Anaphylaxis is a severe, potentially life-threatening, allergic reaction treated by intra-muscular administration of adrenaline.

Adrenaline auto-injectors (AAIs) are prescribed to individuals at risk of anaphylaxis; these devices enable non healthcare professionals to administer potentially lifesaving adrenaline to patients experiencing an anaphylactic reaction.

Children and young people who are identified as being at risk from anaphylaxis are prescribed AAIs and are advised to have them available at all times. Unfortunately evidence suggests that children may not bring their AAI to school or that the AAI may be date expired.

Impact of severe allergy and anaphylaxis in schools

It is estimated that up to 8% of children in the UK have a food allergy[1].  Whilst most food allergies will present with mild to moderate symptoms, some will develop into an anaphylactic reaction. In the UK 17% of fatal allergic reactions in school age children occur whilst the child is at school[2]. This means that schools must take appropriate actions to reduce the risk of an allergic reaction.

Children and young people identified as being at risk of anaphylaxis are frequently prescribed an AAI. Whilst the majority of these children will respond to a single dose of adrenaline, some may require a further dose. Current guidance from MHRA is that all patients at risk of anaphylaxis should carry with them or have access to two AAIs at all times.

Legislation changes

Changes to legislation that came into effect on 1 October 2017 allow schools to purchase adrenaline auto-injectors without a prescription for the urgent treatment of anaphylaxis.

It is important to emphasise that whilst schools can hold stocks of AAI this is not be a requirement, it is simply a discretionary power. However the Children and Families Act 2014 requires school governing bodies to “make arrangements for supporting pupils at school with medical conditions”.

Schools who take appropriate steps to ensure they are able to support pupils suffering from anaphylaxis would be considered to be reasonably fulfilling the schools “duty of care”.

Practical implications

Making the supply- To make a supply the pharmacist will require a written request signed by the principal or head teacher, ideally on headed paper, that includes the following details:

• The name of the school for which the AAI is required
• The purpose for which the product is required
• The total quantity required

Download template requisition form

Pharmacists will then need to make an entry in the POM register to record all supplies of AAIs to schools. This entry should include the following details:

• The date the supply was made
• Name, quantity, formulation and strength of the product supplied
• Name and address of the person and school to whom the device was supplied
• The reason the supply was made
• It would be considered good practice to record the brand of device supplied

The pharmacy does not need to label the AAI before supplying the device.

How many AAIs does the school need?

The number of AAIs that the school needs will be determined by the number of children diagnosed with a severe allergy, the size and the layout of the school. Schools with more pupils or split over several sites will require more AAIs. The final number of devices should be sufficient to ensure that all allergic children are within easy access of an emergency AAI should they need to use it.

Which brand of AAI should the school order?

There are currently three different AAI available within the UK, Epipen, Jext and Emerade. Each AAI is available in different strengths and has differing methods of administration.

Guidance from the DoH advises that each school can decide which brand of AAI to stock, although schools are advised to hold stock of only one brand to minimise possible confusion relating to administration technique and training.

Where the majority of pupils use a particular brand of AAI it would be sensible for the school to hold this brand.

Irrespective of which brand the school chooses it is essential that the designated school staff are appropriately trained in using the device.

Which strength AAI should the school order?

AAIs are available within the UK in 150mcg, 300mcg or 500mcg strengths. Schools should ensure they are aware of the strength of the AAI prescribed for each pupil and ensure they hold an AAI in this strength.

In addition school staff responsible for administering adrenaline should have prompt access to details of which strength AAI should be used for each pupil.

The Resuscitation Council recommends that anaphylaxis is treated using the age-based criteria shown below:

• Children aged under 6 years: 150mcg adrenaline
• Children aged 6-12 years: 300mcg adrenaline
• Children aged 12 years and over: 300mcg or 500mcg adrenaline[3]

Where and how should the AAI be stored?

The AAI should be stored in a safe and secure central location, such as the school office or staff room. An AAI may be required at multiple locations. To ensure easy access in an emergency the AAI should not be locked away. The storage location chosen by the school should be known to all staff and should be an area that all staff have free access to at all times. The AAI should be kept out of the reach and sight of children.

Auto-injectors should be stored at ambient room temperature not exceeding 25˚C, protected from direct sunlight and extremes of temperature.

Emergency use AAIs should be kept separately from any child’s individual device and they should be clearly labelled to avoid confusion.

The anaphylaxis kit

The DoH guidance advises that schools should have an emergency anaphylaxis kit. The guidance advises that this kit should contain:

• One or more AAI,
• Instructions on how to use and store the device,
• Manufacturers information e.g. PIL,
• Checklist of AAI including details of batch number and expiry date including records of monthly kit checks
• Arrangements for replacing the AAI
• Register of pupils who can be administered the AAI
• Administration record

The school allergy policy should detail the responsibilities of school staff for maintaining the anaphylaxis kit. The DoH advise that at least two named members of staff should accept responsibility for checking each month that the AAI are present and in date, and that replacement injectors are obtained when the expiry dates approach.

