School Nurses: Invisible Shields

Last week I had the privilege of moderating a panel discussion with four Wisconsin School Nurses (SN).  The SNs discussed how their roles have changed since the onset of the pandemic.  They shared stories of longer hours, increased responsibilities, and new expectations, such as contact tracing.  SNs are undoubtedly experiencing greater amounts of stress this school year but surprisingly they did not talk much about stress.  The SNs spoke of concern regarding the health of staff and students, satisfaction in supporting student learning and gratitude for the increased recognition of the role of the SN. 

SNs have been silently promoting the health of the youth of our country since 1902 when Lina Rogers was hired to provide care to students who had high rates of absenteeism due to communicable disease.  Fast forward to 2020 and SNs are still implementing strategies, including contact tracing, case management, and disease prevention interventions.  This year, SNs have been working tirelessly to support student learning.  Some SNs are working to keep kids present for in-person instruction, others are creating innovative ways to engage with students who are learning virtually, but all SNs are working to keep kids safe and decrease the spread of COVID-19 to minimize the stress on our healthcare systems. 

During last week’s panel discussion, one of the SNs described the SN as “a shield working hard to decrease disease spread and try to lessen their [hospitals’] numbers [of patients sick with COVID-19] from the outside.”  I was moved by this description of a shield; it offers such as terrific visual representation on what SNs are doing during the COVID-19 pandemic.  But SNs have always been a shield, but most of the time the shield is invisible.  

SNs have been working behind the scenes for over a century ensuring that all students can meet their highest academic potential.  Unfortunately, many have the perception that the SN sits in the health room taking care of the sick or injured child or giving the child with diabetes their insulin each day at lunch.  Most SNs wish their school district had the resources to hire enough SNs so they could provide direct care to all students in need, so there could be a full-time SN in every school building.  But in most schools, the SN is responsible for building the infrastructure of support staff who, in turn, are responsible for performing these tasks.  SNs spend hours educating and training the school community to ensure they are competent, comfortable, and ready to address health concerns and emergencies that will inevitably arise.  The SN ensures the health aide understands how to care for the injured or ill student who comes to the health room or how to test a diabetic student’s blood sugar and administer their insulin.  The SN guarantees there are enough school staff trained to perform CPR or use an AED if a student or more likely a school staff member or visitor experiences a cardiac emergency.  The SN creates emergency action and emergency evacuation plans for students with special healthcare needs.  The SN develops plans of care for students with chronic health conditions to ensure that they have the necessary support to achieve their academic goals

The actions described here represent a minor fraction of the invisible work that a SN does every day, every year to protect every student.  If you have the opportunity to speak to the SN in your community, thank them for playing a vital role in keeping children healthy and safe, not only this school year but every year!

Eosinophilic Esophagitis (EoE) and Considerations for the School Nurse

Eosinophilic esophagitis (EoE) is an allergic condition that is becoming increasingly more common in children and adults. EoE has only been recognized as a specific clinical condition since the early 1990s. Over the past two decades there have been great strides in the understanding and treatment of the disorder. There is still much to be learned and changes to the management of the condition continue to occur. Given the child’s complex relationship with food, school nurses need to be aware of this condition and understand what steps should be taken to help manage this condition and keep the student safe.


What is EoE?

EoE has been defined by a panel of experts as “a chronic, immune/antigen-mediated, esophageal disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation” with other causes excluded.[1]  EoE occurs when eosinophils (a type of white blood cell), accumulates in the esophagus.  The elevated number of eosinophils cause injury and inflammation to the esophagus and this damage may make eating difficult or uncomfortable, potentially resulting in poor growth, chronic pain, and/or difficulty swallowing.[2]


Symptoms of EoE:

Symptoms of EoE may vary from one individual to the next and may differ depending on age.

  • Infants and Toddlers:
    • Food refusal
    • Failure to Thrive
  • School-Age Children:
    • Recurring abdominal pain
    • Trouble swallowing
    • Vomiting
  • Adolescents and Adults:
    • Difficult or painful swallowing
    • Food impaction2


What causes eosinophilic esophagitis?

Healthcare providers have not determined the exact cause of EoE, the general belief is that it is caused by an immune response/allergic reaction to food or substances in the environment. EoE differs from anaphylactic allergies (type I reaction) as the reaction that occurs after exposure to the allergen may not be immediate. The pathogenesis of EoE appears to depend largely upon delayed, cell-mediated hypersensitivity which is different from anaphylaxis food allergies.[3] (See table below for more information regarding different types of allergic reactions.)[4]  Although with EoE, complications from exposure to a food allergen may not be immediate and life threatening, as is the case for anaphylactic food allergies, a food allergen exposure can cause flare-ups, increased symptoms, and potential injury and inflammation to the student’s esophagus. Care and planning need to occur to prevent a student with EoE from an accidental exposure.  Additionally, students who are diagnosed with EoE may be on an elimination diet and undergoing ongoing evaluation and repeated endoscopies to evaluate eosinophilic counts.  An accidental exposure to an allergen could complicate the treatment plan.  If an allergen exposure were to occur it is important to communicate that to the student, family and health care provider.

