children in school class room raising hands

This webinar was held on July 25, 2023 

What you need to know about food allergies at school. We talk about food allergies, anaphylaxis, and a new way to give epinephrine.


Dr. Mike Pistiner
Director of Food Allergy Advocacy, Education and Prevention MassGeneral Hospital for Children, Food Allergy Center. Physician Investigator (Cl)Pediatric Allergy Group, Mass General Research InstituteAssistant PediatricianPediatric Allergy Group, Massachusetts General HospitalInstructor in PediatricsHarvard Medical School

CNE for nurses, and CRCE’s for Respiratory Therapists is available through Allergy & Asthma Network’s Online Learning HQ

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Andrea: Hello everyone. Thank you for joining us. Give us about another 30 seconds. I know it takes a while to connect. We have about 815 people registered for this. We are allowing a few more of those to connect. Hold on just a few more seconds.

Andrea: Good afternoon everyone and thank you for joining us today. We have a few housekeeping items before we start today’s program. I’m Andrea Jensen, I am the Education Specialist for Allergy & Asthma Network and a Certified Asthma Educator. All participants will be on mute for the webinar. We will record today’s webinar and post it on our website within a few days. You can find all of our recorded webinars on our website at Scroll all the way down to the bottom of the page to find our recorded webinars and any upcoming webinars. This webinar will be 1 hour and that includes time for questions. We will take those questions at the end of the webinar, but you can put your questions in the Q&A tab at any time. The Q&A box is at the bottom of your screen. We have someone monitoring the — screen on the left side. We have someone monitoring the chat if you have questions, or need help. We will get to as many questions as we can before we conclude today’s webinar. We will get to as many questions as we can before we conclude today’s webinar. We do NOT offer CEU’s for this particular webinar, however you will get a certificate of attendance. You will receive an email a few days after the webinar with resources from the webinar, and a link to access continuing education credits. You will also have a link to a certificate of attendance. We will also try to add the link to the certificate in the chat. Allergy & Asthma Network is a grassroots organization that was started over 35 years ago by a mom who knew that other mothers like her needed resources and support. Our mission is to end the needless death and suffering due to allergies, asthma and related conditions through outreach, education, advocacy, and research. Today it is my pleasure to introduce our speakers, Dr. Michael Pistener. Michael Pistiner, MD, MMSc is Director of Food Allergy Advocacy, Education and Prevention for the MassGeneral Hospital for Children, Food Allergy Center. He has a special interests in food allergy and anaphylaxis education and advocacy, infant food allergy management, healthcare provider education, facilitating collaborations between the medical home and school health, and maintaining quality of life in children and their families with food allergies. Dr. Pistiner is a fellow in the American Academy of Pediatrics (AAP), where he is a member of the Section on Allergy and Immunology Executive Committee, Council on School Health and the Massachusetts Chapter of the AAP. He is also a member of the American Academy of Allergy Asthma & Immunology and the American College of Allergy, Asthma and Immunology. Additionally, he serves on the medical advisory board of Asthma & Allergy Foundation of America, New England Chapter and is a voluntary consultant for the Massachusetts Department of Public Health School Health Service Unit. He is author of “Everyday Cool With Food allergies”. I will have to get your autograph after this. co-author of the “Living Confidently With Food Allergy” handbook, and co-founder and content creator of I know you did not want me to read your entire bio but I think it is so good we have to let people know who you are. And before restart start, we have a poll for you today. If you are a school nurse, hit the heart emoji. Oh look at all of those hearts. That is fabulous. If you a clinician, you can hit the wave to us. If you are a patient or a caregiver, you can hit the party emoji. And if you fall into another category, I am sorry we do not have enough emojis on here for everyone. If you are in another category you can hit the thumbs up emoji. OK Dr. Mike, there you go. And it was there a certain emoji you did not want them to hit?

Dr. Pistener: Yeah if you do not like what I am saying I was struggling — strongly encourage the Google emoji so I may be able to course correct. Luckily there is no emoji for this on there.

Andrea: OK, take it away.