Who can use the AAI?

The emergency AAI can only be used by children:

• Who have been either been prescribed an AAI for anaphylaxis or serious allergy or who have a care plan provided by a doctor recommending the use of an AAI (Allergy action plans can be downloaded from http://www.bsaci.org/about/pag-allergy-action-plans-for-children )
• Where written parental consent for the use of the emergency AAI has been received

Children who have been prescribed a specific brand of AAI can still use the emergency AAI if their own device is not available as it will help to relieve their symptoms and could save their life. As the method of administration differs for each AAI it would be prudent that the member of staff trained to administer the device undertakes the administration.

There should already be procedures in place to ensure schools are notified of children with specific health needs. This information can be used to compile a list of pupils identified as at risk of severe allergic reactions and prescribed an AAI. This register will be essential in larger schools and secondary schools where it would not be feasible for teachers to be aware of every child who suffers from a medical condition. Using the register to record receipt of parental consent for the use of an emergency AAI will enable staff to quickly check whether a child is able to use the device in an emergency.

Consideration should be given to where the relevant pupil list is located, options could include each designated member of staff trained to administer the AAI having a copy of the list, a copy could be kept in every classroom or a copy could be kept with each emergency AAI.

Schools may wish to consider allowing pupils to keep their AAIs with them as this will reduce delays in treatment, and allows for confirmation of consent without the need to check the register.

What training is required for school staff?

Any staff member can volunteer to take on the responsibility of administering adrenaline in an emergency but they cannot be forced to do so. Schools will need to ensure that there are sufficient numbers of staff trained to ensure there is no delay in pupils receiving treatment. The exact number will depend upon the size and layout of the school, the number of pupils and the number of children at risk of anaphylaxis.

The DoH advice for schools emphasises that severe anaphylaxis is an extremely time critical situation and delays in administering adrenaline have been associated with fatal outcomes, it is therefore appropriate for as many staff as possible to be trained to administer AAI.

Pharmacists are in an ideal position to be able to provide appropriate training on recognising the symptoms of anaphylaxis and the administration of adrenaline. Provision of this training will enable pharmacists to build an on-going professional relationship with their local school and teaching staff.

Pharmacists can also advise schools on the information and resources available on the AAI manufacturer websites such as online training and trainer devices that can be used to practice administration.

Each teacher should:

• Be able to recognise the symptoms of an allergic reaction
• Understand how quickly anaphylaxis can progress to a life-threatening reaction
• Appreciate the need to administer adrenaline without delay
• Be aware of the school’s anaphylaxis policy
• Understand how to check if a child is on the register of pupils who can access the AAI
• Be aware of how to access the AAI according to the schools policy
• Know who the designated members of staff are and how to access their help.
• Be able to respond to requests for help from designated members of staff

In addition to the above designated or trained members of staff should be able to:

• Recognise when emergency action is necessary
• Administer the AAI according to the manufacturer’s instructions
• Recognise the need to call 999 for all cases of anaphylaxis, and provide appropriate care whilst waiting for the ambulance to arrive
• Make appropriate records of allergic reactions

What is the correct procedure for the care of a pupil following an anaphylactic reaction?

Confirmed or suspected anaphylaxis should always be treated as a medical emergency. In all cases of anaphylaxis or suspected anaphylaxis an ambulance should be called and “anaphylaxis” stated.

DoH guidelines advise that where a second dose of adrenaline is administered the school should make a second 999 call to confirm an ambulance has been despatched.

Schools should contact the pupil’s parents at the earliest opportunity. The hospital discharge documentation will be sent to the pupil’s GP to inform them of the reaction.

What are the record keeping requirements for schools?

Each administration of an AAI should be recorded to show who the adrenaline was administered to, when and where it was administered, which brand and strength was administered and by whom. “Supporting pupils” legislation requires that these records are in writing.

Schools should also keep records of the expiry dates of the stock AAIs. Pharmacists can signpost schools to the expiry date alert services operated by the AAI manufacturers.

How to dispose of a used AAI

Pharmacists are ideally placed to advise school staff that each AAI is single use and once it has been used it cannot be re-used and must be disposed of.

Used AAIs can be given to ambulance paramedics on arrival or disposed of in a pre-ordered sharps bin that can be collected by the local council.

Are there any implications over individual liability and insurance?

Schools should already have in place appropriate levels of insurance to cover staff, including liability cover, for the administration of medication in schools.  Department of Health guidance advises that local authorities may provide schools who are administering adrenaline with appropriate indemnity cover; however schools should confirm this cover directly with the local authority or relevant department. An anaphylaxis or allergy policy that details how and when an AAI should be used will help to protect staff by ensuring they are aware of how and when to use the auto-injectors safely