Less than half of schoolchildren in England who are at risk of a serious and potentially life-threatening allergic reaction (anaphylaxis) to food were prescribed the antidote—an adrenaline [epinephrine] autoinjector, or AAI for short—finds an analysis of national prescribing data, published online in the Archives of Disease in Childhood.
This is despite recommendations by the UK and European medicines regulators that those at risk should have access to 2 AAIs at all times, since some reactions need more than one dose or to allow for incorrect use.
And with 1 in 10 episodes of anaphylaxis occurring in schools, providing all of them with 'spare' devices would be safer and save most local health funding bodies £millions, estimate the researchers.
On average, every UK school class will have one or two children at risk of anaphylaxis to a foodstuff, and many schools require these pupils to leave an AAI on the premises, in case they forget to bring one in.
Children with food allergies are not always prescribed AAI. The researchers analysed routinely collected primary care data from the nationally representative Clinical Practice Research Datalink (CPRD) Aurum for children and young people (5-18) diagnosed with a food allergy between 2008 and 2018.
They found that less than half (44%) of schoolchildren with a food allergy in the CPRD had been prescribed at least one AAI, and only a third (34%) had repeat AAIs prescribed. Among pupils who had already experienced anaphylaxis, rates were 59% and 44%, respectively.
To boost access and safety for all school children, UK legislation was changed in 2017 to allow schools to obtain, without a prescription, 'spare' AAI devices for use in emergencies—when the pupil's own AAI is not readily available or they haven't been prescribed one.
But only around half of schools have done this, possibly because of the prohibitive cost, which often exceeds £100 a device, when the subsidised NHS tariff is around £10 for two devices, suggest the researchers.
As a result, some local health funding bodies (Integrated Care Boards or ICBs) have piloted the provision of spare AAIs to local schools for use on any child. The researchers therefore wanted to compare the potential costs of this approach with that of prescribing AAIs for retention on school premises to pupils on a named-patient basis.
They looked at NHS data on AAI prescriptions issued to primary and secondary school age children with a food allergy during the 2023-4 and 2024-5 academic years—specifically, the number of pupils prescribed more than two AAIs.
The researchers then used these data to estimate the potential annual savings if ICBs were to provide every school in England with four spare AAIs on an annual basis during the 2023-24 academic year, rather than funding AAIs to each at-risk pupil over the same time period.
Nearly two thirds (63%) of pupils prescribed AAIs with a food allergy were dispensed more than two AAIs at an estimated cost of over £9 million in 2023-4. Most of these additional AAIs were most likely provided for retention on school premises, given the spike in prescriptions at the start of the school year, suggest the researchers.
The estimated cost of providing spare AAIs to every school was £4.5 million. And the researchers calculated that if spare AAIs were to replace the supply of named-patient AAIs exclusively for retention on school premises, this would potentially save at least £4.6 million—equivalent to 25% of the total national spend on AAIs.
The researchers acknowledge that the study data only included primary care NHS prescriptions, dispensed by community pharmacies and so excluded AAIs dispensed through hospitals and private healthcare.
But they conclude: "Irrespective, there can be little doubt that if ICBs were to limit dispensing to two unexpired AAIs per pupil at any one time (and so no longer provide additional AAIs on a named- patient basis just for school use), then providing spare AAIs to schools (at no cost to the school) would be a cost-neutral strategy for the vast majority of ICBs—and one that is likely to improve emergency access to AAIs and therefore safety."
"The National Child Mortality Database shows that 76% of fatal allergic reactions in children involve modifiable factors, including delays in treating with adrenaline," points out Helen Blythe of the Benedict Blythe Foundation , in a linked editorial.
"Prevention of Future Death reports issued by HM Coroners echo the same failures. Countries like Canada have had laws mandating allergy safety in schools for two decades. In the UK, we're still shaking buckets to raise money for potentially life-saving medication in our schools," she adds.
She calls for Benedict's Law to enter the statute books. First presented to the Department for Education in 2023, this would require schools to hold spare AAIs funded by the government; training for all staff in allergy awareness and emergency response; and the implementation of a school-wide allergy policy.
"Across the country, regional pilots and local initiatives have shown that it's possible, practical, and financially sound to equip schools with AAIs," she emphasises. Such a strategy "would improve emergency access to adrenaline to all pupils, irrespective of whether they had been prescribed AAIs."
