Anaphylaxis is an extremely severe allergic reaction. Reactions usually begin within minutes and progress rapidly, however, they can occur up to 2-3 hours after exposure and exercise can also initiate symptoms a while after exposure to an allergen. Common allergens include food and insect stings. The rise of food allergies poses a significant risk for pupils in schools.
In the UK, 5–8% of children have a food allergy and a fifth of all fatal reactions occur while at school. Anaphylaxis can proceed rapidly and failure to administer adrenaline promptly has been associated with fatalities.
Many children at risk of anaphylaxis are prescribed adrenaline auto-injectors (AAI) by their doctor. These devices should be swiftly accessible to them at school and they should also have immediate access to the auto-injectors all times, outside of school. AAIs deliver a potentially life-saving dose of adrenaline in the event of a severe allergic reaction (anaphylaxis).
Administration of adrenaline can be lifesaving, but you may need more than one dose.
Some anaphylaxis reactions require more than a single dose of adrenaline. It is therefore vital to always dial 999 and request an ambulance whenever anaphylaxis has occurred – even if there has been a good response to the adrenaline injection.
There have occasionally been reported manufacturing faults which have resulted in the adrenaline autoinjector device failing to deliver the necessary dose, there are also issues with human mistakes. It is therefore recommended that anyone prescribed an adrenaline autoinjector, has immediate access to two at all times.
A second adrenaline auto-injector can be given 5 minutes after the first.
Adrenaline can be safely given by non-healthcare workers as an injection into the muscle using an adrenaline auto-injector (AAI). Current brands available in the UK are EpiPen®, Emerade®, Jext®. School staff should ideally have received appropriate training to be confident administering the medication.
Always give adrenaline FIRST in someone with known food allergy who has sudden-onset breathing difficulties (before other medicines such as asthma inhalers) – even if there are no skin symptoms. Delays in giving adrenaline are a common finding in fatal reactions. – advice from www.sparepensinschools.co.uk
IF IN DOUBT, give adrenaline. It is much better to give it early, or unnecessarily than too late!
For non-life-threatening reactions or localised swelling that does not impair breathing, then they can be given antihistamine. Antihistamine tablets or elixir will take around 15 minutes to take effect.
If you have the latest version of the Epipen, you no longer need to hold for 10 seconds – just 2 will suffice. However, holding for longer will do no harm and there is such a problem with supply that people are unsure which version they have!
If you would like a copy of the above posters, please email me firstname.lastname@example.org and I would be delighted to send you one
Supply issues causing worrying problems
The extremely sad and high-profile death of Natasha Ednan-Laperouse and many others who have died from anaphylaxis, has raised the importance of prompt access to emergency medication.
However, there have been major distribution problems with all three drug companies manufacturing the auto-injectors.
As a result, many pharmacies have been advised only to fulfil two auto-injectors – even if more have been prescribed – causing problems for schools, parents and pupils desperately trying to fulfil all requirements with a reduced supply.
Unfortunately, many parents are resorting to buying auto-injectors online where they cannot be sure of the quality or source of their purchase.
Additionally, pharmaceutical companies have also been advising use of their auto-injectors beyond their expiry dates. Previous advice has been the adrenaline deteriorates becomes less potent beyond their expiry date. Manufacturers have issued occasional guidance resulting from these supply issues, indicating that certain doses of autoinjectors can be used up to 3 months after the stated expiry date.
Before using the adrenaline auto-injector, it is vital to check in the viewing window that the solution remains clear and colourless. Keep up to date with the latest drug company and Allergy UK guidance.
In response to the shortages, the Anaphylaxis Campaign have issued the following advice;
- If you are prescribed an alternative AAI device, ensure that you know how to use it and train others that may need to use it in an emergency.
- Always carry two adrenaline auto-injectors with you at all times.
- Ensure you have registered the expiry date of your devices on the relevant manufacturers websites to give you ample warning when a new prescription is required.
