Managing Allergies in School: A Guide for Staff
Allergies are among the most common medical conditions affecting children in the United States. According to the American College of Allergy, Asthma and Immunology:
- 8.4% of U.S. children under age 18 have allergic rhinitis (hay fever);
- 10% have respiratory allergies;
- 5.4% have food allergies; and
- 11.6% have skin allergies (hives or eczema).
Some children with allergies may also have asthma. Their allergies may trigger asthma symptoms – this is called allergic asthma.
With so many kids living with one or more allergies, schools need to be prepared to manage allergies. Management includes preventing exposures to the extent possible. It also involves caring for children who develop allergy symptoms.
Schools need to be prepared to work with and build trust with parents. An allergy diagnosis, especially one that puts a child at risk for a severe allergic reaction (also called anaphylaxis), can understandably create worry for parents and school staff. There are good reasons for worry.
- Parents know that certain foods, substances and supplies could potentially trigger an allergic reaction at school.
- School may be one of the first times that parents entrust their child’s healthcare and safety with people they do not know.
What can schools do to plan for a child with allergies? Safe and effective management of allergies and anaphylaxis is achievable with a collaborative, multi-disciplinary approach.
Allergy management at school
School planning is an essential part of allergy management at school. Safe and effective allergy and anaphylaxis management requires a coordinated approach. Allergy management is typically guided by a written school allergy policy.
What is a school allergy policy?
A school allergy policy contains written guidelines for allergy management. When it comes to schools and allergies, policies are an extremely important part of the school planning process. They should be clear and concise. Policies should include the following:
- Planning and coordination of care.
- Education of staff, students and parents. This includes staff training programs and student health curricula on allergy, food allergy and anaphylaxis (a severe allergic reaction).
- Providing a safe environment. This includes preventing allergen exposures and developing anti-bullying and anti-discrimination policies.
- A prompt emergency response (when needed). This includes emergency preparedness and administering medication.
Policies should align with federal and state laws, nursing practice standards and established safe practices. This ensures every student can fully participate in all school-sponsored events and activities.
Are allergy policies in schools all the same?
Policies are usually developed by each individual school district, so there may be differences in allergy policies. It is recommended that school nurses and other healthcare staff participate in the development of a school’s policies.
Some states have their own food allergy guidelines to include in a school allergy policy. Each state has a unique Nurse Practice Act and specific laws and regulations addressing allergy management in school.
It’s important to know your state’s guidelines and practice parameters. This way the school’s policies reflect what your state allows.
Planning and coordination of care
One of the vital roles of school nurses is to serve as care coordinator. Often the school nurse is the one that is “holding all of the pieces” between home, a child’s school, and the medical home.
School nurses and teachers need to know students with life-threatening allergies. They should get a written statement of diagnosis from the child’s doctor. There can be some confusion with parents as to whether the student has a true allergy or a food intolerance, and having a diagnostic statement avoids confusion and helps direct care. Also, for food allergies, many school food service departments require a diagnosis before substitutions can be made.
In an ideal world, every student at risk for anaphylaxis would have an Anaphylaxis Emergency Care Plan written before the first time they walk through the doors of the school. But often, the school nurse works to get this in place as soon as possible. Ideally, this would come from the child’s doctor, but it can be written by a school nurse if needed. If appropriate, an Individualized Healthcare Plan, or IHP, is developed as well.
The school nurse can provide referrals to parents as needed and is in the perfect position to assess the student’s abilities to both self-carry and self-manage their allergy and any reaction that may occur.
Prevention of allergic reactions
A vital part of allergy management at school is preventing allergic reactions. Prevention requires educating school personnel as well as the family and student. Staff, students and families need evidence-based information about:
- signs and symptoms of an allergic reaction
- prevention strategies to prevent exposures
- how to administer a school healthcare plan, including a Food Allergy Action Plan and an Anaphylaxis Emergency Care Plan (sometimes referred to as an Action Plan)
- federal laws that protect children
Education of staff, students and parents
One of the most important things a school nurse can do is keep up to date on what is “best practice” in allergy management. School personnel need to use evidence-based information in allergy management and all aspects of care. This encourages the staff to combine the latest information from credible resources with the student’s experience and nursing expertise to make the best student health decisions possible.
