From what I can figure out my only way around this rule is to send DS2 to a different school from his brother that is much further away from home but has a full time RN.   We love our current school and I would be sad to send him to a different school that is 20 minutes from home.

I am wondering of others experience or comments with a similar policy.

[Carefulmom]

I think probably this law was enacted after the death of Nathan Walters, a third grader who did not receive epi until at least an hour after his reaction began, so he died.  He was in Washington state, and often there are new laws after a food allergy death.  This may have been part of the settlement agreement.  It was so long ago, I don`t remember all the details.

[ajasfolks2]

No problem that this has been discussed in some form before (likely older threads at archive site -- we can bring some over and copy/paste some here as needed, plus get links in here too). 

From that Washington link, "page 20-21" (according to page #s on the paper) or .pdf "page" 25-26:

Furthermore, in July 2008, the World Allergy Organization published the following
statements,
Anaphylaxis is an acute and potentially lethal multisystem allergic reaction.
Most consensus guidelines for the past 30 years have held that epinephrine is
the drug of choice and the first drug that should be administered in acute
anaphylaxis. Some state that properly administered epinephrine has no
absolute contraindication in this clinical setting. A committee of anaphylaxis
experts assembled by the World Allergy Organization has examined the
evidence from the medical literature concerning the appropriate use of
epinephrine for anaphylaxis. The committee strongly believes that epinephrine
is currently underused and often dosed suboptimally to treat anaphylaxis, is
underprescribed for potential future self-administration, that most of the reasons
Guidelines for Anaphylaxis 21 March 2009
proposed to withhold its clinical use are flawed, and that the therapeutic
benefits of epinephrine exceed the risk when given in appropriate intramuscular
doses.
Based on available evidence, the benefit of using appropriate doses of
intramuscular epinephrine in anaphylaxis far exceeds the risk.... Consensus
opinion and anecdotal evidence recommend epinephrine administration
sooner rather than later, that is, when the initial signs and symptoms of
anaphylaxis occur, regardless of their severity, because fatalities in
anaphylaxis usually result from delayed or inadequate administration of
epinephrine. Experts may differ on how they define the clinical threshold by
which they define and treat anaphylaxis. However, they have no
disagreement whatsoever that appropriate doses of intramuscular
epinephrine should be administered rapidly once that threshold is reached.
There is no absolute contraindication to epinephrine administration in
anaphylaxis, and all subsequent therapeutic interventions depend on the
initial response to epinephrine.6

Over the past three years or so the push from man allergists and LTFA-med-orgs has been to err on the side of caution and GIVE EPI.  However, this is still not always being taught and followed -- varies according to allergist and how he/she is interpreting the test scores (IgE levels and SPTs) in combination with the patient history of EVER having anaphylaxis previously . . . some physicians are still taking into account the type of reactions and manner in which they present as something that should be assessed or taken into account before giving epi . . . while other physicians are going far more conservative route to even a policy/practice of "1 symptom" (even limited hives) in patient with history of anaphylaxis = EPIPEN immediately.

And many of us parents have kids who have (over years) presented pretty often with allergic reactions that so far have not (or rarely) progressed to ana -- and these reactions have responded to Benadryl (diphenhydramine) and/or been self-limiting. 

Then there's a common thread in many of the ana deaths that the person "only had mild reactions" or had not had ana reax (recognized, anyway) in many years -- and the epipen was delayed or not given. 

It's really hard to have a clear understanding as a parent or patient when the medical community is still NOT being heard as speaking in unison with same message on this matter.

The school is seeming to follow a more "err on side of caution" route in effort to assure best outcome so far as reducing number of fatalities. 

But nobody wants his/her child a human pincushion and fearing/refusing the Epi due to multiple uses at school.

I don't know what the answer really is.

But I did want to get some of my thoughts in here today.

~ ~ ~

As an aside, Fairfax County has a "ZERO SYMPTOM RECOGNITION" policy so far as its standard anaphylaxis/allergic reaction policy and procedure.  Here's links to forms to give you an idea of what they do -- they have NO school nurses in the elementary schools.  They administer epipen ON REPORT OF EXPOSURE TO ALLERGEN for those already-identified LTFA students who have epipens at school.  NO stock epipens.:

http://www.fcps.edu/it/forms/se64.pdf

http://www.fcps.edu/supt/activities/atp/PDF%20docs/Med%20Authorization%20se63%5B1%5D.pdf

http://www.fcps.edu/supt/activities/atp/PDF%20docs/AdminMedicationse66.pdf




Lovely, huh?

[ajasfolks2]

I think probably this law was enacted after the death of Nathan Walters, a third grader who did not receive epi until at least an hour after his reaction began, so he died.  He was in Washington state, and often there are new laws after a food allergy death.  This may have been part of the settlement agreement.  It was so long ago, I don`t remember all the details.