- Ensure you gain a replacement device prior to disposing of any out of date devices.
- Always make sure you have a trainer device which can be ordered from the manufacturer’s websites for free
Spare auto-injectors in schools and in the law
A change in the law in 2017 enabled schools in the UK to buy a spare auto-injector from pharmacies without a prescription for emergency use. This legislation allows school staff to administer an emergency AAI to any child who has been assessed as being at risk of anaphylaxis.
The change in legislation applies to local authority maintained nurseries, primary, secondary and special schools, academies, pupil referral units and independent schools in England, Scotland and Wales.
Where clubs occur on school premises as part of official school activities, they can have access to the school’s spare AAI(s).
These auto-injectors are intended for children who are known to have a history of anaphylaxis and have already been prescribed an auto-injector. These spare auto-injectors are for emergency treatment when their device is unavailable; because it is out of date, not immediately to hand, faulty or been wrongly administered. Or they may require an additional dose following the administration of their own auto-injector.
This use of these emergency auto-injectors is subject to the following guidance:
- Only a reasonable number can be purchased, on an occasional basis – AAIs tend to have short expiry dates.
- The school does not intend to profit from the purchase.
- A request, signed by the principal or head teacher is provided which states:
- the name of the school for which the product is required;
- the purpose for which that product is required, and
- the total quantity required.
A template letter which can be used to request emergency autoinjectors in schools can be requested from http://www.sparepensinschools.uk
The spare AAI is a spare or back up device and not a replacement for a pupil’s own medication.
This is emphasised in the Department of Health guidance, which states:
“Children at risk of anaphylaxis should have their prescribed AAI(s) at school for use in an emergency. The MHRA recommends that those prescribed AAIs should carry TWO devices at all times, as some people can require more than one dose of adrenaline and the AAI device can be used wrongly or occasionally misfire.
Depending on their level of understanding and competence, children and particularly teenagers should carry their AAI(s) on their person at all times or they should be quickly and easily accessible at all times. If the AAI(s) are not carried by the pupil, then they should be kept in a central place in a box marked clearly with the pupil’s name but NOT locked in a cupboard or an office where access is restricted.
It is not uncommon for schools (often primary schools) to request a pupil’s AAI(s) are left in school to avoid the situation where a pupil or their family forgets to bring the AAI(s) to school each day. Where this occurs, the pupil must still have access to an AAI when travelling to and from school.”
Current advice from the Medicines and Healthcare products Regulatory Agency “Adrenaline auto-injector advice for patients” recommends that people with allergies and their carers should carry two adrenaline auto-injectors at all times, especially if they also have allergic asthma as they are at increased risk of experiencing a severe anaphylactic reaction.
The Anaphylaxis Campaign support the MHRA guidance. We actively campaign for people to be prescribed two AAIs and firmly recommend that once prescribed they should always be kept with the patient so they have access to them at all times. The reasoning behind two devices always being available is in case one is broken or misfires, or a second injection is needed before emergency help arrives.
Can the ‘spare’ adrenaline autoinjector be given to a child who has not been prescribed one?
Not all children with food allergies and at risk of anaphylaxis are prescribed AAIs. These children can be given a spare AAI in an emergency, so long as:
- the school has a care plan confirming that the child is at risk of anaphylaxis
- a healthcare professional has authorised use of a spare AAI in an emergency in that child
- the child’s parent/guardian has provided consent for a spare AAI to be administered.
Children for whom the spare AAI can be used
- Adrenaline auto-injector devices (AAIs)are used in the emergency management of anaphylaxis and can buy valuable time whilst waiting for an ambulance to arrive.
- If someone appears to be having a severe allergic reaction (anaphylaxis), it is essential to help them administer their device and then call 999 without delay, even if they have already used their own AAI device, or a spare AAI.
