Kara: I don't know about you ladies, but between May and December and August, as a mom now to school age kids, life is so chaotic. I try my best not to schedule anything extra. And if you add allergy and asthma preparation for back to school time, it can be totally overwhelming. So today I am joined by my allergy bestie moms, Dr. Meagan Shepherd and Dr. Amber Patterson. And we are going to break down kind of back to school basics for those families that have kiddos that have allergies, asthma, these different conditions that we really have to think about because our environment changes pretty considerably when we're going from our summertime routines back to that school environment. So welcome to this episode.So we knew this was going to be a meaty topic, and so we're gonna dig into the first half, take a little break, and you can come back then next week to catch the, the second half of what I'm sure will be a really high yield conversation.

But, things that we talked about that we wanna make sure that we cover in these episodes are, what might you need an appointment for? How can you make best use of those appointments? What are all the forms and refills and everything? Why is it so critical that we talk about back to school? What are the, the risks when we go back to school? And then digging in a little bit deeper with some things related to 504 plans and really coming up with a great game plan with thatnew team that's gonna be involved in your kiddos day-to-day life for, gosh, what, eight hours a day or so? It's really important.


Why August is "Back-to-School" Chaos for Allergists
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Kara: So why don't we kick off with, from our perspective as allergists, what happens to our schedules in August? And especially for pediatricians, too.

Amber: Yeah, pediatricians totally get this. Parents, I don't think you need to hear this 'cause you probably have like figured it out, but in case you do, if you plan ahead, you can get an appointment when you want to before school starts so you can have your prescriptions refilled, if you wanna have meds left at school.

If you do want meds at school, your school is going to require a form. You can plan ahead and understand everything you need and schedule an appointment earlier in the summer or really anytime because those forms last for a year from when they're signed. So please, right now, think ahead if you have not already about what you need.

Kara: And usually the school district will have those on their website too. So, one thing that can make it really streamlined and, and oh gosh, I was always so thrilled when parents would do this, but having it printed out to bring with them to the appointment and having the parts that the parent was able to fill out, especially if it wasn't their first, it wasn't a brand new diagnosis. We were kind of updating from the last year, like, if you can, if we can have this be a, a co-creation, a team effort at getting that form filled out, and then I was able to kind of review it, say, "Yeah, this looks great. Here's the signature," that just made everything go so much more smoothly.


Navigating School Forms & Anaphylaxis Action Plans
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Meagan: Do you guys, one of the things that we struggle with here in West Virginia is that there is not a school form that is uniform really so all the schools have their own form, and then they all have a version of some type of anaphylaxis action plan. And so, what we ask for parents is that they bring in everything that their school wants them to have signed.

And we always tell them, by the way, if you have more than one medication, as most atopic or allergic, patients do, so your kid would likely have not just food allergy, but also asthma or something like that, we have to have a separate form for each of those medicines. We can't put two in one. That's something that a lot of people will get kind of aggravated with us or they'll show up thinking that we have the forms for them and we don't.

What we do have that we give out and we give this to everyone, even if their school sends their own version, we do a new food allergy action plan or a food allergy anaphylaxis action plan. That is the most latest version that we use, that we give to everyone. And if I, I've had instances where there's this school form that to me is clearly, clearly very old or based on old guidelines, I just trash that one and give them my new form. So that's something to keep in mind too, that your doctor probably doesn't have the forms that your school wants in hand. You need to get those.

Amber: Well, and you guys probably experienced this too, but I mean, there are, I don't know, five, six school districts in our area. So even though, so we're in Ohio, the state of Ohio, Ohio Nurses Association has a form on the state website, which is, I think essentially what's supposed to be the guideline for schools to use.

So sometimes if, if we can't find a local one or the parents don't know what form, we'll just use that and that usually works. But you're right, every school then seems to tweak it in their own way. And it's, I mean, sometimes they'll change it every year. So you really have to, as the parent, I think at the end of the school year, before you even go for summer break, just check in with the nurse. "Hey, are the forms gonna be the same next year because I wanna make sure to get these done over the summer," so you're good to go.

Meagan: Yeah, that's a great idea. We have one local school district that they had their school nurse was amazing and at the end of each year, she would send a self-addressed stamped envelope along with a letter that said, "This child had these medications at school this year, and we anticipate they will likely need them next year," and they would go ahead and put the forms in there.

I know. I'd wanted to do a study about how wonderful that was. I never got around to it when I was in academics, but that was just life changing because, we, there are times when parents aren't able to get to it. Guardians really don't know what they need, but the child needs the medication at school.

