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Allergies & Child Care Facilities

Written by Dr. Ramon Martinez III
Published on April 25, 2023
Research Highlights

Approximately 1-in-20 children have life-threatening allergic reactions that can lead to hospitalization.

Schools and hospitals are not required to report most allergic reactions to state or federal sources.

Most states regulate allergy planning in school districts, not childcare facilities.

Allergic reactions can be life-threatening.

Allergic reactions to foods, insect stings, medications, or other substances (e.g., latex) can range from acute (e.g., eye/skin irritation) to life-threatening (e.g., anaphylaxis; Dribin 2022).

  • Anaphylaxis can damage or impair multiple critical organs (e.g. lungs, heart, brain, etc.; DHSS 2014; CDC 2021).
  • 1-in-12 children have a food allergy, and 25% of students that have anaphylactic reactions in school have no prior allergy diagnosis (Allergy & Asthma Network n.d.).

Muscular injection of epinephrine is nearly 100% effective at lessening an allergic reaction and can be self-administered or given by a non-medical professional. Immediate medical follow-up is recommended to ensure allergic reactions are cleared, and may require additional short-term treatments or supplemental oxygen as prescribed (Campbell 2022).

Roughly 1-in-50 adults have reported an anaphylactic reaction at some point in their lives. Between 3-6% of children have had significant reactions that led to hospitalizations, often worsened by delayed administration of epinephrine (Yu 2018).

Allergic reactions are not tracked in school-age children.

There is no publicly available reporting mechanism in MO for anaphylactic reactions (e.g. frequency, where they occur).

  • In 2009, out of 860,000 students’ medical records in MO, roughly 1-in-97 students had a food allergy, 1-in-260 students had an insect allergy, and 1-in-1,300 students had a latex allergy (DHSS n.d.). The severity of these allergies and treatment protocols were not recorded.

No federal agency appears to collect anaphylaxis data apart from reactions to some drugs or vaccines that lead to medical interventions.

  • 36% of confirmed anaphylactic reactions in a study of 1,000 U.S. adults resulted in patients going to the hospital (Wood 2014).
  • Of allergic reactions resulting in hospitalization, roughly 30-50% meeting the criteria of anaphylaxis are incorrectly recorded as “acute allergic reactions,” and are difficult to account for in databases (Sclar 2014).


Most state-mandated allergy protocols are specific to schools.

In school or childcare settings, certain strategies can reduce the risk of allergic reactions, including cleaning and sanitizing high-touch surfaces routinely, mandatory hand washing for students and/or staff, allergen-free or safe zones, or planning ahead for events and emergencies surrounding food, such as staff emergency training (DHSS 2014).

School and Childcare Allergy Policies

1-in-3 schools in the U.S. provide some training for school nurses or staff to recognize anaphylactic reactions.

  • In a study of U.S. schools, federal and state school allergy policies resulted in 15-55% of nurses or staff being authorized to administer epinephrine (White 2016).
  • One MO law is directed toward childcare facilities (Figure 1 and Table 1).

Table 1. School or childcare facility allergy policies in MO (RSMo 167.208, RSMo 167.627, RSMo 167.621; RSMo 167.630).

Elijah’s Law

NY and IL have passed ‘Elijah’s Law,’ a comprehensive law that requires state health departments to work with schools and childcare facilities to create plans for epinephrine administration, emergency protocols, exposure reduction, training of at least one staff member, and distribution of these plans to the public (NY OCFS 2023; IL 102-0413 2021).

  • Information on the effectiveness of these laws in reducing anaphylactic reactions or hospitalizations is not readily available.
  • Studies in public settings show that when stock epinephrine injectors are available, they are used in 20-77% of anaphylactic reactions (Waserman 2021).

Figure 1. States with childcare facility allergy policies. States with more preventative allergy policies (Table 1) are filled with darker blue shades. Data from Asthma & Allergy Foundation of America.



After Anaphylaxis: Learning From the Experience. (2021). Icahn School of Medicine at Mt. Sinai. Retrieved from https://www.mountsinai.org/files/MSHealth/Assets/HS/Care/Pediatrics/Allergy%20Immunology/After-Anaphylaxis-Learning-from-the-Experience-AH-Edits-2-1-21.pdf 

Allergy and Anaphylaxis in the School Setting. Missouri Department of Health and Senior Services. Retrieved from https://health.mo.gov/living/families/schoolhealth/ppt/allergy_and_anaphylaxis.ppt 

Allergy Awareness & Elijah’s Law. (2023). New York Division of Child Care Services. Retrieved from https://ocfs.ny.gov/programs/childcare/elijahs-law.php 

Anaphylactic Policy. (2021). Illinois General Assembly. Retrieved from https://ilga.gov/legislation/BillStatus.asp?DocTypeID=HB&DocNum=102&GAID=16&SessionID=110&LegID=127914 

Anaphylaxis Statistics. Allergy & Asthma Network. Retrieved from https://allergyasthmanetwork.org/anaphylaxis/anaphylaxis-statistics/ 

Campbell, R. L., & Kelso, J. M. (2016). Anaphylaxis: emergency treatment. Up to Date. , 14. Retrieved from https://www.uptodate.com/contents/anaphylaxis-emergency-treatment 

Child Care Policies for Food Allergy: Elijah's Law Report. (2022). Asthma and Allergy Foundation of America. Retrieved from https://issuu.com/aafa.org/docs/elijahs_law_toolkit-v1-1 

Dribin, T. E., Motosue, M. S., & Campbell, R. L. (2022). Overview of Allergy and Anaphylaxis. Emergency Medicine Clinics of North America, 40(1), 1-17. doi:10.1016/j.emc.2021.08.007 

Guidelines For Allergy Prevention And Response. Missouri Department of Health and Senior Services. Retrieved from https://health.mo.gov/living/families/schoolhealth/pdf/mo_allergy_manual.pdf 

Mangold, M., & Qureshi, M. (2018). Neurologic manifestations in anaphylaxis due to subcutaneous allergy immunotherapy: A case report. Medicine (Baltimore), 97(18), e0578. doi:10.1097/md.0000000000010578 

Prince, B. T., Mikhail, I., & Stukus, D. R. (2018). Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. Journal of Asthma and Allergy, 11, 143-151. doi:10.2147/jaa.S159400 

Recognizing and Responding to Anaphylaxis. (2021). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/vaccines/covid-19/downloads/recognizing-responding-to-anaphylaxis-508.pdf 

Sclar, D. A., & Lieberman, P. L. (2014). Anaphylaxis: underdiagnosed, underreported, and undertreated. American Journal of Medicine, 127(1 Suppl), S1-5. doi:10.1016/j.amjmed.2013.09.007 

Waserman, S., et al. (2021). Prevention and management of allergic reactions to food in child care centers and schools: Practice guidelines. Journal of Allergy and Clinical Immunology, 147(5), 1561-1578. doi:10.1016/j.jaci.2021.01.034 

White, M. V., et al. (2016). Anaphylaxis in Schools: Results of the EPIPEN4SCHOOLS Survey Combined Analysis. Pediatric Allergy, Immunology, and Pulmonology, 29(3), 149-154. doi:10.1089/ped.2016.0675 

Wood, R. A., et al. (2014). Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol, 133(2), 461-467. doi:10.1016/j.jaci.2013.08.016 

Yu, J. E., & Lin, R. Y. (2018). The Epidemiology of Anaphylaxis. Clinical Reviews in Allergy & Immunology, 54(3), 366-374. doi:10.1007/s12016-015-8503-x 

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