If a pupil is having anaphylaxis but does not have the required medical authorisation and parent/guardian consent for a spare AAI to be used, the school should immediately call 999 and seek advice: If spare AAIs are available, mention this to the call handler/emergency medical dispatcher, as they can authorise the use of these devices if appropriate to do so.
Legislation and legalities
All pupils with medical conditions – including food allergies – should have an Individual Healthcare Plan agreed between the parents and the school. This is particularly important where an adrenaline auto-injector (AAI) has been prescribed for use in emergencies. Template Individual Healthcare Plans and a wealth of other resources can be accessed from this excellent site: www.sparepensinschools.uk/ www.firstaidforlife.org.uk have helpful online courses covering care of children with Complex Medical Conditions and another on Giving Medication in Schools.
Teachers and other non-healthcare professionals are permitted – but not obliged – to administer an AAI under existing legislation, but only to the person for whom the AAI device has been prescribed.
They cannot use an AAI prescribed for one child to treat another child experiencing anaphylaxis. They can however administer the spare autoinjector to a child who hasn’t been prescribed one, but is experiencing anaphylaxis – in specific circumstances – see above.
Costs to schools and legalities
Schools are not required to hold spare AAI(s) – it is entirely at the discretion of the school. Legislation covers primary and secondary schools, (including independent schools) in the UK. There is no obligation for schools to provide them.
Pharmacies will not provide AAIs free of charge to schools: if the school decides to purchase spare AAI, then the school must pay for them as a retail item. There are no funds held centrally or by local authorities to cover the cost, the pharmacy is .
Existing duty of care
However, the change in law does not affect a school’s responsibility to be able to look after a pupil at risk of anaphylaxis. Schools already had a duty to be able to care for pupils with allergies (and provide emergency care for a child having anaphylaxis) under The Children and Families Act 2014, supported by the statutory guidance Supporting pupils at school with medical conditions.
Which autoinjector should schools have as the spare?
All the available brands of adrenaline autoinjector contain adrenaline, however there are differences in the available doses and needle length. There are also minor differences in the administration.
Ideally staff first aid training should involve all available AAI’s so staff are familiar with every type, as due to frequent supply issues, pupils may need to change brands. Ensure your first aid training provider is able to provide the comprehensive training you need.
- Emerade: 150, 300 and 500 microgram doses available and the 500mcg dose has a longer needle, to allow for deeper fat penetration for larger children.
- Epipen: 150 and 300 microgram doses available. Epipen Junior delivers a 150 microgram dose
- Jext: 150 and 300 microgram doses available
Where and how to store AAIs
Delays in administering adrenaline have been associated with fatalities following reactions.
- Be accessible at all times, in a safe and suitably central location, or with the pupil
- NOT be locked away in a cupboard or kept in an office where access is restricted.
Allowing pupils to keep their AAIs with them will reduce delays and simplifies the need to confirm consent without having to check a register. Schools should aim to ensure pupils are able to keep their AAIs with them at all times.
Spare AAI devices in the Emergency Kit should be stored separately from any AAIs prescribed to pupils and clearly labelled. AAIs should be kept at room temperature, away from direct sunlight and extremes of temperature. They should not be stored in a refrigerator.
Checks and replacements
It is recommended at least two named volunteers amongst school staff are responsible for monthly checks to ensure AAI’s are in date, and replacement AAIs are obtained when expiry dates approach. Schools can sign up for free expiry alerts system for the emergency device, via the relevant AAI manufacturer’s website.
It is good practice to require parents to take their child’s own prescribed AAI(s) home before all school holidays. Parents should register the autoinjectors with the manufacturers in order to receive alerts when they are nearing expiry.
Current guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) recommends that 2 AAI devices are prescribed, which patients should have available at all times.
AAIs are for single-use and cannot be reused. Used AAIs can be given to the ambulance paramedics on arrival or can be disposed of in a pre-ordered sharps bin for collection by the local council.