Following are key topics to include in any staff training regarding allergies and allergy management:
Signs and symptoms of an allergic reaction
All personnel should receive education on signs and symptoms of an allergic reaction. They should be taught that each child’s symptoms may vary, and that each reaction might be different from the last reaction.
Post a chart that outlines the signs and symptoms in each classroom. Download a printable pdf of signs and symptoms of allergies.
Strategies to prevent exposure to allergens
All personnel who work with students need to know prevention strategies to avoid exposures. This includes:
- knowing and removing allergens (if possible);
- avoiding cross contact or cross-contamination.
How to respond to an allergic reaction
Follow the Emergency Care Plan when there is a student with a known allergy. Staff also need to know what to do if a student without a prior history of severe allergies shows signs of an allergic reaction or anaphylaxis. Staff need training on the use of epinephrine devices. Several different devices are available, each with different operating instructions.
Laws that protect students with allergies
It is important that the school staff understand the federal laws that could apply, such as the ADA, Section 504 and FERPA, as well as any state law, regulations or district policies that apply. All 50 states allow for students to self-carry their epinephrine auto-injectors and albuterol inhalers. Most states allow schools to stock epinephrine.
Effective staff and family communication
Parents and guardians live with food allergy issues 24 hours a day, 7 days a week. They want partners at their child’s school. Look for ways to work together because that ultimately benefits the student. Parent and guardians of students with allergies appreciate opportunities to get together and share their stories and successes. They often look to each other for help. Developing strong communication with parents also helps them better understand school policies and practices.
Students need to be educated regarding allergy management in school, including:
- understanding how to self-manage their allergy during the school day;
- understanding the pathophysiology in an age-appropriate manner;
- knowing how to avoid their allergens;
- recognizing their own allergy symptoms;
- learning how to self-administer epinephrine, if that is in their plan;
- learning when to notify an adult that they need help. (Younger children may need help even knowing how to ask for help.)
What kind of training does staff need for allergy management?
Instruction should be provided to any staff member supervising a student with a known allergy who is at risk for anaphylaxis.
In addition, school-wide faculty meetings are useful to provide general training of personnel regarding:
- allergy management;
- signs and symptoms of allergies;
- generalized allergy care.
Examples of what to include in general staff training:
- How to respond to an allergy emergency.
- Information about federal laws that could apply, such as the ADA, Section 504, and FERPA. Information about any state law, including regulations, or district policies that apply.
- How to administer epinephrine with an auto-injector (for those formally delegated to do so).
- How to help children treat their own allergy episodes.
- Effects of allergies on children’s behavior and ability to learn.
- Importance of giving emotional support to children with allergies, food allergies, and to other children who might witness a severe allergic reaction (anaphylaxis).
- Common risk factors, triggers and areas of exposure to allergens and food allergens in schools.
Managing risk of exposure
Personnel also need training on how to fully include children with allergies into school and classroom activities. Staff need to know how to manage the risk of exposure to allergens in the following locations:
- during meals (in the cafeteria)
- during nonacademic outings
- on field trips
- during official activities before and after school programs and sports
- during events sponsored by schools programs that are held outside of regular hours
Risk reduction strategies
These strategies could address (but are not limited to) the following:
- Special seating arrangements (e.g., during meal times, birthday parties) when age appropriate.
- Plans for keeping foods with allergens separate from allergy-safe foods.
- Rules on how staff and students should wash their hands and clean surfaces to reduce the risk of exposure to food allergens.
- The importance of not sharing food.
- How to read food labels to identify food allergens.
- Making sure any food in the classroom has ingredients listed on a label; no home-baked treats.
25% of anaphylaxis reactions at school occur in students previously undiagnosed with a life-threatening allergy.
Staff training resources
Several valuable resources are available to develop a training program for managing allergies in schools:
CDC Voluntary Guidelines for the Management of Food Allergies in Schools and Early Care and Education Centers
In consultation with the U.S. Department of Education and a number of other federal agencies, the U.S. Centers for Disease Control and Prevention (CDC) developed the Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Centers. This was part of the 2011 FDA Food Safety Modernization Act to improve food safety in the United States.
