Food Allergy Education and Management in Schools: A Scoping Review on Current Practices and Gaps

Increasing teachers' confidence during health emergencies: A hands-on quality improvement program led by the school nurse

INTRODUCTION

One in four school-age children has a chronic health condition, with approximately 6% of them having multiple chronic health conditions. These students are at an elevated risk of individual health emergencies during school hours. While teachers receive online training to assist in these emergencies, they lack practicing with rescue medications.

METHODS

We developed a Quality Improvement (QI) program that had a) a live presentation; b) a hands-on workshop to practice using rescue medications for allergies, asthma, seizures, and diabetes; c) fliers with first-aid guidelines; and d) a web-based reference toolkit. Teachers' confidence and knowledge were measured using the Learning Self-Efficacy Scale and a knowledge questionnaire with a pre- and post-intervention survey. We also assessed their clinical skills using the rescue medications.

RESULTS

129 teachers took part in this QI program. We collected 95 pre- and 81 post-surveys, with 47 matched. We saw statistically significant increases in confidence, as well as in the individual cognitive, affective, and psychomotor domains. Teachers also increased their overall knowledge. Collaterally, other district-wide improvements developed.

CONCLUSION

This evidence-based, hands-on QI program provided teachers the opportunity to put into practice clinical skills, increasing their confidence to help students when experiencing an individual health emergency. Furthermore, changes beyond the primary goal of this QI program were implemented, highlighting the lead role of the registered nurse as the public health advocate.

IMPLICATION TO PRACTICE

Laypeople benefit from hands-on training to learn clinical skills. This program serves as a basis for improving health emergencies preparedness in schools.

Evaluation of a video training program's impact on primary teachers' knowledge of allergies and skills in using an adrenaline autoinjector during the 2021-2022 school year

AIM

The aim of the study was to assess the impact of a video training program (VTP) on primary school teachers' skills in using an adrenaline auto-injector (AAI), in correlation with knowledge regarding allergies, in cases of anaphylaxis.

METHODS

A questionnaire on teachers' knowledge of allergies and on their level of confidence in using an AAI was distributed in primary schools in the French department of Manche (2173 teachers). A VTP followed this questionnaire. A second questionnaire was then distributed. Theoretical knowledge was assessed with a score out of 20. The confidence level was rated on a scale from 1 to 4.

RESULTS

We collected 218 responses to the first questionnaire (10.0 % of the population included). The response rate to the second questionnaire was 4.7 % (103 participants), and from this group, 93 of the 103 participants viewed the video (90.3 %). Overall, 76 of the 218 (34.9 %) participants who completed the first questionnaire also completed the second questionnaire and watched the VTP. The number of participants who completed the whole survey was 76 (out of 2173, 3.5 %). The VTP significantly improved teachers' knowledge of the subject of allergies (the average score increased by 2.11 points, p < 0.001) as well as their confidence in recognizing the signs of a severe allergic reaction and in using an AAI: 85.4 % (n = 88) of self-confident teachers after the VTP versus 42.3 % (n = 92) before the VTP (p < 0.001).

CONCLUSION

The VTP improved teachers' level of knowledge and confidence in using an AAI in cases of anaphylaxis. A similar VTP could be circulated more widely in schools to offer easy access to training tools about allergies.

Milk-induced anaphylaxis among children presenting to Canadian emergency departments

BACKGROUND

Cow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse.

OBJECTIVE

To describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration.

METHODS

Between April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used.

RESULTS

Of 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema.

CONCLUSION

Prehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods.

Food allergy issues among consumers: a comprehensive review

Food Allergy (FA) is a growing global public health concern. In the United States alone, 8% of children and 11% of adults have a convincing FA (symptoms consistent with an IgE-mediated reaction to a specific allergen). Given the significant prevalence of this condition, the objective of this mini-review is to illustrate the many dimensions of life that are impacted among those with FA. Summarizing findings from a breadth of current literature, we present how FA affects social, psychological, and economic-related quality of life. With this informative review, we endeavor to bring increased awareness to these issues and help cultivate a better future for individuals with FA.

Protocol Development of a Personalized Balanced Nutrition Concept for Preschool Children, Primarily Those with Food Allergies, Using an IT Platform

Children with food allergies are at higher risk for severe anaphylactic reactions and for key nutrient deficiency. In order to address these concerns, enable early detection, and improve the monitoring of children with food allergies, an innovative IT platform will be developed by IT experts (IN2 Ltd. Zagreb, Croatia, part of Constellation Software Inc. (Toronto, ON, Canada)) and Srebrnjak Children's Hospital, Zagreb, Croatia (SCH) for the effective implementation of personalized balanced nutrition in preschool institutions in Croatia. Additionally, the data obtained through this research, including epidemiological data on allergic diseases, clinical data (diagnostic allergy tests and others), anthropometry, and physical activity status, will be used to create a national Allergy registry. Other than being a tool for personalized and balanced nutrition for children, especially those with special dietary requirements (including food allergy and intolerance), the IT platform developed in this study will enable the continuous monitoring of these children as a part of their clinical management plan and earlier detection of food allergies, intolerance, and other conditions, even outside of the healthcare system. This research also aims at optimizing current and developing novel personalized therapeutic regimes, detecting novel early biomarkers in children with food allergies and intolerances, and involving all key stakeholders (caregivers, preschool institutions, etc.) in the shared-care approach in the management of food allergies in children.