Dr. Pistener: All right. The goals of this talk. Let me kind of just hold on just a second and let me — so the goals of this talk are to help you partner with others to replace the uncertainty of food allergy with facts and empowerment. To help you provide awareness within your — school communities that support students with food allergies and tell help you motivate and inspire your schools to create communities of support. So, navigating food allergies in schools and anaphylaxis can be challenging. School nurses are the captains of the ship. They can guide schools to safely manage anaphylaxis to help — to allow students to not only be safe but learn and thrive. Schools and others in the school health services can guide their schools to save and manage their food allergies from anaphylaxis. To allow students to not only be safe to thrive. This is a challenging mission especially in areas where school nurse and student ratios are optimal. If mission of effective food allergy and anaphylaxis management can be accomplished — cannot be accomplished by school nurses alone. One person cannot possibly manage this on their own. They need a crew. A crew, school staff as well as other members of the school community including families and administration, help school nurses cap in the ship. They help navigate this management. All members need to be on board. Now, uncertainty can lead to answers or myths that are way scarier than reality. Myth can cause fear, divide communities, divide the crew and ultimately lead to mutiny. For early day captains and crews it was seen monsters and flat earth with an edge that you could fall straight off of. For modern day cool nurses and school communities, it is common miss perception — misperceptions that can divide these division in — divide these communities. Or cause a reaction. What do our schools need to do? You need to identify this and replace it with fact. If we need to strengthen our team and our missions. It is our responsibility to use evidence to educate and guide our teams and communities to places of awareness and understanding. So how do we do it? Let’s see — let’s take a complicated issue and divided into two major parts. These are the pillars of food allergy management. Prevention which is preventing any allergic reaction and emergency preparedness, being ready to deal with an allergic emergency. These pillars will drive emergency intervention in our schools. So let’s start off by discussing some of the myth that you can — that can compromise prevention and emergency preparedness in a single blow. Our first myth is that only staff and the only staff that need to be trained are those that work directly with the students with food allergies. So the food allergy fact as the any staff member that might interact with the child with the child with a food allergy or might be asked to help respond to a food allergy or emergency should be trained. So the CDC guidelines suggest that all staff in the school be trained. Anybody that might have interaction with students and also those who do not necessarily. There might be a can still end — custodian or someone in the office that is around during an allergic emergency of not only a student, but also perhaps another employee or presenter to the school. The CDC really recommends that all people in the building are trained. Now, as far as what people need to know. This is going to depend on their role and interaction with students. And so, CDC guidelines suggest that all employees know about school policies and practices, that they have a food allergy overview and understand some of the basics and bet they understand the difference between a potentially life-threatening allergy and other food related problems that people are aware of signs and symptoms of an allergic emergency and anaphylaxis. And that they have some information and awareness about emergency medication. And they are also aware of prevention strategies of reducing exposure to allergen and understanding the school policies on bullying or an aspect. And also the school emergency protocol. Now, there are different levels of training that ultimately should be done in each of the schools. So, for those who are managing children and food allergies, in buildings where there are school nurses, the school nurses will have the opportunity to have — to train others so that they can ultimately extend themselves. For those with known allergies that school nurses will train delegates to be able to administer this medication for children with known allergies. In some states, Andrea, I would love for you to jump in here with what your account is as far as which states have stock epinephrine and then the optional ones and the mandated ones and in those states, there will be designees who will be able to administer epinephrine to the first time reaction when the school nurse is not available.

Andrea: according to the CDC, all 50 states allow undesignated epinephrine in school use for allergic or anaphylactic reactions. And then, another thing that this is really interesting and this may be in another part of the presentation is that there is something called public places stocking epinephrine. There’s about 35 states that have this. This is in addition to schools. They have colleges, universities, day cares, day care centers, hotels, restaurants, shopping malls, sports arenas, theme parks, and they all stock this for anyone who is there that needs it. There are three states that have pending legislation and another 13 who do not have any legislation. We are making great strides in this.

Dr. Pistener: If anybody has questions about advocacy reach out to the allergy network. Andrea and the rest of the team as well area all right, our next myth.

Andrea: Did it cut off? Oh good go ahead. [LAUGHTER]

