Microsoft word - faq nj ana management in schools.doc

Frequently Asked Questions about PL 57 and
Management of Severe Allergies in NJ Schools

What is a food allergy?

A food allergy is an abnormal response to a food, triggered by the body’s immune
system. Once the immune system decides that a particular food is harmful, it creates
specific antibodies against it. An allergic reaction to food may cause serious illness and,
in some cases, death.

What is a food intolerance?

A food intolerance refers to a condition when the body has difficulty digesting a food.
However, the immune system is not affected. For example, a person who is lactose
intolerant lacks an enzyme necessary to digest milk sugar. Symptoms of food intolerance
include gas, bloating and abdominal pain.
What is anaphylaxis?

Anaphylaxis is a severe allergic reaction, and can be fatal if not treated quickly with
adrenaline (epinephrine). This can occur after exposure to certain allergens. The entire
body can be affected within minutes to hours after exposure. The most dangerous
symptoms include difficulty breathing, swelling, dizziness, and shock; if left untreated, it
can be fatal. Epinephrine is the treatment of choice for anaphylaxis, followed by
appropriate medical care (i.e., calling 911 and transport to an ER). Studies clearly show
that fatalities to anaphylaxis are due to a failure to administer epinephrine, or a delay in
its use.
Is anaphylaxis a medical emergency?

Yes, anaphylaxis requires immediate attention; death may occur within minutes.
Should emergency information be posted at school?

It is recommended that schools post general instructions for identifying the symptoms of
anaphylaxis reactions, and for contacting emergency medical services. Useful posters
and informational materials are available through and
What are some of the causes of anaphylaxis?

Food – most commonly, peanuts, tree nuts (walnuts, cashews, pecans, hazelnuts,
almonds), milk, eggs, fish, shellfish, soy, and wheat. However, individuals can be
allergic to any food; some may be allergic to more than one food.
Medication – antibiotics, seizure medication, muscle relaxants.
Latex – elastic bands, kitchen gloves, balloons, other household items.
Rare – exercise-induced anaphylaxis.
Some anaphylactic reactions are idiopathic, i.e., unknown cause.
Who is at risk for anaphylaxis?

Anyone can experience an anaphylactic reaction, not just those with known allergies.
Allergies can affect children and adults of all races and ethnicity and can develop at any

How can anaphylaxis be prevented?

Strict avoidance of the offending allergen is the only way to prevent a reaction.
What is the treatment for anaphylaxis?

Epinephrine by auto-injector should be given immediately. Antihistamines, such as
Benadryl, should be considered secondary medications.
How does epinephrine work?

Epinephrine quickly constricts blood vessels, relaxes smooth muscles in the lungs to
improve breathing, stimulates the heartbeat, and works to reverse hives and swelling
around the face and lips.
What is New Jersey P.L. 2007, c. 57?

This law, passed unanimously by the legislature and signed on March 16, 2007, clarifies
existing law and adds new provisions in order to safeguard the growing number of food
allergic students in New Jersey schools. It strives to improve food allergy management
in schools by requiring more reliable allergen avoidance plans and emergency action
plans that make life-saving epinephrine and trained users readily available to students at
risk for anaphylaxis.
Key points:
1. Clarifies issues pertaining to self-administration of epinephrine. 2. Replaces reference to “epi-pen” with “pre-filled auto-injector mechanism” in recognition of the fact that there are a variety of injectable epinephrine devices on the market. 3. Requires designation and training of employee volunteers to administer epinephrine to a student for anaphylaxis in emergency situations when the nurse is not physically present at the scene. 4. Requires that epinephrine by readily accessible by the school nurse and designees. 5. Requires that the school nurse or a designee be promptly available on site at the school and school-sponsored functions in the event of an allergic reaction. 6. Provides that neither permission to self-administer medication, a coexisting diagnosis of asthma, or prescription for epinephrine coupled with another medication i.e., antihistamine, should preclude delegation of administration of epinephrine in an emergency. 7. Directs Department of Education and the Department of Health and Senior Services to jointly develop training protocols in effort to assist school nurses in the delegation process. 8. Requires that the pupil be transported to the hospital by emergency medical services personnel following the administration of epinephrine for anaphylaxis, even if the student’s symptoms 9. Requires the Department of Education, in consultation with the Department of Health and Senior Services, appropriate medical experts and professional organizations representing school nurses, principals, teachers, and the food allergy community, to develop and disseminate guidelines for the development of school policies on the management of food allergies in the school setting and the emergency administration of epinephrine for anaphylaxis. 10. Directs each board of education and nonpublic school to implement the guidelines established by 11. Addresses issues concerning liability. Does this law apply to both public and private schools?

