Allergies and Anaphylaxis

Recognition, response, and prevention of severe allergic reactions in school

Why this brief

Roughly 1 in 13 U.S. children has a food allergy, and about 40% of those have already had a severe allergic reaction. Most U.S. states require schools to maintain emergency epinephrine and have trained personnel to administer it; specific protocols vary widely. Paraprofessionals — especially those supporting students at lunch, on field trips, or in 1:1 settings — are often the closest adult when a reaction begins. Knowing what to look for and what to do is not optional.

This brief covers the categories of allergic reaction, recognition signs, response steps, the role of epinephrine, prevention practices, and the documentation that follows. It does not replace the training your district provides — and most districts that handle this well provide annual trained-staff PD on epinephrine administration plus general-staff awareness training.

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| This brief is general. The student's plan is specific.Any student known to have severe allergies should have a Food Allergy Action Plan (FAAP) or Anaphylaxis Action Plan in their file, signed by their physician and family. That plan tells you the specific allergens, signs to watch for, when and how to administer epinephrine, who to call, and what to do after. Read the plan before the day starts. If you can't find it, ask the school nurse — before, not during. |

1\. Types of allergic reactions

1.1 Mild reactions

Limited to skin or stomach symptoms; the student is uncomfortable but not in danger of immediate harm. Common signs:

Hives or red, raised welts in one area.

Itchy mouth, throat, or skin.

A few bumps or skin redness.

Mild stomach pain or nausea.

Sneezing or runny nose.

Mild reactions can sometimes progress. Watch carefully for the next 30–60 minutes; a reaction that started mild can become severe.

1.2 Severe reactions (anaphylaxis)

Anaphylaxis is a multi-system, life-threatening allergic reaction. It develops quickly — sometimes within minutes of exposure — and can cause death without prompt treatment. The defining feature is involvement of multiple body systems and/or symptoms affecting breathing, circulation, or consciousness.

If any of these signs are present, treat as anaphylaxis:

Trouble breathing — wheezing, gasping, persistent cough, tight throat, hoarseness.

Swelling — face, lips, eyes, tongue, or throat.

Skin signs across the body — widespread hives, redness, or pale color.

Vomiting, especially with skin or breathing symptoms.

Drop in blood pressure — pale, weak, lightheaded, dizzy, fainting.

Sudden behavior change — unusual sleepiness, confusion, sense of doom, agitation.

In young children: sudden refusal to eat, drooling, behavior change paired with any other sign.

1.3 Biphasic reactions

Some severe reactions resolve and then return — sometimes hours later — without further exposure. This is why students who receive epinephrine for anaphylaxis must be transported to an emergency room and observed, even if they appear to recover quickly.

2\. Epinephrine: the only first-line treatment

Epinephrine is the only medication that reverses anaphylaxis. Antihistamines (Benadryl) treat hives and itching but do not stop the airway, blood pressure, or systemic effects of anaphylaxis. Albuterol inhalers help asthma but not anaphylaxis. If a reaction looks severe, epinephrine is the answer; nothing else.

2.1 Forms of epinephrine

EpiPen and EpiPen Jr — auto-injector, intramuscular, most common in U.S. schools.

Auvi-Q — auto-injector with audible voice instructions.

Generic epinephrine auto-injector — same drug, fewer dollars.

Neffy — needle-free intranasal epinephrine, FDA approved 2024 for adults and adolescents (12+ years and 30 kg+).

Manual syringe epinephrine — used by trained nurses and EMS, not typical school use.

2.2 When to use it

If the student has a known severe allergy and shows any signs of anaphylaxis after possible exposure, use epinephrine. The Food Allergy Action Plan should specify the trigger criteria — most plans say to use epinephrine for any single severe symptom (trouble breathing, throat tightness, repeated vomiting, etc.) or any combination of two or more body systems.

There is no situation where giving epinephrine for a true reaction causes more harm than waiting. The risk-benefit is asymmetrical: too late is dangerous; too early is, at most, a brief racing heart.

2.3 Who can administer it

Authorization is governed by state law and district policy. Common patterns:

All 50 states allow school nurses to administer prescribed epinephrine.

Most states allow specifically trained, designated school personnel — often including paraprofessionals — to administer prescribed and stock epinephrine.

Most states have stock-epinephrine laws permitting schools to maintain unassigned epinephrine for emergencies in students without a known allergy.

The student or family may carry and self-administer the auto-injector if authorized in their plan.

A para should not administer epinephrine unless they have completed authorized training, are designated for that student or for stock administration, and the order is in place. If the student has an EpiPen but you're not designated, your job is to get the trained person to the student, not to use the device yourself.

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| Know the path before the reactionIf a student you support has a severe allergy: where is their epinephrine stored, who is trained to use it, what's in their action plan, what's the call protocol, and what happens after? You should be able to answer all five questions today, not in the moment. |

3\. Response steps

If you suspect anaphylaxis, the response is fast and follows a fixed sequence. Memorize this. Many state and district anaphylaxis trainings teach a similar protocol; specifics may vary slightly by district.

