1.1 What are allergies?

An allergy is when the immune system reacts to substances (allergens) in the environment which are usually harmless, such as food, pollens, dust mites and insects. This results in the production of allergy antibodies. Antibodies are proteins in the immune system which identify and react with foreign substances.

1.2 What is an allergic reaction?

An allergic reaction is when someone develops symptoms such as hives, swelling of the lips, eyes or face, vomiting or wheeze following exposure to an allergen. Only some people with allergy antibodies will develop symptoms following exposure to the allergen. Allergic reactions range from mild to severe. Anaphylaxis is the most severe form of allergic reaction.

1.3 Food allergy or intolerance?

There is often confusion about the difference between food allergy and food intolerance. Symptoms of food intolerance can sometimes resemble those of mild or moderate food allergy. Unlike food allergy, food intolerance does not involve the immune system and does not result in anaphylaxis.

Diagnosis of food allergy and risk of anaphylaxis should always be medically confirmed.

1.4 What is anaphylaxis?

Anaphylaxis is the most severe form of allergic reaction. Symptoms can start within minutes of exposure. Progress of reaction can be very rapid at any time over a period of two hours from exposure to the allergen. Anaphylaxis is potentially life-threatening and must ALWAYS be treated as a medical emergency. Diagnosis of individuals at risk of anaphylaxis should always be medically confirmed.

1.5 Signs and symptoms of allergic reactions and anaphylaxis

Mild to moderate allergic reactions can involve the skin and gastrointestinal system. Anaphylaxis involves the respiratory system and/or cardiovascular system, however, skin and gastrointestinal symptoms may also (but not always) occur.

1.6 Risk factors for fatal anaphylaxis

Mild to moderate and even severe allergic reactions (anaphylaxis) are common. Deaths from anaphylaxis are rare.

Deaths from anaphylaxis are highest in teenagers and young adults whilst eating away from home. Deaths from anaphylaxis have often occurred in situations where the emergency medication has not been readily available and/or has not been administered in a timely manner. Individuals with asthma and severe food allergy are at increased risk of anaphylaxis.

Previous mild or moderate allergic reactions may not rule out subsequent severe or fatal allergic reactions. It is rare for deaths to occur if the individual is given adrenaline in a timely manner and as instructed.

1.7 Common causes of anaphylaxis food

Peanuts, eggs, milk, tree nuts (such as hazelnuts, cashews, almonds), soy, wheat, fish, shellfish and sesame are the most common food allergens. Whilst these foods cause 90% of allergic reactions to foods, any food may cause an allergic reaction.

Sensitivity to food allergens is variable so it is important that food allergy is confirmed by a medical practitioner before risk minimisation strategies are considered.

1.8 Peanut allergy

Whilst egg and milk are more common food allergies, peanut allergy is the most common cause of deaths from food-related anaphylaxis.

Peanut allergy is increasingly common, particularly in children (rates have doubled in the last 10 years) and is now seen in approximately 1 in 50 children and 1 in 200 adults. Small amounts of peanut can cause an allergic reaction in extremely sensitive individuals. Not all people with peanut allergy have severe reactions.

1.9 Common causes of anaphylaxis stings, bites and medications

Insects - Bee, wasp and jumper ant stings are the most common insect allergens. Ticks and fire ants also cause anaphylaxis in susceptible individuals. Medications Pain killers and antibiotics are the most common medication and allergens.

2.1 Allergic reactions can be mild to moderate or severe (anaphylaxis)

Sometimes an allergic reaction can start as mild to moderate, but can progress to severe (anaphylaxis). Some individuals will experience signs and symptoms of anaphylaxis without having mild to moderate symptoms beforehand.

2.2 Signs and symptoms of mild to moderate allergic reaction

Swelling of lips, face, eyes. Hives or welts. Tingling mouth. Abdominal pain, vomiting (these are signs of a severe allergic reaction to insects).