Winnipeg-based elementary school teachers' perspectives on food allergy management: a qualitative analysis

BACKGROUND

Food allergy affects 7-8% of children worldwide. Teachers supervise children in school, where most children spend their day. Yet, teachers have variable food allergy-related knowledge.

OBJECTIVE

We aimed to identify how Winnipeg-based elementary school teachers manage food allergy and prevent food-triggered allergic reactions in their classrooms and schools.

METHODS

Kindergarten-Grade 6 public and private school teachers, from Winnipeg, Canada, were interviewed virtually upon providing written informed consent. Interviews were recorded and transcribed verbatim. The study followed a pragmatic framework. Data were analysed via thematic analysis by multiple researchers.

RESULTS

We interviewed 16 teachers, who primarily identified as female (87.5%). Most teachers worked in public schools (87.5%) and, on average, had 5.8 years of teaching experience. We identified four themes within the data. Most teachers (68.9%) had direct or indirect experience with food allergy. Theme 1 described the minimal standardization and inconsistent enforcement of food allergy policies between and within schools. Teachers also had varied food allergy knowledge. Theme 2 reflected teachers' variable confidence/perceived knowledge towards food allergy management, including feeling of stress and anxiety. Theme 3 captured the lack of standardized food allergy education for teachers, and concerns about the adequacy of the current provincial program. Theme 4 described how teachers spoke of relying on other school staff, families and students to have effective communication.

CONCLUSION

Teachers' food allergy management was informed by their knowledge and lived experience, guided by their school policies and individualized students' needs. Teachers identified gaps in knowledge and communication, and desired more training and resources.

Food Allergy Education and Management in Early Learning and Childcare Centres: A Scoping Review on Current Practices and Gaps

Anaphylaxis has occurred in preschools/schools yet there are no consistent food allergy (FA) management practices in early learning and childcare centres (ELCC) across jurisdictions. Presently, there are no reviews that have synthesized FA-related knowledge and management practices within ELCC. We aimed to perform a scoping review of FA management in ELCC, and report on perceived gaps or barriers. A PRISMA-ScR-guided search was conducted for North American, European and Australian articles in English/French in the OVID-MedLine, Scopus, and PsycInfo databases. Two independent reviewers screened the titles/abstracts of 2010 articles and full-text screened 77 articles; 15 of which were specifically related to ELCC. If the two reviewers could not agree to the relevance of a given study, a third reviewer provided guidance. This third reviewer also screened French articles. Thematic and descriptive reports of the studies were presented. We reported solely on pre-Coronavirus Disease pandemic ELCC studies. We included ten articles in this review, which provide evidence that ELCC staff have variable baseline knowledge, comprehension, experience, and practices in place to manage FA. ELCC staff also have limited FA-related training and experience regarding administration of epinephrine auto-injectors (EAI). Emergency Anaphylaxis Plans (EAP) were described in four studies. One study reported the parental influence on the site's food purchasing and FA management. Three studies provided educational interventions, which demonstrated increased and sustained FA-related knowledge and confidence post-intervention. Participants deemed the training beneficial and desired annual training and more FA resources to be available. Across jurisdictions, ELCC staff have provided care and administered EAI in emergencies, but training remained variable. Communication and care planning amongst ELCC staff, and parents, is crucial. Annual education, available EAI and EAPs are tools necessary for effectively managing emergencies.