Dr. Pistener: Food allergy with peanuts or tree nuts is mild. The fact is any reaction with food can cause a reaction and reactions can occur with foods including meat, — milk, wheat, eggs and others. Although half of the nut reactions were considered severe, food reactions can be severe as well. Wheat milk and egg — wheat, milk, and egg reactions were also severe. So policies must be put in place for accommodating students with various allergies. All right. Next myth. The cafeteria is the riskiest place in the school. The fact is that the classroom is the most common place for symptoms of an allergic reaction to begin in Massachusetts, we have mandated reporting for now almost two decades. And the statistics that developed pretty stable that the majority or 45% of the cases had symptoms that developed in the classroom. The cafeteria, about 15% of the time in. And also in the health office, also playgrounds, the point here is that allergic reactions can occur in a new place on school property. This helped support the importance of staff education. All staff education and it creates a schoolwide emergency preparedness. Some of the epinephrine administrations on school grounds look at things other than food like insect stings. And people other like — other than the kids and I will get to this later like school staff and visitors. All right, the next myth we cannot afford a school nurse. School nurses cost too much. The fact is, when you are playing the long game, school nurses save money. An 2014 study posted in JAMA pediatrics said that $2.20 is returned to schools. Compared to what is invested. This study suggest that an annual — by the way I am loving the emoji thing. So like being in their is 167 of you and just one of me. It give me as much love as possible especially when I am kind of — again, if I am saying stuff you do not agree in you could poop emoji me if we had it. But otherwise I am loving this and this will be our interaction for now and hopefully in the chapel will be able to interact a little bit more. So this study back in 2014 projected in annual savings of 129 million dollars in teaching time. $28 million in lost parent productivity. $20 million in medical care cost. When a school nurses in a building, the teacher did not need to do the health related things that the school nurse would. Kids stayed in school instead of being home and their parents being with them. And they also help to keep the health issues under control. So bedded against the investment in school nurses the bottom line projected the annual savings of 98 million dollars. This is a good start for changing the dialogue about the validity of school nurses. All right. Now let’s start talking a little bit about things that compromise the pillar prevention. Another common myth is that you will experience severe allergic reaction in the food that you are allergic to touching your skin. The fact is that healthy skin is a good barrier. Although local skin reactions can occur, isolated contact with skin is unlikely to cause an anaphylactic reaction. More severe reactions can occur if the allergen then gets in your mouth, eyes, nose. — for nose. There are two studies that looked at –or nosse. there are two studies that looked at when peanut was in contact with skin. Nobody had systemic reactions. Now, as we know, if you put your hand in your mouth after putting your hand in an hour gin, then you are eating the food. All bets are off — hand in your mouth then you are eating the food. All bets are off on that. But we were looking at pesticide exposure in children. Kids between the age of one and to put their hands or an object in their mouth 80 times an hour. And children ages 2-4 it is 40 times an hour. There is a study on adults in the library where looking at hands touching eyes, mouth, or going in the nose. 15 times an hour. This is where a skin exposure could turn into an oral exposure. All right. Our next myth. The smell of peanut butter will cause an allergic reaction and someone with the peanut allergy. So that smell that we smell, that is caused by something called the peer is seen –pyr izine. if there is something that air’s allies is proteins and puts it in the air that can be something that causes symptoms. There was a small study that had peanut butter in the cup held in front of the face of children with a known peanut allergy for 10 minute. None of those children had a — an allergic reaction. Again, this was peanut. This is not powder or proteins that were then aerosolized and bring — breathed in. But caution should be taken with things that can be aerosolized and been breathed in. Such as powders, flowers, and small particulates. These respiratory situations are predictable. This can be really very useful especially if you’re dealing with a kid who might be a little worried or anxious. Or also thinking about building policies where simply being around someone consuming peanut products should not cause respiratory symptoms. But being careful about activities, chemistry, projects, different things that could potentially use fire and pulverize different foods, those are the exposures that we will want to be careful about avoiding. Our next myth is that not free schools are safest. The fact is comprehensive policies that include prevention and emergency preparedness strategies that apply