Asthma and food allergy management in Chicago Public Schools

Evaluating Standardized Job Competencies for Managing Students at Risk for Anaphylaxis in Elementary School Nurses

This study aimed to evaluate standardized job competencies of elementary school nurses in managing the health of students at risk for anaphylaxis (SRAs). A total of 166 elementary school nurses from across Korea participated in this study. The tool utilized was a list of standardized job tasks of elementary school nurses in managing SRAs' health. Seven factors were obtained from the factor analysis, with a cumulative variance explained of 68.6%. The importance-performance analysis method was employed to suggest priority areas for training. The factors placed in quadrant II included: (1) "offering psychological support", among elementary school nurses who have been provided with clinical information on anaphylaxis, (2) "providing emergency care", among those who have not been provided with clinical information on anaphylaxis, (3) the factors "utilizing individualized healthcare plans", "conducting health education and staff training", and "evaluating the student", among those who agreed that schools need legal protection to purchase epinephrine auto-injectors, and (4) the factor "preparing a school emergency system", among those with less than five years of experience as a school nurse. When planning continuing education strategies to improve elementary school nurses' management of SRAs, factors such as career experience, access to clinical information, and beliefs regarding legal protection for schools to purchase epinephrine auto-injectors should be considered.

Evaluating the Food Allergy Passport: A Novel Food Allergy Clinical Support Tool

BACKGROUND

The prevalence of pediatric food allergy (FA) has increased in the past 2 decades. The previous literature suggests that FA presents burdens, both economically and psychosocially, to children and their caregivers, especially families in lower-income strata. Using data from a previously published needs assessment, the Food Allergy Management in Low-Income Youth study, the FA Passport and Workbook tools were developed to address identified needs.

OBJECTIVE

This study evaluated the utility of the FA Passport in helping families insured by Medicaid to manage FA better and improve quality of life.

METHODS

Families insured through Illinois Medicaid were recruited from two Chicago-based allergy clinics. Caregivers of children with FA completed a pretest evaluating knowledge, attitudes, beliefs, and practices regarding FA management. A clinician guided caregivers through the FA Passport. The caregivers then completed a posttest immediately afterward and again 3 months later. Changes were evaluated from baseline responses and direct feedback was elicited about the tool.

RESULTS

The FA Passport successfully improved caregiver-reported confidence with epinephrine autoinjector use (from 69% to 93%), caregiver anaphylaxis recognition (from 66% to 73%), and reported quality of life, and it nearly doubled caregiver comfort regarding leaving the child in the care of others (from 40% to 75.7%). Caregivers rated the FA Passport tool as extremely helpful overall (9.4 out of 10).

CONCLUSIONS

The FA Passport is a novel FA clinical support tool that addresses barriers to proper FA management described in previous studies. It proved effective at improving caregiver comfort with regarding leaving the food-allergic children with other caregivers, increasing FA knowledge, and improving the quality of life in families affected by FA.

Social disparities in early childhood prevention and management of food allergy

Food allergy (FA) affects 8% of US children. Navigating and managing FA permeates across multiple facets of childhood. In this article, we review research on social disparities in feeding practices, managing meals, and selecting childcare and schools. Key highlights include the following: (1) although preference for breast-feeding or formula feeding does not reduce FA risk, there are disparities in access to formula that may affect children with FA; (2) disparities likely exist in the early introduction to allergenic foods, though additional research is needed to identify barriers to following the most recent consensus guidelines on early introduction; (3) families with limited income face challenges in providing safe meals for their children; (4) disparities exist in early childcare options for preschool-age children, though there is a lack of research on FA practices in these settings; and (5) there is evidence that schools with different student demographics implement different types of FA policies. Further research is needed to better understand and characterize social disparities in FA prevention and management in early childhood and to develop evidence-based strategies to reduce them.