2.3 Action for mild to moderate allergic reaction

Stay with child or adult and call for help - do not leave child or adult unattended. Give medications if prescribed (such as non-sedating antihistamine). Locate adrenaline autoinjector (if available). Contact parent/guardian (or other emergency contact).

It is important to stay with the child or adult and watch for any signs of anaphylaxis. Mild to moderate signs can present first and then progress to anaphylaxis. Antihistamines The human body releases many chemical substances that cause allergic reactions histamine is only one of the chemicals and this is why antihistamines are sometimes used to treat mild to moderate allergic reactions (such as hives) but are not an effective treatment for anaphylaxis.

2.4 Signs and symptoms of anaphylaxis

Watch for any one of the signs and symptoms of anaphylaxis: Difficult/noisy breathing. Swelling of tongue. Swelling/tightness in throat. Difficulty talking and/or hoarse voice. Wheeze or persistent cough.

Persistent dizziness or collapse. Pale and floppy (young children).

Unlike food allergy, abdominal pain and vomiting are SEVERE symptoms for those experiencing an allergic reaction to insects.

2.5 Action for anaphylaxis

Lay the child or adult flat. Do not allow them to stand or walk. If breathing is difficult, allow them to sit. Give the adrenaline autoinjector immediately. Phone ambulance - 000 (Australia), 111 (New Zealand), 112 (mobile). Contact the parent/guardian or other emergency contact. Note the time the adrenaline autoinjector was given. If the needle is exposed, place used adrenaline autoinjector into safe container (e.g. hard plastic lunch box) to give to ambulance officers. Calm and reassure the child or adult.

If in doubt, give the adrenaline autoinjector. It is important to take the medication to the child or adult rather than move them as they should not stand or walk.

2.6 It is important to lay the child or adult flat

Having the child or adult in an upright position can lead to insufficient blood returning to the heart, leaving the heart with no blood to pump. Laying them flat (and if possible elevating their legs) will improve blood return to the heart.

If breathing is difficult, allow to the child or adult to sit but not stand. If vomiting, lay the child or adult on their side (recovery position).

2.7 Further adrenaline autoinjector doses may be given if

Occasionally, it may be necessary to use a second adrenaline autoinjector if available, when: There is no improvement after 5 minutes. Symptoms of anaphylaxis continue to progress. Symptoms resolve and then recur. If the child or adult does not have a second adrenaline autoinjector and there is an adrenaline autoinjector for general use, this can be used. Advice from the local education and/or health authorities should be sought regarding adrenaline autoinjectors for general use. Further information about adrenaline autoinjectors for general use: www.allergy.org.au/health-professionals/anaphylaxisresources/adrenaline-autoinjectors-for-general-use

2.8 Is it anaphylaxis or asthma?

If the child or adult is known to be at risk of anaphylaxis and you are unsure whether they are experiencing anaphylaxis or severe asthma:

Give the adrenaline autoinjector first. Then give asthma reliever medication.

Phone ambulance - 000 (Australia), 111 (New Zealand), 112 (mobile). Continue asthma first aid. Follow their ASCIA Action Plan for Anaphylaxis.

2.9 Action for anaphylaxis without a prescribed adrenaline autoinjector

Lay the child or adult flat. Do not allow them to stand or walk. If breathing is difficult, allow them to sit. If you have an adrenaline autoinjector for general use, give it immediately. Phone ambulance 000 (Australia), 111 (New Zealand), 112 (mobile). If unconscious and not breathing, commence CPR. Contact parent/guardian or other emergency contact.

For children aged approximately 1-5 years a 0.15 mg (green labelled) adrenaline autoinjector is generally used. Advice from the local education and/or health authorities should be sought regarding adrenaline autoinjectors for general use. Further information about adrenaline autoinjectors for general use: www.allergy.org.au/health-professionals/anaphylaxisresources/adrenaline-autoinjectors-for-general-use

3.1 Adrenaline is the only effective treatment for anaphylaxis

Adrenaline: is a hormone that is produced naturally in the human body.

is very safe when given as instructed via an adrenaline autoinjector. assists breathing, maintains heart function and blood pressure. works in minutes and lasts approximately 10-20 minutes. may need to be repeated. reverses a severe allergic reaction and can be life saving.

