Epi pen at daycare - are my expectations unrealistic?

November 5, 2012 12:27 PM

Epi pen at daycare - are my expectations unrealistic?

My 12 month old son was recently diagnosed with several food allergies (milk, eggs, sesame, peanuts, tree nuts). The allergist gave us an rx for Epi pens, one to keep with us and one at daycare.

I went to speak with the daycare's director today and, since she wasn't there (she is frequently out, I have noticed), I spoke with another staff member who was there. She said that there are only 2 people trained to administer the pens: the director and herself. I was asked to leave the pen at the office until I talk to the director. My questions are:

1) Shouldn't everyone on staff be trained or certified to give an Epi shot? I'm concerned that in the time it would take to find one of the only 2 people available, a reaction could worsen. The director is often out, and the other staff member is not always at the office, she is sometimes in classrooms.

2) Shouldn't it be in his classroom instead of the office? Again, it seems to me that it's a waste of time to go running to the office and back.

Any experience with this? Before I talk to the director I'd be interested in hearing if this is normal or if other places handle it differently.

posted by DrGirlfriend to health & fitness (21 answers total)

I've worked at day camps (4-6 year age range) before, as an assistant. If a child had an EpiPen, we were supposed to read up on how to use it. I don't remember getting specially trained for it or that it was especially difficult to learn. (But we did have to have FirstAid training, though I don't remember if it included EpiPen training.)

It was supposed to be in their packpacks where it was easily accessible by anyone, and usually a child would bring 2.
posted by ethidda at 12:31 PM on November 5, 2012

When I coached a child with allergies I was given a pen to keep with the team first aid kit. I don't remember the details, but I don't think it was something that any normal adult couldn't perform. I'm guessing it's an insurance issue for them - perhaps you could provide a note indicating that in an emergency any teacher who has been told how to perform the shot has your permission? I would also be sure to include detailed instructions with the pen to the school...
posted by NoDef at 12:32 PM on November 5, 2012

I learned how to use an epi pen during my very basic first aid/CPR certification course. I'd be very surprised if all staff members at the daycare weren't required to have at least basic first aid certification, which would include epi pen education. Epi pens don't require certification to use. (Our lesson on epi pens took all of five minutes, and most of that was practice.)
posted by mochapickle at 12:33 PM on November 5, 2012 [1 favorite]

I'd call the doctor's office for guidance and then pass that on to the daycare as needed.

Anecdata: I have a friend who carries an Epi pen - she has a "practice" pen for training people, you might be able to get one from your doctor. Also, I know some epi pens are meant to be kept cold, which might be why they're keeping it in the office.
posted by momus_window at 12:45 PM on November 5, 2012 [1 favorite]

Your day-care is a dangerous place if what you are describing is the case.

I have an epi-pen and whenever I go out with someone where I might be near bees, I give them a quick tutorial.

Your prescription comes with two pens, and one training pen.

Basically all you have to do is flip the plastic end up and jam into thigh. That's it. It takes about 5 seconds to train someone.

In my CPR/Basic First aid class, one thing we were told is not to use our own Epi pens on other people. We said "screw that" and now we have an extra two in the office, just in case.

The pens can be kept at room temperature. No extremes. Unless it's tropically hot in your childs classroom, the pen can be kept there.
posted by Ruthless Bunny at 12:55 PM on November 5, 2012 [6 favorites]

Training everybody is expensive, especially in an industry that frequently sees near 100% turnover in teachers in a year. At least in our state the teachers need to be state certified to give the kids a damn Tums.

Then factor in that parents don't want to pay decently for daycare and will yank their kid over a $10 a week price difference...

My wife is a daycare director. I might be biased.
posted by COD at 12:55 PM on November 5, 2012 [1 favorite]

A call to your state's licensing agency wouldn't be out of order in this case, to check what is mandated by the state. I suspect, though, that since it's a prescription, it has to be kept along with other prescriptions in a locked cabinet, etc., which is a state law.
posted by FergieBelle at 12:55 PM on November 5, 2012 [1 favorite]

There is in fact a separate epipen certification given by the American Red Cross. It is an add-on to the basic CPR/Firt aid cert but the actual classes can be difficult to find. As day care often have high turn over it is quite likely that the center doesn't want to pay for the cert.

As a former camp counselor I was not allowed to administer epipens (but I could open the case and put it in their hand for them) despite being a lifeguard and having CPR/ first aid for the professional rescuer (but not that separate epi cert).