Individual Medical Emergencies Occurring at School

Children and adults may face emergency medical situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. The American Academy of Pediatrics published a policy statement in 2001 titled "Guidelines for Emergency Medical Care in Schools," and in 2008, published its revision, "Medical Emergencies Occurring at School." Those statements focused on the preparedness of schools to address individual student emergencies. The increase in the number of children with special health care needs and chronic medical conditions attending schools, together with the added challenges faced by school districts to ensure that schools have access to on-site, licensed health care professionals on an ongoing basis, have contributed to added risks that medical and nonmedical personnel face in dealing with medical emergencies in schools. This newly revised policy statement serves as an update of the statement published in 2008 and reaffirmed in 2017, and intends to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and provide recommendations for the medical home and school physicians on how to assist and support school personnel. This statement does not address schoolwide or communitywide emergencies that might occur as a result of natural or man-made disasters.

Food Allergies in Inner-City Schools: Addressing Disparities and Improving Management

OBJECTIVE

Food allergy (FA) affects approximately 8% of children in the United States. Management comprises both preventing and treating allergic reactions, which poses unique challenges in the inner-city school setting. In this article, we review the epidemiology of FA in school-aged children and management challenges and opportunities specific to the inner-city population.

DATA SOURCES

A literature search of the PubMed database was performed to identify published literature on FA epidemiology, FA management, school policies, disparities, inner-city, race, ethnicity, and socioeconomic status.

STUDY SELECTIONS

Relevant articles on FA management best practices and challenges in schools, with a particular emphasis on inner-city schools and populations and socioeconomic, racial, and ethnic disparities, were reviewed in detail.

RESULTS

Disparities in FA prevalence, management, and treatment exist. Additional research is needed to better characterize these disparities and elucidate the mechanisms leading to them. There is a lack of evidence-based interventions for the prevention and treatment of food allergic reactions in schools and specifically in inner-city schools, in which a greater proportion of students may rely on school food.

CONCLUSION

There are opportunities for partnership among health care providers, schools, and communities to address unmet needs in FA management and disparities in the inner-city school setting.

A Qualitative Investigation of Parent and Child Perceptions of School Food Allergy Policies in the United States

BACKGROUND

Many schools implement well-intentioned food allergy policies; however, may not ease parents'/children's worry and concern. The purpose of this study was to (1) explore children's and parents' perceptions their school's food allergy policy and (2) compare these perceptions to the documented school policy.

METHODS

Children ages 8 to 18 with a food allergy and their parents (N = 18 pairs) across the US completed one-on-one semi-structured, audio-recorded phone interviews. School food allergy policies were collected from school websites. Content analysis was applied to the transcriptions by two investigators to identify themes among parents and children.

RESULTS

Parents and children described policies may impact the child's social and/or emotional well-being. Many opportunities for improvement were provided by parents and children. There is a wide variation in food allergy policies across the schools in this study, and overall, parents and children thought that policy enforcement needs to be improved.

CONCLUSIONS

With so much variation in food allergy policies in schools coupled with inconsistent enforcement, parents and children may feel unsafe or unsupported by the school. Schools should adopt a team- or whole-school approach to develop and enforce policies that help protect children with food allergies.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019)

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Food allergy-related bullying and associated peer dynamics among Black and White children in the FORWARD study

BACKGROUND

The experiences of Black children with food allergy (FA) are not well characterized, particularly with respect to bullying victimization and other psychosocial outcomes.

OBJECTIVE

To evaluate bullying experiences of Black and White children with FA, including associations with peer relationships, anxiety, and school policies.

METHODS

Surveys were administered to parents of 252 children with physician-diagnosed FA enrolled in the multisite FORWARD cohort. The surveys assessed demographics, atopic disease, bullying victimization, and school FA management practices and policies. Descriptive statistics of bullying by race were compared by χ² tests. Multiple logistic regression analyses adjusting for race, age, parental education, household income, child sex, and multi-FA compared adjusted probabilities of bullying victimization by school policies.

