**4. Discussion**

In this scoping review of the European and North American literature on in-school management of food allergies, we identified several perceived gaps and barriers in management. First, teachers and school staff acknowledged the significance of food allergies [42] yet lacked experience and knowledge. We identified participants' knowledge differences [33,39] and EAI availability [34] from schools in economically-advantaged and disadvantaged areas. Studies also reported that teachers and school staff did not know which students had a food allergy [37,39]. Second, there exists wide variation, and reporting, of food allergy management practices including the provision of policies/guidelines, EAP implementation, and inconsistency in EAI availability and knowledge in EAI administration, as similarly described in other studies [13,14,22,24,25]. Third, preparedness and self-efficacy of teachers and school staff to manage anaphylaxis effectively are correspondingly variable. Unsurprisingly, additional training was desired by many.

The need for additional training is underscored by the commonality of students with food allergies, juxtaposed against inconsistent policies across and between jurisdictions [17–20]. As school staff are likely to be the first adults to be notified of food allergy-related emergencies [15], adequate and universal emergency management skills are essential in student safety, including EAI administration. One USA-based study in our review reported that not all teachers have administered EAI but have not been previously trained [35],

which illustrated that teachers are key players in emergency management in schools, especially when there are no school nurses available. School nurses have also reported to have inconsistent training, or were "self-taught" [15,25,26]. Reliance on one nurse to manage medical emergencies may be impractical as allergic reactions can occur anywhere within school premises. Additionally, if parents are less involved and/or unaware of serious food allergy concerns, teachers may also assume caregiving responsibilities and help students learn about their own food allergy management.

Our review highlights the need to share food allergy management responsibilities, including, but not limited to, maintaining individual EAPs, knowing where EAI are located and how to use it, promoting preventative practices (e.g., handwashing) and recognizing signs and symptoms of allergic reactions, and knowing own roles in emergencies by providing food allergy training for all teachers and school staff, including school nurses where available. Such training may also reduce the propensity of other school staff to turn to online, non-academic resources for food allergy education [39,42,43]. Moreover, early (pre-hospital) treatment decreases the risk of hospitalization [13], while delayed treatment from symptom onset was associated with the risk of having a biphasic reaction and fatality [12,24]. As the long-term effects of staff training on food allergy management knowledge are unknown, the implementation of post-training evaluation may also be beneficial [11].

School meal programs also raise the value of food allergy training for other school staff such as cafeteria personnel and food monitors, as proper food handling and preparation are foundational in preventing allergic reactions [6,46]. Our study reported on two studies with school food program participation that did not discuss how food allergies were accommodated [34,36]. Future training programs should also address how school food programs apply food allergy education in practice, including safe food handling training, cleaning protocols, and increased mealtime supervision for younger students who may have more impulsive behaviors [47].

Although a universally accepted EAP and laws to provide stock epinephrine in schools would prove challenging to develop and garner acceptance, we purport that such calls are essential at a national, or regional level. Collaborative efforts and partnerships among all stakeholders including affected students and families should focus on identifying students at risk of anaphylaxis. Thus, planning and implementation of medically sound EAPs, yet relevant and clearly understood by its intended users, is essential. Additionally, in conjunction with staff training and the implementation of EAPs, stock EAI in schools would be advantageous as not all students with a food allergy may have an EAI, or do not carry them around school. Meetings with teachers, children, and their families may also increase communication and consensus on stock EAI usage and care plans [40]. Likewise, training, EAP implementation, and stock epinephrine availability align with international recommendations [11,28], and may increase staff awareness of food allergies, and help alleviate concern, anxiety, fear, and helplessness reported by teachers and school staff [43]. In turn, training may contribute to teachers and school staff's confidence, self-efficacy, knowledge, and ability to perform in emergency situations.

To our knowledge, this is the first scoping review to provide an overview in some school jurisdictions in Europe and USA. We did not restrict the publications to the English language only and presented available data from multiple Western countries. Our review also extends the findings from Waserman et al. (2021), such as the positive uptake and perceived benefits of teachers and school staff of food allergy training, providing available EAI and implementation of action plans [11].

We acknowledge that searching only within three databases and the publication year cut-off may have introduced some reporting bias and reduced eligible studies. We also did not perform a quality appraisal of the included studies or comparisons of the interventions. Moreover, our ability to compare the interventions and results into a cohesive analysis were limited given the heterogeneity of design of the included studies [48]. However, we were able to identify common themes. We recognize that we excluded all grey literature,

as well as publications outside Europe and North America, and in languages other than English or French.

Nevertheless, our review highlights several key take-away messages (Box 1), including the need for further research and the creation of a food allergy training strategy that includes EAI administration for all school staff. Our review findings can also be used to inform policymakers to consider implementing an evaluation program for existing training courses. In light of the COVID-19 pandemic, the usage of virtual platforms for training purposes can be an accessible communication medium. Lastly, the provision of stock EAI and individualized EAPs should be considered as mandatory as jurisdictions are able. The execution of such may pose greater benefits beyond having available rescue medication but may also help increase the confidence and self-efficacy of teachers and staff to be able to manage emergency situations appropriately.

**Box 1.** Key take-away messages.