Additionally the epi cert is only good for one year so centers do not have a large incentive to get the whole staff trained.

I would offer to have your child's classroom teacher's training paid for (and their time in the class perhaps compensated as well) or see if there was some kind of waiver you could fill out.
posted by raccoon409 at 1:17 PM on November 5, 2012

The bigger issue here is whether the daycare is nut-free, or has a nut-free room that your child will be in. The best epi-pen procedures are those that guard against ever having to use the pen in the first place. I'd be much less worried about the pens if I knew his exposure to potential allergens was unlikely to begin with.
posted by apparently at 1:19 PM on November 5, 2012 [2 favorites]

Yes, everyone who cares for your son at the daycare should be trained. No, it will not be easy to convince the daycare of this fact. Yes, you should do whatever it takes to convince them anyway. Yes, that means they may not like you anymore. If they choose not to like you over this, they and you will all have to suck it up. You are going to have to be That Mom. The squeaky wheel mom. The butting-into-people's-business and telling-people-how-to-do-their-jobs mom. Permanently. It sucks. Hard. My son was diagnosed with a life-threatening peanut allergy three years ago, so I know how much it sucks to have to be this way firsthand. I am sorry.

Get a letter from your allergist, requesting that all daycare staff who regularly interact with your son attend a training session on 1.) how to properly handle his food and 2.) how to administer his medication promptly and properly in the event of an emergency. Every single staff member there needs to know that every second counts in a severe allergic reaction, and everyone who cares for your son should feel capable of and confident about using your child's EpiPen in the event of an emergency.

Give the school a printed copy of the FAAN guidelines for how school should handle food allergies. These guidelines apply to daycares, too. Make sure someone actually reads it. You may have to sit and watch them read it. You may have to read out loud it to them.

Your profile says you live in Oregon. Consult these resources from the Oregon Food Allergy Network. You may find state-specific information there that can help you make your case.

If it becomes necessary, remind the daycare director, gently or otherwise, that food allergies are a legally protected disability, and children with food allergies are protected under the Americans with Disabilities Act -- even at private daycare centers and private schools. In fact over a decade ago La Petite Academy got in serious, serious trouble with the federal government specifically for their policy at the time of not allowing staff to administer EpiPens to children with food allergies and instead insisting on calling 911 and waiting for emergency personnel to do so. It was a precedent-setting case.

I would also recommend that you talk to the school in detail about how they are going to handle keeping your child away from his allergens. Particularly in a daycare setting, with children who are too young to understand rules about not sharing food, your child will be at risk every day from the food other children are bringing in / being served. As he gets older, he may also be at risk from activities that involve food (these happen OFTEN in a school or daycare setting -- think: making collages with pasta; baking cookies; finger painting with pudding; making a birdfeeder and filling it with seeds -- your kid could even run into trouble on a field trip to a petting zoo, because of the allergens in the animal feed).

The daycare needs to come up with a clearly written set of guidelines on handling food and keeping your child away from his allergens. If food your son is allergic to is handled regularly by staff, they need to be cleaning prep surfaces and washing their hands before they touch your kid's food. If the kids eat together at group tables, your son needs a special safe place to eat that is free of his allergens. If group snacks brought in by parents or activities run by parent volunteers are a thing at your daycare, the daycare will also need to send a letter home to other parents telling them that there is a kids at the facility with food allergies and certain foods / activities may be restricted. Etc., etc. Your kid's allergist should be able to help with guidelines if the daycare staff seem utterly lost about where to begin.

You can do this. Good luck. Hang in there. You can't see us, but an army of fellow parents of food allergic kids has got your back.
posted by BlueJae at 1:23 PM on November 5, 2012 [6 favorites]

Daycares and preschools have rules with administering drugs. It could be a city or state sort of thing. In NYC, I could put my daughter's allergy medication in her schoolbag, but they could not administer it. I had to run to her school when I had a break (or have someone in my family) to go to the school and give her the medication. Thank goodness it was seasonal allergies and I have since found a way to minimize her allergies and don't have troubles with that anymore. With the Epi pen, it may be that they have to keep it in the office because they don't have a nurse at the day care. What is your child allergic to? They can probably prevent the item from entering the school easier than figuring out what to do with the pen.
posted by Yellow at 1:47 PM on November 5, 2012

Personally quiz your child's teachers and principal as to what happens if your child needs the pen during a school lockdown or extreme weather situation.