The guidelines provide practical information and planning steps for parents, school district administrators, staff, and early childhood educators to develop or strengthen plans for food allergy management and prevention. The guidelines include recommendations for each of the five priority areas that should be addressed in each school’s or early childhood education program’s Food Allergy Management Prevention Plan:
- Ensure the daily management of food allergies in children.
- Prepare for food allergy emergencies.
- Provide professional development on food allergies for staff members.
- Educate children and family members about food allergies.
- Create and maintain a healthy and safe educational environment.
No Appetite for Bullying
No Appetite for Bullying aims to make a positive, lasting impact on the lives of children, teens and all students with food allergies. The program aims to encourage students, their parents, and peers to be voices against food allergy bullying.
AllergyHome’s School Staff Training Module is a 30-minute module to assist the school nurse in training staff to manage life-threatening allergic reactions and increasing food allergy awareness. The training module is consistent with the CDC’s Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. The training module includes:
- School Staff Quiz – a certificate of completion is available to be printed or emailed after passing the exam.
- Label Reading Handout
- Preventing Cross-Contact Handout
- Be Prepared to R.E.A.C.T. (Recognize allergic reaction; Epinephrine; ACTivate emergency response)
- AllergyHome Resource Flyer for School Nurses
The Food Allergy Management & Education (FAME) manual and toolkit is designed to help school nurses, administrators and staff work with parents and students to create a safer school environment and develop a comprehensive school-based food allergy program. It features a 504 Plan decision chart and a list of accommodations in classrooms, the cafeteria, and on school buses and field trips.
Posters and resources, each available as a printable pdf:
Providing a safe environment
School nurses work to keep the environment safe for students with allergies. It’s important to continually assess the school environment to be sure all areas are “allergen safe.”
It’s vital for the school nurse to assist staff in identifying potential allergens and to discuss specific prevention strategies for each area of the school. It’s also important for the school nurse to work with counseling staff, teachers, administrators and others to provide mental health support to students with food allergies.
Prompt emergency response
The school nurse is the ideal staff member to develop a school-wide emergency response plan when faced with anaphylaxis. The school nurse should assign specific roles to personnel. Develop a “table top drill” with school staff members who may need to respond to allergy emergencies.
Response and administration of Emergency Care Plan
Staff need to be willing and able to administer an Emergency Care Plan. Training and reinforcement should occur every 6 months. Staff needs to know:
- Signs and symptoms of an allergic reaction or anaphylaxis.
- Location of student’s epinephrine and/or school’s stock epinephrine.
- How to administer epinephrine if needed.
- Epinephrine should be accessible. There should be a process in place to monitor the expiration dates of the medication. Replace them when out of date.
- The term “stock epinephrine” refers to an undesignated epinephrine auto-injector. It can be used in the event that a student does not have an epinephrine auto-injector. It can also be used when a student with no prior history of a life-threatening allergy has a first anaphylactic episode at school. Be sure to know your state laws and regulations about who can give this life-saving medication dose.
Debriefing the emergency incident
Following an emergency, the staff should always have a debriefing meeting with all involved in the incident. It allows non-medical staff to express their feelings and concerns. It helps the school evaluate the incident and improve outcomes moving forward.
Suggested agenda for a debriefing meeting:
- What caused the allergic reaction?
- Who responded and what was the outcome?
- How did the student and classmates feel the response went?
- Did staff respond appropriately?
- Was staff comfortable with their roles?
- What can be done better the next time?
Allergy care at school checklist
From medication to emergency care plans to education, the school must be prepared to provide care for students with allergies throughout the school year.
What’s important to do before the first day? During the school year? At the end of each school year? Are the tasks the same for each new school year? Download this printable PDF for tasks on what to do throughout the school year.
Before the first day of school:
☑ Identify students who are at risk for anaphylaxis. Anaphylaxis can be life-threatening.
☑ Set up a medication system for emergency medications.
- Include a method to track medication expiration dates.