RESULTS

Nearly 20% of school-aged children were bullied for FA with no substantial racial differences overall, though for children ages 11 years and up, White children reported higher rates of bullying. However, Black children experienced non-FA-related bullying twice as frequently as White children (38.6% vs 17.7%; P = .002). Most of the caregivers (85.7%) who intervened in their child's bullying reported that it was helpful. Among parents, 17.3% reported that they were teased or bullied owing to their child's FA. More than half of the respondents (54.8%) reported that some allergens are banned from their child's school, most typically peanut. In schools banning peanuts, FA-related bullying was less frequently reported by all students who have food allergy.

CONCLUSION

Bullying owing to FA is common, and caregivers, medical professionals, and school administrators can help reduce bullying by screening for bullying and supporting and educating school policies.

Food allergy and asthma

Food allergies (FA) and asthma commonly coexist in patients, with asthma affecting 14% of school-age children and with FA affecting up to 8% of children in the United States. Compared with children without FA, children with FA are two to four times more likely to have asthma. The timings of food sensitization and FA seem to be strong predictors of asthma onset in childhood; results of studies show that food sensitization in the first few years of life is associated with increased odds of developing early wheeze. Having multiple FAs as opposed to a single FA further compounds the risk of asthma. Reciprocally, there is a strong association between the presence of food sensitization and/or FA and poor asthma control, including increased asthma-related healthcare utilization and emergency medication use. Asthma is a risk factor in ~75% of fatal food-related anaphylaxis cases. Therefore, besides FA education and management, patients with FA and with asthma should optimize medical therapy of their asthma and receive asthma education, including identifying possible asthma triggers. Furthermore, allergists should ensure that asthma must be well controlled before conducting oral food challenges. Timely administration of epinephrine is lifesaving and remains the firstline treatment during food-induced anaphylaxis, especially in patients with asthma. Among those biologic therapies that have been highly effective in treating asthma, omalizumab and dupilumab are now also being studied as treatments for FA.

Food Allergy Management at School in the Era of Immunotherapy

PURPOSE OF REVIEW

Food allergy is increasing in prevalence, and management focuses on strict avoidance of known allergens and appropriately treating reactions. Any reaction has the potential to result in anaphylaxis, which can be fatal. Children spend a significant amount of time in the childcare or school setting, and interactions between families, school personnel, and clinicians are important to ensure the health and safety of children with allergies and asthma.

RECENT FINDINGS

This review examines current food allergy guidelines and legislation, an assessment of allergen-free schools, the importance of written anaphylaxis action plans, training and education of school personnel, emerging treatment options, and the social implications of having food allergies. As the clinical use and research into food allergen immunotherapy continues to expand, an additional level of education and management is required of school personnel and caregivers. Food allergy has both medical and social implications, which are magnified in the school setting.

Food Allergy Management at School

BACKGROUND

Approximately 8% of schoolchildren in the United States experience potentially life-threatening food allergies. They must diligently avoid allergenic foods and have prompt access to epinephrine to treat anaphylaxis. These prevention strategies must be sustained without interruption, posing a range of challenges at school.

METHODS

We conducted semi-structured interviews with 178 participants about their experiences managing food allergies outside the home. Interviews were transcribed and analyzed using an iterative approach in NVivo 10.

RESULTS

Participants reported highly varied school experiences across the ecological model. They described the need to be proactive and self-sufficient to manage food allergies. Whereas food allergy-related social exclusion was common, participants also described positive peer interactions, including intensive peer engagement and support. They perceived that formal school policies were limited in scope and inconsistently implemented. Prevention-oriented policies were more common in lower grades than in higher grades.

CONCLUSIONS

Poorly defined and implemented policies disrupted students' social and educational experiences at school, families' relationships with school staff, and, ultimately, the safety and wellbeing of students with allergies. Given the high prevalence of food allergies among children, these findings demonstrate the need for multiple layers of support to facilitate safe, socially inclusive food allergy management at schools.