all allergens are critical. We mentioned this before. It cannot be replaced by attempts to a specific allergy. So a Canadian study showed that despite known at policies, nuts were found in schools. So, that reinforces the fact that there need to be general prevention strategies because of the ways — doesn’t always work. Now, what does need to be taken into consideration is the developmentally age of the kids. As we were talking about before, young kids explore the world with their hands and their mouth. In especially a preschool setting or a setting where the children are eating and at the same time perhaps age three and four if they are in a preschool in that is in us — in a school setting or kindergarten it will be harder to prevent cross contact especially if there isn’t necessarily the resources to be able to decrease those exposures. That is where you want to work with your school to figure out how is it that we can reduce these cross contact exposures and is it viable in this setting. Another myth. High heat eliminates allergen. The fact is, food allergens are not eliminated by heating or drying. and so if cheese drips on a grill, despite the heat of the grill, you’re still going to have the milk protein on it. If fish is deep-fried enough right later and then French fries are consumed, then freight — fish protein can still be on those French fries. These concepts need to be taken into consideration for any school that needs to be feeding and serving children with food allergies. Similar, it is also a myth that hand sanitizing gels eliminate food allergen. They are great for viruses and bacteria, but food allergens are not eliminated simply by hand sanitizing gels. It dries and again does a great job with fighting bacteria, but again, it is not going to change the proteins of the allergens. And so, there was a study that demonstrated that soap and water and commercial whites work — wipes worked to clean hands. And that soap and water and commercial cleaners worked to clean tabletops. Now, simply soap and water on the tabletops work. you don’tNeed bleach, you don’t need other materials. You are going to need to physically eliminate the protein from the surfaces. That is the same with handwashing. That is where soap and water work when you take the protein off. That is where using a wipe that mechanically eliminates the protein. But if you were to just use hand sanitizing gel and the protein remains on the hands, then it would still be detectable. Training schools about cross contact are going to be important. Training all staff to clean before and after children, custodian staff, cafeteria staff, and anybody cleaning in spaces especially where food is eaten or — are going to be really important and the training is going to be important with that. Next myth, advisory statements don’t mean anything. They are just there to protect the company from liability. It is safest to avoid foods with advisory statements or food allergens. Studies demonstrate that some items have detectable allergen. Now, when you are thinking about it from the perspective of the school nurse or the school staff, you will want to go under the assumption that someone is avoiding. Now, the family with their clinician and or allergist may give loosened restrictions. There may be some cases where they do include items with a cautionary statement, but when you — need to make the call yourself make the assumption that you need to avoid an otherwise be in communication with the family and use the recommendations of that families clinician indoor allergist — and or allergist if there’s going to be food there. There is a study that looked at items that have a cautionary statement for peanuts. About 70% of the items tested had detectable peanut. In most of the cases, it was not high enough to actually cause an allergic reaction, but it was still detectable. When the statements said may contain or processed in a facility or manufactured on equipment, it did not seem to confer any added or less risk. In that particular study, the ones that said reduced — produced in a facility had a more detectable peanut than those that said may contain. The take-home point is that the language they use is — it doesn’t really — can’t be trusted. It is not really under regulation. The take-home point here is to assume that the family is avoiding those unless undone by the family and their health care provider. And as far as label reading training, you want anybody serving and preparing food for children, they will need to be trained on how to read a label. And of note, as of January 2023, Sesame has now included as a major nine. So if your staff training in the past has not included it, you need to update the staff on how to train full on label reading to include sesame and what we are finding now is that some companies have actually included — this is where poop emojis come up. Some companies have actually included sesame in certain foods that they did not include in the past. And so now it is really important to be reading the labels of the food served. This will be something you want to give a heads up to your cafeteria services and nutrition services. And Andrea, can I have you jumping there? I am assuming that you guys have been very aware of this and you have some advocacy efforts in place when it comes to sesame.

