*3.4. School-Based Policies and Guidelines*

School-based policies/guidelines were described in 5/12 (41.7%) of studies, although implementation and adherence were variably enforced among participating schools [34,36,37,39,40]. An outline of policies and guidelines are listed in Table 2.

**Table 2.** Summary of in-school policies, emergency action plan, epinephrine auto-injector availability, and other management practices among schools, presented in alphabetical order by first author's last name.


Abbreviations: *EAI* = epinephrine auto-injector; *K* = Kindergarten; *NS* = not specified; *SPSMFAA* = School Personnel's Self-efficacy in Managing Food Allergy and Anaphylaxis; *UK* = United Kingdom; *USA* = United States of America; *y* = years.

EAP usage was inconsistently implemented (5.9–89.5%) among participating schools from Italy, UK, and the USA [36,37,39,40]. EAI was available, as prescribed in one UK study [37,42], and unspecified in one Spanish study [40]. In Spanish schools where EAI was available, only 66.0% of teachers and school staff reported to know where it was located [40]. One Houston, USA-based study stated more stock EAI was available in two schools in economically-advantaged areas (*n* = 6–9 per school) compared to two schools in economically-disadvantaged areas (*n* = 1 each) [34].

Food bans and mealtime accommodations were the most common policies imposed in schools as reported by 3/12 (25.0%) of the Milwaukee, USA; Spanish; UK studies [36,37,40]. Other preventative policies implemented among these schools were distancing measures, e.g., separate lunch table for students with food allergies, safe food/utensil handling, handwashing, surface cleaning, food sharing, and reviewed food items for classroom projects [36,37]. Teachers were primarily responsible for carrying out tasks to manage food allergies such as mealtime supervision [36,37] and meeting with the parents and students with food allergies [40].

In a study by Eldredge et al. (2014), of which 76.1% of responding Milwaukee schools included primary school students, the authors reported on rates of food allergy policy implementation. Authors also noted that policies in this school district were independently determined by governing parishes and/or school boards. Nevertheless, enrollment of students with food allergy appeared to determine policy/ guideline implementation. In this study, 71.0% (53/75) of schools reported some policy/guideline in place. Schools with students with food allergies had an increased likelihood of implementing policies compared to schools without students with a food allergy (Odds Ratio (OR) = 6.30, 1.50–2.60). In fact, 85.0% of schools who had students with a food allergy enrolled had policies implemented, compared to the 15.0% of schools without policies (*p* ≤ 0.0001). Schools with policies were also 3.5 times more likely to require EAPs than schools without policies (67.0% vs. 35.0%, respectively; *p* < 0.0001; OR = 3.50, 95% Confidence Interval (CI) = 1.00–12.20) [36].

In a UK study of primary schools, 76.0% (111/152; 95% CI = 68.0–83.0%) reported having a standard management protocol. An estimated 0.7% (165/24,174) of students had a history of anaphylaxis, or were at risk for severe reactions, and had an EAI. Compared to schools at which there were no students at risk for anaphylaxis, schools attended by students at risk were significantly more likely to have a standard management protocol (57.0% vs. 90.0%, respectively; *p* < 0.001) [37].
