Anaphylaxis and Allergy – NSW Anaphylaxis Education Program, Sydney Children’s Hospitals Network

The Supporting Children’s Health Workshop was delivered by the NSW Department of Education in partnership with health professionals from the Sydney Children’s Hospitals Network, Red Nose Australia and CPR Kids.

The Anaphylaxis and Allergy video is the second of five presentations from the Workshop. This video provides guidance on managing, recognising and responding to anaphylaxis and allergy in children, including the use of Action Plans. The video also includes practical information on the National Quality Framework requirements relating to your medical conditions policy, including developing a risk-minimisation plan.

By viewing this presentations you will:

  • understand the importance of risk management in caring for children with allergies
  • learn the signs and symptoms of allergic reactions
  • learn the correct way to give an adrenaline auto-injector(EpiPen).

Regulation 136 of the National Regulations provides requirements relating to current approved first aid qualification, anaphylaxis management training, and emergency asthma management training for centre-based and family day care services.

This video is not an approved qualification or training, and viewing this video will not satisfy the requirements of regulation 136. Services must ensure they continue to meet these requirements by completing qualifications and training approved by ACECQA.

Video on anaphylaxis and allergy. Presented by Kylie Hollinshead and Kathryn Mulligan from the Sydney Children’s Hospitals Network.

 

Good morning everyone. Can I just get a raise of hand here who has ever seen an allergic reaction? If you've seen an allergic reaction can you just put your hand in the air? Good, a good number of people here. Excellent. Ok, not that it's excellent that you've seen allergic reactions, but some of the stuff we go through today you might be able to think back on how you managed that incident or if you would do things differently next time. And for those of you who haven't seen an allergic reaction you'll get some information today about what to do if you do see one.

Now my name is Kylie Hollinshead and this is my colleague Kathryn Mulligan. We are both clinical nurse specialists at the NSW Anaphylaxis Education Program. We're a recognised training body and we offer an advice and consultative service. So we're based at the children's hospital at Westmead and we're going to talk to you today about allergy management, about what strategies you can put in place for children at risk with allergies. You can look at signs and symptoms and we'll have some images to show you what different types of allergic reactions might look like. What we're really going to focus on is some action plans and we've put some action plans on the tables so we'll go through those and later on we'll have a turn with the EpiPen. I know some of you probably have done this in the past but we're going to go through it again and add some helpful hints if you ever have to give an EpiPen to one of the children you're looking after.

So, the list up there is the common causes of allergic reactions in Australia. As you can see it's quite a long list but the one thing that you really have to look out for is foods. For people under 30 it's the most common cause of anaphylaxis in Australia. For children who are under one, it's about one in ten who will have a food hypersensitivity. That decreases when they're at school to about five percent so that's one in 20, so you're thinking about at least one child in every classroom. This image here is the cause of most of the allergic reactions or anaphylaxis, again in Australia because it depends on where you live in the world to what foods are more likely to cause anaphylaxis.

So these ones up here cause about 90 percent of allergic reactions and the ones on the top row, they're the ones you often hear about in the media: the tree nuts, peanuts, and seafood, and often children won't grow out of these, they'll have those lifelong. The ones on the bottom, egg, milk, wheat, soy, and not so much sesame, but the first four tend to be more common in younger children and they are often grown out of. So you might have some children in your service who are allergic to these and they may eventually grow out of them, however there are some who will not grow out of these allergies. So you'll have to think about how you're going to manage children with allergies to foods and these are called essential foods.

So, like every health condition, you have to manage risk, and risk management is one of the most important parts of caring for children who have allergies. We can't eliminate risk but we can minimise risk and that's what the aim of this discussion is, to give you tips on how to minimise risk. When we're looking at risk, there is a difference between casual contact, so that's contact when you get an allergen on your skin, compared to when you are in the room with someone who's ingested or eating something you're allergic to. There's a big difference between that casual contact and the contact that could cause an allergic reaction.

To have anaphylaxis, you actually need to ingest the food you're allergic to. So that means touching the mucus membrane, so basically the lips or beyond the lips. So you can have peanut butter on the hands or the skin of someone who's highly peanut allergic and they probably would just get a little bit of skin irritation. When you wash the peanut butter off their skin, nothing happens, the irritation goes away, everything settles down. The problem though starts when we have the peanut butter for instance or milk on the skin, and it gets put in the mouth. So it can be from chewing fingers, it can be from biting pens, chewing nails; in the early childhood setting, it is from children putting objects like toys in their mouth. So that's an important consideration when you're looking at risk management.

Now everybody in the early childhood and care services, even OSHCs, have a responsibility. That includes the centre, the child themselves and the family. So if you have a child that is enrolled in your service that identifies as having an allergy or they're at risk of anaphylaxis, there needs to be some preparation. So there needs to be some staff training. The staff need to be aware of how to recognise an allergic reaction and how to manage an allergic reaction. Individual health care plans are vital and this is where the planning, preparation and risk management strategies come in. That's where there's a discussion between the family and the service about what can be done to minimise risk for the child that's involved.

Now communication, I can't stress this enough and you would probably already have a good idea about this, but if there's good communication between the family and the service, things tend to go a lot nicer. You're more able to ring the family and say, look we've got this activity coming up, how can we keep your child safe but include them? So communication is absolutely key and we find that when the individual healthcare plan is done, there's much better communication. There's a lot more to and fro'ing about how we're going to keep the child safe, how we're going to include the child and parents also feel more comfortable to say, look his asthma is playing up so can you keep an eye on him. Communication is absolutely key.

In terms of staff training, keeping in mind this is best practice, it's recommended there is face to face training every two years. Now this is one of those things where you have to have some face to face training because the use of an EpiPen is not natural, it's not something you can do without practice. It takes practice, and it takes practice so you become familiar with the EpiPen and how to use it, where to use it, how to restrain a child, and all those kind of things, so face to face training is recommended every two years. There's also ASCIA e-training which is more of the theory component of the training. That can be done yearly, and can be done in the alternate years when you don't have the face to face training. It can also be done when you have new staff, so you can say as part of your induction, can you do this e-training? Or if you just want to enrol and refresh your knowledge, you can pop onto the e-training site and do the e-training.

When the child starts out the service, the family needs to provide the service with the prescribed EpiPen and also the action plan. So it's a prescribed action plan that goes with the prescription EpiPen and it's the red and blue one you can see there, or if they haven't been prescribed an EpiPen, they should have that green and blue action plan you can see on the screen there and that's an ASCIA action plan for allergic reactions. So that is for children who aren't considered to be at risk of anaphylaxis, they may have mild to moderate allergic reactions but unfortunately we can never 100% guarantee that a child's not going to have anaphylaxis, so it is very very similar to the ASCIA action plan for anaphylaxis and we'll touch on that a bit more later.

All staff should be aware of a lot of what we are going to cover today but you know, what are allergies and anaphylaxis? Risk management strategies, what strategies are in place in your service for that child? And strategies can be different between each individual child, so you might have five children in a service with five different allergies. Maybe a few of them are the same, but each risk management strategy needs to be tailored to that child. You can't have a blanket risk management strategy for all children with allergies because the risks do differ. You need to know which of the children are at risk of anaphylaxis, but I want you to keep in mind that children can have their first anaphylaxis or their first allergic reaction in your care. We know that about 20% of reactions that happen in Department of Education schools happen to children who have never had a history of allergic reaction. So you have to be a little bit open-minded when you see a child with an allergic reaction. Don't just pigeon-hole them and say, that child doesn't have an EpiPen action plan, it can't be an allergic reaction. You need to look at every child and every child’s symptoms on face value and treat them accordingly.

