As she tied pink ribbons in her daughter Ammaria’s hair that January morning in 2012, Laura Pendleton had no way of knowing it would be the last time she would see her daughter alive.
Ammaria was allergic to peanuts, and although the school was aware of her allergy, her mother was reportedly told that it was not necessary to provide the school with her EpiPens (an injectable medication to treat a severe allergic reaction). This was the first of several mistakes and misunderstandings that could not be undone.
Ammaria’s family members also believed—as many parents of children with food allergies do—that she would never eat a food unless she was sure it was safe for her. But Ammaria was a 7-year-old child, incapable of fully comprehending the dangers posed by her medical condition.
On that chilly day on the playground, with no idea of the monumental consequences of her choice, Ammaria ate a peanut given to her by a classmate who was unaware of her allergy.
Ammaria knew immediately that something was wrong—a sense of impending doom is common in severe allergic reactions—and she approached her teacher to report trouble breathing. The teacher took her to the school health clinic, where things only got worse.
Ammaria was covered with hives at this point and crying hysterically saying, “My throat, my throat!” The school called 911 and attempted to reach Ammaria’s mother. By the time emergency services technicians arrived, Ammaria had collapsed in cardiac arrest. The health aide administered CPR, but it was too late. She was pronounced dead that same day.
The school district later settled a multimillion-dollar lawsuit, but obviously no amount of money can erase the pain of this loss and the far-reaching impact on the community.
The “what-ifs” are hard to dismiss in food allergy fatalities. Experts say that most fatal reactions are preventable with proper avoidance measures or immediate treatment with epinephrine. We can learn from these tragedies and be prepared to react not if, but when a severe allergic reaction happens.
Be Ready to Respond
Is your school ready to respond? Consider these key points.
Food allergies can be fatal. Anaphylaxis is a severe allergic reaction and a medical emergency. It must be treated immediately with an epinephrine auto-injector, such as an EpiPen or Auvi-Q. Antihistamines like Benadryl will not stop an anaphylactic reaction. Studies have shown that fatal reactions are linked to a delay in administering epinephrine.
Any food has the potential to provoke an allergic reaction. Eight foods cause the majority of allergic reactions—milk, eggs, peanuts, tree nuts (such as almonds, walnuts, or cashews), fish, shellfish, soy, and wheat—but any food can cause a reaction. Although peanuts, tree nuts, and shellfish are the best-known allergens, individuals have been known to react to more than 180 different foods. All food allergies should be taken seriously.
A food allergy is not an intolerance. A food allergy is a medical condition in which exposure to a food elicits a harmful immune response. The immune system attacks proteins in the food that are normally harmless. A food intolerance (such as lactose intolerance) involves the digestive system and is not life-threatening.
Past reactions do not predict future reactions. Some people may characterize an allergy as mild, when, in fact, they are referring to a history of mild reactions rather than a mild allergy. It’s important to know that an individual can have a mild or moderate reaction to a food one day and then have a severe—even life-threatening—reaction upon the next exposure.
Food allergy reactions are common. A food allergy reaction sends someone to the emergency room every three minutes, resulting in 210,000 visits each year. Forty percent of children with food allergies have experienced a severe or life-threatening reaction. One in 6 children with food allergies will have a reaction while at school. Roughly 1 in 4 doses of stock epinephrine given at a school is used to treat a student or staff member who had no previous diagnosis or history of allergic reactions.
Food allergies are increasing in prevalence. Today, 1 in 13 children has at least one food allergy. One-third of these children have multiple food allergies. A 2013 report by the Centers for Disease Control and Prevention (CDC) cites a 50 percent increase in food allergies between 1997 and 2011.
Reactions can occur from ingestion, contact, or inhalation. Most severe allergic reactions happen through ingestion. However, some individuals react from contact and inhalation of allergens, most commonly from cooking or steaming (for example, milk and fish). Young children can transfer food debris from their fingers to their eyes, mouth, or their food, which can trigger an allergic reaction.
Not all reactions can be successfully treated. Most reactions can be treated quickly and effectively with epinephrine. Unfortunately, not every individual will respond to treatment with epinephrine, even when it is given in a timely fashion. This is why prevention and allergen-avoidance measures are critical. Restricting identified allergens from certain areas, such as tables or a classroom, is a common accommodation in preschool and grade school.
Food allergies take an emotional toll. One-third of students with food allergies are bullied because of their allergies. Children have reported being threatened with their allergen, having food thrown at them, or having food rubbed on them and their belongings. Students also report experiencing emotional distress when they are excluded from classroom activities, parties, celebrations, field trips, or extracurricular events.
Food allergies are a medical and a legal issue. A food allergy may constitute a disability under federal laws such as the Americans with Disabilities Act (ADA), the ADA Amendments Act, Section 504 of the Rehabilitation Act, and the Individuals with Disabilities Education Act (IDEA). School staff should be aware of the need to accommodate students with food allergies in the least restrictive environment to allow for safety and inclusion.
In public schools, students whose food allergies constitute a disability under these laws and who require accommodations should be evaluated for a Section 504 plan. The 504 team consists of individuals who are knowledgeable about food allergies, the child, and the placement options. The team will agree upon accommodations needed so the student has safe access to school activities, including those in the classroom, at lunch, during parties, and at extracurricular events.
Food allergy management guidelines may reduce risk. The CDC published “Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs” in October 2013. The guidelines recommend that schools implement district-wide policies and procedures for managing food allergies. The guidelines recommend the following key components:
- Establishing procedures for identification of children with food allergies
- Developing individual emergency care plans and accommodation plans, such as a Section 504 plan
- Creating protocols and quick access to epinephrine auto-injectors
- Establishing a safe educational environment where exposure to food allergens is minimized
- Creating a positive psychosocial climate that reduces bullying and social isolation and promotes acceptance and understanding of children with food allergies
Evidence-Based Training Programs
To supplement the national guidelines, the nonprofit Food Allergy Research & Education (FARE) offers two evidence-based training programs for schools. The first, “Keeping Students Safe and Included,” is an online training course designed to help school staff and administrators become better prepared to manage students with food allergies and respond to food allergy emergencies.
“How to Save a Life: Recognizing and Responding to Anaphylaxis” is FARE’s online training to help individuals learn more about anaphylaxis, its causes, and the proper emergency response. Individuals are often reluctant to administer epinephrine. Specific training on when and how to use epinephrine, as well as a video demonstration of the various epinephrine auto-injectors, helps increase confidence.
After her daughter’s untimely death, Laura Pendleton advocated to pass “Ammaria’s Law” in Virginia, which requires schools to stock undesignated epinephrine and staff to be trained to use it. While students in Virginia can take comfort in these measures, educators should act immediately to implement safety measures and training. Everyone caring for children today must have a healthy respect for food allergies and be prepared to save a life.
Gina Clowes is the national director of training and community outreach for Food Allergy Research & Education (FARE) in McLean, VA.
To Learn More…
Want to know more about food allergies or FARE’s programs? Visit www.foodallergy.org.