Sometimes allergies seem a popular joke. Teenagers are allergic to mornings.
Loony headteachers ban peanut butter and conkers. Would-be witty householders put up plaques saying, "We got rid of the kids... the cat was allergic." So are schools and families over-reacting when they find the subject of allergy distinctly unfunny?
A quarter of all children have hay fever at some time in their lives. One child in 10 has eczema. One in 50 has a food allergy. One in 70 has a potentially fatal allergy to nuts. When South Birmingham primary health care trust drew up a list of seriously allergic children in local schools eight years ago, 19 names were on it. Today, says South Birmingham nurse adviser Chris Hale, the total is 790.
Theories about why so many more children have allergies today vary from over-clean houses to over-adulterated food. Certainly, our raised awareness of allergy means fewer allergic children go unnoticed. But when "being allergic" can mean being a bit excitable after consuming three fizzy drinks, is it time for a dose of scepticism?
After all, the number of allergy-related deaths is tiny - between 1990 and 2000, eight of Britain's 13 million under-15s died from an allergic reaction: four of them to milk, one to peanuts. One fatality is always one too many. But how can schools and society balance a duty of care to the minority without the debilitating effect of everyone living in fear?
WHAT IS AN ALLERGY?
Part of the solution to this dilemma is a clear definition of allergy.
Allergy and intolerance are not the same thing. Children who have a food intolerance - perhaps to food colourings or yeast - may become hyperactive or have digestive difficulties if they eat food containing these substances. The most serious food intolerance is coeliac disease - sensitivity to gluten - which can lead to tiredness, restricted growth and anaemia if not well managed. Children with this condition avoid eating cereal, bread and pasta, but their reaction is not potentially fatal, and it is not allergic.
An allergic reaction occurs when the immune system believes a substance (called the allergen or trigger) is harmful and creates an abnormally large amount of antibodies to deal with it. These chemicals then cause the allergic symptoms: usually dry skin, watery eyes, sneezing, itching and so on.
The most common allergens are milk, eggs, kiwi fruit, seafood, grass and tree pollen, animals, (particularly cats and dogs, but also birds, rabbits and horses), the house dust mite, wasp stings and insect bites, mould and fungi spores. Less common triggers are latex, legumes (beans and seeds) and nuts.
Most allergic reactions are localised and small. But in some cases the body's immune system goes into overdrive. A rush of antibodies causes blood vessels to leak, bronchial and facial tissues to swell, and blood pressure to fall dramatically. This reaction is called anaphylactic shock. It is rare but unpredictable. If not treated fast, it can be fatal.
A mildly allergic child will cough or sneeze. Their eyes may run; they may have a localised rash. Even children with allergic asthma, provided their asthma is under control (see TES Extra for Special Needs, April 2004), are safe if they show no other symptoms.
The difficulty for schools is that the symptoms of a severe allergic reaction may not immediately seem dramatic. If every adult in a school knows nothing else about allergies, say campaigners, they should memorise the following list. Once these start, a child can deteriorate from completely healthy to very sick in about five minutes.
SEVERE ALLERGIC SYMPTOMS
* swelling of the throat andor mouth
* difficulty in swallowing or speaking
* generalised flushing of the skin
* sudden weakness or floppiness
* stomach pain, nausea and vomiting
* nettle rash (hives) anywhere on the body
* alterations in heart rate; rapid or slow pulse
* a sense of something dreadful about to happen
* collapse and unconsciousness
Mild allergic reactions can be treated by removing the child from the allergen or setting up a physical barrier (children with hay fever may find dark glasses help) and by using antihistamine medicine or inhalers.
Children with eczema should be kept away from radiators, because heat will make their itching skin worse. They may need both antihistamine medicine and emollient or steroid creams, sometimes in large quantities.
Over-sevens can probably apply their own cream, says the charity Eczema UK; younger children may need help. Some eczema is so severe that if the child goes through the school day without additional cream their skin may crack and bleed. The same child can have mild eczema one day and severe the next: a severe outbreak will probably mean poor sleep. Since some antihistamines cause drowsiness, children with allergies are often sleepy or miss school altogether.
Many more children will need help for sleepiness or itching than will ever need it for anaphylactic shock. And yet, understandably and rightly, says Chris Hale, it is for the emergency scenario that schools want her training and help.
The child with a severe reaction needs an injection of adrenaline to relax the lung muscles and stimulate the heartbeat - sometimes before an ambulance can arrive. With an EpiPen, giving the injection is quite a simple procedure.
USING AN EPIPEN
"Eight years ago an EpiPen in school was a real issue. Once we went in with trainer pens and showed people how to use them, that changed," says Hale.