You need to know how to recognise an allergic reaction, and you need to know how to use an auto-injector, so that's where your face to face training comes in, your e-training and also today, because we will go through it with you today. You need to know where the EpiPens or the auto-injectors are kept and where the actions plans for anaphylaxis are kept, and when to give an auto injector. When do you just watch the child and call the parents or when do you give an EpiPen? So it is important to actually know when the right time to give an EpiPen is.

The storage of EpiPens is really important. The EpiPens should be ideally in a central location that's easy to access and is unlocked. We don't want you having to fish around for keys, unlocking doors, and unlocking cupboards to get your hands on an EpiPen. In our experience, most centres have their EpiPen stash in the office which is usually a fairly central place, or it might be in the kitchen. That's a centre by centre decision but it needs to be easy to access, not locked, and not locked in cupboards either; it's not just the doors, it's the cupboards as well. The EpiPens which are prescription EpiPens need to be labelled. If it's a prescription EpiPen, it needs the child's name on it, and if it's a general use or a first aid EpiPen, sometimes it helps to just have ‘first aid’ or ‘general use’ on those ones as well. They need to be out of the reach of children. We want you guys as grown-ups to have easy access, but we don't want kids to have easy access because EpiPens are nice and bright and colourful, and sometimes they get played with.

The EpiPen should always be stored with their ASCIA action plan for anaphylaxis. So if it's a prescribed EpiPen it should have a copy of the child's red and blue action plan. If it's a general use or first aid EpiPen, the general use action plan should go with it. You should not have access to an EpiPen without an action plan because they are like best friends, they need to go together all the time. All staff should know where the EpiPens are stored, not just the room staff but the kitchen staff and the administration staff. All staff should know where those EpiPens are kept because even people who may not be on the front line with the children might be called in to be an assistant. So they might have to go and get the EpiPen, they might have to make a phone call, or they might have to go and bring the ambulance in. Everybody has potentially got a role in the management of an allergic reaction or anaphylaxis.

So just touching on those individual health care plans, I'm sure you're all very familiar with them but I just want to reiterate how important they are. The kind of things you're talking about in terms of allergy and anaphylaxis are things like, the individual health care plan and the action plan, a copy of the action plan should be with the individual health care plan. It should have things like avoidance strategies, working through what that child's going to be doing for activities, so incursions, excursions and things like that. Celebration days, how are you going to keep this child included and safe? Day to day, meal time, how are we going to keep this child safe? And having those strategies listed down so that everybody is on the same page and everybody is aware of what should be done.

Awareness raising, so you might put in a newsletter or an email to families saying, we have some children here at the centre or at the service who have allergies and we ask you to be aware of what you pack in the child's lunch. Or saying, this is our strategy for managing that, and building awareness so that other families are aware of what's going on in the centre. We don't want the child identified by name, so we don't want, little Johnny has a milk allergy so this is what we're going to do about it. It's just a general, there's children in this service who have allergies, and we need to be aware of it. Bullying can sometimes happen with allergies and there have been cases where kids have been threatened with what they're allergic to and it can be really frightening, so it's about having policies in place so that, if that is identified to be happening, that it is managed and managed swiftly. But often it's about awareness. When kids actually are aware of how serious food allergies can be, they're more likely to be more empathic about it.

The individual health care plan should have staff training details, communication strategies so you know, saying, this is how we're going to communicate with the family, with the other children in the service, with the child themselves, and it's important. The individual health care plan should be reviewed every year. So initially when the child starts at the service it might be quite a big meeting about, this is how we're going to keep the child safe, and it's looking at the year to come. And then every year, it needs to be at least reviewed, because some things will change as the child gets older.

There are a couple of documents that can help you in developing individual health care planning and strategies. The document there on the left are examples of risk minimisation for schools, pre-schools and child care services, so there's some really practical strategies in there. That's available on the ASCIA website and the document on the right is for Department of Education services, and there's another document that you can refer to.

So we've talked a lot about food and we do focus a lot on foods, because food is going to be the main allergen that you'll come across with this services that you're providing. A lot of people think that if it's a food allergy, the easiest thing for us to do is ban the food. Now in some cases that might be ok. If you're providing all the food and no outside food is coming into your centre, it's much easier to police. However if you're bringing food in from outside the centre, it's more difficult to police. I think a lot of centres or a lot of services will say, look, we don't like nuts and we don't like egg, and you know, that's ok. People can be aware of that but you have to think about other people bringing food into the services and whether they're going to make mistakes. And people do make mistakes, we know in schools that even though people are asked not to bring foods in, they still come into schools. So what we want is not to develop a false sense of complacency, so like a surety that ok, there's never going to be an allergic reaction here because we don't have any nuts and we don't have any eggs. Because what can happen is a child can be allergic to any food.

So you remember the slide up here, it was the nine most common food allergens, and it's ok to not have some foods that are not essential, but think about how you're going to manage when a child that comes into your service is allergic to either milk, cow's milk, wheat or soy. You can't ask families not to bring these foods in, but you cannot provide a full nutritious diet for children without including these essential foods. So this is where you have to think about other strategies, not just blanket bans, other strategies for how we are going to keep the children safe. As Kath said earlier, you cannot completely eliminate risk, but you can minimise it. And as she said earlier, with the individual health care plans, communication is really a good start. So from that communication between families and yourselves, you'll get ideas from them. They know their child better than anyone, they've already been doing it before they're going to start with you, and they know how they manage it, so they can offer a lot of information and really helpful resources for you.

So as I said earlier, minimise exposure. Bans are not going to work so minimising exposure is key. And what we would think about is, don't just think about meal times, you want to think about wider activities, so craft activities, incursions, excursions, and what you're doing, because even then sometimes those allergens can slip into those things. You also need to have age appropriate strategies when you're having special occasions or normal things so with the bottom line near that age, implementing appropriate avoidance strategies. Sometimes if you're having birthday parties the service might provide their own cake if you have a celebration, and then you can make sure there's no allergens in that cake. However if that's not the way it goes, you can ask the family of the child with the allergies to bring in a safe treat, have that there and then they can have something special while the other kids have something special. They're not left out and they're still included in these things.

So at meal times, again, this is your really high risk areas around food allergy, and so what we really advocate for is not sharing food. I know we're trying to teach children to share things, share toys, let's share, be kind, but when it comes to food we really need to say, don't share your food. Now we follow up in Department of Education schools with anaphylaxis and incidents that occur there, and we do know a good percentage of anaphylaxis is caused by children sharing food with their friends. So not sharing food is a really strong way of keeping children safe. You also need to think about sharing drink bottles, utensils or, I haven't finished but you can share my food, and scrape it off onto another child's plate. And having utensils labelled and keeping everyone clear of whose is whose, so that no one is sharing cups or plates.