Preventing Asthma Emergencies in Schools

Asthma is a significant public health issue, impacting quality of life, morbidity, and health care costs nationally. Stock asthma rescue medication policies authorize school districts to maintain unassigned albuterol and enable trained staff members to administer the medication in response to asthma symptoms, exercise premedication, and asthma emergencies. Stock asthma rescue (or reliever) medication laws serve as an important fail-safe measure. Such laws provide districts with the ability to respond if a student has an asthma emergency at school but either lacks a diagnosis or does not have access to their own medication. As of September 2019, 13 states have enacted either a law or regulation authorizing the stocking of asthma rescue medication in schools: Arizona, Colorado, Georgia, Illinois, Missouri, New Hampshire, New Jersey, New Mexico, Oklahoma, Ohio, Texas, Utah, and West Virginia. Three additional states provide stock albuterol asthma guidelines but do not have legislation: Indiana, New York, and Nebraska. Some states have found that these policies reduce the need for 911 calls and emergency medical services transports as a result of asthma exacerbations. Initial data also demonstrate that these policies reach populations in need and improve health outcomes. This case study will describe the current state of asthma in Illinois, an innovative policy solution to address asthma emergencies in schools, and the steps taken to advocate for stock asthma rescue medication in Illinois. Legislation for stock albuterol in Illinois was signed into law in August 2018.

Skin Prick Testing to Identify Food Allergens in 8393 Children and Adolescents with Asthma in Chongqing, Southwest China

BACKGROUND The prevalence of food allergies in asthmatic children and adolescents has significantly increased over recent years. Nevertheless, the relevant clinical analyses are still lacking in China. Therefore, the present study aimed to determine common food allergens in pediatric patients with asthma in Chongqing, Southwest China. MATERIAL AND METHODS A total of 8393 asthmatic patients from Children's Hospital of Chongqing Medical University (CHCMU) were enrolled in this retrospective study between October 2014 and July 2017. All patients underwent skin prick test (SPT) with 10 food allergens and recorded history of clinical reactivity. The correlations among the positive rates, categories of allergens, gender, age, and living environment were analyzed. RESULTS A total of 2544 patients (30.31%) had a positive SPT, while the prevalence of food allergy was 8%. Sea crab, peanut, and sea shrimp were the most common food allergens found in the studied population. The frequent food allergies were sea crab, peanuts, and sea shrimp. CONCLUSIONS Identifying allergens is important for the diagnosis and management of allergic disorders, and for performing immunotherapy.

Asthma and Food Allergy: Which Risks?

Over the past few decades, an increase in the prevalence of asthma and food allergy has been observed in the pediatric population. In infants, food sensitization, particularly to egg, has increased the risk of developing allergic asthma. This is even more likely if sensitization to food allergens occurs early within the first few years of life. It is indeed known that both diseases may be present simultaneously in the pediatric population, but coexistence may negatively influence the severity of both conditions by increasing the risk of life-threatening asthmatic episodes as well as food-related anaphylaxis. Therefore, an accurate clinical and phenotype characterization of this high-risk group of children with both asthma and food allergy and a more aggressive management might lead to reducing related morbidity and mortality. The aim of this review is to provide an updated overview on the close link between food allergy and asthma and their negative mutual influence.

Educators' Perspectives of Collaboration With Pediatricians to Support Low-Income Children

BACKGROUND

Educational and healthcare systems operate in silos. Few studies explore educators' perspectives of collaboration with pediatricians or cross-system solutions for school-identified concerns. We sought to investigate educators' viewpoints of collaboration with pediatricians.

METHODS

We conducted semistructured, qualitative interviews with full-time teachers, vice-principals, and principals, who worked with low-income first- or second-grade students. Interviews explored which students were concerning to educators, educators' experiences with collaboration, and barriers and facilitators of collaboration. Interview transcripts were analyzed with modified grounded theory.

RESULTS

We interviewed 12 teachers and 3 principals/vice-principals. Students' socioemotional problems were a foremost concern. Effective collaboration with pediatricians was not typical. Participants described not knowing they could communicate with pediatricians or that collaboration was often limited or unidirectional. Respecting boundaries of parental privacy and maintaining parental trust emerged as potential barriers. Some participants described negative experiences with pediatricians and reflected on societal perceptions of doctors and teachers, which could affect the development of relationships. Participants recognized potential benefits to collaboration, including gaining a holistic understanding of a child's health and home life.