If in doubt, give the adrenaline autoinjector. If anaphylaxis is suspected, not giving the adrenaline autoinjector can be more harmful than giving it, even when it may not have been necessary. Transient (temporary) side effects of adrenaline such as increased heart rate, trembling and paleness are to be expected. Therefore, someone may look unwell even after the adrenaline autoinjector has been given. Further doses of adrenaline should only be given when signs of anaphylaxis are still present.

3.2 Adrenaline autoinjectors...

are automatic injectors containing a SINGLE fixed dose of adrenaline. are designed for use by non-medical people. should be injected into the outer mid-thigh muscle. can be administered through a single layer of clothing (not seams or pockets). should be stored in an easily accessible, unlocked location with an ASCIA Action Plan for Anaphylaxis. should be clearly labelled with the name of the child or adult.

If carried by the person, an ASCIA Action Plan for Anaphylaxis should be with the adrenaline autoinjector.

3.8 EpiPen is different to the EpiPen trainer device

EpiPen trainers are used to practise giving the real EpiPen. Unlike the EpiPen trainer, the real EpiPen has: a single pre-measured dose of adrenaline. an expiry date. a window which allows you to check if adrenaline is discoloured. a louder click than the EpiPen trainer device. a stronger spring action than the EpiPen trainer device (remember to hold firmly against the outer mid thigh). a different colour (the trainer device has a grey label).

3.14 How to position a very small child while giving an

A very small child who is conscious and requires restraint may need to be held on the adults lap if there is only one person available.

3.16 Self administration of adrenaline autoinjectors

Older children or adults may be comfortable sitting while the adrenaline autoinjector is being given or if they are able to give it to themselves, whilst being supervised by an adult. In many cases the child or adult will be too unwell to self administer and someone else will need to give the adrenaline autoinjector.

3.17 Adrenaline autoinjectors frequently asked questions

Question: If I don't think its worked or I pull the adrenaline autoinjector out too quickly, can I stick it back in? Answer: No. The device is automatic and therefore can only be used once. The adrenaline is automatically expelled once the device is activated. It can only be activated once. Question: Should I use an expired adrenaline autoinjector if it is the only one available? Answer: Expired adrenaline autoinjectors are not as effective when used for treating anaphylaxis. However, an expired adrenaline autoinjector should be used in preference to not using one at all. Further information: www.allergy.org.au/health-professionals/anaphylaxisresources/adrenaline-autoinjectors-faqs

Green Epipen/Anapen are for children under 20kg

4.1 ASCIA Action Plans for allergic reactions and anaphylaxis

ASCIA Action Plans include: Actions to take when a child or adult has a mild to moderate allergic reaction. Actions to take when a child or adult has anaphylaxis Diagrams on how to give an adrenaline autoinjector. Actions to take after giving the adrenaline autoinjector.

Emergency contact details of the parent/guardian (or other emergency contact).

ASCIA Action Plans should be: Prepared and signed by the childs or adults medical practitioner only it should not be completed by a parent/guardian. Reviewed each year or as the childs or adults medical condition changes. Stored with the adrenaline autoinjector, even if it is carried by the person. Clearly displayed in areas that are accessible to all staff members in schools or childcare services (privacy issues may need to be considered).

4.2 There are three types of ASCIA Action Plans

ASCIA Action Plan for Allergic Reactions Green

ASCIA Action Plan for Anaphylaxis (personal) Red

ASCIA Action Plan for Anaphylaxis (general) Orange

4.3 ASCIA Action Plan for Anaphylaxis (personal) - Red

Provided to children or adults at risk of anaphylaxis to any allergen/s (including insects), who have been prescribed an adrenaline autoinjector.