So we really want the right food to get to the right child. Now this sounds basic but we do know that people are serving children with allergies their allergenic food, so the right child and the right food and putting processes in place so that the risk of error happening is minimised. So close supervision at meal times, not leaving the children alone to eat, making sure people are supervised, and not isolating that child with the allergies, not having them sitting on the far corner of the room to keep them safe. Meal times are a really social thing and this is where children learn so much as you know, so they need to be included but kept safe.

Keeping surfaces clean so using placemats to try and contain food miss, moving the children away and washing the area really well afterwards. Now you can just use soap and warm water to do that, you don't need any high powered disinfectants or cleaning products or such like that, good old fashioned soap and water with thorough cleaning once the children have moved away, especially if they come back to do other things in that area because if you think about wheat particles on the ground after sandwiches or crackers they need to be really cleaned up if a child with wheat allergies is going to be playing in that area. And hand washing... sorry, keeping surfaces clean, yep, and hand washing.

So, hand washing is really important it sounds really basic but it's a really strong way of keeping people safe. If you've been touching foods that a child's allergic to just go and wash your hands with soap and water, that gets rid of those food proteins and you're safe to then handle that other person. Ok. The person with the allergies. Hand sanitiser does not work. Hand sanitiser is really good for cleaning off bacteria and killing bacteria and viruses on your hand. It will not wash away food proteins. So all you're doing is rubbing the food protein around in your hand, they are still there. So you need to mechanically wash them away with running water and soap.

So in the kitchen, especially if you are providing all the meals in your service you need to think about what food you're ordering and making sure you are supplied with the ingredients of all your products. So if a product comes into your service and it doesn't have an ingredients list, your supplier must supply you with the ingredients list so you can check that the products are safe for the children. Ok, and then if the supplier changes the product, it still might be the same thing as such but it's a different company, you again will need to check those ingredients list and get them from the supplier to check that the food is still safe. There are some minor variations in different food products so sometimes they some contain no allergens and where others may contain some allergens.

Standardising all your recipes is another way to keep safe, so that way it doesn't matter who is in the kitchen the food is going to be produced in the same way the same products are going to be used in the same amounts and there's no variations. What can happen is someone might turn up to the kitchen and go oh I'll just spice up this meal a little bit and add something else and then that throws everything out because that they've just thrown in something might be allergenic to the child with food allergies. So keeping those recipes standardised and everyone following them. And again, if something has to be substituted that is checked thoroughly by a few people to make sure it is still safe. And what you can do with the standardised recipes is create a food matrix. So the National Allergy Strategy has done some food allergy training and there's some bookmarks on your table and that talks a little bit more about these food matrixes and what that does is you can say well these are the meals we supply over the two weeks and then they're the main allergens that are in this meal this meal and this meal. So you mark it out in a grid so you know which foods are safe for which child and that can be really helpful.

Storage is also important making sure food is covered so you don't get spills and slips and that sort of thing. So especially if you've got a child who has allergies to milk you don't want their food stored down at the bottom because if something spills on the top shelf you're going to get dripping down and it could contaminate their food. So keeping those children their food on the upper shelves keeping them covered and well labelled is very important and especially keeping things like soy milk and cow’s milk away from each other and stored in separate locations so people know which is which so when you're in a hurry and you grab something it's not going to be the wrong thing.

Some services will say well when that child's in the service we're just not going to serve that allergen, so we're just not going to have I don't know, wheat that day and that's ok and that might be something your service does and if that's something you'd like to do that's fine however if that child's in your service for five days then you're going to have to bring wheat in at some stage so yes, again it's going back to food bans they can be helpful in some ways but they're not going to solve all of your problems. And cross contamination that is another thing so making sure your utensils are clean, not using the same spoon to stir something and then stirring something else with it or serving some meals and then serving other meals. Cross contamination is a huge problem so even a dirty knife can be enough in some sensitised children to cause an allergic reaction if a little bit of that say peanut butter is put onto their own sandwich which has their Vegemite on it. So really careful care in the kitchen of not having cross contamination.

So meal times again I'll say right food right child. And the way your service would do this you need to figure out what is going to work best for you. You might have two people checking that yes this is the food for this child and it's safe, it's labelled, again, it's up to staff numbers and how best you can manage it. Another hint with that is have your permanent staff serve the child with the food allergies so they know that child better and with casual staff coming and they're often learning new things or they're not that familiar with the place so try and get your permanent staff to serve the child with the food allergies.

Again, washing your hands and getting the children to wash their hands too, having the child with the food allergies wash their hands before they eat and that way if they've touched anything that's been contaminated they've washed that off their hands before they're putting food in their mouth and serving themselves. Washing their hands afterwards of course I know services do that anyway. That stops that risk of cross contamination of other toys, books and other things that are in that service. Supervision again I can't stress that strongly enough because of impulse control, people are likely, children are likely to grab things, they take from other people's plates and also they want to share they want to be kind and they can see that their friend doesn't have the same thing that they have so you can have some of mine, so really close supervision and no sharing.

So insects may be a problem, they are more common in older children but there are some strategies that you can put in place with that. So it's trying to minimise that risk of areas that are higher risk. So if you've got flowering bushes near your service and there's lots of bees around, encouraging the children to play elsewhere while that's happening and when you're purchasing plants for the service if you're ever doing that making sure you get some that don't attract quite so many insects and bees, bees especially. Making sure children wear appropriate clothing and footwear, we're very sunsafe and have hats and that on, but when you're out, especially with a child with allergies to insects, ensure they've got appropriate footwear and clothing on.

Now, water play, lovely thing, but before you go out and do that with the children checking that there's no bees or wasps in the water is really important if you've got a child with an insect allergy, same thing with swimming pools and grassed areas, that sort of thing, especially if there's a lot of clover around in the springtime. Open drink containers, now I know most water bottles are covered but you still might have some cups in your service so checking the cups before the child drinks out of it is another risk management strategy. And some of you may work in areas where ticks are a problem and what we would suggest is if you've been outside, specially in bushy areas to shake off clothing before you go back into the classroom if you're going back inside because sometimes there could be ticks on the clothing you just shake them off and that way it lessens the likelihood of a tick getting on the skin.

So when you leave a service on an excursion or you have outside companies come in, the risk of accidental exposure will increase again, so having careful risk management planning around those things as well. So talking about who is going to be responsible for first aid kits, knowing who's going on the excursion or who's coming in and what they're allergic to and whether that's going to be a high risk situation. So planning, planning, planning.

Ok, so as a minimum you need to know, as staff members, who's carrying the EpiPens and action plans and other medication, who's going to be responsible for that, and who here knows how to use it and how to give it. What avoidance strategies you're going to put in place, so say you're having farm animals coming in and what farm produce do they feed those animals if there's wheat with a wheat allergic child is that something you'll need to think about. Same thing with chickens and hatching chickens and eggs, how are you going to manage that and there are resources around to help you try and plan for things like that. And do this prior to the activity. Give families some sort of notice if you can and that way it gets them prepared, there's a whole lot of anxiety around allergies so if families are better prepared and get advanced notice about what's happening then they can prepare and you can have that communication with them to put plans in place to keep their children safe.

So like I mentioned before, the children themselves do have a responsibility in their own health and it is very age appropriate, you will see if you came to our allergy clinics you would see that children very young can still tell you a little bit about their allergies. So very young children we would ask that they don't take food off somebody they don't know or generally their parents but we get parents to train the children to not take food from strangers and even just saying something simple like I have soy allergy, or I can't eat that because I have an allergy. That one sentence is a really powerful tool that that child can use to stop people kind of offering food. So the children have responsibilities themselves. We get our parents in the hospital and any kind of parents we come across with children with allergies to discourage their child from sharing food.