Food Allergy Management Competence in Greek Schools

Background: Schoolchildren are likely to consume meals and snacks at school, with a possibility of allergic food reactions and anaphylaxis in the school environment. The school personnel should be informed of the presence of schoolchildren with food allergy (FA) and need to be trained in the management of allergic reactions, as to prepare them to intervene appropriately when necessary. Limited knowledge of FA and its management is documented globally among school staff and there is no uniform protocol in schools. Methods: In this observational cross-sectional study, teachers at state schools throughout Greece completed an online anonymous questionnaire on their awareness of FA reactions and the plans for the management of medical emergencies in their schools of employment. Results: Among the 289 teachers who responded the online invitation, 203 (70.24%) were female and 157 (54%) were aged under 40 years. Females expressed a higher level of concern about the presence of school personnel trained to manage FA symptoms (p = 0.001), written instructions, and the availability of adrenaline (epinephrine) at school (p < 0.001). A younger age was associated with a higher level of both interest and knowledge on FA management in schools. School directors were more certain about the availability of a special record of children with FA at school (p = 0.01), the availability of adrenaline (p = 0.006), and written guidelines on the management of serious health incidents at school (p = 0.04). Written guidelines instructing children to avoid sharing cutlery, glasses, home-prepared meals, and snacks bought from the school canteen were more common in schools in urban areas (p = 0.015). Only 20% of respondents could confirm with certainty that adrenaline autoinjectors (AAIs) were available at their schools, for the purpose of administering to children in the case of a severe FA reaction. Approximately 3/4 of the participating teachers stated that completion of this questionnaire raised their awareness of the risk of FA reactions in children at school. Conclusions: This study, the first in Greece to explore the knowledge of teachers about FA in schoolchildren, revealed the following absences in many schools: a process for identifying children with FA, a written emergency treatment plan, and immediate access to emergency AAI. School FA guidelines are necessary in Greece, and training, which includes the use of AAIs, is required to prepare teachers to manage FA reactions in children at school.

Food allergy knowledge, attitudes and beliefs of kindergarten teachers in Kuwait: a cross-sectional study

BACKGROUND

Food allergy (FA) affects up to 10% of children globally, with clinical symptoms varying from mild to severe, and in rare instances, it is life-threatening. Approximately one in five children with FA experience a food-induced allergic reaction in school, leaving teachers as the first line of intervention. This study aimed to assess kindergarten teachers' knowledge, attitudes and beliefs regarding FA.

METHODS

This cross-sectional study enrolled kindergarten teachers in Kuwait using stratified cluster sampling. The Chicago Food Allergy Research Survey for the General Public was used to assess teachers' knowledge, attitudes and beliefs regarding FA. The overall FA knowledge score was calculated for each participant. The χ² test was used to assess the differences in the distribution of categorical variables.

RESULTS

Responses were obtained from 882 public kindergarten teachers from 63 kindergartens. Most teachers (81.9%) encountered students with FA in their classrooms. Only 13.5% of the teachers reported receiving training in FA. Overall, participants scored an average of 52.2% on the FA knowledge assessment, with participants receiving prior training in FA scoring on average higher than those with no prior training in FA (55.9% vs 51.6%, p=0.005). A few teachers (10.7%) were aware that lactose intolerance was not equivalent to milk allergy. In terms of attitudes regarding FA, only 14.9% of the participants acknowledged that children with FA are teased/stigmatised due to their condition, and 33.7% recognised that avoidance of allergenic food is difficult. Moreover, only 9.9% of the teachers self-reported their ability to use an epinephrine autoinjector.

CONCLUSIONS

Improved knowledge and awareness of FA among public kindergarten teachers in Kuwait are needed to ensure the safety of children with FA in schools. Teachers should be trained to prevent, recognise and manage FA-related allergic reactions.

Carbon Nanotube-Based Biosensors Using Fusion Technologies with Biologicals & Chemicals for Food Assessment

High-sensitivity sensors applied in various diagnostic systems are considered to be a promising technology in the era of the fourth industrial revolution. Biosensors that can quickly detect the presence and concentration of specific biomaterials are receiving research attention owing to the breakthroughs in detection technology. In particular, the latest technologies involving the miniaturization of biosensors using nanomaterials, such as nanowires, carbon nanotubes, and nanometals, have been widely studied. Nano-sized biosensors applied in food assessment and in in vivo measurements have the advantages of rapid diagnosis, high sensitivity and selectivity. Nanomaterial-based biosensors are inexpensive and can be applied to various fields. In the present society, where people are paying attention to health and wellness, high-technology food assessment is becoming essential as the consumer demand for healthy food increases. Thus, biosensor technology is required in the food and medical fields. Carbon nanotubes (CNTs) are widely studied for use in electrochemical biosensors. The sensitive electrical characteristics of CNTs allow them to act as electron transfer mediators in electrochemical biosensors. CNT-based biosensors require novel technologies for immobilizing CNTs on electrodes, such as silicon wafers, to use as biosensor templates. CNT-based electrochemical biosensors that serve as field-effect transistors (FET) increase sensitivity. In this review, we critically discuss the recent advances in CNT-based electrochemical biosensors applied with various receptors (antibodies, DNA fragments, and other nanomaterials) for food evaluation, including pathogens, food allergens, and other food-based substances.

