Table 2.

Summary of Recommendations for Managing Food Allergic Reactions in Schools

Recommendation	Strength of recommendation	Certainty of evidence	Specific considerations for inner-city schools
Food allergy training, allergy action plans, and site-wide protocols
1. Suggest that schools implement training for teachers and other personnel in the prevention, recognition, and treatment of food allergic reactions.	Conditional	Very low	Requires budget and resources for training. Requires access to quality educational materials.
2. Suggest that schools require all parents of students with diagnosed food allergy to submit an up-to-date Emergency Action Plan.	Conditional	Very low	Requires communication between schools and parents. Consider barriers to referrals to and follow-up with an Allergist.
3. Suggest that schools implement site-wide protocols for management of suspected food allergic reactions in individuals with no Emergency Action Plan on file.	Conditional	Very low	Important for inner-city schools, in which food allergy may be underdiagnosed by health care providers or underreported by families. Requires budget, resources, training, and bureaucratic support to develop and implement protocols.
Epinephrine vs other treatments for allergic reactions
4. Suggest that school personnel use epinephrine only when they suspect someone is experiencing anaphylaxis, rather than use epinephrine as the first universal treatment for all suspected allergic reactions.	Conditional	Very low	Requires budget, resources, training, and bureaucratic support to develop and implement protocols.
5. Suggest that school personnel do not preemptively administer epinephrine in cases when no signs or symptoms of an allergic reaction have developed, even if a student has eaten a food to which they have a known allergy or history of anaphylaxis.	Conditional	Very low	Requires budget and resources for training.
Stocking unassigned epinephrine autoinjectors
6. Suggest that schools stock unassigned epinephrine autoinjectors on site, instead of requiring students with allergy to submit personal autoinjectors to be stored on site.	Conditional	Very low	Requires access to unassigned epinephrine autoinjectors. Overcomes barriers by increasing access to epinephrine.
Site-wide food prohibitions and allergen-restricted zones
7. Suggest that schools do not prohibit specific foods site-wide (eg, nut-free schools).	Conditional	Very low	Requires budget, resources, and bureaucratic support to change existing policies. Requires education of students and school personnel to promote the safety of students with food allergy. Important to ensure access to allergen-free school meals.
8. Suggest that schools do not establish allergen-restricted zones (eg, peanut-free classrooms, milk-free tables), except in limited special circumstances.	Conditional	Very low	Requires budget, resources, and bureaucratic support to change existing policies. Requires education of students and school personnel to promote the safety of students with food allergy.

NOTE. Modified from practice guidelines developed by Waserman et al.⁵