And as Kylie said before it is really hard when we're trying to get children to be friendly and share their toys, not to share their food but there has to be a distinction because those foods, sharing food is a dangerous practise for kids with allergies. And it includes drink bottles and straws. So I usually suggest that the kids that I come across have a two step drink bottle so that it's not just a straw sticking out of a drink bottle they have to actually unscrew a lid or they have to flip a lid so that there's an extra step in the routine of getting a drink out of the drink bottle. We ask that kids don't pick food up off the floor. I teach my children that and that's why we have a dog to do that for us. It's so that the kids don't pick up something that they don't know what it is and put it in their mouth. Washing hands after eating, the kids still need to do that and that's I'm sure in your service that's something you encourage the children to do anyway but for kids with food allergies they need to do it before and after they eat. Not with sanitiser.

The other and this can be the most challenging aspect of it, is getting children to tell somebody when they're feeling sick. You might have children in your service who have communication problems or they may be shy, they may feel shame. We have had incidents where kids have not told teachers that they're having allergic reactions because they did the wrong thing, they shared food and they knew they did the wrong thing so they didn't want to tell anybody and get help because they didn't want to get in trouble. So it's about opening communication making sure that these children know that it's really important that they get help if they're feeling unwell. Things like storyboards can be really helpful with this role plays, so sitting down with a child and say how can you get help if you feel sick and giving them strategies to work with.

So we have a case study so little Ruby, she is an 11 month old baby, she's had anaphylaxis to infant formula the first time she was given it at home at four months. She now drinks soy infant formula and she's also egg and nut allergic. So she's got egg, nut and milk allergy. So as you can imagine her parents are very anxious so parental anxiety I'm sure you've come across it in various forms with various different things but parental anxiety is real and it's a big, it can be a big barrier. So parents need to be reassured that their child is going to be as safe as possible in your service. And that's why sometimes you need to get help.

So these, Ruby's parents are very anxious that the service that Ruby was going into had very little experience with milk allergy they'd had kids with nut allergy before and egg allergy but not with the milk. Our program's asked to assist the parents and we met with the parents and the service and we helped to develop an individual health care plan. The parents supplied Ruby's EpiPen junior and the action plan and on that action plan was those in that circled bit there that's what Ruby needs to avoid so she needs avoid strictly avoid cows milk, egg and nuts. The parents also supplied antihistamine sorry which is that little bottle there. So, tag team.

So as you can imagine challenges are quite a lot when you're trying to manage a milk allergy. So we went in the kitchen and luckily the service already had standardised recipes and the people and the staff in the kitchen were really keen to get as much information as they could about how to best manage this when they were producing and providing the food for the service. So the standardised recipes were in place they did have a full time cook there as well so it wasn't that there was a number of staff they had to train however I did say it needed to be we did put in that if you've got casual people coming in they needed the same sort of training and be aware of the same processes of what needed to be put in place so I know some services will have staff from the floor come in and fill in if the cook is away so those people need to be up to scratch on what strategies are in the kitchen. We advise that the staff do in the kitchen do their e-training so the food allergy e-training it's free training that's online and we also advise to devise that allergy matrix so that box with all the ticks on it down the bottom that is what an allergy matrix looks like so it's got all the foods to the one side, it's got the list of the nine most common allergens that cause anaphylaxis and then you just tick what is included in which meal.

Again we talked about the storage and having Ruby's food stored at the top of the fridge labelled, covered, with her name on it, and making sure that it was her meals were prepared first before the other children or all the allergy meals were served first or created first covered then labelled then the other foods served and then hand washing so again really pressing that hand washing and using clean utensils for that cross contamination risk so we needed to make sure that there was allocated staff there.

So in the room, it was being communication was a big one as well so making sure all staff knew who Ruby was, knew what her allergens were, knew what day she came knew who her parents were and talked with the families about how to manage it and feel. So the family could feel confident that she was going to be looked after. Her EpiPen was in an unlocked cupboard with her action plan installed with it but the service also took copies of the action plan and had it in other places as well around the service maintaining privacy but so staff could access it should they needed to.

The centre also had two general use EpiPens so they had Ruby's own personal EpiPen but they also had their first aid kit and they had their general use action plan which was kept with those general use EpiPens. We also had strict labelling of utensils so cups bottles plates. Ruby had her own coloured plates and also her own coloured place mats and that sort of distinguished her in a way that was kind of fun but it sort of highlighted the point that this child had allergies and we needed to be careful with that.

Craft, we talked about what products were to be used with craft, so it's not just containers like washed out yoghurt containers and those sort of things that were risky. But sometimes especially if a child had a wheat allergy you had to look at your glues and your paints and your Playdohs so not just rubbish containers that you've sometimes used in craft but other products that you've used in craft. So it was having a look to see if there were any milk products within the craft products in their service.

So having a close supervision we talked about meal times and Ruby was going to be because she was so little she was 11 months old she was actually going to have a dedicated high chair that sat with the other kids it was a low high low chair but they still had the tray and that kept her surface clean and only she used that because she was attending the service a number of days, they were able to do that so she had her own chair that would be kept clean and had it so she could join the other children but it was still a safe space for her.

Other parents were asked not to bring food from outside the service so to try and keep things clean and when it came to milk and milk bottles and other children having their bottles before their rest time and that, what we did with this service is have an allocated area. I think it's up there, there we go... So all the children who had milk bottles or milk out a cup that needed it and that was part of the routine they would have this in a specific spot where Ruby wasn't allowed to play. Because we all know that milk drips and it drops around and makes a mess and you can't possibly manage to clean up every single speck so to try and minimise risk of exposure to Ruby the milk was kept in one place and Ruby wasn't allowed to play in that particular area. It was only a small area of the service, but she could play everywhere else and it just was to contain those milk drops.

So action plans, we've talked already a number of times about action plans and I know some people think of action plans as we get it from the family we've ticked the box, right we've done it. But what staff need to recognise is they are really good tools for you to use in an allergic reaction. That is your go to guide, it is going to tell you how to recognise the allergic reaction and exactly what to do. So it's not just a matter of ticking the box, yes, we've got it from the person it's going to tell us what we need to avoid. It's going to help you should you ever have a face with an allergic reaction.

And we're lucky in Australia there's only one type of ASCIA action plan there's 3 variations of that, but it's only one action plan. Places like the States there's over 50. So you know it's standardised care. So the first one there on the left the red and blue one is the personal use action plan so that's given to a person who's been prescribed an EpiPen by a specialist. The middle action plan the green and blue action plan is for a person who still has allergies but they have not been prescribed an EpiPen. But they still are known to have allergies and the orange and blue one is for people who are not known to have allergies and so it's for people who have anaphylaxis for the first time and so this needs to be stored in first aid kits or in the sick bay so people can use it to help that person who's never had an allergic reaction before. These are available online through the ASCIA website and they do need to be filled in by a medical doctor. So there's a lot of things you need to put in place when it comes to allergy management so you really want it confirmed by a medical officer and that's why they need to complete these forms here.