Does this law apply to preschools?

No, it applies to K-12 students; however, many preschools recognize the growing
numbers of young children are at risk for anaphylaxis. Preschools are certainly free to use
the guidelines provided in order to create a safe environment.
Is it reasonable to keep certain areas of a school free of a particular allergen?

Schools should strive to maintain safe learning environments for food-allergic children,
including but not limited to the following areas:
¾ School nurse’s office

In addition, food products should not be used as displays or components of displays in
Should allergens be restricted in the classroom?

Classrooms must be maintained as safe spaces for all students. It is strongly suggested
that schools strive to eliminate or reduce the use of allergen-containing food in the
classroom for both academic and social purposes. Reliable risk-reduction procedures
must be established, including but not limited to the following:
• Avoid the use of foods for classroom activities, e.g., arts and crafts, counting, science projects, parties, holidays and celebrations, cooking, or other projects. • Use non-food alternatives: stickers, pencils or other non-food items as rewards • Inform parents of any school events where food will be served or used. • Eliminate or reduce classroom snacks (except in cases of students with medical • For birthday parties, consider a once-a-month celebration, with a non-food treat. • If food is consumed in the classroom, establish procedures to ensure that the student with life-threatening food allergies eats only what s/he brings from home. • If classroom snacks are eaten, it is recommended that the parent or guardian of a student with food allergies provide safe classroom snacks for his/her own child. These snacks should be kept in a separate, secure place. • Encourage parents /guardians to provide a non-perishable safe lunch in case their • Take care that students do not share or trade snacks, drinks, straws or utensils. • Students should use hand wipes or wash with soap and water after eating to remove food residue from their hands (sanitizers are ineffective). • Welcome parental involvement in organizing class parties and special events • If a student inadvertently brings a restricted food to the classroom, he/she should not be allowed to eat that snack in the classroom. • Avoid using the classroom of the food-allergic student and other allergen-free spaces as lunchrooms or locations for extra-curricular activities and events, if possible. • Recognize that classroom animals can be problematic on many levels. If an animal is present, special attention must be paid to the ingredients in their food and bedding, since many of these contain allergens such as peanuts and nuts. Some animals may also aggravate asthma symptoms.
What cleaning protocols should be followed?

Establish cleaning protocols for various areas of the school where allergens may be
found. Determine when and how to clean areas to minimize the presence of food
• Use dedicated cleaning cloths for cleaning allergen-free tables and chairs in the • Identify areas at high risk for cross-contact (such as desk and table tops), and • Cleaning Solutions: A published research study showed that common household
cleaning agents, such as Formula 409, Lysol Sanitizing wipes, and Target brand TM cleaner with bleach, removed peanut allergen from tabletops; however, dishwashing liquid was shown to leave traces of the allergen on 4 out of 12 tables. “The distribution of peanut allergen in the environment” (Journal of Allergy and Clinical Immunology, Vol. 113, No. 5) Is proper handwashing important?

