Writing about food allergies from a pediatric allergist's perspective

Life-Threatening Allergies, School Nurses, and You: The Massachusetts Journey

It is a great honor and pleasure for AllergyHome to introduce Anne Sheetz, BSN, MPH, NEA-BC. Ms. Sheetz is the former Director of the Massachusetts Department of Public Health, School Health Services Unit, and is a dedicated advocate for student health and school nursing. She has been instrumental and deeply influential in national school health issues, especially the management of students with life-threatening allergies. Thank you, Anne, for joining us!

The Massachusetts Journey: Before Guidelines for Managing Life-Threatening Allergies in School 

Massachusetts and Life-threatening allergiesAs parents in many states work with their schools to create safe environments for their children with life threatening allergies, it might be helpful to learn about the Massachusetts journey on this issue.  In 1993 the Commonwealth had approximately 900 school nurses.  Rates of asthma and allergies were slowly increasing as were other chronic health conditions among children, thus leading to several milestone changes.  In that year, through the efforts of the Massachusetts School Nurse Organization, the legislature passed a law requiring that all school nurses be licensed by the then Department of Education.  Licensure requirements for school nurses (registered nurses) included a BSN or MSN upon entry as school nursing is a public health profession that requires a wide range of skills.  In 1993 the Massachusetts Department of Public Health also promulgated a comprehensive set of Regulations Governing the Administration of Prescription Medications in Public and Private Schools (105 CMR 210.000), which permitted school nurses to train unlicensed personnel in the administration of epinephrine by auto injector to children diagnosed with a life threatening allergic condition.

Introducing Massachusetts’ Guidelines for Managing Life-Threatening Allergies in School 

However, after three Massachusetts school-related deaths in 2000, parents from schools within Massachusetts along with the Asthma and Allergy Foundation of America, New England Chapter approached the Massachusetts Department of Public Health and the Massachusetts Department of Elementary and Secondary Education to address the critical issue of children with life threatening allergies in schools.  The focus was on both prevention and emergency response.   Subsequently the two agencies formed a committee to develop statewide guidelines.  Members included parents, allergists, school nurses, nutritionists, school physicians and others.  The Massachusetts Guidelines for Managing Life-Threatening Allergies in School were published and distributed to every superintendent and school nurse in 2002.  School staff training was also provided.

“The Guidelines recommend that the child with a life-threatening allergy be enrolled in a school with a full-time school nurse.”

As demonstrated, the Guidelines provide a comprehensive approach supporting food allergy awareness for the whole school, the need for policies and procedures, pre-entry planning for the child with life-threatening allergies, and preparation for an emergency should an unintended exposure occur.  They also outline the responsibilities of parents, administrators, food service personnel, school nurses and others. Because preparation for the child is best done by a professional whose primary role is health, the Guidelines recommend that the child with life-threatening allergies be enrolled in a school with a full-time school nurse.  The school nurse’s responsibilities are clearly delineated: (a) planning prior to entry, (b) development of a care plan, (c) allergy awareness for the entire school population (now, often using the school training materials from AllergyHome), (d) training of unlicensed personnel to administer epinephrine,  (e) reviewing their skills  every six months, and (f) debriefing after any incident.  Having a full-time school nurse is clearly the goal; however, not every Massachusetts school had a full-time school nurse—although with the support of parents (of children with life-threatening allergies and other special health conditions, e.g., diabetes), the numbers were rising.

Mandated Reporting of Epinephrine Administrations: Vast Majority of Epinephrine Administrations Are By the School Nurse

In order to assess statewide school response to a life threatening allergic event, as well as provide for quality improvement, in 2004 Massachusetts amended the school medication regulations by requiring schools to report any administration of epinephrine for a life threatening allergic reaction.  In the last several years there have been more than 200 such administrations annually in the Commonwealth’s schools, all with positive outcomes for the child.  While unlicensed personnel may be trained to administer epinephrine by auto-injector to students diagnosed with life threatening allergies, the vast majority of the administrations have been by the school nurse (close to 90%).

Challenges in implementing policies and procedures for children with life-threatening allergies

The implementation of policies and procedures for children with life-threatening allergies has faced many challenges: (a) the lack of understanding of the critical nature of these allergies, (b) the push back from other parents whose children “only eat peanut butter”, and (c) the creativity needed to establish reasonable practices in classrooms and cafeterias.  However, each challenge increases the opportunities to teach others, both in the school and community, about life-threatening allergies. This education is vital because in Massachusetts—like so many states—the numbers of children with life-threatening allergies are increasing.  Massachusetts students with epinephrine prescriptions for life-threatening allergies rose from 7.2 per 1000 in 2001 to 25.1 per 1000 in 2012.


Parallel to the rising prevalence rates of this and other special health care conditions, the numbers of qualified school nurses has also grown.  Schools are increasingly recognizing the important contributions of the professional school nurses to the health, safety and attendance of students.  School nurses also free teachers to teach rather than address health conditions!  Currently in Massachusetts there are 2100-2300 professional school nurses—although some schools still remain uncovered.