CONCLUSIONS

Educators perceived collaboration with pediatricians as inadequate. More developed and tested programs that foster collaboration between schools and pediatricians are needed to support low-income youth.

Epinephrine Auto-Injectors for Anaphylaxis Treatment in the School Setting: A Discussion Paper

Introduction:Anaphylaxis is a serious, life-threatening systemic allergic reaction that may occur in individuals not previously diagnosed with an allergy. Emergency first-line treatment of choice for acute anaphylaxis is intramuscular administration of epinephrine via an auto-injector. In the school setting, students with known allergies typically keep or carry an epinephrine auto-injector (EAI). For students who do not have a known allergy or for those whose personal EAIs are unavailable, an anaphylactic event could have serious adverse outcomes if an EAI is not available via an undesignated stock supply in the school.

Methods:We searched the published literature from 2000 through 2018 in CINAHL, MEDLINE, and PubMed using the following search terms: anaphylaxis, school setting, epinephrine auto-injector, and food allergies. Throughout this article, undesignated stock EAIs, stock EAIs, EAI stock, and open-order EAIs are used interchangeably.

Conclusion:Anaphylaxis is increasing worldwide as the incidence of food allergies increases. Although stock EAIs for students in schools can have important benefits, the availability of EAIs in the school setting is limited. Barriers to undesignated stock EAIs include the lengthy administrative process for developing school policies and protocols; gaps in nurses' self-perceived knowledge versus objective knowledge on the topic of anaphylaxis; limited resources in many school districts; and complex role demands, lack of confidence in trained staff, or insufficient school nurse staffing. It is important that epinephrine be readily available in schools. Barriers to facilitating stock EAIs include those that can be addressed directly by nurses and those that may require policy changes. Nurses, particularly those working in school settings or pediatrics, could take the lead in discussions about the benefits of stock EAIs in schools, advocating for policy changes as warranted. Fully informed nurses can be better prepared to serve as advocates in ensuring that EAIs are available in school settings.

Chicago Public School nurses examine barriers to school asthma care coordination

OBJECTIVE/DESIGN

Well documented asthma disparities in Chicago pose a continual challenge for the Chicago Public Schools (CPS). Coordinated Healthcare for Complex Kids (CHECK) is a health care demonstration project funded by a Centers for Medicare and Medicaid Services Health Care Innovation Award. A collaborative partnership was formed between CHECK and CPS. With CHECK support, CPS administered a survey to 160 nurses to understand the asthma problems nurses perceived and interest in intervention.

RESULTS

Seventy-five per cent (n = 120) completed the survey. While asthma was the top diagnosis managed by 95%, 72% reported gaps in asthma understanding. Appropriate communication between school nurses and providers occurred 33% of the time; 18% believed they received sufficient support to follow-up on deficient paperwork. The barriers mentioned were lack of medications (73%), time (67%), and communication with providers (61%). When asked their opinions on potential interventions, 78% of nurses supported web-based applications, 66% community health workers (CHW), and 66% stock albuterol in schools.

CONCLUSIONS

The greatest barriers for CPS nurses with asthma management are time and communication. Potential interventions such as web-based communication applications and CHW in schools were well received.