Andrea: We do. This is something that we talk about every day during allergy and asthma and Marinus Nash awareness month. We know that sesame was listed as the ninth ingredient but as Dr. Mike said, it is unfortunate because some companies rather than trying to clean all of their equipment and maintain a separation, they feel it is easier for them to just add the sesame flower to some products that were previously safe just so they do not have to try to reclean their equipment all the time. Though if you’re interested in advocacy and have worries about this, if you want to help out with this, Congress is always listening and welcome to hear feedback. Please contact us at RG asthma network. And we can put you in contact with our advocacy person. We love getting the input from the people that actually live with this. And we love to hear the stories about how it has impacted your life. Because of legislatures actually — the people actually listen to that. These contact us and we would love to you. — love to help you.

Dr. Pistener: Thank you. Now we are moving on to the myths that compromise emergency preparedness. Another one that we hear a lot is all anaphylactic reactions have skin findings. This is not the case. This is something that is going to be important to train yourself — staff — your staff and everyone in the school to potentially recognize and allergic emergency. 10-20% of people experiencing anaphylactic allergic reaction may not have any skin findings. Most of them do though. Also about 70% have respiratory findings. 40% G.I. like vomiting or diarrhea. 35% cardiovascular like dizziness, Tyco cardio, hypotension. In young kids, for those of you in the preschool setting, kids may not communicate in the same way as older children. Therefore training the staff to be able to recognize these symptoms and signs in the Unger population will be really and. — really important. Something that is important is using allergy reaction plans. American Academy of pediatrics has a great plan that the National Association of school nurses has endorsed and has worked with them to roll this out. So, the hope is that this is going to be something that is pretty understandable by school staff so that it can be used by your delegates and that this will be something that primary care and allergists fill out and will be able to pass along. It delineates the signs and symptoms that would be considered anaphylaxis or severe. Things to keep in mind, so, when we have been talking about when someone would give epinephrine. Some of what I communicate to my families that I take care of is that if you had even a single severe symptom after exposure to allergen, something like coughing or trouble leaving — breathing that would be time to treat with epinephrine. If you have more than one system, even if it is a couple of mild symptoms, that is also a time to treat with epinephrine. So, if somebody is having even a mild response and they have hives on their face and they have hiccups with the Bert –br –burps after eating the food they are allergic to that would be a time to treat with epinephrine. At the beginning of the school year, it would be good to get a plan for students with known allergies will be really important. Now, along the same lines, keeping in mind the kids who may have a reaction that don’t have a known allergy. So in the Massachusetts data that I mentioned before, the mandated reporting, about 20-25% of people who need epinephrine in schools have been unknown to the school to have a history of allergy. So having policies and plans in place to be able to administer epinephrine in of timely fashion is important. Ends the epinephrine laws that we have been talking about before. And then, being able to build into the policy ways to trigger that and that is going to be something that you’re going to need to take your stock epinephrine policies and procedures and fuse them with your food allergy management strategies. So that way even if you have a handful of people who are trained to recognize the first time — first line of allergic reaction in your school, all the other staff are going to be — is going to be necessary for them to understand how to make everyone aware of the situation and to be able to get those who can administer to come and access the situation. So, you will need to in a sense merger policies to make it effective. Common myth, we are always up against this. Antihistamine first. The fact is that epinephrine is the treatment of choice for anaphylaxis. The antihistamines, alike to communicate to people that they are comfort medicine. — I like to communicate to people that they are comfort medicine. It is good for itchy skin or reactions, but it is not going to do what we need to take care of potentially severe allergic reactions. Epinephrine is safe and it works quickly. When in doubt, treating with evident — epinephrine, will kind of take the urgency out of the situation. And so, the use of antihistamines is the most common reason reported for not using epinephrine. And it may place a patient at significant increase for risk of potentially life-threatening reaction. And so, you want to make sure that your use of antihistamine ever gets in the way of using epinephrine. Another myth is that epinephrine autoinjector’s cannot be up size to the .3 milligram dose to the 66 pounds — until 66 pounds. — it can be — data suggest that upsizing autoinjector’s at 55 pounds is the correct way to go. The reason why this is important to talk about it especially in schools where you guys stock — do not stock epi = plus you will not have the opportunity — epi plus you will not have opportunity to talk to the provider that is where finding how much of a dose is important. With epinephrine .15 milligrams at and then around 55 kilos is where you position — transition into .3 milligrams. If you use the .15 milligram dose in a 55 pound kid then you have a 1.7 fold under dose. If you use .3 milligrams and the same for 55 — in the same 55 pound kid then you have a 1.2 fold overdose. So it is a saver medicine. The type of overdosing we are worried about is invented body — is if anybody ever overdosed — and that is exceedingly challenging and dangerous. In the case of especially around five pounds, a little bit more epi is better been a lot less epi. Another masses — myth is the needle is huge. The needle is actually shorter than the width of a dime. In the case of the .1 five Junior autoinjector Junior doses, that is going to be about .5 inches. And in the case of .3 autoinjector doses, it is about .75 inches. So what I have opportunity to talk to kids and kind of answer their questions about autoinjector’s, sometimes if I asked a kindergartner how long they called the needle was then many of them will show me it is the length of the device. I would be terrified. It is really reassuring to know that it is very short and very skinny. One anecdote that I like to say, I have never used and autoinjector myself, but I have gotten a flu shot and a flu shot needle that I got was much thicker and longer and sometimes when I get a flu shot I did not even feel it. So that is really reassuring information that you can try to pass along if you have students who you manage or children who you manage to have had that fear. It is actually way less scary than the — then some people think. Now, we are talking about autoinjector’s, but coming soon, there are intranasal epinephrine. That is going to be approved shortly. Within this school season, this might be something that is available. And Andrea, I will have you jump in here.