Yes, proper handwashing can help avoid cross-contact with allergens. Encourage
proper hand washing both before and after meals and at other times, as needed.
Consider providing warm water in sinks, touch-free faucets, wipes in classrooms and
at cafeteria entrance/exit, and portable sinks.
• In the study cited above, liquid soap, bar soap, and commercial wipes were very effective for removal of peanut allergens from hands. Plain water and antibacterial hand sanitizer were inadequate; they left detectable levels of peanut allergen on 3 out of 12, and 6 out of 12 hands, respectively. • Do not use soap that contains major food allergens, such as milk or nut oils. • Post proper hand-washing instructions. Are there any special considerations for physical education classes?

It is recommended that medical alert bracelets/necklaces remain on the student (unless
safety is compromised). Medical bracelets can be safely covered with a stretch
wristband; medical necklaces can be tucked inside a shirt. School staff that is present in
the gym or on the playground should have a walkie-talkie, cell phone or similar
communication device for emergency communication, and designated assistance should
be readily available.

What are the special considerations for school food services?

Cross-contact with a food allergen poses a serious risk to a child with food allergies.
Some examples of cross-contact include lifting peanut butter cookies with a spatula and
then using the same spatula to lift sugar cookies; using a knife to make peanut butter
sandwiches, wiping the knife, and then using that same knife to spread mustard on a
cheese sandwich; using tongs to serve cheese French fries and then using those same
tongs to serve plain French fries.
• When preparing and serving food, it is critical to make sure that food preparation and serving utensils are not exposed to allergens and then used for another food. Food production surface areas should be cleaned before, during and after food preparation. Serving utensils must not be shared. • Training for all food service personnel about cross-contact should be part of the regularly-scheduled food safety program.
What policies should be considered in the cafeteria for food-allergic students?

Some suggestions for food allergy management in the cafeteria include the following:
• Create special areas that will be allergen-safe as an option (but not required) for students with particular food allergies. • Or, consider allergen-full tables as an option (i.e., have all the children eating peanut butter sit at designated tables, instead of separating the children with allergies). • Train cafeteria monitors to take note of the situation surrounding a child with aller- gies and intervene quickly to help prevent trading of food or bullying. • All students eating meals in the cafeteria should be encouraged to wash hands before and after eating so that no traces of allergens are left on their hands. • After each meal service, all tables, chairs and trays must be thoroughly cleaned using dedicated and disposable supplies to avoid cross-contact. • Take all complaints seriously from any student with a life-threatening allergy. • In schools with a cafeteria, classrooms should not be used for meals. • Be prepared to take emergency action, if needed.
How should bake sales and other fundraisers be handled?
It is recommended that bake sales and other food fundraisers not be held on school
grounds during school hours. If bake sales and other food fundraisers are otherwise
held on school grounds, consideration should be given to students with life-threatening
food allergies. For example, food items should be tightly wrapped or sealed, and
display tables should be washed after use.
What are school-sponsored functions?

“School-sponsored function” means any activity, event or program occurring on or off
school grounds, whether during or outside of regular school hours, that is organized and/or
supported by the school. School-sponsored functions include field trips, school team
sporting events, dances, club meetings, detention, performances, etc.

How should field trips and school-sponsored functions be handled?

Field trips and school-sponsored functions must be planned with consideration of the
needs of food-allergic students.
• Avoid high risk places and activities. • Parents/guardians of a student at risk for anaphylaxis should be invited but not required to accompany their child on school trips. In the absence of an accompanying parent/guardian, a registered nurse or a properly trained designee should guard the student’s welfare and handle any emergency. • If a parent/guardian, registered nurse, or trained designees cannot be present, the • Ensure that epinephrine and emergency instructions are taken on field trips and school-sponsored functions. The adult carrying and responsible for administration of epinephrine should be identified to the student as well as the other chaperones. • Know where the closest medical facility is located, “911” procedures, and whether the ambulance carries epinephrine. Whenever students travel on field trips, the name and phone number of the nearest hospital and means for summoning emergency services should be part of the chaperone’s emergency plan. • Ensure that a 2-way communication device or cell phone is available on the trip • Avoid eating on the bus. It is an industry standard that eating be prohibited on buses, including school buses. If necessary to eat on a long trip, the school bus should be considered an extension of the classroom and life-threatening allergens should be prohibited. • Facilitate hand-washing before and after the consumption of food. If hand- washing facilities are unavailable, wipes should be provided.
Does this law apply to after school programs?