And so at least for that particular school system we were able to sort of, to bypass that and, and just make sure the child had it written down for the school that they were able to use their medication there. And so that was a really great thing. So if there are any educators listening or people working in the school system, please think about doing that because it will really help the children get what they need there. Because I always think whenever people come in after a week or so of school and say, "Hey, I need these school papers filled out," and I'm like, "Oh, of course. We'll do it. But I mean, have we been this whole week without our epi there?" Like what have we, and that, that concerns me. I don't want people to have to go through that.


Planning for Medication Refills & Your "Allergy Toolbox"
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Amber: Sure. I think the other thing to think about is from a parent perspective, what medicines or things like that, like we'll say Kleenex or hand soap or something, what things that, what?

Kara: Tools in your allergy toolbox.

Amber: Yeah. What allergy toolbox things might your child need at school and what kind of approval do you need for your child to have that?

So like, over-the-counter medicines. You probably don't need a school form for that because in many states, the nurses have the authority for certain things to just keep on hand and dispense as needed. But talk to your school nurse. Know what she or he has at their disposal and if you're okay with your child having that there are things that require school form.

So we mentioned epinephrine, albuterol, things that require a prescription. And then there are things that maybe you would need more of a 504 plan, which we can get into that a little bit more later. Or maybe it's just a conversation with the teacher. "Hey, do you mind if Susie Q keeps a box of tissues on her desk so she doesn't disrupt the class going up to your desk for tissues every two minutes?"

Kara: In the same conversations I remember both from general pediatrics, but also the last few years seeing a lot of a lot of folks with PoTS. So a condition where you're, you really need to stay very hydrated in order to keep your blood pressure and heart rate in a happy place. And so if you're drinking a lot of water that requires you to fill up your water bottle, it requires you to go to the bathroom a little more frequently. And so that's, something that sometimes can be taken care of with those open lines of communication. And other times may require some additional paperwork like a 504, which like I said, we'll talk about some more.

Meagan: In my experience, I have not had allergists who would get upset at just writing an extra little letter. We can get it straight out of our electronic medical record. Now, there's various, of course, out there available. But with mine, I can just write a little letter. But even for vocal cord dysfunction, I've had to write letters to the school that say, please let so and so keep their water on hand so that they can have a drink if needed, so that they can stop coughing or be able to talk or whatever. And so I think most doctors are okay with writing something like that if it's required. You just have to kind of ask the school what they need for that. And then if your child has an issue with the particular teacher or particular class or situation, once they're there, then you can, do what you can to help with that specific situation by writing a letter or doing whatever you need to do for that. 

Amber: I think it's also good to have a measure of reasonableness or common sense with those types of requests too. Like for example I had a patient who, she was an adolescent and she could not drink milk, and so she wanted a letter asking the school if they would provide an alternative milk because they were only offering, I wanna say maybe water as an alternative.

And so it was a like, first of all, I was so proud of her for speaking up to advocate for what she wanted.

Kara: Yeah.

Amber: And she and her mom and I had a conversation about it. And in the end, she came to the conclusion that, "You know what? Water's okay for me. I don't need to have the school provide a different type of milk for lunch when I can get that at home. I'm okay with accepting what they're giving me." But it was a conversation and it was, if she felt differently, maybe we would've done something else to advocate for what she felt she needed. But just kind of a note that sometimes, there are options that you don't even need to really do anything except change your mind about.

Kara: Yeah.

Meagan: One of the things that comes up a lot in my practice is when people are getting ready to go back to school people start realizing, Oh gosh, I'm going to need epinephrine and I'm going to need, like, for food allergy for example, or for asthma with inhalers that they're going to need an extra because,

Kara: Mm-hmm.

Meagan: I'll have patients say, "Oh, we keep them, one at school and we keep one at home." And I'm like, "So right now you don't have one?" "No." Okay. I'm like, "Well, that, that can't work." Number one, for the epinephrine whatever type you have need two of them, two devices because each one just delivers one dose.


The Epinephrine Dilemma: Getting Enough Two-Packs for School
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Meagan: So if you accidentally misfire, which is not easy to do, but I have actually done one day in clinic myself. Or if you are, you don't get better with one and you need a second. You need to have two together. And it is correct that it is, it is, it sucks basically that we need to get two two-packs or of whatever it is to have both at school, sometimes on the bus. That's a big question. Where I live in a rural area, lots of kids, ride the bus and they'll say, "Do we have to get extra for the bus?" Depends on what your school will let you do. In my experience, it has been very hard for children to get their epi from the school and to the bus and to home.