The EpiPen is simply pressed against the child's leg with a slight jabbing motion. It delivers a preloaded dose that, unless the child has a heart condition, will do no harm even if the suspected allergic reaction turns out not to be severe after all. If a child shows no improvement five to 10 minutes after an EpiPen is administered, another dose can safely be given.
The Anaphylaxis Campaign produces a video that demonstrates both a child with allergic symptoms and an EpiPen in use - see resources.
Managing EpiPens has also become easier since they became more common, says child and family nurse Sue Clarke, who trains staff in Cambridgeshire on allergy issues.
Training generally takes around an hour, and most local education authorities offer legal indemnity to staff administering them, provided they receive training from an approved trainer every 12 months.
Clarke says that children with suspected anaphylactic shock should not be moved. That means schools need to think carefully about how many pens they need and where to keep them. Over 10s often carry their own but even then schools may want a back-up always accessible in a permanently-staffed office, not locked away. If the school is spread over a large site additional pens may be needed in several buildings.
Some lessons are more likely to trigger allergies than others: pollens in PE, sand, clay or craft materials in early years settings, and art and design later on; foods in food technology. Pets can be an issue in the classroom, though they are easily avoided outdoors.
But the biggest headache is lunchtime. Younger children, even if warned not to share or accept food, are at risk of spillages of milk or crumbs of peanut butter sandwich. Older ones, particularly teenagers, may feel the loss of status in refusing a chip makes eating it worth the risk.
Schools need to train their lunchtime staff, particularly to deal quickly with spillages of milk, but most of all to look out for allergic symptoms in at-risk children, says Sue Clarke.
Some schools ban nuts; others simply move the child with the nuts (not the allergic child) to another table. When children go on day or residential trips, parents need to be shown menus in advance, so they can provide alternative food if necessary.
The same preventative planning applies to birthday and end of term parties.
"We ask parents to provide their children with sweets to keep in the classroom for treats. Then if another child brings something in for a birthday, the teacher doesn't have to look at the label and make a judgement about whether it's all right for the child to eat, and the child isn't left out," says Chris Hale.
Older children can feel the sting of this separateness powerfully, particularly if they also look different, says Margaret Cox, chief executive of Eczema UK. "What you look like and can wear is an issue if you are one of the unlucky 30 per cent stuck with this wretched condition. It can be a tough time."
Children can feel stifled by self-protection or the protectiveness of others - or in some cases can be the butt of cruelty. Allergy UK knows of playground incidents where peanuts were thrown at allergic children to try to provoke a reaction.
"I think if children have been unfortunate enough to have a life-threatening reaction, they grow up very quickly," says Chris Hale. "We have nursery-age children who say to their teachers, I'm not sure I can eat that. They become very wary outside the home about what's safe for them."
A recent Southampton university study showed some peanut-allergic children were scared of dying even if they just knew peanuts were nearby. They were more worried than they need be, says researcher Dr Jonathan Hourihane. "As long as children are aware, they don't need to be so frightened."
TRAINING AND PROTOCOLS
Awareness and planning hold the balance between over and under-reaction to allergy. If schools know what to look for and what to do, and they know they know, then they can be confident of doing it should an emergency arise.
That confidence starts with good communication between the school and primary health care trust, says Chris Hale. In Birmingham, the hospital allergy clinic contacts her every time a child with allergies is diagnosed on her patch. She then contacts the school, just in case the parents, fearing stigma or uncertain of the school's reaction, fail to do so.
When children move to secondary school, the training and support system moves with them, though not all secondary schools use it. "Every member of staff has to know the symptoms," says Sue Clarke. "It's not enough when schools just train first aiders. Children are going to be with their teachers, not the first aiders."
Chris Hale says good schools create simple and effective systems: individual plans for each child, drawn up in consultation with parents, that detail known allergens; a note in the primary school class register so supply teachers identify allergic children; a medical needs noticeboard in the staffroom; a strict emergency protocol in which an ambulance is called, a member of staff deputed to ensure its easy access, and there is a rule that the child goes in the ambulance even if apparently recovered, in case of a relapse.
"It's all about planning. Once you have a system in place then it's not unmanageable, and it's very easy when you get more children in school with the same kind of problem. It's getting the system in place to start with that's essential," she says.
* Allergy UK: helpline 01322 619864; www.allergyuk.org
* Anaphylaxis Campaign:www.anaphylaxis.org.uk; helpline 01252 542029; training videoDVD pound;16.50pound;18 available from PO Box 275, Farnborough, Hants GU14 6SX or orderline 01252 373793
* Schools website: www.allergyinschools.org.uk
* National Eczema Society www.eczema.org
* Schools' Eczema activity packs (KS123) available free, orderline 0870 2407183
* Coeliac UK: www.coeliac.co.uk
* Food allergies: www.foodsmatter.com