We often say that these need to be done we recommend an action plan be done every time a person gets a new prescription for an EpiPen so about every year sometimes it goes slightly over but especially with the younger ones it's important they do it round about on a yearly basis because often children will outgrow allergies or things will change so it's good to have it done on around about a yearly basis. And always store them with those EpiPens. Now we're lucky to live in such a diverse society and so ASCIA have done, have done over 20 translations of the action plans.

So they're actually called something different they're called first aid for anaphylaxis but the information is the same so if you have families who may benefit from some of these you can go on to the website and print them off. If you've got staff who might also benefit from them as well you can print them off and they're readily available on the ASCIA website. There's also other resources like how to give an EpiPen and a fact sheet on anaphylaxis.

So if you've been prescribed risk of... been diagnosed at risk of anaphylaxis in Australia you will get two EpiPens on the PBS, ok? And there's only one type of adrenaline auto injector in Australia which is the EpiPen so when using those two interchangeably and there's two doses, the green EpiPen junior and that's for people between 10 and 20 kg, ok and those are the ones you might most likely see in an early childhood service and for those early childhood services that is the type of EpiPen you would need in a first aid kit. The other EpiPen is for anyone over 20kg so it doesn't matter if they're 5 or 55 if you're over 20kg you're going to get the EpiPen which is yellow. And so for those sort of older children school age children first aid kits that's the EpiPen we would recommend to go in there. They are, so only two on the PBS and if they have a health care card they will come at a cheaper price. A service or a family can buy more if they want but they are very expensive so if you're asking families to buy multiple adrenaline auto injectors multiple EpiPens then please have that in mind because they are very expensive and can be quite a financial burden for families.

This is what a real EpiPen will look like. The two ends you really need to worry about is the blue end which is the safety cap and the orange end which is the needle. You can check the expiry date but I'd recommend you do that prior to an emergency so when you're checking your stock and making sure things are fine make sure you know what your expiry dates are the last thing you want to be doing during an emergency is quickly checking your EpiPen to see if it's in date and find that it's expired. You can use an expired EpiPen if that's the only EpiPen you have but again it's not best practise so planning ahead and seeing what your expiry date is. There is also instructions on the back, so we always say to families take a big deep breath, read the instructions and then go and give the EpiPen. And storage it needs to be available to where that person is. So if you're taking the children out of the service and they're just going maybe across the road for some reason, that EpiPen needs to go with them it needs to be available to them at all times.

So anaphylaxis it's a big scary word between us Kylie and I have seen many many anaphylaxis and dealt with many many anaphylaxis so we're good people to be talking about it aren't we. Yeah. So what is anaphylaxis? Anaphylaxis is the most severe form of allergic reaction so an allergic reaction is a spectrum so you can have a mild to moderate allergic reaction or you can have a severe allergic reaction. And a severe allergic reaction is called anaphylaxis. Usually symptoms start within minutes of exposure to the allergen but that's not always the case so there is actually about a two hour window period where you might see symptoms start so a lot of people think that if it doesn't happen within 10 minutes of exposure it's not going to happen. The window period is about two hours, ok so if you have a child that you think has been exposed their allergen they need to be watched for a couple of hours.

Once symptoms start they generally tend to be quite rapid so once symptoms start it can progress quite quickly and they can be quite unwell. With anaphylaxis you don't always get mild to moderate symptoms beforehand so hives tend to be synonymous with allergic reactions and if the child doesn't have any outside kind of visual signs of allergic reaction it can still be an allergic reaction. So I think about 50% of the anaphylaxis that I've dealt with there were no mild to moderate symptoms before the anaphylaxis developed so you do need to be aware of that. Anaphylaxis is potentially life threatening and it must always always always always be treated as a medical emergency.

We do like the allergies and the management plans to be diagnosed and kind of a plan put in place by a doctor and that's not doctor Google. You want sound evidence based plans put in place for these children. Now anaphylaxis is a bit like an avalanche. The key to managing anaphylaxis really well is to try and stop it at the top of the mountain. So if you can imagine the snow starting to release from the top of the mountain, we want to stop it up there rather than trying to stop, stop the avalanche at the bottom of the mountain. Once the momentum started and things have deteriorated. It's a bit, you can think of it as a snowball try to stop it at the top of the mountain rather than at the bottom.

Now when we're looking at the management for anaphylaxis there are four risk factors which we .... there's four risk factors that have been linked to fatal anaphylaxis's. So remember that anaphylaxis can be fatal. There was a study done by some doctors including our head of department they looked at the fatalities from anaphylaxis and they found four common threads that went through those fatalities. The first one was delayed or absent emergency treatment. So it doesn't take brain surgeon apparently... ok so you don't have to be. No big surprise that if you have an emergency situation and you don't get emergency help, the outcomes aren't going to be great. So we know that delayed administration of the EpiPen can lead to poor outcomes or no EpiPen or adrenaline being administered at all can lead to, can lead to poor outcomes. So EpiPens should be given in a timely fashion as soon as anaphylaxis is identified the EpiPen or the adrenaline needs to be administered.

Upright postures, so, you'll see us go on about this quite a bit, in the action plan when we go through the action plan 'cos the action plan is built around these four kind of risk factors. Upright posture can lead to catastrophic drop in blood pressure so you will see us from the beginning of an allergic reaction right through to when the ambulance drives off that that child is not put in an upright position and I'm in an upright position and so are all of you. You are sitting with your legs hanging and that's considered an upright posture. What do you think is complicating the situation when you are sitting with your legs hanging. What's making it harder for your blood to be pumped around your body? No physicists in the room? Pardon? Gravity. Exactly. So when you're standing and when you're sitting with your legs hanging, gravity is making it harder for your blood to get your heart to get blood from your feet to your heart. So upright posture needs to be avoided. If you have someone having an allergic reaction who has asthma particularly uncontrolled asthma and food allergy they're at higher risk of fatal anaphylaxis simply because their airways are not healthy to start with you add swelling from anaphylaxis and their airways can close up sooner than someone who has nice healthy robust airways that aren't really reactive.

And the last one which is relevant for the OSHCs, is teens and young adults eating away from home and I'm not going to go too much into that but it's basically because young people don't make great decision about the food they put in their mouth. So like I said before some allergic reactions will be mild to moderate so that's where they stop so on that spectrum you might have a mild to moderate reaction and it might stop and not progress to anything. Excellent, they're our favourite kind of allergic reactions. Some reactions start with a mild to moderate symptom so you get that warm up you get that idea that something is happening to this child. And you get time to put you get lots of kind of build up and you're more prepared for anaphylaxis should it start. So you can have the mild to moderate reactions symptoms before and then anaphylaxis develops.

Sometimes though, the first sign of trouble is actually signs of anaphylaxis so you might find that the child has exposure to their allergen and the first sign of trouble that you see is a wheeze and persistent cough. You don't always get those mild to moderate symptoms beforehand you don't always get warning that something's happening. So when we're looking at the signs and symptoms of allergic reaction, this table is really helpful so it is colour coded kind of the same as the blue and red action plan so on the left side you can see the mild to moderate symptoms and they're on the blue side now the symptoms that you can the mild to moderate symptoms can be categorised into skin or the gastrointestinal symptoms so the skin symptoms are hives or swelling.