Memail me if you would like to hear more. I stop here because it may be NSFL or triggering for some.
posted by RolandOfEld at 1:55 PM on November 5, 2012 [2 favorites]

Administering an epipen is not very complicated - that's the whole point - but staff are probably intimidated. I'd do the following:

1) Schedule a meeting with the director for sometime this week.
2) Explain the deal, be calm, assume s/he wants to help. Bring some print outs explaining how easy it is to administer the epipen, what the signs of anaphylaxis are, etc. Offer to "train" a couple teachers yourself (this would involve less than 5 minutes of "training" and handing them the same print outs.) Reinforce that this is a medication designed to be administered by the general public.

As a nurse (but not your nurse) I can say that in general, the distance it takes to walk to the office to get an epipen is unlikely to be a big deal, and probably no farther than say, how far the nurse would have to walk to get the medication from the medication room, even if your child was in the hospital when he had an allergic reaction, and the teacher will have plenty of time to get it as long as it is somewhere obvious, well-marked and easy to find in the office.
posted by latkes at 1:59 PM on November 5, 2012 [1 favorite]

His daycare is nut free, which is helpful. I just got confirmation of his allergies last week but he has had reactions to those foods before so I asked the center to not provide any of the suspected foods some time ago. So far they have been great about that,. However, he is in the infant room still, which is a more controlled environment than the toddler room he will be moving to in the next few weeks.

Re: calling the allergist for guidance - part of my reason for posting this was because his instructions made it seem like administering this was pretty time sensitive, so the staff member's response seemed at odds with that. I will definitely call the allergist if the center's rules end up being as described to me today to get his take on it.

I appreciate the different perspectives and scenarios, that's the kind of information I wanted to have in my back pocket before initiating the conversation with the director. And thanks for the support as well - food allergies are not a thing in either my family or my husband's, so we're on a huge and learning curve here!
posted by DrGirlfriend at 2:04 PM on November 5, 2012

At our daycare, the medications were kept in a locked cabinet in the child's classroom, not in the office. This might not be a big issue if it's a small daycare, but if there are multiple rooms and/or floors, I would think having it in the classroom would be better. Also, I'm sure this varies by state, but Connecticut supposedly required a weekly nurse visit to every classroom to check the medicine cabinet. They were to review and confirm that all the meds, flu shots, health forms, signatures, and prescriptions were current. The last few nurses were current preschool parents and they gave epi-pen instructions to the staff as part of their rounds. I'm not sure what the legal requirement for that was, but the director considered it essential since they had a number of students with severe food allergies. Good luck.
posted by victoriab at 2:35 PM on November 5, 2012

My understanding from my first aid & CPR class is that because using an epi pen on someone is technically administering medication, it's not something you are "supposed" to do as someone without medical training. Apparently there is also some variation in good samaritan laws across states, so this may be different depending on where you are.

Of course, any sensible individual in an emergency would probably just use the pen anyway, but the daycare is likely concerned about liability issues, and it seems unlikely you'll get them to budge on this.
posted by ktkt at 2:46 PM on November 5, 2012

My daughter is almost three and has similar food allergies. At her daycare, all staff were trained in how to use the epi-pen about a year ago.

There are two epi-pens (and two pre-measured doses of Benadryl) kept at the center. One stays in the classroom; the other is kept in a backpack that teachers take with them to the playground, on field trips etc. I often pick up my daughter at the playground and check to make sure they have the backpack every time. And the few times they didn’t I made sure to let the teachers and director know that it was a big deal.

I make it my job to be sure that teachers know her allergies, including the teachers who float between classrooms. My daughter has a stash of special snacks kept at daycare for the occasional times when food is brought in by other parents. The daycare has a box of Ener-G egg replacer to use for cooking projects. I regularly go through the kitchen (at the director’s invitation) to check snacks for sesame in cereal or crackers – have caught this twice. The daycare serves hummus only on days that she does not attend. Children wash their hands both before and after lunch and brush their teeth after lunch. Teachers are great about making sure that children do not share food from their lunches.

The culture at this center is very supportive about food allergies. Hope that you can work things out or find a center that is safe for your son!
posted by poodelina at 4:31 PM on November 5, 2012

The part of this that would make me nervous is the way they'll have AT BEST two people in the building permitted to administer it to your son.