Type of allergic reactions:
·        Type I reactions (i.e., immediate hypersensitivity reactions) involve immunoglobulin E (IgE)–mediated release of histamine and other mediators from mast cells and basophils. Examples include anaphylaxis and allergic rhinoconjunctivitis.
·        Type II reactions (i.e., cytotoxic hypersensitivity reactions) involve immunoglobulin G or immunoglobulin M antibodies bound to cell surface antigens, with subsequent complement fixation. An example is drug-induced hemolytic anemia.
·        Type III reactions (i.e., immune-complex reactions) involve circulating antigen-antibody immune complexes that deposit in postcapillary venules, with subsequent complement fixation. An example is serum sickness.
·        Type IV reactions (i.e., delayed hypersensitivity reactions, cell-mediated immunity) are mediated by T cells rather than by antibodies. An example is contact dermatitis from poison ivy or nickel allergy and eosinophilic esophagitis.


Who is affected?

Eosinophilic esophagitis is considered a rare disease, but increasing in prevalence with an estimated 1 out of 2,000 people affected. EoE affects people of all ages and ethnic backgrounds. While both males and females may be affected, a higher incidence is seen in males. People with EoE commonly have other allergic diseases such as rhinitis, asthma, and/or eczema. Certain families may have an inherited tendency to develop EoE.2


How is eosinophilic esophagitis diagnosed?

EoE is diagnosed by examining a biopsy of the esophagus.  A count of 15 or more eosinophils per high-powered microscopic field is highly suggestive of EoE.2


EoE Treatment:

The two main treatments recommended for EoE are diet management and medication. In some cases, a combination of these therapies may be used.


Diet Management:

Elimination Diet:

Diet therapy involves removal of suspected or known food triggers. Often, this includes removal of common allergy-causing foods such as milk, wheat, eggs, soy, peanuts/tree nuts, and fish/shellfish.2

Elemental Nutrition:

For some individuals, elemental nutrition may be recommended to supplement the diet, or for full nutrition. Elemental diets consist of special amino acid-based formulas that do not elicit an allergic response. If an individual with EoE has difficulty drinking sufficient amounts of formula and/or the health care provider believes it is necessary for other reasons, there may be the need for placement of a temporary nasogastric tube (NG tube) or a gastrostomy tube (g-tube).2


Common Medications used to Treat EoE:

Topical steroids

There are currently no FDA-approved medicines available indicated specifically for the treatment of EoE. However, health care providers have found that topical steroids are often successful in putting EoE into remission. Topical steroids (fluticasone or budesonide) are swallowed from an asthma inhaler or mixture to control inflammation and suppress the eosinophils. (Systemic corticosteroids such as Prednisone are not used for chronic management of the disorder, but may be prescribed for acute situations and short periods of time.)2

Acid suppressors (proton pump inhibitors, commonly abbreviated as PPIs)

May also help relieve reflux symptoms in some patients in combination with dietary therapy or medications.2


Additional Treatment:

Dilation of the Esophagus:

If the esophagus has become too narrow as the result of EoE, it may cause food to become impacted. An esophageal dilation may be recommended to treat a narrowed esophagus. This procedure involves inflating a balloon or inserting a tube into the narrowed section of the esophagus and stretching it out.2


Considerations for the School Nurse:

As with students with other chronic health conditions, students with EoE should have an individualized health plan and may benefit from a 504 plan. Students with EoE may have a complex relationship with food that can create some challenges in the school setting. Communication between the student, family, healthcare provider and school is vital. Below are some action steps the school nurse should consider.

 The school nurse should:

  1. Meet with the student and family to discuss how the child is impacted by EoE:
    1. Are there known food allergies?
    2. What food(s) is the child avoiding?
    3. What symptoms does the student currently have?
    4. What does the child do to treat symptoms?
    5. Are there different/additional symptoms that occur during a flare-up?
    6. Does the student require any accommodations related to food, meal times and snacks?
    7. Does the student require any modifications related to bathroom use?
  2. Discuss and develop a plan regarding how to communicate food allergy and food restrictions to teachers and other school staff.
    1. Students with EoE may have a very restricted diet and may require accommodations at school, such as access to a refrigerator and/or microwave.
    2. If the healthcare provider orders a restricted diet, prepare the appropriate paperwork so that the school’s food service will provide the needed food items.
  3. Discuss with student and family if other students and families will be notified of the student’s condition.
    1. If other families will be notified, discuss how information will be communicated.
  4. Develop a plan to communicate changes in student’s diet, symptom tracking, what to do if an accidental exposure occurs at school, etc.
  5. Develop an emergency care plan that outlines what to do and whom to contact if a food impaction occurs at school.
  6. If the student has an NG or G-tube, develop an individualized health plan for management of the NG or G-tube while at school.
    1. The individualized health plan should include information regarding what to do if the tube becomes dislodged.
    2. The individualized health plan should include who is allowed to manage the NG or G-tube (see School Health Associate’s School Nurse Procedure page for additional school nurse resources).

 

Acknowledgment: Thank you to American Partnership for Eosinophilic Disorders for their permission to include content from their website and for the review of this document.

 

Additional EoE Resources:

References:

[1] Dellon et al. (2018). Updated international consensus diagnostic criteria for eosinophilic esophagitis: Proceedings of the AGREE conference. Gastroenterology. 155(4): 1022–1033 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174113/pdf/nihms-1500097.pdf

[2] American Partnership for Eosinophilic Disorders. (2020). EoE. Available at: https://apfed.org/about-ead/egids/eoe/

[3] Aceves, S.S. (2018). Dietary management of eosinophilic esophagitis. Up To Date. Available at: https://www.uptodate.com/contents/dietary-management-of-eosinophilic-esophagitis

[4] Buelow, B. (2015). Immediate Hypersensitivity Reactions. Medscape. Available at: https://emedicine.medscape.com/article/136217-overview