Student perspectives on asthma management in schools: a mixed-methods study examining experiences, facilitators, and barriers to care

Objective: Children spend nearly a third of their day at school, making it a critical point of intervention for those with asthma. This study aimed to illuminate minority students' experiences with asthma at school and perceptions of facilitators and barriers to care. Methods: A mixed-methods study was conducted with elementary students with asthma. Participants completed a 24-question survey, drawing exercise to depict experiences caring for their asthma at school, and focus group discussion. Drawings were analyzed for narrative and pictorial themes. Discussions were audio-recorded, transcribed, and independently coded for themes. Results: Fifteen children with asthma (8-11 years) participated from two Chicago schools with predominately African-American populations. Most students (79%) indicated they had control of asthma at school, while 85% identified asthma as a problem when exercising. Half (53%) received help with asthma care at school. Drawings depicted cooperative management with adults or peers and the central role of inhalers as part of everyday asthma care in school. Finally, focus groups produced six key themes within the domains of facilitators: 1) support of others, 2) self-efficacy; 3) perception of being normal; and barriers: 4) lack of support from others; 5) difficulty accessing inhaler; 6) perception of being different. Conclusions: This study suggests asthma care plays an important role in students' school experiences. Stigma around inhaler use, lack of concern by school staff, and limited access to medications remain as barriers to school-based asthma management. Although facilitators, such as support from teachers and peers, do exist, future interventions must address existing barriers.

A qualitative study of parent perspectives on barriers, facilitators and expectations for school asthma care among urban, African-American children

Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study's goal was to determine parents' perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.

Implementation of an Allergic Reaction Reporting Tool for School Health Personnel: A Pilot Study of Three Chicago Schools

Food allergy (FA) impacts 8% of U.S. children, thus it is critical to document allergic reactions to assist schools in managing FAs. We implemented and evaluated an online tool to assist school health personnel in tracking the characteristics of allergic reactions occurring at schools. The Online School Allergic Reaction Registry (OScARR) was modified from the Epinephrine Administration Form developed by the Massachusetts Department of Public Health, adapted for integration into existing school health records, and implemented in three Chicago schools during the 2016–2017 school year. All allergic reactions occurring at participating schools were recorded by school nurses. Twenty-five percent of the 20 allergic reactions reported were characterized as anaphylaxis by school nurses. School nurses reported that they would recommend OScARR for use in other schools. Detailed data obtained from three Chicago schools underscore the importance of proper documentation to improve the understanding of the causative allergen and location and management of allergic reactions in schools.

Real-world evaluation of a mobile health application in children with asthma

BACKGROUND

Mobile health applications for asthma are increasingly being developed. However, there are no published randomized controlled trials evaluating efficacy in decreasing exacerbations.

OBJECTIVE

To evaluate the impact of a mobile asthma application for asthma-related urgent health care usage.

METHODS

We conducted a 6-month prospective randomized controlled trial for patients (6 months-21 years old) with persistent asthma presenting with an asthma exacerbation to the emergency department of a pediatric academic medical center. Participants were randomized to AsthmaCare (application providing medication and trigger reminders and treatment plan) or the control (online asthma information). Primary outcome measures were comparison of emergency department and urgent care visits and hospitalizations 6 months before and after randomization.

RESULTS

AsthmaCare participants (n = 98) were slightly older (7.84 vs 6.24 years; P = .02) than controls (n = 95) but similar for sex (55% vs 62% boys), race (83% vs 77% African American), and insurer (89% vs 98% Medicaid). The 2 groups were similar in having more than 2 comorbidities (34% vs 32%) and receiving National Heart, Lung, and Blood Institute step 3 treatment or higher (69% vs 57%). There was no significant decrease in emergency department or urgent care visits or hospitalizations between the intervention and control groups. AsthmaCare participants were more likely to report improvement in asthma management 6 months after study enrollment (79% vs 64%; P = .06).

CONCLUSION

This randomized controlled trial did not demonstrate a significant decrease in asthma-related emergency department visits or hospitalizations among children who used a mobile health application.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT02333630.

The Allergist's Role in Anaphylaxis and Food Allergy Management in the School and Childcare Setting

Anaphylaxis and food allergy management in childcare facilities and schools are growing challenges. An increasing number of children experience severe allergic reactions on school grounds as evidenced by reports of epinephrine use. Data also suggest that the prevalence of food allergy may be increasing, with a large percentage of school-aged children at risk for anaphylaxis. Moreover, anaphylaxis may occur for the first time in a previously undiagnosed child at school or childcare setting, suggesting that general preparedness is essential. Management includes strategies for minimizing the risk of reactions and allergen exposures as well as readiness to recognize and treat allergic reactions of any severity. The primary objective of this report is to offer health care providers an overview of relevant evidence, resources, and expert opinion to assist with developing interprofessional collaborative counsel on school food allergy management and anaphylaxis preparedness with families, schools, and childcare settings. We present the current evidence base, suggest resources, and highlight areas of current controversy that warrant further study.