Yes, I do believe that the original Washington LTFA policy was developed as part of settlement/agreement with Nathan Walters' family.

[Carefulmom]

To the OP, if your child starts school and you find that the epi is being given frequently (which I doubt would really happen), what about getting your allergist to write a letter specifying when exactly to give epi, and when to give antihistamine?  I would think that an allergist`s letter regarding a particular student would supercede district policy, KWIM?  I would think that district policy would be a general rule, but if the allergist gives specific instructions, those would be followed.

BTW, our action plan does state if she has a reaction to use epi and that antihistamine is to be used after epi, not instead of epi.  This coincides with current recommendations.  But my child is not your child and each child has their own history.

[ajasfolks2]

You might find this (and other links there) interesting:

http://www.aaaai.org/Global/latest-research---news/Current-JACI-Research/Anaphylaxis-management-plans-for-the-acute-and-(1).aspx

[Curry]

Thank you for your reply's.

It's a tricky grey area that I am trying to understand better.

When I read the literature it's an anaphylaxis plan.  My son has an epi because he has the potential to need it, for some of his allergies, but has never had a reaction to date, that has required it.  My concern is that he will be getting it for mild non-progressing reactions and could in the future not report when he has a reaction for fear of getting the epi. 

I have talked with the school nurses and pointed out to them that their policy does not follow ds2 doctor orders and EMP.  Which clearly state to give epi and benadryl for multisystem involvement and or vomiting multiple times etc, and to give benadryl for lesser reactions like hives only.  The doctors orders do clearly differentiate by symptoms.  The nurses response was that they follow district policy and always give epi and they can't differentiate even with clear doctor orders.   Though she also said she doesn't like the new policy. 

When he was in private preschool with no nurse, everything has been run very smoothly.  The staff were already trained in epi, were very watchful for his allergies and when he did have a reaction handled it appropriately and professionally.  DS2 had a reaction to grass at preschool with big itchy puffy eyes.  Staff immediately called me gave him benadryl and he improved.  They had the EMP and knew how to follow it.     It doesn't seem fair to me that I don't have a say in how an allergic reaction is handled in public school.   

I want to do what is safest and best for him.  Is there literature that supports always giving epi to a child who has the potential to need it, but so far has not needed epi, as the best management?

Could you link me to the other prior to discussions on this too please? 

[Carefulmom]

Playing devil`s advocate a bit here, I`d like to draw an analogy.  Dd`s kindergarten teacher once told me that if a child complains twice about abdominal pain, she sends the child to the nurse, because teacher does not have a medical background and cannot be the one to decide if it is indigestion (no big deal) or appendicitis (a true emergency).  She was not in a position to make that decision.  So I can see where the district would say that teachers are not qualified to make the call if epi is necessary or not, and therefore to give it.  I am not defending it, and can definitely see why you would be upset.  But I`m pretty sure that the current AAAAI recommendations are to epi if it is a reaction.  Again, each child is different.  When I have time I will look on the AAAAI website.

I can understand your concern that your child might not report symptoms out of fear of getting an epi, but also have to comment that I believe that can be prevented.  I believe that to some degree fear of epi is a learned response, and depends on how the parents present the situation.  I never had that issue with dd, because of how I portrayed getting shots.   It is just part of life.  It hurts for a few seconds, but makes you feel so much better if you are having an allergic reaction.  Also, from the age of 2 on, I made sure to bring her with me for every flu shot, even though it is way easier to go without bringing a toddler.  I wanted her to see me get a shot, and see that it is really no big deal.  Whenever dd had to get immunization shots or a blood test, I would bring a wrapped present and give it to her the minute the needle was out.  I just think you really need to teach your child that they must report symptoms and that a shot only hurts for a few seconds and makes them feel better after.  I believe that when children are terrified of needles, it is usually a learned behavior.  There are so many ways to prevent that.  If the parent is fearful, the child picks up on that also.  I have seen parents clutching their kids as immunization shots are given, as though the parent thinks the child is going to die from the shot.  It always astounds me when they then comment that their child is terrified of shots as though they can`t see why.  (Not saying you would do that, just saying I have seen that so many times.)

Lastly, the majority of people who die from anaphylaxis have never had a history of a severe reaction.  That is food for thought.  I`d much rather have them epi my child who didn`t need it than have my child become a Nathan Walters or Sabrina Shannon or any one of a number of children who got epi too late.  Our memory thread (is it on this new board?) is full of children who got epi too late or not at all. 

[ajasfolks2]

Curry,

I will do my best to get back in here with older discussions and links -- maybe will have some time over the long weekend. 

To all of our members -- though I know we'll be busy over he next week -- if you can quickly think of a helpful/related thread to link in here, please feel free to do so (from archived site or here now).

Please.

Hang in there, Curry -- this is a tough position and situation to be in, for all of us.

Glad you are here.