EpiPen version Anapen version

This Action Plan is for an individual. It includes personal details and an area to place a photo.

Note: ASCIA Action Plans for Anaphylaxis (insect allergy) have been phased out and information relevant to insect allergy is now included in this ASCIA Action Plan for Anaphylaxis.

5.1 Responsibilities of parent/guardian

Notify school of childs allergies and provide medical information as appropriate. Ensure that the school is notified of changes to the childs medical condition. Provide an ASCIA Action Plan for Anaphylaxis from childs doctor. Provide an adrenaline autoinjector clearly labelled with childs name. Replace your childs adrenaline autoinjector in a timely manner if it is used and before it reaches its expiry date.

5.2 Children at risk of anaphylaxis should have

Knowledge of allergen avoidance strategies. An ASCIA Action Plan for Anaphylaxis. An adrenaline autoinjector provided to the school and readily available for use in an emergency.

5.3 Older more independent students should be encouraged to take greater responsibility for ...

Communicating about their allergies to their peers and teachers including the possible need for emergency treatment. Reading food labels.

Knowing the signs and symptoms of an allergic reaction. Being familiar with the use of an adrenaline autoinjector. Ensuring they have ready access to their adrenaline autoinjector. Ensuring their adrenaline autoinjector is within its expiry date.

5.4 To support a student diagnosed at risk of anaphylaxis, schools should

Seek information from the parent about allergies that affect their child as part of health information at enrolment and as part of regular health updates. Where this or any other information indicates a student has an allergy or is at risk of anaphylaxis, schools use Appendix 1 in Anaphylaxis Guidelines for Schools. Ensure an individual health care plan has been developed in consultation with the students doctor, relevant staff, parent/guardian and student. Individual health care plans are reviewed at least annually. Ensure staff have anaphylaxis training and keep an updated register of staff who have completed training. Ensure safety in each school activity, with strategies in place to minimise the risk of exposure to known allergens. Develop risk management strategies, including for school excursions. Ensure the school anti-bullying plan is inclusive of students with allergies.

5.5 Anaphylaxis training options for NSW schools

Schools need to arrange anaphylaxis training for staff where students in the school have been diagnosed to be at risk of

anaphylaxis. The training must include demonstration and practice with an adrenaline autoinjector. This face to face anaphylaxis training is available through the NSW Health anaphylaxis training program:www.health.nsw.gov.au/policies/ib/2009/pdf/IB2009_06 3.pdfwww.schools.nsw.edu.au/studentsupport/studenthealth/co nditions/anaphylaxis/index.php DV01157 can be used by schools to register ASCIA e training (title: ASCIA Anaphylaxis e training). DV00029 can be used by schools to register face to face training ( course is now called: Registration of specialist anaphylaxis training). ASCIA anaphylaxis e-training (developed with NSW Health) can be used when face to face training isn't possible, as a refresher, or for interim training whilst waiting for face to face training: www.allergy.org.au/etraining

Anaphylaxis training should be completed approximately every two years.

5.6 To support a student diagnosed at risk of anaphylaxis, staff should be aware of

What anaphylaxis and allergies are. Which students are at risk of anaphylaxis. How to recognise an anaphylactic reaction. Where the students adrenaline autoinjector and ASCIA Action Plan for Anaphylaxis is stored. When and how to give the adrenaline autoinjector.

5.7 Anaphylaxis Guidelines for NSW Schools

Provide a step by step guide for principals and teachers to assist with effective management of students at risk of anaphylaxis. Developed jointly by NSW Health, NSW Department of Education and Training, Catholic Education Commission and the Association of Independent Schools. Focuses on the development of an individual health care plan, developed jointly by the principal and the students parent/guardian, which incorporates information and planned emergency treatment that are relevant to the individual student.