Andrea: Yes, and I for 1 am very excited about this. I have food allergies as well and I have the purse because I have to carry around both of my autoinjector’s. So this is been a long time coming and I know the FDA to get input from people that do have food allergies and need to carry epinephrine. A lot of people were a little bit discouraged that the device has not changed in what over 30 years? So, for those of you that are familiar with the nasal spray, you may have seen or can –NARC AN that is people that have overdose. And they have the nasal spray. And there are a few different companies that have come out that will look similar to that. One is a nasal spray. Next year, I don’t know which quarter, there is another version they are working on and it is going to be a little sublingual film a. It will be about the size of the posted stamp, it will go right and nervous tongue. — right under the tongue. There’s new options coming out finally. The only problem with this is that most of you that have stopped epi laws, you will need to edit your law. You can reach out to us. I can help you or the director of education working with Wisconsin on their law. She has a template that you can use. It will be changed instead of saying autoinjector, it will say any FDA approved epinephrine device I believe is what the wording is. Just a heads up, that is going to need to be change, but I think everybody is really excited to have another option because needle phobia is really real. And it paralyzes a lot of people that really need epi and desperately should be taking it but they are just afraid of needles. So keep your eyeballs — your eyes out for that. And we will have a big announcement when it comes out on the market.

Dr. Pistiner: And until then, being able to give them lots of reassuring words and ways to think about the autoinjector’s that are currently available is so doable. That is something just to keep in mind. When the other forms are available, the epinephrine regulations need to be incorporated and the standards need to be updated in the laws. Another myth. You need to call an ambulance because epinephrine is dangerous. So, this is a misnomer. So, a lot of times we say when use your epinephrine then call 911. It is not because the epi is making it so that you need to call 911. It is because the allergic reaction is that enough to need epi in the first place and that is why somebody called 911. So epi is really a safe medicine. It works like I was saying before it works equally, in all of the places where we need it to, and it is not the reason why we are calling an ambulance. This is one of the reassuring things to pass along to people. In the case of the autoinjector’s and the reason it is reported in the thigh is that it is well vascularized and it gets everywhere we wanted to it too quickly. It starts taking effect way before antihistamines would be able to help with comfort. Antihistamines take 30 minutes-60 minutes to work — 30-60 minutes to work. Peak levels of epinephrine eight minutes. It works faster than that. Nowadays, around the time of COVID, and allergists released a statement saying that just because you use epinephrine it doesn’t mean that you have to call 911. And so, some of these statements included some examples of cases where you might not need to. If it immediately works, if the symptoms were multiple mild symptoms in the first place, then these conversations were being had. Many allergists had these conversations during the time where they use the epi and did not call 911. Because it is so important to use the epi that by using the epi earlier, it decreased the chance that you would need the backup that the ambulance would bring. That being or epi, more people, more IV fluid, and oxygen. The longer somebody delays using epi the work you need the — what the ambulance brings. These are reassuring conversations. Another myth, only students will experience allergic emergencies. I mentioned this before. The Massachusetts data show that close to 10% of those requiring epinephrine in Massachusetts schools were staff or visitors. So being able to accommodate this need is important. Including in your policies and procedures the ability to train staff to recognize allergic reactions amongst their colleagues and other visitors like the mailman who might be stung by a bee or a parent visiting who might also have had a bee sting and they are waiting to be in — be taken care of on school grounds. All right. So, hopefully some other perspective that we share today — some of the perspective that we shared today will help you address and an — and educate and empower your schools. All right, Andrea, I think I am ready.

Andrea: Ready for all of the questions. [LAUGHTER] Thank you. We were talking about this a moment ago when you are helping a child in jack or self inject, can you talk about we are on the thigh where you would self inject so that we are all in the same area here.

Dr. Pistiner: Oh, yeah. I am actually looking for I feel silly for I do not have a training device around me. Give me one second.

Andrea: OK feel free to use a pen or whatever. I should have given you a heads up that we want demo.

Dr. Pistiner: No self-proclaimed allergist doesn’t have a trainer or something else available.

Andrea: [LAUGHTER] OK. We can talk about another question while you talk about that.

Dr. Pistiner: These are old ones. So, this is one of the devices that I just happen to have an old version of. I like training and showing f –folks the training one because you can get a sense of the sound. We have been to training devices here that we have. There are other devices that have been made let me take off my screen filters so that — to make this a little bit easier. All right. Here we go, so, first off, using the closed device I will show you where I would put it. I promise you, showing it in the thigh. You would go for halfway between the knee and the hip. In the meaty part of the thigh. And in a big kid or a grown-up, that is quite easy. In a smaller kid, being able to make sure their hands do not come down if they feel the Pope and pool would be something important. Figuring out how they get so that there — feel the Pope and — Ppoke and pull would be something to figure out. — so first off you take it out of the plastic carrying case. You put it in your writing hand, your dominant hand. You hold it in the hand that you’re right with. With your nondominant hand, you take off the safety in this particular model. Then, pressure on the orange tip on where I showed you on the outer thigh with firm pressing which is like 10 pounds of pressure to release a spring that releases a short needle. Now, I will show you pressure on the orange tip, let’s see. So, pressure on the orange tip, I shoot this across my office here. It releases a short, skinny needle. There is. Now, if I take pressure off of the orange tip then the needle protector goes over it so nobody can be injured by the exposed needle.