- Determine if students will self-carry their medication.
- Plan for transporting emergency medications in the event of a building evacuation.
☑ Meet with parents to build a trusting relationship. Obtain:
- Medication orders
- All required school forms
- Anaphylaxis Emergency Care Plan
- Reliable emergency contact information
☑ Communicate with staff to alert them to student health needs.
☑ Review signs of allergies with all staff. Post a chart with signs and symptoms in the classroom.
☑ Provide staff education as needed.
☑ Talk with students who are at risk for anaphylaxis. Discuss management of their health condition at school.
☑ Assess their ability for self-care and self-medication.
☑ Write an Individualized Healthcare Plan or other school healthcare plan as needed with family and student input.
During school year
☑ Talk to students with allergies to discuss management of their health condition at school.
- Assess their ability for self-care and self-medication.
☑ Obtain medications, medication orders and Anaphylaxis Emergency Care Plan if not previously completed.
☑ Track expiration dates for medications.
At the end of the school year:
☑ When parent picks up medication stored at school:
- Return unused medication.
- Provide medication and treatment forms with plans to be completed for the next school year.
- Remind the parent to make a doctor appointment to be sure to get a health update and forms completed for the next school year. Doctors’ offices tend to get very busy close to the start of school.
- Discuss progress made in self-management and encourage continuation at home.
Student healthcare plans
Allergy management at school requires planning, prevention and preparation. A student health care plan helps to document the process. School nurses and administration are responsible for being sure that each student is identified who needs a healthcare plan are in place.
There are four main types of plans used in the school setting:
Individualized Healthcare Plans
This plan outlines the plan of care for students with complex, chronic health needs at school. It outlines the student’s needs for medication, treatment and education. It is written in nursing language to be used by a school nurse.
Emergency Action or Care Plans
This plan is written to direct care for a student experiencing an allergic emergency. It lists the specific steps to take to respond to an allergic reaction. It is written in easy to understand language for non-medical personnel to use.
Section 504 Plans
Section 504 is a federal law that protects the civil rights of persons with disabilities. The Act prohibits any organization that receives federal funds from discriminating against otherwise qualified individuals because of a disability. It outlines the accommodations needed for a student to fully participate in school.
Individualized Education Plans
An Individualized Education Plan (or Program) is also known as an IEP. This is a plan or program developed to ensure a child with an identified disability receives specialized instruction and related services at school. An IEP is not usually applied to students at risk for anaphylaxis unless an educational disability also exists.
For more information:
Questions & Answers for school allergy planning (Q&A)
What can schools do to plan for allergies and keep a child healthy? Following are some common questions and answers about how schools can plan for allergy management and emergencies.
Should parents write an allergy letter for school?
Parents should provide the school with a doctor’s statement identifying any allergies. They should also provide any required forms.
If parents want to inform other families of their child’s severe allergy, have the parent and school nurse co-write a letter to help maintain the child’s right to confidentiality.
Is there allergy training for school staff?
Many programs are available for school training and education. Personnel in each department should be trained to identify anaphylaxis and administer epinephrine.
What is the allergies at school action plan?
The terms Anaphylaxis Action Plan and Allergy and Anaphylaxis Emergency Care Plan are often used to identify the same type of plan. There is no required school health care plan, but it is advisable to choose one plan for your school district to avoid confusion during an allergy emergency.
- American Academy of Pediatrics Allergy and Anaphylaxis Emergency Care Plan
- SN CHAT – Download the tool to get the Anaphylaxis Action Plan
What privacy rights do children with allergies have?
The Family Education Rights and Privacy Act, or FERPA, requires that information can only be shared on a need-to-know basis. Children have the right to have their health information protected.
Remind staff that health-related conversations should occur in private – not in hallways or public areas. Information about a child’s allergies should not be shared with other parents.
Managing food allergies in the school setting
How can schools manage food allergies? What food allergy policies and procedures should be in place? Following is information for school administrators and staff:
Food allergy management
Prevention and preparation are key components of creating an “allergy-safe” environment at school. For details, see the information on our Food Allergies at School page.