And so the other issue with that is insurance doesn't like to pay for multiple two pack devices on the same day. So I tell a lot of families at the beginning of summer, start getting prepared for this now, go ahead and get a refill, then next month get another refill. And this is assuming that your insurance would cover one every 30 days.

Which is sometimes sometimes they'll do that. And that way you have stocked up to have multiple two packs. It is not fair that that has to be done. It would be nice if the world worked in such a way that you could get the number that you needed right away. But sometimes it takes some preparation to get there.

Kara: learning the system.

Meagan: Yep.

Amber: Yep. Yeah. And with Epinephrine, that's one where schools can now keep stock on hand. Most prescription medicines, they have to have one prescribed dose for each patient and a school form to go with it. But that's one thing that many states have legislated that schools can keep that on hand. But still, most children should have their own at the school.

But it, it buys time for those situations like you were saying, Meagan, like, "Oh, we only have two two-packs and we need one for daycare, and they need one here." And if you have like a gap, there's a little bit of reprieve, but that's only for epi. It's not for albuterol.

Meagan: Yep. And one of the things as well that I think parents will want to think about, especially if they have a new sort of child in with this situation entering the school system, is where is the epinephrine kept? Around here, again, we're rural. There are often schools that don't have school nurses, or they'll have a school nurse and, and they're there one hour a week, something like that. And so when they say, "Oh, locked in the nurse's cabinet," but no one can get in the cabinet, it's not going to help anybody.


Where is the Epi Kept? Crucial Questions for Your School
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Meagan: And so, if you are the parent of an allergic child or you have, a different your child has a different disease, it's going to require something as needed, like a seizure disorder or something like that. I would strongly encourage you to try to figure out the logistics of that and make sure that that works for you and your comfort level.

Amber: How do you guys counsel patients on when to self carry if that's allowed? And what we mean by self-carry is when the child would keep the medication on their person or near them, rather than keeping it in a separate location like the nurse's office.


Is Your Child Ready to Self-Carry Their Medication?
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Meagan: Well, first is comfort level. Honestly, that's the first thing that we talk about is whether or not, like when I talk to the parent, do you think they would be comfortable doing this? Now that we have alternative options to the injectable form, there are more people saying yes to use like the intranasal form of epinephrine.

But but the first thing is really how comfortable the child would be because having them carry it is not all that useful if they're like, I would never do this to myself. And I, I'm not telling my friends either. I'm just not doing that, well then.

Amber: Yeah.

Kara: I think each kiddo, even like thinking about now, granted mine are nine, almost seven and three and a half. But I see even between my older two, such differences in their personalities, their ability to, take on a little bit more responsibility in various ways. Thinking about other diagnoses that may play in one of my kiddos has has ADHD. And so that affects, how she's wired a little differently. And that's amazing. And, we support that. But that also comes with, some other some other differences in how she might respond under stress.

And so, I think each, each kiddo in each family is gonna have to really work with their, their physician, their allergist, to come up with a in maybe a training plan of, okay, well this year we're gonna do X, Y, Z and we're gonna work towards this goal, this year or next year.

Amber: Mm-hmm.

Meagan: That brings up another good point too, that I always tell parents that it's probably a good idea to try to speak with your child's teacher or teachers before school starts, just to make sure that they're familiar with their autoinjector device or if it's an intranasal device or if it's an inhaler or whatever, and how to properly use it because sometimes we make assumptions that people get this training and you know. being a physician, there are times when I do a training and three years later I'm like, "Oh gosh, how do I do that again?" For something. And so, just not assuming that everybody knows how to use the epi.

Those of us who have patients who have family members with those issues, most of us have, came in to contact with that world before and have at least some inkling. But there are a lot of people who have never dealt with that, and so they don't know how. And that's, that's important to bring up and make sure everyone's comfortable with it.

Kara: Well, this has been, we've already We talked about scheduling our appointments, paperwork and forms, refills, coming up with a game plan, and even a little bit of patient autonomy. I think we've hit a lot, so.

Amber: Mm-hmm.

Kara: Stay tuned for part two. We're gonna talk more about 504 plans, why it's so important that we are really on top of things going into August, September from an allergy standpoint and environment standpoint. And I'm sure we'll think of some more stuff too. In the meantime, make sure to like, share and subscribe. Pass this along to some of your, your mom friends who are also getting ready for back to school. And if you are looking for an allergist that you wanna partner with and, and work with with your family, make sure to check out the AUNI Learning Network. Great forward-thinking, amazing group of allergists located across the country who are gonna offer really a, a wide array of treatment options to really personalize care for you. So until next time, this has been Allergy, Actually.

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