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Managing Chronic Health Needs in Child Care and Schools—Anaphylaxis

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What is anaphylaxis?

  • Anaphylaxis is a life-threatening allergic reaction that affects the whole body. It happens when the body has an intense response to an allergen. Symptoms can include

    • Drop in blood pressure

    • Flushing, sweating, or paleness of the skin

    • Swelling of the skin, lips, mouth, or throat

    • Raised red rash (hives) and itching

    • Nausea or stomach cramps

    • Difficulty breathing, including wheezing

    • Fainting, light-headedness, or convulsions

    • Cardiorespiratory arrest

  • These symptoms usually occur within minutes of contact with the allergen or allergy-causing substance; however, sometimes symptoms can be delayed a few hours.

  • Anaphylaxis can be caused by many things, but insect stings, food (especially nuts), medications, and latex are some of the more common allergens.

How common is it?

  • Anaphylaxis occurs in 30 out of 100,000 persons.

  • Food allergy occurs in between 2% and 8% of children.

What are some characteristics of children with anaphylaxis?

  • Anaphylaxis usually occurs with no warning, although it can happen more frequently in children with other known allergies.

  • A child may come to your child care program or school with a diagnosis of being at risk for anaphylaxis, or the child may develop the condition while enrolled.

Who is the treatment team?

  • The primary care provider in the medical home is the major point of contact.

  • Allergists may also be important team members.

  • Consider contacting local emergency medical services (EMS)/911 providers for questions about planning for emergencies.

What adaptations may be needed?


  • Anaphylaxis is treated with injected epinephrine, which is commonly packaged in an automatically injected device like EpiPen or EpiPen Jr. The pen is pressed against the skin (usually the thigh) and activated.

  • Always call EMS/911 when injected epinephrine is used.

  • Always call parents/guardians and tell them what hospital the child has been transported to.

  • Injected epinephrine is effective for 15 to 20 minutes. It may need to be used a second time if EMS/911 are not able to respond quickly.

    • Side effects of epinephrine include pallor, vomiting, fast heart rate, and jitteriness.

  • There may be instructions to use other medications as well for allergies such as diphenhydramine (Benadryl is one brand name).

    • Side effects of diphenhydramine include sleepiness, but some children may experience excitement.

  • All medications should be properly stored. Procedures should be in place to check expiration dates and obtain fresh medication as needed.

  • Staff training on EpiPen and Benadryl use is very important.

Dietary considerations

  • Avoiding foods that cause anaphylaxis for the involved child is crucial. Some foods that are common allergens include peanuts, tree nuts, soy, eggs, and milk. It is not easy to avoid peanuts because peanut oil is in many products. Cross contamination can occur when foods are processed and packaged. Strategies include starting a table that has whatever food restriction is necessary or making the classroom and any other areas the child uses free of the allergen. In some cases, strict hand-washing precautions after eating or avoiding the offending food must involve all the children who share the spaces that the allergic child uses to protect the allergic child from exposure to the allergen while at the child care or school. Even touching a surface touched by a child who has had contact with the allergen can be sufficient to cause a reaction for very sensitive children. Using specially marked place mats to remind caregivers which child has a food allergy can be helpful, but it does not stop children from sharing food.

  • In some cases, it is best for parents/guardians to supply food for the child with the allergy. In other cases, the child care/school staff may be able to provide food as long as they have been fully educated about avoiding specific food allergens.

  • A policy about accepting foods from parents/guardians should be maintained (see Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs, 2nd Edition, Standard 4.040). Parents/guardians of all the children in the child’s class should be advised to avoid any known allergens in any treats that they supply to the class.

  • Store-bought or commercial products are acceptable as long as the package list of ingredients is provided. Parents of children with food allergies are usually very willing to take time to read these ingredients to ensure the safety of their children.

  • The American Academy of Allergy, Asthma & Immunology position paper, “Anaphylaxis in Schools and Other Child-Care Settings” (, states, “…hand washing after food handling should be encouraged in day care and preschool settings, as well as in lower schools.” Soap and warm water should be sufficient for washing (see Caring for Our Children, 2nd Edition, standards 3.020–3.021).

  • A list of children with any known allergies should be posted where it can be easily seen by staff but not by the public and other children.

Physical environment

The key adaptation to avoiding anaphylaxis is to try to avoid the allergen. This may mean

  • Avoiding products with latex or those with strong perfumes.

  • Being extra cautious during outside play if stinging insects are around, and avoiding eating outside. Encourage closed-toe shoes in children with known allergies.

  • Avoiding food allergens. In some cases, just physical contact with the food can cause a reaction even if the child doesn’t eat it.

Transportation considerations

  • Injectable epinephrine should be available as the child is transported to and from child care or school. For field trips, the injectable epinephrine and someone who can administer it should be available. A mobile phone and a copy of the child’s Care Plan should be carried at all times.

  • In emergency evacuation situations, injectable epinephrine should be carried.

What should be considered an emergency?

  • Early symptoms of anaphylaxis can include hoarse voice, sore throat, or feeling of throat closing or tingling. Other common symptoms include skin or mouth swelling, a feeling of panic, and stomach cramps or vomiting. Difficulty breathing or wheezing are serious symptoms as well. The child may be pale or dizzy.

  • Children who are stung by an insect should be monitored closely for symptoms of anaphylaxis.

  • If symptoms of anaphylaxis are present, call EMS/911 immediately. Inject epin ephrine if available and keep the child relaxed and in the position of greatest comfort.

  • If symptoms do not improve after 10 minutes or if symptoms return, a second dose of epinephrine can be given if EMS/911 first responders have not yet arrived.

  • Be prepared to start CPR if the child stops breathing.

  • If the child has a symptom about which you are unsure, call the parent/guardian immediately and prepare to give injectable epinephrine if necessary.

  • Parents/guardians should be notified of any possible exposure to an allergen even if a reaction did not occur.

What types of training or policies are advised?

  • Care Plan outlining specific instructions.

  • Avoiding food allergens.

  • Recognizing anaphylaxis.

  • Responding to anaphylaxis.

  • The Food Allergy & Anaphylaxis Network Web site ( has great training information.

  • Some pharmaceutical companies also have good training materials.

  • Consider having a health consultant give a training presentation.

  • A policy on food allergies should be written.

What are some resources?

  • Food Allergy & Anaphylaxis Network, 11781 Lee Jackson Hwy, Suite 160, Fairfax, VA 22033-3309; 800/929-4040;

  • American Academy of Allergy, Asthma & Immunology,

  • American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care. Standard 4.009: feeding plans. In: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care. Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002:153–154

  • American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care. Standard 4.010: care for children with food allergies. In: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care. Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002:154–155

Source: Managing Chronic Health Needs in Child Care and Schools: A Quick Reference Guide.

Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics.

Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright © 2010 American Academy of Pediatrics. All rights reserved.

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