Key components of a food allergy management plan include:
- Policies and protocols
- Allergy management plan including prevention strategies, medication administration and emergency response plan.
- Education, including:
- avoidance of allergens;
- how an allergic reaction occurs;
- signs and symptoms of anaphylaxis;
- how to respond to an emergency.
- Adherence to federal and state laws regarding discrimination, food labels and disabilities.
The school should coordinate with the child’s teacher(s), food services director, cafeteria staff and family to be sure of the following:
- medication is at school;
- food substitutions are available;
- measures to prevent food allergen exposures are in place.
No matter how prepared a child’s school is for a severe food-allergic reaction, the staff needs to be ready to deliver emergency care if needed.
Good communication and empathy are important skills to use with parents and children with food allergies. A food allergy diagnosis can be emotional for parents who understandably worry about their child’s safety at school.
Questions & Answers on food allergies in school (Q&A)
What do schools need to know to successfully manage food allergies? Here are some frequently asked questions and answers:
Are food allergies common in schools?
Do grade schools have to know about children's allergies?
Does law require schools to accommodate children with food allergies?
Section 504 helps outline the needed accommodations for children to attend school and have full access to school programs and activities.
Food allergy questions and concerns
Many schools employ peanut-free classrooms, but do they work? Should your school carry an emergency supply of epinephrine auto-injectors — and if so, where should they be stored? What to do if a student with a food allergy is bullied because of their food allergy? Following are common questions and concerns for food allergy management in school.
Should schools ban foods, especially peanuts?
Peanut-free policies may not be effective in preventing reactions. School personnel should use proven strategies that include hand/mouth washing, no sharing of food and awareness of a child’s food restrictions. Studies have shown that:
- Peanut residue is easily cleaned from hands with soap and from surfaces with commercial products.
- Smelling peanut butter does not cause allergic reactions.
- Peanut dust or peanut residue may accumulate on surfaces where peanuts or peanut butter are eaten regularly. Touching the dust or residue on surfaces and then placing fingers in the mouth can cause an allergic reaction.
- Peanut proteins can become airborne during the grinding or pulverization of peanuts. Inhaling peanut protein in this type of situation could cause an allergic reaction.
Simply stating that a school is “peanut-free” does not guarantee that it is. Even with strict measures, some peanut allergen can be present. “Peanut free” designations can decrease vigilance in the school community. It’s important to educate staff on food allergy and prevention strategies that lead to a “peanut-safe” environment.
Are students with food allergies bullied?
Children with food allergies are at risk of being bullied.
What schools can do:
Put anti-bullying policies in place. Make it a school responsibility to resolve conflicts in a positive manner.
Teach specific skills and values in the classroom. Teach children how to problem solve.
Establish and enforce consequences for bullying. Combine sanctions with supportive interventions that encourage positive behaviors.
Are schools allowed to have stock epinephrine?
Every state, except Hawaii, either mandates or allows stock epinephrine in the school setting. This means that the school will keep a supply of epinephrine available in the event it’s needed for an emergency. It’s important to be familiar with stock epinephrine laws in your state to know whether the school is eligible to have stock epinephrine available. Not all schools allowed to store stock epinephrine will have it, so check with your child’s school to see if it is available.
How to implement a stock epinephrine program in your school? Follow the “Steps to Stock”:
Policy: The school district should adopt a policy to guide the use of stock epinephrine. The National Association of School Nurses (NASN) offers a sample school district policy.
Protocol: The school district develops a protocol to guide use of stock epinephrine. NASN offers a sample anaphylaxis and emergency epinephrine administration protocol.
Prescription: The school identifies a prescriber to write the prescription and standing order. The American College of Allergy, Asthma and Immunology (ACAAI) offers an Allergists’ Toolkit with more information.
Partnership: The administrator and school nurse partner to implement stock epinephrine policy with staff. The CDC offers guidance for school administrators in implementing a policy.
Download Steps to Stock Epinephrine PDF
How can schools get epinephrine for use in their school?