Andrea: That was perfect that is exactly what we needed. Thank you. I think some people are still afraid to use it. Look at all the love coming up. I know that people are really afraid of using epi. So I do not know how to help them get over that. You talked about the needle size, but I know some people are hesitant thinking I don’t — I don’t know if I really need it. Should I inject it or give it to my child? I know when I had to self inject my heart races for a little while afterwards but the nausea of a — fades. It is not that scary. But I do not know how to help will get over that because that seems to be a barrier are a lot of people.

Dr. Pistiner: Like a said before epinephrine is a safe medicine. It works ugly and it works equally in all of the places we want it to — it works quickly and — it works quickly and moves to all the places we want it to. So with the majority, I am simplifying a kind of complicated process here, but they are with me. Our allergy cells are mass cells and we are loaded with all these mediators of inflammation. Things like histamine, — different things that when they release they — those mediators of inflammation have effects on our cardiovascular system. They have effects on our blood vessels. When that happens, it releases — it allows the blood vessels to leak and it allows our veins to get floppy. But when epi is around it tighten things up and keep that from happening. It reverses that process and it works quickly. Now, when these mediators of information are released, they also can affect the respiratory new Coso. They can affect build lungs and upper airway. They can make somebody smooth muscle in their lungs twitchy. And you can secrete causing asthma type symptoms, coughing, wheezing, shortness of breath. Epi works as a dilator. It works quickly and so it also decreases the mucus production. — perspective, epi works great. G.I. wise, we can get nauseous, puke, have diarrhea. Epi works to help there as well. And on our skin, like I was saying, it decreases the leaking as. It also takes care and improve itchiness. So, epi really works great. One of the things that — also that can be expected is some people might get shaky after they use it. I kind of like it because then you know it is working. So we have receptors in our skeletal muscle. So that shakiness is amply a very expected side effect of epi. In the very young kids, we do not see it quite as much but we see it when the kids get older. And I actually — I say OK, that is great. They inspect it it will not be as weird and freaky. The other thing to ask which is awesome is you get pale. That is the point. It restricts the blood vessels bringing blood back to where we need it. It goes back to the heart and epi is everything we want it to data — does everything we want it to do.

Dr. Pistiner: What I love about everything you just explained is —

Andrea: What I love about what you just explained is we have parents and many people insisting on using antihistamine area you know that will not help with asthma and everything else going on in the body. I like how you asked leaned back. So a couple questions that we have about using antihistamine and one of the questions was about parents that are wanting to use an antihistamine because it is less expensive and we know that auto injectors can be expensive. So, I don’t know if you wanted to answer that. I know there are resources out there that I have people in my asthma am visit program that I can share.

Dr. Pistiner: I can say when I make an action plan for my patients, I do not include an antihistamine. This is where our — everybody’s allergist or health care clinician will be a little different in the way they talk about it and the way the use antihistamine. What everybody is going to say is epi is a treatment for anaphylaxis. Nobody will be on their right mind paying antihistamine can replace epi. Now, where you get variability in us is going to be the inclusion in the action plan. So I like to call my action plan and emergency action plan. Epinephrine is emergency medicine. I think about antihistamine as comfort medicine. In an emergency plan I give to a family I did not include antihistamine area for me I want the family considering can I continue to observe and watch or do any distraught this — do I need to shut this down right now with epinephrine? An antihistamine is not going to take care of the symptoms that are going to pose a threat. The antihistamine is going to take care of skin findings, mild symptoms. Now in the case of Benadryl, it can make somebody tired. In young kids, I really want families to be watching their child’s behavior I want them interacting and laying with that kid. I want them to know if that person — that kid is getting pokey and lethargic because of allergic reaction. That is where me personally I am not use — into using Benadryl. In an older person or an older kid or a grown that can could indicate — communicate to you. But a sleepy kindergartner now that we give them an anti-histamine and they are still in some of the — like it is not that long ago that they had an allergic reaction, that kind of makes me a little uncomfortable area I want to know that that kid is like watching their TV show, into, having a great time. Feeling fine but they have a little bit of itch. That is a kid I am OK with giving an antihistamine to after we are no longer considering and allergic emergency. Once they get past the emergency setting, I am totally fine with treating and itch and something that is annoying the kid. That is a way I like to talk about it ends — and us allergists are all different in our approach. But all of us will say that epi is the treatment for anaphylaxis. It is about whether or not an answer histamine will be added on top of it — and an anti-histamine will be added on top of it.