So that's swelling of the skin. So we're talking about swelling of the lips, swelling of the eyes, swelling of the ears, it's skin swelling essentially. The swelling of the lips is not a life threatening symptom because no matter how swollen your lips are as long as you can open your mouth and there's no swelling inside your mouth you can breathe. It's a mild to moderate symptom. Now you can see vomiting and abdominal pain in food allergy is a mild to moderate sign so it makes sense if you've got something your allergic to sitting in your tummy it's breaking down you get a localised allergic reaction it makes sense you're going get a tummy ache or you might even vomit because your body is going nah eject this is wrong I don't like it get rid of it.

Just a bit of pub trivia for you if you have someone who has been stung by an insect and they develop abdominal pain and vomiting that's actually anaphylaxis. So that's different it doesn't really make sense if you're bitten on your foot that you develop abdominal pain and vomiting and what this means if you've been stung by something and then you develop those symptoms that means that your body has gone into the fight flight or freeze response the blood is shunted away from your digestive system which is essentially a non-vital process when you're in an emergency situation and you will actually get abdominal pain and vomiting so that's an important distinction to make it's not the only symptom of insect anaphylaxis but it makes it different to food anaphylaxis. The way it presents.

So on the right side you can see there's severe signs. So severe symptoms or the signs of anaphylaxis involve the respiratory system or the cardiovascular system so the breathing or the circulation. So you can develop difficult or noisy breathing, swelling of the tongue so that's different to swelling of the lips can you all see the difference between swelling of the lips and swelling of the tongue because swelling of your tongue can actually block your airway so it's a life threatening symptom. Swelling or tightness in the throat again can block the airway. Difficulty talking or hoarse voice so these symptoms indicate that there's swelling around the vocal cords and there's swelling in the airway or the throat. And wheeze or persistent cough so that is the respiratory symptom of anaphylaxis. Cardio vascular symptoms, low blood pressure persistent dizziness or collapse and young children can actually present as pale and floppy.

All right. So we're going to just go through a bit of a practical sessions spice it up a bit as it were. So, we have case study number 2 so this is Sam. We don't actually have a picture of Sam but he's a little three year old boy he is milk and egg allergic, he's been prescribed an EpiPen junior and an action plan junior which has been brought in by the parents into the centre. There is an individual health care plan in place but on this day during rest time you notice that Sam seems to be restless and scratching. You take Sam into the next room so he doesn't disturb the other children and where the light's better. You notice that he has some hives and he's developing some swelling around his eye.

So I want you to get out the red and blue action plans that you have on the table in front of you so make sure it's the red and blue one. This is a personal ASCIA action plan for anaphylaxis. What does swelling around his eye and hive indicate. So find where they are. Can anyone find those symptoms on the action plan? Mild to moderate, yep. So it's an allergic reaction. So the important thing is that you look for that you can identify signs of allergic reaction so the first thing you do is you say well this child's showing signs of a swelling eye and hives. This is an allergic reaction so what do you need to send for? What do you need. If you identified a child with an allergic reaction what do you need to get your hands on? Pardon? Yep. So remember that Sam has a prescribed EpiPen and an action plan so you need to get your hands on his EpiPen and his action plan. And his antihistamine. So the antihistamine is usually kept in the same pack with the action plan and the EpiPen.

So there are two places on the action plans to identify symptoms. So I got you to have a look before but that is one place to find the symptoms and allergic reactions so that's talking about the mild to moderate symptoms. And then that second box there is where you will find the symptoms of anaphylaxis. So what you actually need to do if you have a child who you identify as having an allergic reaction is find where on that action plan the symptoms sit. Have a look in the mild to moderate box and have a look in the anaphylaxis box and see if where the symptoms lie. So you've had a look and you've found that the hives and swelling are in the blue box there on the action plan so it's a mild, he's displaying a mild to moderate reaction at this point. Can everyone find it? Yes. Swelling in the eye and hives?

So here's some pictures of a mild to moderate reaction now you can see how frightening. It looks frightening doesn't it, if you had a child that presented with these symptoms you'd probably be quite anxious about it. And parents get very very worried about these symptoms because it's a real in your face this child's having an allergic reaction kind of thing. They're actually mild to moderate symptoms, they're not life-threatening symptoms. Swelling of the eye, he might not be able to see a while but the swelling will go down and he'll be fine. Swelling of the lips looks terrible but as long as there's no swelling inside the mouth then it's mild to moderate.

So what do we do for mild to moderate reaction. So if you look underneath the box the symptoms for mild to moderate allergic reaction you'll see the action for a mild to moderate reaction. So there's a couple of points there about tick allergy, we won't worry about that for today. It says stay with the person and call for help so make sure that you don't leave that child alone. It says locate adrenaline auto injector so get their EpiPen out and have it ready. So this doesn't mean give the EpiPen at this point it means have it available so that you don't have to go riffling through cupboards or... you've got it there ready as soon as anaphylaxis should or should anaphylaxis present. It then says give medications if prescribed. So if there is antihistamines written on the action plan, this action plan is a medical document and if it is written on the action plan you can give the antihistamine and the parents should be supplying the antihistamine that is written on the action plan. And it then says phone the family and the emergency contact so you work your way through the action plan.

All the while though you need to watch for signs of anaphylaxis so remembering that anaphylaxis can develop after mild to moderate symptoms. Anaphylaxis can also present without those signs of anaphylaxis. Just a word about antihistamines. Antihistamines are for the child's comfort only. So they can get rid of a sick tummy. They can take away the itch in their mouth. Antihistamines do not stop anaphylaxis and they do not stop the progress of anaphylaxis. So antihistamines should never ever be given instead of an EpiPen. You need to give the EpiPen if you identify signs of anaphylaxis. Antihistamines are purely for the child's to make them feel a little bit less uncomfortable from the symptoms of mild to moderate allergic reaction.

So you have Sam sitting there. He is sitting on the lounge with another staff member ok, you've given him the dose of the antihistamine as it's written on his action plan and his parents have been called. Ok, and you think ok, we're alright here and then he vomits. And shortly he goes pale and floppy. And he just is lying there. What do those symptoms indicate? Right. Anaphylaxis. Pale and floppy in young children is a sign of anaphylaxis. And you can see right at the top of that box there where we've got it circled any one sign. So it's not like you need to tick off and get a certain amount, any one sign of anaphylaxis is then diagnosed as anaphylaxis.

And so you've got some signs here of a young child now the sign with the boy he's holding his throat so it could be saying that he's got a tight throat he might be having trouble breathing it might become noisy. He's leaning forward looking anxious so that is definitely symptoms of anaphylaxis. And our little girl there she has got swollen lips you can see those in the picture there that is not the main problem you can see she is pale and floppy, she is lying there while we're doing her blood pressure and children don't like to lie there when they're have their blood pressure taken they don't like it very much. So she is pale and floppy so her behaviour is very very concerning.

So what do you do? You follow the action plan and if you look at the actions below the signs of anaphylaxis it steps you through exactly what you need to do. And so it's been done because we know this is good management and the best management for anaphylaxis. Number one positioning. So we've talked about that earlier and the reasons positioning is so important. But people still get it wrong which is why it's number one and there's even pictures there to help you realise show you what positioning is best. Now if little kids they will quite often want to be held want to be comforted they're crying they might be upset and the most natural response is to pick them up and hold them. But you can see their legs are down so they are still upright. So we do not recommend hold children like this if they are having signs of anaphylaxis. You get down with them on the floor or on the couch so they can maintain that position either lying flat or their legs outstretched in front of them.