Food Allergy Trends and Epinephrine Autoinjector Presence in Summer Camps

BACKGROUND

Pediatric campers with food allergies are at greater risk for exposure and anaphylaxis. A diagnosis of asthma increases risk for anaphylaxis. Epidemiological investigations of food-allergic children at high risk for allergic reactions requiring intervention in camp settings are lacking.

OBJECTIVE

The objectives of this study were to estimate the prevalence of food allergies among otherwise healthy campers in summer camps throughout the United States and Canada, and to assess asthma comorbidity and determine rates of epinephrine autoinjector prescriptions present in this population.

METHODS

We partnered with CampDoc.com, a web-based camp electronic health record system. Deidentified data were abstracted from 170 camps representing 122,424 campers. Only food allergies with a parental report of symptoms requiring intervention or with a camp prescription for an epinephrine autoinjector were included, whereas gluten, lactose intolerance, and food dyes were excluded. Asthma status and epinephrine presence on the camp medication list were assessed.

RESULTS

Overall, 2.5% of campers (n = 3055) had documented food allergies. Of these campers, 22% had multiple food allergies. Median age was 11 years; 52% were female. Nuts (81%), seafood (17.4%), egg (8.5%), fruit (8.1%), and seeds (7.2%) were the top 5 food allergies reported. Of food-allergic campers, 44.3% had concurrent asthma and 34.7% of those campers were taking multiple asthma medications. Less than half (39.7%) of food-allergic children brought an epinephrine autoinjector to the camp.

CONCLUSIONS

Life-saving epinephrine is not necessarily available for food-allergic children in camp settings. A substantial proportion of food-allergic campers are at higher risk for anaphylaxis based on concurrent asthma status.

Food allergy prevalence and management at an overnight summer camp

BACKGROUND

In recent years, increased awareness of food allergy management has focused on the school setting. A lack of awareness and relevant literature prompted evaluation of the camp experience.

OBJECTIVE

To characterize the prevalence of food allergies among children attending an overnight summer camp and to evaluate the knowledge and comfort of camp personnel before and after a training session.

METHODS

The database for the 2014 season at Flying Horse Farms was reviewed for information pertaining to food allergies and provision of epinephrine and treatment plans. Camp personnel completed surveys regarding food allergy knowledge and comfort. Surveys were redistributed 30 days after the training session.

RESULTS

Among 445 campers, 15% reported at least one food allergy, with 8.5% reporting allergy to 1 of the top 8 food allergens. Only 32% of campers with food allergy supplied an epinephrine autoinjector, and 0% provided written treatment plans. Before training, 84% of personnel desired additional information about food allergies. Knowledge of food allergies among personnel was high at baseline but increased after training in regard to epinephrine use for anaphylaxis and postepinephrine management. Staffers who reported feeling very comfortable caring for campers with food allergy increased from 16% to 46% after the training session; comfort in treating a food allergy emergency increased from 2% to 29%.

CONCLUSION

Management of food allergies at overnight summer camps warrants similar education and preparation strategies as those implemented in schools. Camp personnel should receive annual training regarding food allergies and anaphylaxis.