No Full-time School Nurse in Your School? The following are some suggestions for families with a child with life-threatening allergies:


  • See National Association of School Nurses for position statement, “Chronic Health Conditions Managed by School Nurses
  • Request a 504 plan for your child—possibly including the presence of a full-time school nurse in the building. Also include plans for field trips.
  • Ask for a copy of the school’s policy/procedure on the care of children with life threatening allergies; if not available, offer to assist in writing it.
  • Take the initiative to increase the allergy awareness of a range of others who could be helpful:  parent-teacher organizations, municipal leaders, state decision-makers.
  • Enlist the assistance of your child’s physician and/or allergist to educate school administrators and others on the special issues faced by the child with life-threatening allergies.
  • Work with your State School Nurse Consultant (usually located in either the Department of Education or Department of Health) to ensure there are statewide guidelines on managing the care of the child with a life-threatening allergy in school.
  • Consider identifying other parents of children with life-threatening allergies, diabetes, allergies, etc., who are also working to improve the presence of professional nurses in their schools.  Develop a plan to advocate with the local school administration, school committee and municipal government.  (In one Massachusetts school district, parents placed an ad in the local newspaper requesting a meeting of all parents of children with life threatening allergies—many attended and, together, they were ultimately successful in advocating for a full-time nurse in every building.)

Hopefully the Massachusetts journey–which has been fraught with challenges and is still evolving–will assist parents in other states to collaborate with school and health professionals to prepare schools for children with life-threatening allergies.  The common goal is to promote the health and safety of children with life threatening allergies—and all children– in their school settings.

Additional Resources:

Kids With Food Allergies Foundation Webinars addressing the importance of school nurses:

  1. Partnering With Your School Nurse for a Safe School Year
  2. A Review of State School Policies for Protecting Kids with Allergies and Asthma

AllergyHome guest blog post by Sally Schoessler, director of Nursing Education for the National Association of School Nurses:

  1. Food Allergies and Your School Nurse

Please drop us a comment below. Does your school have a full-time school nurse? What state is your school located in? Is it elementary, middle or high-school? Thanks in advance for the info.

IMG_0029_final_2Anne H. Sheetz, RN, MPH, NEA-BC, was the Director of School Health Services at the Massachusetts Department of Health from 1990-2013, when she retired from government service.  In this role she was responsible for providing consultation to the Commonwealth’s 2100 school nurses, developing regulations for school health, implementing continuing education programs through the Northeastern University School Health Institute, editing the Comprehensive School Health Manual (2007), overseeing the Essential School Health Service grants, implementing school health data systems and establishing performance improvement programs for school nursing services.  She saw her major responsibility as supporting the 2100-2300 Massachusetts school nurses in their critical role of caring for the Commonwealth’s 1.2 million students.  Ms. Sheetz has a BSN from CornellUniversity-New York Hospital School of Nursing, a Masters in Public Health from the University of Michigan and a Graduate Certificate in Management from Harvard University Extension.  She was awarded a Johnson and Johnson-Wharton Nurse Executive Fellowship and is certified as an Advanced Nursing Administrator.  Ms. Sheetz has presented and published on a wide range of school health issues, including but not limited to developing school health services, managing life threatening allergies in the schools, school nurse tobacco cessation programs, pre-school vision screening, the use of data, and establishing a school nurse research network.  During her school health career she ahs received numerous awards such as the American Nurses Association “In Search of Excellence” Award for Massachusetts, Robert Byron Award for Effectiveness and Integrity in Public Service,  Cornell University-New York Hospital School of Nursing Distinguished Alumnus Award, the Martin C. Ushkow Community Service Award: American Academy of Pediatrics Section on School Health, the National Association of School Nurses Outstanding Achievement Award for School Nurse Consulting, Massachusetts March of Dimes Nurse of the Year: Education, among others.


  1. We do not have a nurse at all. Elementary school in Hawaii. The health aide is only cpr certified, and because she is hired by the department of education and not by the department of health, no one regulates her certification be up to date or expanded to include first aide and anaphylaxis. 504s are a struggle each year, as they refuse to allow the staff to be red cross certified to us the epi, they just have a public health nurse show them how. She’s not a certified instructor, and is still clueless as to the updates made in 2010 regarding the possibility of two injections. I even offered to pay for the school staff to become certified and they refused. My son has to carry his own epi becasue they still believe they can only administer one dose, despite our doctor and advocates attempts to teach them otherwise.

    • Hello Melissa,

      Here are recommendations from Anne Sheetz:

      •First the child is entitled to a 504 and the parent can inquire with the Federal Department of Educating Office of Civil Rights
      •They might ask for assistance from their allergist to do some school training
      •They might meet with the nurse who periodically covers the building and share our guidelines—they could also share the guidelines with other school staff
      •They can consider finding other parents in the same situation and work together
      •Are the local EMTs certified to give epinephrine? How far are they from the school
      •It would be great if Hawaii established statewide guidelines. Consider speaking with the State School Nurse Consultant.

  2. We have a full-time school nurse. Pittsburgh PA – Elementary School

  3. Full time nurse, Elementary school, Moorhead, MN

  4. This is the first time I have been at this school full time. We have several medically fragile students and a developmental pre-school in our elementary building. Our food allergies this year are not as life threatening as in past years.

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