Number two on that action plan if you read it down there it says give adrenaline auto-injector, ok so that is the EpiPen we don't want to delay that's why it's number two. Note the time when you give it and one of the points we'd just like to say there too is see the thumb is down the way it's being held so when you have an EpiPen and we do have some training devices on the table for you to practise with, that thumb is on your fingers it's not at the end of the EpiPen that way you don't accidentally inject yourself. So number two for actions for anaphylaxis is give the adrenaline auto-injector. Where are you going to give it? Now this slide shows X marks the spot. It's like a treasure map that is where we're going and it's called the outer mid-thigh. So where we're talking about here is about halfway between the knee and the hip. Ok. Not the very top of the leg, not the very side, but the outer mid-thigh. And when you're giving an EpiPen to a child you really must ensure that they're not going to move so you're going to have to hold them. So Kath do you want to grab the EpiPen? And we'll get Kathryn to demonstrate first of how to give an EpiPen there's three simple steps. Ok so first as I said before you're going to form a fist around the EpiPen and pull off the blue safety release, hold the leg still that is so important. Hold the leg still and place the orange end against the outer mid-thigh. Push down hard until a click is heard or felt and hold in place for three seconds then remove the EpiPen.

Ok, I'd like you to all grab the EpiPens that you have on the table there, I know you've probably done this before but practise just really reinforces how to give it. So hold your own legs, make sure you hold your knee and it sounds stupid because it's your leg but it's a really important kind of a memory trigger to make you remember that the holding the leg's really important. Grab it hold it hold the EpiPen in a fist, what's the rhyme? Anyone know? Blue to the sky, orange to the thigh. Safety cap off... Hold it against your leg, now you don't need to swing and jab, I don't want to see any swinging and jabbing that's a very not Australian thing. So it needs to be, you need to put the EpiPen on the muscle where you want it to go. Ok. So you put it on the muscle and you press[clicks] and you count to what? Three. One, two, three. Then you take it away.

Kylie

Just show them how to reset.

Kathryn

Now to reset, you just squeeze the orange, the side of the orange thing in and push nice and gently. The reason I said it's not an Australian thing is because you will see some EpiPen videos from America and they show this kind of stuff. It's not what we do here, we're nice and controlled, ok, we put the EpiPen where we want the EpiPen to go. How many doses does an EpiPen have? One. Which is why we're getting you to practise with training devices, we don't want you to learn on the job we want you to be sure of what you're doing if you're ever having to give a real one. Alright.

So this slide here shows some holding positions and we'll just talk through them as well no child wants to get a needle, no one likes giving an EpiPen and even if they seem pale and floppy and not moving you still need to make sure you're keeping those legs immobilised and those arms out of the way because they may wake up and knock it away that source of discomfort they will knock it away. So I know people might be able to see but I'll need Kath to lie down in a position, sit with their legs that way. Legs that way. Yep, ok. So as with those pictures there I'm coming to her from this side now I know people you look after are much smaller than an adult but these are still some hints you can use.

So I'm coming to her from this way because this is my dominant hand and that way that leaves my left hand free to hold that knee. And then I'm going to use my knees to lock her knees in so you see I've got like a vice and I'm holding them secure using my own legs and my hand. She has got her hands behind because she's a nice and compliant person, ok, but you may need to get another staff member to help comfort give a cuddle like they're doing in that picture there or another thing you can do is pop their hands on their shoulders, ok, just to keep them out of the way. Because I'm coming from this side I can also use my body to go in front. So I'm going to take off the blue safety cap I'm holding that leg in place and then coming through... [click] one, two, three [click] and giving the EpiPen. Ok. I'm not crossing my arms over I'm trying to do it the best way most uncomplicated way I can. Any questions with that? Ok. And as you can see, when I'm coming to give the EpiPen I'm pulling the EpiPen towards me. It's a much more smoother approach than trying to do it like this. Ok. So pulling it towards you in that sort of motion.

Ok, so we've talked about the EpiPen, it's a very important point that you know that there are two that if you're in an emergency situation you have a child that needs an EpiPen you do not need parental consent. Ok. So you don't need to ring the parents first and say is it ok. You need to give the EpiPen and follow the action plan and let the parents know as soon as you can afterwards but you don't need consent and that also goes you don't need the consent from the ambulance to give an EpiPen and this is probably more going to be relevant if it's a child who doesn't have a history of anaphylaxis but you don't need to ask permission. If you think it's anaphylaxis you give the EpiPen and then you follow the action plan.

So we've given the EpiPen it then says phone an ambulance so notice it's number three. Ok. So you give the EpiPen you then phone the ambulance Ah. Forgot about a little magic. So phone the ambulance. Number four says phone the family and this order is very important that you don't, that you don't do it in a different order. Often it happens all at once because you've got somebody dealing with the child or a couple of people dealing with the child and then somebody else is calling the ambulance and the parents that's great but you need to do it in this order.

Number five, further adrenaline doses may be given if no response after five minutes, so you note the time you give the first EpiPen and if five minutes later that child is showing no signs of improvement you can give another one if you have access to one and in a service you normally have at least one general use EpiPen. Number six says transfer to hospital. So this is not negotiable it's not only if the child is still unwell. Sometimes adrenaline works really well and the child looks fine and fit and healthy when the ambulance arrives they're not actually out of the woods yet. They need to go to hospital and be put on a stretcher not walked or carried to the ambulance in an upright position and need to go on the stretcher of the ambulance and into the ambulance. And they need four hours of observation. That's so they can be medically monitored but also so they can have an EpiPen script renewed.

Now this is going to really hit home when Sarah talks to you later about CPR, but the one, two, three, four, five, six of the action for anaphylaxis is just like your doctor's ABCD in CPR. You wouldn't stop at, you wouldn't do CPR and go oh doctors A we'll just stop at B we won't do C, D. You don't do that, you work your way systematically through the doctor's ABC. With anaphylaxis management it's exactly the same you work your way systematically from one to six and you don't skip any of those points.

There are other things that you need be aware of on that action plan so there's a reminder in the middle there that says mild to moderate allergic reactions do not always precede anaphylaxis. There is a box at the bottom that talks about asthma and anaphylaxis. If you're unsure if it's asthma or anaphylaxis you give the EpiPen. It's as simple as that. Ok. If you're unsure give the EpiPen. This is I think is probably the most important line on the whole action plan. If in doubt, give the auto-injector. If you're not sure if it's a mild to moderate allergic reaction or if it's anaphylaxis so you're not sure if it's asthma anaphylaxis give the EpiPen you're not going to do any harm by giving someone an EpiPen who's not actually having anaphylaxis. It's only adrenaline I am up to here with it right now I'm public speaking. So it's only adrenaline we make it in our own body it's nothing to be frightened off. Ok. And you've all experienced it when you're nervous you get shaky you're going oh my goodness. If you've ever had a near miss in a car, had to slam on the brakes you get the oh my goodness kind of feeling. That's adrenaline. It's completely harmless. So please don't be afraid to give an EpiPen.