The new law in New Jersey applies to functions sponsored by the school and the school
district. However, programs located in a school building but not sponsored by the district
are not covered by the law.
Who should be trained to administer epinephrine by auto-injector in a life-
threatening situation?

Any member of the school staff can accept the delegation of epinephrine administration,
provided that the staff member is a willing participant.

Can cafeteria workers be designated to administer the epinephrine auto-injector if
they are only contracted by the district and not a true employee?

Yes, contracted staff such as cafeteria workers and bus drivers is considered to be
employees of the board of education or nonpublic school and may serve as designees.

Can athletic trainers be designated by the nurse to administer epinephrine
autoinjector for anaphylaxis?


Who conducts training?

The school nurse is responsible for training delegates.
How often should staff be trained?

Training should occur annually, and preferably, twice per year.

Can there be more than one designee for the same student?

Yes, there should be as many designees as is necessary to ensure that the student is
Can there be more than one student for the same designee?

Yes. The “one client/one task” principle means that the designee cannot further delegate
the task to someone else. This does not mean, however, that the same designee cannot
receive individual training and delegation for more than one pupil.

How many staff members should be trained in the administration of epinephrine?

While the precise ratio of trained staff members to students who may require epinephrine
for anaphylaxis has not been defined, it seems reasonable that there be three to five staff
members trained at an average-size school of about 400 students to ensure adequate
provision for emergency situations, with an additional staff member trained for every 100
What happens if no one is willing to be a designee?

The clarifications provided in P.L. 2007, c. 57 concerning immunity and the removal of
common barriers to delegation should make this a rare circumstance. While staff
members can be approached and asked to accept the role of designee, they can not be
forced to do so. The delegation must be accepted willingly. In an instance in which no
designee can be successfully selected and trained, the school administrator or board of
education should be consulted for assistance. The law requires trained designees for
students enrolled in a school who may require the emergency administration of
epinephrine for anaphylaxis when the school nurse is not available.
Schools that take a positive and proactive approach in educating staff about managing
allergies in school and recognizing the signs of anaphylaxis do not usually have a
problem in recruiting delegates. Schools where leadership takes a negative approach
towards implementing the law may find that they also compromise the safety of students
at risk for anaphylaxis.

Is the school district obligated to designate someone to administer epinephrine other
than the school nurse?

P.L. 2007, c. 57 makes clear that there must always be a nurse or trained staff member
available and with access to epinephrine for anaphylaxis at school and school-sponsored
functions. Someone must be available in the absence of a nurse from the scene of an
allergy emergency.
Should an Individualized Emergency Health Plan (IEHP) and an Individualized
Health Plan (IHP) be written for a student at risk for anaphylaxis?

Yes. Both an IHP and an IEHP must be written for each student at risk for anaphylaxis.
The IHP must be kept in a place that is accessible to anyone providing emergency
treatment, and should be reviewed frequently by the designee.
What about 504 Plans? Does the amended law replace the need for a 504 for a food
allergic student?

According to a January 26, 2009 memo from the NJ Department of Education, “districts
must continue to follow their standard operating procedures to identify and determine the
food allergic student’s eligibility for services under section 504.” An IHP or an IEHP
doesn’t “relinquish the district from its responsibility to evaluate students who need
services under Section 504 and make individual placement determinations.”
Is it necessary to maintain more than one auto-injector for a specific child?