Andrea: Perfect I like how you word that. Here at the network we always say epi first, epi fast. It beats the alternative because many people see somebody on the news where they waited too long to give somebody the epi and it is not a great outcome.

Dr. Pistiner: To jump and they are. And I would like to say that epi makes you feel better. It works quick. If there is a kid that is having a stomach ache and they are getting sniffly and they are starting to cough and they just feel miserable and they are itchy all over, you treat them with epi there — they are going to feel better. We not only need to be treating with epi because we want to prevent terrible things from happening but we are also treating with epi because we want you to feel better.

Andrea: Yes and 100% that is what happened with my next anaphylaxis. It was so nice when that kicked in. And the last question when someone asked if about epi being expensive. Times have changed when they were $600. I remember paying that much for my auto injectors, but there are some generic out there on the market. The last prescription that I just add — had filled was $20 and that was my co-pay. I know everyone’s insurance is different. What may help with the move you who are listening, there is an organization I do not have ties to it, but I would recommend able to my asthma home visit program which is called maze be — maybe meds. When you as you can search for a low income clinic if you have families that cannot afford medications. A lot of the low income clinicians will have low-cost pharmacies. They can get this based on their patient ability to pay. They can pay $10 for epinephrine. Check into that it is a great resource. OK not be just buzz through a few of the questions we have on here. Someone said if they are talking about the myth that heat does not eliminate the allergy, what about if they are students that are allergic to raw eggs or eggs themselves. And they are OK that they eat something that has — eggs that have been cooked. How does that work?

Dr. Pistiner: They say about 80% of people with an egg allergy can tolerate egg when it is baked into something when it is an ingredient when you preheat something. That is starting to change the shape. A similar thing can happen in a similar number of kids with dairy allergy. Dairy is a minor ingredient and they may be able to tolerate it. The kids who are seen being able to eat the baked in items are likely to out road there milk and egg — outgrow their milk or egg allergy. There may be kids that need you to avoid other forms of dairy or egg. And they cannot consume these baked in items. That will be under the guidance of the health care provider like maybe an allergist or working with the family. That will probably be included in the action plan and in the list of what food can be included or excluded.

Andrea: Thank you we have a lot of questions. We will not be able to get to them all but Dr. Mike is willing to write up something for us. With Q&A I am going to do that. Ask one last question. We cook and serve this at school. The smell is strong in the school are the teens aerosolized and potentially harmful for those with the fish allergy? What is the best way to protect a student with a fish allergy on the days fish is served?

Dr. Pistiner: Fish is one of the ones that for every reason — whatever reason the proteins can be aerosolized more so than others. So if there was someone with a food allergy and they went to an open grill or like a hibachi station and the steam was coming up, that can cause reaction. That would be something to keep in mind thinking about the layout of the school. The cafeteria, where the child would be when they go to the cafeteria, if there is actively cooking food. These are things to consider and think about. And if there are any questions in working with the kids mission and working with the kids allergist if they have them, one would be great.

Andrea: Wonderful. Thank you. If you could just move forward one more slide. That should be our next — there we go. Thank you. Our next webinar is what to do if the student has an asthma attack. It is just in time for back-to-school. Both of these back-to-back these back to back helping student in the school with food allergies as well as asthma. Often times it can go hand in hand. As I mentioned Dr. Mike is kind enough to be able to finish answering all the questions in the chapter. If you keep and I out — an eye out there will be a link to the recorded version of the webinar. We will try to get that posted as soon as we can as well as the Q&A from others that were able to have their questions answered. Thank you again for joining us Dr. Mike and for doing that fantastic demo on the — I had did teach my family how to do it. I said if I’m incapacitated I — you have to jab me. I think that is a great thing to show people.

Dr. Pistiner: Cannot push back on the word jab and say gently administered.

Andrea: OK that sounds much better for my family to gently administer [LAUGHTER] .

Dr. Pistiner: They are more likely to gently administer. [LAUGHTER]

Andrea: [LAUGHTER] Yes depending on how annoying I am, right? Thank you all for joining us and I hope you all have a wonderful day.