As far as keeping it in the office goes: that sort of sounds like a reasonable thing to do, with all the kids that are roaming around the place with their curious little fingers; of course, that's only reasonable IF the epi pen is quickly available --- if, for instance, it's locked up in a safe or something, making it less easily accessible, that's not so reasonable.

But back to there being only two people in the entire daycare facility allowed to administer the epi pen: there obviously has to be someone 100% easily available to administer the thing, because there's no predicting when your little boy will need it. Either the director (who as you say "is frequently out" of the facility), or that single qualified teacher..... and what happens if, heaven forbid, your son needs the epi pen while that teacher is out of town on vacation plus the director is off who-knows-where? COULD someone else locate and adminsister the epipen?
posted by easily confused at 4:31 PM on November 5, 2012

Administering the EpiPen is definitely a time-sensitive thing. As the Mayo Clinic says, "Anaphylaxis can lead to death within half an hour."

Half an hour may seem like plenty of time, but consider this: it is not always immediately obvious to nearby adults that a child is having a severe allergic reaction, especially if that child is too young to clearly explain what is going on. Some reactions present with obvious external symptoms like hives. But sometimes swelling of the throat and tongue comes before hives, or completely without hives. Sometimes a kid starts a reaction off with vomiting, or goes into shock and loses consciousness (which can look like falling asleep).

And the same person can get hives one time and throat swelling or fainting the next time. Food allergy reactions are really unpredictable, which is why the doctor gave you an EpiPen prescription on the basis of testing alone, even though your kid has presumably not had a life-threatening reaction before.

In a busy daycare environment, given everything going on with the other children, it could be ten or fifteen minutes before anyone notices that your child is having difficulty breathing or is otherwise in distress, even if the caregivers are really attentive. That leaves a critically short time to go find the EpiPen, go find someone who is "authorized" to administer the EpiPen, restrain your toddler (because a toddler is DEFINITELY going to have to be restrained for an injection -- heck, I worry that I might still have to sit on my fairly sensible eight-year-old to use his EpiPen -- that is a BIG needle) and then use the EpiPen.

It's really, really easy to learn how to use an EpiPen, and it should not be difficult for the staff to learn to use it. I am sure your child will not be the only child the daycare will have to keep an EpiPen on hand for.

While I'm at it I should note that not even all general practice medical personnel are aware of how important it is to use an EpiPen quickly. In fact when my son had his first severe reaction, the emergency room doctor who treated him did not give him epinephrine at all -- even though my child was clearly suffering from full-blown anaphylaxis, with symptoms including loss of consciousness and difficulty breathing. The ER gave him a double dose of Benadryl, which is not really effective in stopping anaphylaxis. Thankfully my son did recover anyway.

I did not know enough about food allergies to protest at the time. It was only after we saw an allergist and learned more about proper treatment of food allergies that I realized how appallingly bad it was that the ER doc did not use an EpiPen on my kid. He could have died right there in the hospital with the medicine he needed sitting on a shelf.
posted by BlueJae at 6:12 PM on November 5, 2012 [1 favorite]

I worked as a parent volunteer at a co-op preschool and everyone who volunteered in-classroom had to know who had epi-pens, where they were stored, and how to administer them. And we were only there a few hours a week each.
posted by padraigin at 6:52 PM on November 5, 2012 [1 favorite]

A few points:

Laws vary by state as to who can administer this prescription med and what training they need. Check out your state's regs and if a special class is required, consider whether you can arrange (i.e. pay for) one at the school.

Having only two people in the place who can give the med sounds very dangerous. (A child in my town died at day care last month, not from allergies, but in part because only two in the day care center knew CPR and neither was available.) Most kids having allergic reactions can afford to wait a few minutes. But some deteriorate insanely fast. Sorry to say that reactions to peanuts account for many of these.

Storing the autoinjector in an office might be to keep it out of reach of small children. Epi is an extremely potent med, and though it's lifesaving in some cases, it's nothing to mess around with. Could it be attached by velcro to a wall in an obvious place in the classroom that is out of reach of the kids?

Learning how to use the autoinjector is very, very easy. Remembering is surprisingly difficult. There is an astonishing number of people who have administered the shot into their own thumbs because the training in this simple procedure flew out of their heads during an emergency. Suggestion: obtain a couple practice pens (They're cheap.) and keep one at the school. Or do off-the-cuff drills occasionally when you pick your child up.

Good luck to you and your son.
posted by wjm at 2:19 AM on November 6, 2012