Yes. Up to 30% of the time, someone experiencing anaphylaxis may experience a
biphasic reaction, where symptoms return and additional medication is needed.
Where should the epinephrine auto-injector(s) be kept for a student at risk for

P.L. 2007, c. 57 requires that epinephrine auto-injectors be kept in unlocked, secure
locations so as to be readily available during an emergency. This will vary depending
upon the student’s schedule and the circumstances surrounding the possible emergency.
In addition to the nurse’s office, possible locations for unlocked, secure storage of
epinephrine include the classroom, cafeteria, the principal’s office, teacher’s room, on the
person of the designee, etc. Location should be noted on the IHP and during the training
of the designee by the school nurse.
Bear in mind, though, that epinephrine is medication held by the school by virtue of a
physician’s order. Only school nurses, designees or students able to self-medicate should
have an epinephrine autoinjector on their person.
Should a designee(s) be assigned to a student if the physician’s order contains both
epinephrine and antihistamine?

Yes, P.L. 2007, c. 57 makes clear that a physician’s order for epinephrine coupled with
another medication e.g., adjunctive antihistamine, shall not prohibit a delegation of
administration of epinephrine for anaphylaxis.
Should a designee(s) be assigned if the student has a co-existing condition of
Yes. Several factors may also increase the risk of a severe or fatal anaphylactic reaction,
• a previous history of anaphylaxis, especially involving respiratory symptoms such as breathing difficulty and throat tightness; • peanut, tree nut, and/or shellfish allergies; • teenagers who exhibit risky behaviors i.e., eating a food item without reading the ingredient label, or eating a potentially unsafe food item as a way to “fit in” with their peers; and • a delay in epinephrine administration, or a failure to administer epinephrine at all.
P.L. 2007, c. 57, makes clear that a student with asthma and anaphylaxis should have a
designee assigned for administration of epinephrine for anaphylaxis in the absence of the
Should a designee(s) be assigned for administration of epinephrine even if the
student is permitted to self-administer medication?

Yes. It is possible that an anaphylactic reaction can be so disabling that anyone,
including an adult, would not be able to self-medicate, and designated assistance must be
available. It is possible to conceive of other situations (i.e., a student permitted to self-
administer medication may have inadvertently left their medication at home). P.L. 2007,
c. 57, makes clear that permission to self-administer must not preclude delegation.
Can schools eliminate or “ban” peanut butter and peanut products from the
cafeteria menu?

Schools are certainly free to do this, but it is not required.

Given certain circumstances, such as the age of the students involved, this could be a
reasonable approach. One might say that keeping peanuts out of the school is a way to
avoid exposure in the first place. For instance, it might be prudent to keep peanuts and/or
other messy allergen-containing foods, such as yogurt, to which other students are
allergic away from preschoolers and other young children whose hand washing skills are
However, caution is urged, because the are possible problems with this approach: (1) It
is not failsafe; (2) The term must be very clearly defined and understood, because there
can be a range of meaning; (3) The majority of schools in the country do not have a ban;
(4) Professional, medical, nursing or school organizations do not advocate for a ban.
Many schools have taken more moderate measures, such as designating allergen-free
tables as an option for allergic children and their friends who are not eating peanut
products for lunch, while children who have brought peanut products from home eat at
other tables. This strategy must be combined with adequate supervision when food is
eaten, reinforcement of “no food sharing”, encouragement and facilitation of proper
handwashing before and after eating, enforcement of a zero-tolerance bullying policy,
arrangement of lunch times so the lunchroom will be thoroughly cleaned, and proper
custodial cleaning protocol.
Note that classrooms and learning areas should be kept free of foods to which a student is
Does delegation to school staff put the nurse’s license at risk?

P.L. 2007, c. 57, provides immunity for both the delegating nurse and the designee. In
addition, the prerequisite training should ensure complete understanding of the task being
delegated and a successful delegation process.
Can nurses delegate administration of antihistamine?

Under the current law, only the administration of epinephrine for anaphylaxis is
delegable. Note that the presence of antihistamine in the physician’s order does not
preclude the delegation of epinephrine for anaphylaxis.
Department of Education memos dated 3/8/05 and 8/8/05 permit a student who has
permission to carry and self-administer epinephrine for anaphylaxis to also carry and
administer antihistamine as an adjunctive medication for anaphylaxis.


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