Liability and indemnity
Appropriate levels of insurance should be in place to cover staff including liability cover relating to the administration of medication such as AAIs. This is a legal requirement under Supporting Pupils with Medical Needs. The only exception to this are acts of serious and wilful misconduct. Carelessness or a simple mistake does not amount to serious and wilful misconduct.
Local Authorities may provide schools with appropriate indemnity cover; however, schools need to agree any such cover directly with the relevant authority. Academies should ensure that they are appropriately insured or covered under the Department for Education’s Risk Protection Arrangement (RPA).
The necessary paperwork
The British Society for Allergy and Clinical Immunology (BSACI) has produced a range of Allergy Plans. All children with a diagnosis of food allergy and at risk of anaphylaxis should have a written Allergy Management Plan as part of or instead of their Individual Healthcare Plan. The BSACI plans can be used as the pupil’s individual healthcare plan to meet the school’s duty under Supporting Pupils with medical needs, where the pupil has no other healthcare needs.
The plan should include the following:
- Known allergens and risk factors for anaphylaxis in the pupil.
- Whether the pupil has been prescribed AAI(s) (and if so what type and dose).
- Where a pupil has been prescribed an AAI: if parental consent has been given for use of the spare AAI.
- A photograph of the pupil to allow a visual check to be made (this will require parental consent).
Accessible in an emergency
These details should also be kept in a register in school. In larger schools (and secondary schools, in particular), it may not be feasible for individual staff members to know which pupils have been prescribed AAIs. Schools must ensure that the register is accessible, clear and easy to read in an emergency to prevent delays. Reading the register does not need to be undertaken by the designated member of staff. Delays in giving adrenaline have been associated with fatal outcomes.
The Department of Health has stated it is reasonable for ALL staff to:
- be trained to recognise the signs and symptoms of an allergic reaction;
- understand the rapidity with which anaphylaxis can progress to a life-threatening reaction, and that anaphylaxis may occur with or without prior mild (e.g. skin) symptoms;
- appreciate the need to administer adrenaline (using an AAI) without delay as soon as anaphylaxis occurs, before the patient might reach a state of collapse (after which it may be too late for the adrenaline to be effective);
- be aware of the anaphylaxis policy;
- be aware of how to check if a pupil is on the register;
- be aware of how to access the AAI;
- be aware of which staff members have received training to administer AAIs, and how to access their help.
Specialist staff training
Schools must arrange specialist anaphylaxis training for staff where a pupil in the school has been diagnosed as being at risk of anaphylaxis. This should include practical instruction in how to use the different AAI devices available. Online resources and e-learning modules are NOT a substitute for face-to-face training but can provide useful refreshers.
Any staff member may volunteer to take on the responsibilities set out in this guidance, but they cannot be required to do so.
Furthermore, it is appropriate for as many staff as possible to be trained in how to administer AAIs. Schools will want to ensure there are a reasonable number of designated members of staff to provide sufficient coverage, including when staff are on leave.
Designated members of staff should be trained in:
- recognising the range of signs and symptoms of severe allergic reactions;
- responding appropriately to a request for help from another member of staff;
- recognising when emergency action is necessary;
- administering AAIs according to the manufacturer’s instructions;
- making appropriate records of allergic reactions.
Written by Emma Hammett RGN – Founder and CEO of First Aid for Life.
First Aid for Life specialise in first aid for schools. We are the leading provider of first aid training for staff and pupils and our team of highly experienced medical, health and emergency services professionals will tailor the training to your needs. We incorporate Anaphylaxis training in all our school first aid courses and can provide specialist annual refreshers as needed. We always train using all devices.
It is strongly advised that you attend a First Aid course to understand what to do in a medical emergency. First Aid for Life run specific courses covering in detail how to help someone having an asthma attack.
Please visit www.firstaidforlife.org.uk, email@example.com or tel: 0208 675 4036 for more information about our courses. First Aid for life provides this information for guidance and it is not in any way a substitute for medical advice. First Aid for Life is not responsible or liable for any diagnosis made, or actions taken based on this information.