And it also says commence CPR and it's down the bottom there above the asthma box but is says commence CPR anytime if the person's unresponsive and not breathing normally. CPR at times is part of the treatment for anaphylaxis. Not very often but you need to be aware that if the child's unresponsive not breathing normally you have to do CPR as well you have to start the doctor's ABC and I'll leave that to Sarah.

Now if you have a child with a green action plan so they don't have a prescribed EpiPen in the service but they do have this green action plan you treat them exactly the same. The only difference is you can see on their number two on that green action plan it says give adrenaline epinephrine auto-injector if available. Now if your service has a general use EpiPen that's what you go for. You give one if there is one available. If there isn't one available for whatever reason you go to number three and you keep a very close eye on that child and wait for the ambulance.

We've alluded a couple of times before to the fact that sometimes kids have their first reactions in a childcare service or in a service. And for those children the management is again exactly the same as with the other kids with the other action plans. The difference is what action plan you follow and what EpiPen you use. So you would use the general use or the first aid action plan and use the first aid EpiPen or the first aid... First aid action... General use or first aid EpiPen and the first aid or general use action plan. Exactly the same. You follow it. And you'll see the information's the same.

Alright, nearly finished guys. There's a lot of resources out there for you to use in how to manage and part of those resources are those action plans which are available freely on the ASCIA website and that is on the top of the action plans. Now this is our brochure, we left a few on the table there for people now you can ring us and say hey this is what we've got can you please give us advice on how we manage this or we're going to do this excursion and we're kind of thinking we're going to do this what do you think about it. Or if you've got families who are really asking you to do some unusual things and you're not quite sure you can ring us for advice and see what we would recommend. So we are a free service so please help yourself to one of those brochures.

We can also provide anaphylaxis training there is a cost to that and again you could look on the website or contact us if you need to. We are evidence based practice so we are endorsed as a recommended training provider and that's because we really look at what's the most recent evidence on managing and allergies and anaphylaxis and how we can do that well in the community and education and care services. We also follow up on anaphylaxis episodes in Department of Education schools so we hear a lot about what's going on in the school community.

So here are a couple of websites as well so I've talked about ASCIA a lot so that's the Australian Society of Clinical Immunology and Allergy. And that is the peak professional body in Australia. All the information you find on that is evidence based, research based, and it's factual information. So there's a lot of fact sheets on there, there's like I said you can get the action plans but there is a lot of information and if you've got questions you could search their website to see if you can find information on that. Allergy and Anaphylaxis Australia is a consumer group. It's a national consumer group and again they have very very good resources on there. One of their resources if you're hatching chickens in your service and what to do with a child with egg allergy so there's those sort of things if you want resources about around that.

And of course the ASCIA e-training so that is just your anaphylaxis training that you can do online for free to update your knowledge on how to manage allergies. This is all about allergens, it's the food allergy training that's been developed by the National Allergy Strategy. So it was designed initially for restaurants and other food services but it's very very relevant for education and care services who do have kitchen and are providing food because some of the information on there really is very sound advice and it gives you good strategies to minimise the risk of exposure with allergens. And again that's free and they've just released a second component which talks about camps and that sort of thing.

So there's always more information coming out and more resources being developed for managing allergies the best way we can. So what we want you to take home from today is that prevention and planning is important. You can never completely eliminate risk but you can certainly try and minimise it and try to plan things in advance instead of making up, reacting to being proactive and not reaction is a way to really help the children and the families attending the services. Please remember anaphylaxis can be life threatening so it must always be treated as a medical emergency and there are those resources and one of the key ones which we've talked about a lot is that action plan, if you're managing an allergic reaction or anaphylaxis you're key resource there is that action plan. You follow that you're doing very well.

Any questions? So that question there was with the EpiPen on the earlier slide. It did have one to five in the brackets beside it. It's actually from 10 to 20 kilos, the EpiPen junior and sometimes it's actually prescribed for some children under 10 kilos and that's done by an immunologist so, yeah, it's more done on weight so even though there might be some children under one with an EpiPen junior...

Audience

So for the general first aid...

Kylie

For the general... yep

Audience

[inaudible]... than five children like a nine month old would you...

Kylie

So in your first aid kit we would recommend you have your EpiPen junior if you've got the younger children in your service.

Kathryn

If they're having their first episode in your care, we would suggest you and they don't have prescribed EpiPen and they are under 10 kilos, we would suggest that you follow the direction of ambulance dispatch officer. If they're a lot smaller like if they're very small.

Audience

In regards to a child who has a mild to moderate reaction, when calling the family, specially when it's a first time do we have to tell them to go to hospital for monitoring? Because some families who have never had a child have reaction won't take it seriously. So what do we say in early childhood centre to tell the families do they go to a GP do they go to a hospital what would we say that they need to do?

Kylie

That's a really great questions and what you could do is... if you are able to, and Kath can correct me in that is talk to them about what the signs of anaphylaxis are and that they need to be continuing to monitor their child for at least two hours after that exposure and if you can print off or provide them with that general use action plan even if it's black and white copied to take home and saying these are the signs you look for if anything like that happens call an ambulance. A lot of families they might just take their child to the GP anyway and that's probably for a first reaction you probably want some medical intervention anyway.

Kathryn

And also make sure you tell the family what happened leading up to that allergic reaction. So what did they eat, what activities were they doing because it can help doctors figure out what the trigger was.

Audience

In the case of an emergency can you provide an auto-injector from Sam to new child or do you keep that EpiPen for Sam and not have an EpiPen for new child.

Kathryn

So the fact is that if you don't give someone an EpiPen who needs an EpiPen they may not make it. People can answer but from our point of view if there's an EpiPen there the great thing about services is that you can access general use EpiPens so you should have one in your service and if that's there, then use that. If not then it would be a real shame if someone were to die and there was the kind of antidote sitting there. So we would say you would use someone else's EpiPen if that's all you had and then you do everything you can to replace that ASAP.

Kylie

And it would need to contact that family's who's child's EpiPen you used to let them know that this is what's happened and that their child is now in the service without an EpiPen and then they would have to decide. So you might get some fallout from that so again you would have to think how you would manage that as a centre but that is why we recommend the first aid kit EpiPen so you're not faced with...

Kathryn

And they are well justified, those general use EpiPens are absolutely invaluable and we know that from our follow-ups with schools that they are used and they are used a lot.

Audience

Sorry just a quick one. In regards to administering an EpiPen if the child's very distressed and sort of. I've been told that during anaphylaxis you're trying to keep them calm so they're not getting more worked up and you've used the EpiPen and they're trying to run away and you're really trying to restrain them but they're getting more more worked up. Is it ok to sort of pick them up and hold them elevated above like what was in that picture or is that unsafe for dropping and ....

Kylie

It's a really good point and it has been one which has recently come up with us how do you keep them in that position after the EpiPen's given they're really just stressed and that's when your distractions can come in whether you can try to read them a book show them an iPad or something like that. If you're trying to... if you do need to carry them try and maintain that position of their legs outstretched.

So trying to manage whether you need a couple of staff to do that but it's really you'll have to really think outside the square of how am I going to distract this child how am I going to, you know, they're scared, they're not thinking properly they've just had an awful experience how are we going to manage to try and keep them safe and not just let them run around so great question, but yeah, if you need to move them trying to keep them in that position maybe move them up onto a couch if they're not happy on the floor but try and maintain that position, no sudden standing or moving them around.

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