Prevalence of parent-reported food allergy among children in China: A population-based cross-sectional survey

Objective

The prevalence of food allergy (FA) has been increasing in recent years and has become an important public health, food safety, and clinical nutrition problem. However, population-based studies on the prevalence of FA are very limited in China. This study aims to determine the prevalence and pattern of parent-reported FA among school children in Jiangxi Province, China.

Methods

A multicenter cross-sectional study on FA was conducted on primary school children aged 6-11 years old using random cluster sampling with a questionnaire survey. Parent-reported FA was used and defined as individual-reported FA by parent or guardian through a questionnaire in this study.

Result

Among the total of 8,856 (96.36%) complete questionnaires received, 727 (8.2%) children had adverse reactions to food (ARF). The prevalence rates of parent-reported FA and doctor-diagnosed FA were 6.2% and 3.3%, respectively. Animal-derived foods were the main causative source of FA, and the three leading allergenic foods were shrimp, mango, and mollusks. Skin reactions were the most common clinical manifestations of FA, accounting for 63.7%, and 45.32% of the subjects with parent-reported FA experienced severe allergic reactions. There was a significant difference in parent-reported FA between different survey centers, and FA risk increased significantly in children with other allergic diseases (P<0.001) and small family size (P=0.026). The FA prevalence was significantly higher among children aged 8-11 years than those aged 6-7 years (P=0.020).

Conclusions

A high prevalence of parent-reported FA was observed among children in general primary schools in Jiangxi Province, China. Shrimp, mango, and mollusks were the most common causative foods. The main common symptoms of FA were adverse reactions relating to the skin system. The rate of severe allergic reactions was also high in Jiangxi Children with reported FA. Local standards and policies for the prevention and management of FA need to be adjusted on a timely basis according to actual local conditions.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

BACKGROUND

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).

OBJECTIVE

We sought to investigate the setting, management, and severity of pediatric FIA.

METHODS

We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.

RESULTS

We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.

CONCLUSIONS

Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Children's Perspectives on Food Allergy in Schools: A Qualitative Study

Approximately 7% of children live with food allergy, a condition that requires dietary avoidance to prevent an allergic reaction. In this qualitative study, we aimed to understand food allergy-related experiences, beliefs and learning preferences among children with and without food allergies, to inform a school-based, food allergy education program. Data were analysed thematically. We virtually interviewed children in Kindergarten-Grade 8 in Manitoba, Canada, with (n = 7) and without (n = 9) parent-reported, physician-diagnosed food allergies. We identified three themes: Naive reliance on peers and school staff to assist with food allergy management; Limited food allergy knowledge; and, Recommended food allergy curricula: complementary perspective. Our findings will help inform the development of a school-based, food allergy education program, with a long-term goal of minimizing food allergy-related worries and optimizing safety for children with food allergy. Ongoing, school-based food allergy education is needed.

Self-Reported Food Allergy Prevalence Among Elementary School Children - Nanchang City, Jiangxi Province, China, 2021

What is already known about this topic?

The prevalence of food allergy (FA) among the general population has been increasing in recent decades, and seriously affects the physical and mental health and the quality of life of many people - especially children.

What is added by this report?

The survey estimated self-reported FA prevalence using a standardized FA questionnaire among school children in Nanchang City, Jiangxi Province, China in 2021.

What are the implications for public health practice?

Based on the local, epidemiological characteristics of food allergy, public policies on the prevention and management of FA should be developed and preventive practices should be promoted to decrease the overall prevalence of FA.

Elementary School Teachers’ Perceptions of COVID-19-Related Restrictions on Food Allergy Management

(1) Background: Approximately 7% of Canadian children live with a food allergy (FA). Pre-COVID-19, ~20% of anaphylactic reactions occurred in schools. Yet, teachers reported poor FA-related knowledge, and experiences during the COVID-19 pandemic are not well-studied. Additionally, teachers’ management approaches vary widely. We aimed to describe elementary school teachers’ perceptions about FA management during the COVID-19 pandemic; (2) Methods: Using a semi-structured interview guide, English-speaking elementary school teachers in Winnipeg, Canada were interviewed virtually. Interviews were audio-recorded and transcribed verbatim. Data were analysed thematically; (3) Results: Most teachers were female and taught in public schools. Two themes were identified. Theme 1, COVID-19 restrictions made mealtimes more manageable, capturing the positive impacts of pandemic restrictions such as seating arrangements and enhanced cleaning. Limited lunchtime supervision prompted some teachers to assume this role. Theme 2, Food allergy management was indirectly adapted to fit changing COVID-19 restrictions, describing how changing restrictions influenced FA-related practices. FA training was offered virtually with less nursing support. Class cohorts and remote learning decreased teachers’ perceived risk and FA-related management responsibility; (4) Conclusions: COVID-19-related practices were perceived as positively influencing in-school FA management, although unintended consequences, such as increased supervisory roles for teachers and reduced nursing support, were described.