There are currently two programs for obtaining free epinephrine auto-injectors for schools:
EpiPen(R) is available through the EpiPen4Schools program
AUVI-Q(R) is available through the Q Your School program
Latex allergies in school
Latex allergy is a reaction to proteins from the Hevea brasiliensis rubber tree sap, the milky fluid used to manufacture more than 40,000 products. Latex can be carried on small particles and become airborne and inhaled into the lungs. The proteins can stimulate the immune system to make an allergic antibody (IgE) that can be measured in the blood that initiates the allergic response.
The difficulty in managing a latex allergy at school is that latex and latex proteins are found in many common every day products. Rubber bands, latex balloons, erasers, sports equipment and goggles may all cause a sudden and unexpected allergy emergency. Latex can also be found on a stethoscope, non-vinyl gloves and the blood pressure cuff in the school health office.
Foods with similar proteins to latex are known to cause an allergic reaction in 50% of people with latex allergy. Certain foods have a high, moderate or low likelihood of causing a reaction. High-risk foods primarily include avocado, banana, chestnut and kiwi fruit, but there are many others. Schools need to exercise caution with foods offered to a student with a latex allergy.
Where in the World is Latex?
Latex Allergy Page
Latex Allergy: A Practical Guide for Patients & Providers
Environmental allergies school management plan
Environmental allergies occur when your immune system overreacts to substances that exist in our everyday surroundings, including home, work, and the great outdoors. You may sometimes hear this immune system response referred to as hay fever or allergic rhinitis.
Environmental allergy symptoms include sneezing, coughing, runny nose, nasal congestion, postnasal drip and shortness of breath. Eyes may begin to itch or get watery. Skin may develop hives or eczema.
Outdoor environmental allergies
- Pollen from trees, grasses and weeds float through the air in spring, summer and fall.
- Mold spores are a fungus that grow in damp, dark places such as under fallen leaves or in rotting vegetation.
- Insects and insect venom from bug bites or bee stings.
- Plants like poison ivy may cause allergic skin reactions.
Indoor environmental allergies
- Furry classroom pets shed dander from their skin. People are also allergic to pets’ saliva and urine.
- Dust mites are microscopic critters live in upholstered furniture, pillows and mattresses, thriving in warm, humid environments.
- Cockroaches and mice scavenge at night for food and water, leaving behind trails of allergens.
- Indoor mold causes brown/yellow or black/green splotches to grow inside walls, under sinks, around garbage containers and in underground storage areas.
- Dust may contain pollen, animal dander, mold and other allergens.
- Chalk dust can be an irritant to anyone who breathes it in, particularly for people with asthma.
Irritants that may cause a reaction at school
- Idling school buses emit exhaust fumes in parking lots that can enter classrooms through open windows.
- Scented products such as perfume, cologne, air fresheners (including the plug-in kind), hair products and soaps/lotions may cause allergy-like symptoms in some children.
- Some cellphones, jewelry and metals may contain nickel that can can cause an allergic skin reaction.
- Cleaning products and school supplies may contain harsh chemicals, including formaldehyde, that can cause breathing problems and burning in the eyes and throat.
Creating a healthy environment for children with environmental allergies
- Remove pets that trigger allergy symptoms.
- Promote an odor-free environment, including no perfumes and no strong odors from cleaning supplies.
- Ensure adequate ventilation throughout the school.
- Allow the child to stay in from recess on days when pollen counts are impacting their day.
- Close windows during times of high pollen counts to reduce allergens in the environment.
- Address use of pesticides with school administration.
- Ask school administration to establish a “No Idling” policy for school buses.
- Encourage staff to not wear perfume or cologne and avoid using scented air fresheners in the classroom.
- Us dry-erase boards with unscented markers instead of chalkboards. (Most schools have already transitioned to dry-erase boards, but some older schools may still use chalkboards.)
School Health Resources
See Additional School Health Resources ➡
Don Bukstein, MD, FACAAI, is a board-certified allergist and immunologist and pediatric pulmonologist. He serves as Medical Director for Allergy & Asthma Network. Dr. Bukstein also volunteers at a Medicaid clinic in inner city Milwaukee. He is the former Director of Allergy and Asthma Research at Dean Medical Center in Madison, Wisconsin.