IgG Expression upon Oral Sensitization in Association with Maternal Exposure to Ovalbumin

The role of maternal allergen exposure in the allergenicity of the offspring remains controversial. Some studies have shown that maternal exposure is a risk factor for allergy in the offspring, whereas other studies have shown that maternal exposure induces immune tolerance and protects offspring from allergy disease. Therefore, we utilized maternal rat allergen exposure model to evaluate the offspring immune reactions to ovalbumin protein and to determine whether the Brown Norway (BN) rat model is a suitable animal model for studying the allergenicity of food proteins. For three generations, rats received an allergens or non-allergens by gavage during the pregnancy and lactation periods. After weaning, the offspring rats were used for oral sensitization experiment. In the sensitization experiment, the control rat, which had maternal exposure to phosphate-buffered saline (PBS), exhibited full response of IgG to oral exposure to OVA. The IgG level was significantly lower in F1 rats that were sensitized by maternal exposure to ovalbumin(OVA). Moreover, the lowest IgG level was found for the F3b sensitized by maternal rats exposed to OVA allergen for three continuous generations. Compared with maternal OVA exposure prior to postnatal sensitization, the sensitization via maternal PBS led to a higher serum level of OVA-specific IgG. However, the OVA-specific IgG levels for the two generations of maternal PBS exposure prior to postnatal sensitization was not higher than that for the one generation of maternal rats exposed to PBS prior to postnatal sensitization. Our studies demonstrate that maternal OVA exposure during the pregnancy and lactation can affect the results of oral sensitization studies using ovalbumin protein. BN rats must be bred in non-allergen conditions for at least one generation to avoid problems in rat models for studying the allergenicity of food proteins.

Emergency epinephrine use for food allergy reactions in Chicago Public Schools

BACKGROUND

Given the increase in childhood food allergy, national and local policies have been developed to encourage schools to stock undesignated epinephrine auto-injectors in case of an anaphylactic emergency.

PURPOSE

To describe the use of epinephrine auto-injectors in Chicago Public Schools during the 2012-2013 school year, specifically for food-induced allergic reactions.

METHODS

District-issued epinephrine auto-injectors were distributed to all public and charter schools in Chicago prior to the start of the 2012-2013 school year. Data on their use were collected, and frequencies were computed in the autumn of 2013.

RESULTS

Thirty-eight district-issued epinephrine auto-injectors were administered during the inaugural year of the Chicago Public Schools initiative. Epinephrine auto-injectors were administered to students (92.1%) and school staff (7.9%). Most district-issued epinephrine auto-injectors were administered in elementary schools (63.2%) and on Chicago's North-Northwest Side (36.8%). More than half (55.0%) of all district-issued epinephrine auto-injectors were administered for first-time anaphylactic events. Food-induced reactions accounted for more than half (55.3%) of all reactions requiring epinephrine auto-injector use, whereas the trigger of more than one third (34.2%) of all reactions requiring the use of an epinephrine auto-injector remained unknown.

CONCLUSIONS

Chicago Public Schools is the first large, urban school district in the U.S. to develop and implement the District-Issued Emergency Epinephrine Initiative, which helped 38 students and staff avoid potential morbidity and mortality. The impact of this initiative during its first year underscores the need for stocking undesignated epinephrine in schools across the country.

Identifying barriers to chronic disease reporting in Chicago Public Schools: a mixed-methods approach

BACKGROUND

Chronic disease among school-aged children is a public health concern, particularly for asthma and food allergy. In Chicago Public Schools (CPS), rates of asthma and food allergy among students are underreported. The aim of this study was to determine the barriers to chronic disease reporting as experienced by CPS parents and school nurses.

METHODS

A mixed-methods approach included focus groups and key informant interviews with parents and school nurses, and a cross-sectional survey was completed by parents. Qualitative data analysis was performed and survey data were analyzed to determine the significant demographic and knowledge variables associated with successfully completing the reporting process.

RESULTS

The three main barriers identified were 1) a lack of parental process knowledge; 2) limited communication from schools; and 3) insufficient availability of school nurses. Parents were significantly more likely to successfully complete the reporting process if they knew about special accommodations for chronic diseases, understood the need for physician verification, and/or knew the school nurse.

CONCLUSIONS

These findings suggest that increasing parental knowledge of the reporting process will allow schools to better identify and manage their students' chronic conditions. A parent-focused intervention informed by these results has been completed.