Anaphylaxis Guidelines for NSW Schools www.schools.nsw.edu.au/studentsupport/studenthealth/conditions/ anaphylaxis/index.php

5.8 Individual health care plans include

An emergency response plan (ASCIA Action Plan for Anaphylaxis) completed and signed by the students doctor. Medical information provided by the students doctor. Strategies the school will take to minimise the risk of exposure to known allergens. Training strategy : - awareness raising with students and staff. - training for staff, including the use of an adrenaline autoinjector. Communication strategies. Annual review date.

5.9 Prevention strategies food

Minimise exposure to known food allergens. Implement age appropriate avoidance strategies for routine and non routine activities (consider, for example, meal times, special occasions and excursions). Identify foods used in activities that contain known allergens and replace with other suitable foods. Avoid sharing food or eating utensils (close supervision may be required for younger students at meal times). Keep surfaces clean and prevent cross-contamination during handling, preparation and serving of food. Promote good communication between parent/guardian, staff and student.

Further information on how to minimise high risk foods: www.allergy.org.au/patients/anaphylaxis-e-training-schools-andchildcare/etraining-resources www.schools.nsw.edu.au/studentsupport/studenthealth/conditions/ anaphylaxis/index.php

5.10 Prevention strategies insects

Specify play areas that are lowest risk and encourage the student and peers to play in these areas. Decrease number of plants in school grounds that attract bees. Ensure students wear appropriate clothing and shoes when outdoors. Be aware of bees in pools, around water and in grassed or garden areas. Avoid drinking from open drink containers, particularly those that contain sweet drinks.

To help prevent tick bites, cover skin and shake clothing once indoors.

5.11 On excursions, supervising staff need to...

Know which students are at risk of anaphylaxis and the known allergens. Know what risk minimisation strategies are in place. Issues such as the administration of prescribed emergency medication and risk management strategies need to be considered when planning and organising an excursion. Have the adrenaline autoinjector and ASCIA Action Plan for Anaphylaxis readily available. Know when and how to give the adrenaline autoinjector.

5.12 Legal liability of staff administering medication

School education authorities have a duty of care to take reasonable steps to keep students safe at school and this includes administration of adrenaline autoinjectors and any other emergency care when a student has signs of anaphylaxis. A legal principle called vicarious liability means that school staff acting in the course of their employment enjoy full legal protection, in the unlikely event of a student suffering injury as a result of emergency treatment of anaphylaxis.

5.13 Summary of important points

Anaphylaxis is potentially life threatening and should always be treated as a medical emergency.

Adrenaline is the only effective treatment for anaphylaxis. School staff should be trained to know: Which students are at risk of anaphylaxis. How to minimise exposure to known allergens. How to recognise anaphylaxis. Where the students adrenaline autoinjector and ASCIA Action Plan is stored. When and how to give an adrenaline autoinjector.

5.14 Further information

NSW Department of Education and Training Anaphylaxis information (including link to Anaphylaxis Guidelines for Schools) www.schools.nsw.edu.au/studentsupport/studenthealth/conditions/ anaphylaxis/index.php Student Health in NSW Public Schools: A summary and consolidation of policy www.det.nsw.edu.au/policies/student_serv/student_health/student _health/PD20040034.shtml NSW Health Anaphylaxis Education Program NSW Statewide www.health.nsw.gov.au/policies/ib/2009/pdf/IB2009_063.pdf Allergies and Anaphylaxis fact sheets www.health.nsw.gov.au/factsheets/general/allergies.html

5.15 Further information (continued)

Australasian Society of Clinical Immunology and Allergy (ASCIA)

Anaphylaxis resources (including ASCIA Action Plans) www.allergy.org.au/health-professionals/anaphylaxis-resources Anaphylaxis Australia - Patient support organisation www.allergyfacts.org.au A PDF version of this information is also available at www.allergy.org.au/patients/anaphylaxis-e-training-schools-andchildcare/etraining-resources