Back to School With Allergies/Asthma: Care Planning With Families and Schools

Back-to-school season is an exciting time for kids and their families. But for those with asthma or allergies, the excitement can be mixed with anxiety and concern. Managing chronic health conditions in school-age children requires the collaborative effort of clinicians, parents, school nurses, and staff. While some schools have these procedures down to a science, there are sometimes challenges and barriers in the school setting that leave vulnerable children at risk.

In the US, food allergies affect over 7% of children,¹ with some involving life-threatening reactions. Additionally, the 6 million children who have asthma miss about 14 million school days as a result.²  

To learn more about keeping these kids safe and healthy in school, we spoke to Neeta Ogden, MD, an allergist based in Edison, NJ, who is a spokesperson for the American College of Allergy, Asthma, and Immunology, as well as members of the National Association of School Nurses (NASN), whose views were represented by NASN spokesperson Kate McDuffie. Here’s what they had to say.

School Action Plans

“Management of asthma during the school day is essential in promoting school attendance,” stressed NASN’s McDuffie. “Asthma is a key factor in chronic absenteeism and impacts the ability of students to engage in learning during the day.”

Effective management of both asthma and allergies is best accomplished by each child having a solid, written action plan for the school setting that is regularly reviewed, updated, and shared.

From the perspective of school personnel, having a health care plan (including an asthma action plan) that has been developed collaboratively by health care providers and school nurses is of critical importance, said McDuffie. Unified efforts to promote “student self-management skills,” and to ensure access to needed medications (including 1 inhaler for school and 1 for home) are also critical, she added.

For clinicians, having good communication with parents and school personnel involved in making the care plan work is critical, said Dr Ogden. Lack of effective communication can result in lack of effective care. “The biggest obstacles can be the effective communication of an allergy and asthma action plan to both parents and then the health care providers in the school setting,” she noted.

Clinicians and parents also need to ensure that children fully understand how and when to use needed medication, such as a rescue inhaler or allergy medicine. This includes making sure that children know how to seek help when they need it, said Dr Ogden. As Dr Ogden advises:

• “Speak with the child; if they are able to, help them identify [their] symptoms, so they are empowered to seek help if they are having an exacerbation or need further help,” he noted.
• Remember that “complacency can occur when children haven’t had a reaction in a while.”
• In children with food allergies, said Dr Ogden, “always review the use of the EpiPen and a food allergy action plan — once is never enough! Share videos and always discuss.”
• The same advice holds for asthma and the asthma action plan. Dr Ogden advised clinicians to “review triggers, avoidance, and what to do at the first sign of an exacerbation. This is so important and can curtail an asthma exacerbation from becoming more severe.”

It’s also a good idea for clinicians to talk with parents about what they are expecting from children with asthma or allergies. Surveys suggest² that allergists believe children aren’t ready to carry an autoinjector and self-inject for anaphylaxis before they reach 12 years of age. But parents may expect children as young as 6 years of age to start recognizing and self-treating for anaphylaxis. Ultimately, clear communication and teamwork is essential to evaluate the individual child’s readiness and ability to take an active role in managing their health at school.

Recognizing Uncommon Symptoms

Dr Ogden emphasized the importance of identifying a child’s unique pattern of symptoms. “Not everyone’s symptoms are the same. An asthmatic child may only have a cough or experience tightness at recess, rather than the typical ‘wheeze’ that people associate with asthma. Teasing out these nuances is essential to proper treatment at home and school.”

When a clinician takes the extra step of investigating a child’s symptoms in depth, it can make all the difference in that child’s school year. “Communication is key,” said Dr Ogden; this means “asking clinical questions that address the myriad symptoms that present in childhood allergy and asthma,” rather than assuming that the symptoms are “the classic: sneeze, wheeze, itch. Headaches, fatigue, brain fog, nocturnal cough, for example, can all be due to allergy and asthma and affect school performance and lead to missed days.”

Sleep disturbances resulting from asthma and allergies may be an underrecognized factor affecting children’s school performance and experience. “Uncontrolled asthma may cause sleep interruptions from coughing at night, which impacts the brain’s capacity to think and learn during the school day,” noted McDuffie. “These students may experience tardiness and chronic absenteeism related to their asthma.”

Challenges in the School Setting

School nurses that McDuffie conferred with for this article had several insights to share with clinicians about the management of asthma and allergies in the school setting:

• The school setting can harbor a unique set of environmental triggers. These may involve cleaning supplies, scents (from air freshener/aromatherapy), tobacco smoke, pests, mold, dust mites, and outdoor air wafting in through open windows — air that may contain pollutants from school bus idling, lawn maintenance, or even wildfire smoke. “Many triggers may be outside of the school building, but open windows provide opportunities for exposure in the building and impact a student’s ability to learn,” noted McDuffie.
• Schools don’t always have adequate stocks of epinephrine, the first-line treatment for allergic reactions. “Approximately 25% of epinephrine administered in schools is for students or staff with a first-time allergic reaction. School access to stock epinephrine is essential, but not standard, due to the cost to maintain and barriers around gaining a prescriber’s order,” said McDuffie.
• Access to medications can be an issue. “Note that the cost and need for at least 1 inhaler at home and 1 inhaler at school (including spacers) is a challenge for many families. Clinicians and parents should understand that any school ‘stock’ or ‘stand-by’ epinephrine programs are not intended to be provided for their student who has a prescription,” said McDuffie.
• Rules for administration of medications in schools may vary. McDuffie noted that state rules differ regarding whether students are permitted to “self-carry/self-administer” medications. “’Self-carry/medicate’ means a student has permission to carry their inhaler in their backpack/purse and use it as needed vs the school nurse administering the inhaler and housing it in the school nurse’s office. Each state is different in this regard. For example, in Montana, there is a law specific to this and a specific form required to be completed by the health care provider and parent.”

New NASN Allergy Guideline

With respect to food allergies, said McDuffie, “Items that need additional emphasis from providers include replacing first-generation antihistamines (diphenhydramine) with second-generation antihistamines (cetirizine), which are less sedating, and the difference between IgE [immunoglobulin E] and non-IgE allergic reactions.”

She added that “For food allergies, there are new medicines on the horizon, but these are not projected to be available until December or later. As new epinephrine delivery systems become FDA approved, federal and state laws will need to be addressed to modify the autoinjector-only language to include the least restrictive delivery method to accommodate the nasal delivery.”

To help address these and other concerns, the National Association of School Nurses will release a new evidence-based clinical practice guideline for students with allergies and risk for anaphylaxis in the fall of 2023; the guideline will include an implementation toolkit of resources specific to school nurses.

 Mobilizing Parents

Ultimately, families of children with allergies and asthma need to understand the importance of proactively ensuring that their child’s school-day needs are met, rather than simply assuming that school staff will take care of whatever may be needed. “It remains very much in the hands of families to ensure that their child’s allergy and asthma needs are properly understood and treated,” said Dr Ogden.

As an allergist, Dr Ogden encourages families to do more than just fill out a standard school health form at the start of the school year; parents should be encouraged to “follow up with a phone call or in-person meeting with the school’s health care provider so [that they] are on the same page about the child’s symptoms, treatments, and what medications or monitoring should be given at school.”

Parental awareness of what schools need to keep children with allergies and asthma safe is hugely important, NASN’s McDuffie agreed. “Parents should be aware that provider orders and correct paperwork are required by schools for medications to be administered at schools, even on the first day of school.”