Stay with the student. Do not leave them alone.

Call for help. Use a runner, radio, intercom — get the school nurse and a designated trained adult to the student immediately.

Position the student. If conscious and not vomiting, lay flat with legs elevated. If breathing is difficult, sit upright. If vomiting or unconscious, recovery position (on their side).

Administer epinephrine — by the trained adult, per the action plan, in the outer mid-thigh, through clothing if needed.

Call 911 (or your district's equivalent). Even after epinephrine. Every anaphylaxis case requires emergency room evaluation because of biphasic reaction risk.

Note the time of administration and the time of onset.

Be prepared for a second dose — if symptoms have not improved 5–15 minutes after the first dose and EMS has not arrived, the action plan may authorize a second epinephrine dose. The trained adult administers.

Stay with the student until EMS arrives. Watch for breathing, color, and consciousness.

Notify the family — usually the school nurse or admin makes this call.

3.1 What NOT to do

Do not assume an oral antihistamine (Benadryl) is enough. If the criteria for epinephrine are met, give epinephrine first — antihistamine is not a substitute.

Do not wait to see if the reaction will improve on its own.

Do not stand the student up if blood pressure may be low.

Do not give the student food or water.

Do not assume the reaction is over after the first dose. ER evaluation is required.

4\. Prevention practices

4.1 Classroom and lunchroom

Know each student's allergens. Read the action plan.

Read labels. Many products contain hidden ingredients. "May contain" warnings are not optional information for severely allergic students.

No food sharing. Strict no-trade rules at lunch.

Hand washing — soap and water (not just hand sanitizer) before and after eating.

Clean shared surfaces (cafeteria tables, desks) before food activities.

Designated allergy-aware seating in cafeteria where appropriate.

Clear protocol for treats brought from home (many schools require pre-approval).

Coordination with art (some art supplies contain food proteins — playdough, finger paint, soaps).

Coordination with science (food in experiments).

Field trip planning includes allergy emergency supplies, EpiPens, action plans.

4.2 When the para is the food monitor

If you're the person watching the student eat — at lunch, at snack, on field trip — you're the front line. You are not necessarily preparing the food, but you are watching for cross-contact, sharing, and unexpected ingredients.

Know what the student is eating. Check the lunchbox if relevant; check the cafeteria menu against the allergens.

Watch for sharing among peers.

Have the action plan and emergency supplies physically with you on field trips.

Know where the EpiPen is at every moment, even if you're not the one to use it.

Know where the nearest phone is.

4.3 Bullying and stigma

Children with severe allergies are bullied at higher rates than peers, sometimes including "jokes" involving the allergen. This is dangerous, not playful. School policies generally treat allergen-based intimidation as a form of bullying. Surface concerns to the supervising teacher and admin.

5\. After a reaction — documentation

Every reaction, whether mild or severe, should be documented. The school nurse usually owns the formal record; the para is often the closest observer.

Time of onset of symptoms.

Symptoms observed, with progression.

Suspected exposure (food, ingredient, route — eaten, touched, airborne).

Treatments given (epinephrine — by whom, time; other medications; positioning).

Time 911 was called and time of EMS arrival.

Time family was notified and by whom.

Disposition (transported to ER, returned to class, etc.).

Action plan review — does anything need updating?

6\. Common pitfalls

Treating mild reactions as too minor to act on. A mild reaction requires watchful waiting; sometimes mild becomes severe.

Giving Benadryl and watching to see if it works before giving epinephrine. The right sequence is epinephrine first; antihistamine is not first-line.

Letting the student rest at school without ER transport after epinephrine. ER evaluation is required.

Storing the EpiPen somewhere remote ("in the office") for a student who has been advised to keep it close.

Allowing food sharing because "it's just one bite."

Forgetting the EpiPen on field trips. Without it, the school is choosing to be ill-prepared for a known risk.

Not training all staff who may be alone with the student. Emergencies happen at lunch, at recess, in the hallway, on the bus.

Treating allergy bullying as a peer issue rather than a safety issue.

Assuming a stable student no longer needs the protocol. Severe allergies can return without warning.

Letting expired epinephrine sit in the file. Auto-injectors expire; check the dates regularly.

7\. Resources

FARE (Food Allergy Research and Education) — foodallergy.org — Major U.S. nonprofit; school resources, action plan templates, training materials.

FARE — Food Allergy & Anaphylaxis Emergency Care Plan — foodallergy.org/resources — Standard action plan template.

CDC — Voluntary Guidelines for Managing Food Allergies in Schools — cdc.gov/healthyschools — Federal recommendations; foundational document.

AAAAI (American Academy of Allergy, Asthma, and Immunology) — aaaai.org — Professional clinical guidance.

National Association of School Nurses — Anaphylaxis position — nasn.org — School nursing standards on anaphylaxis.

Allergy & Asthma Network — allergyasthmanetwork.org — Patient-family advocacy.

Brief 09.04 — Medication Administration — this library — Cross-reference for state delegation rules.

Brief 09.07 — Asthma — this library — Many students have both.

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