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Early childhood facility staff knowledge and confidence with food allergy management: a preliminary study.


The aim of this study was to conduct a preliminary investigation into the level of staff knowledge and confidence in managing food allergies among children attending early childhood facilities (ECFs) in regional Australia.


Food allergy produces an undesirable physical reaction resulting from the ingestion or inhalation of a specific food antigen and is referred to as either a non-severe food allergy or a severe food allergy resulting in anaphylaxis (Burks, 2002). Non-severe food allergies are an abnormal physiological response to an ingested food and are in most cases not life-threatening but may cause physical complications for the child (Burks, 2002). Severe food allergy, of which anaphylaxis is a subset, is defined by Kumar and Clark (2009, p. 73) as 'a serious allergic reaction that is rapid in onset and may cause death'. Clinically, it can manifest itself as bronchospasm, facial and laryngeal oedema, hypotension, nausea, vomiting and diarrhoea (Kumar & Clark, 2009). Food allergies are most commonly caused by nine food items: cow's milk, fish, shellfish and seafood, egg, peanut, soy, tree nuts (brazil nut, hazel nut, walnut and cashew nut), sesame seeds and cereals (wheat, barley, rye) (Anaphylaxis Australia, 2011a).

In Australia, it is estimated that at least 3-5 per cent of children aged 0-5 years suffer from severe food allergies which can result in anaphylaxis (Anaphylaxis Australia, 2006). However, historic trends may indicate that this group is increasing. Mullins (2007), in an analysis of clinical records of patients referred to a community-based specialist allergy practice in the Australian Capital Territory (ACT), found that the percentage of children diagnosed with anaphylaxis increased from 9 per cent to 15.4 per cent. He also found similar trends in national hospital admission rates for anaphylaxis in children aged 0-4 years. While this study was confined to one practice in the ACT, the confirming trend in national hospital admissions may indicate transferability of the ACT findings to the similar-aged general population. Coupling this with Australian Bureau of Statistics (ABS, 2011) data indicating a trend towards greater use of ECFs (17% of children aged 0-5 years in formal child care in 1999 rising to 22% in 2008) provides grounds for concern that a similar group (3-5%) of children attending an ECF may be at risk because of the lack of both preventative and proactive knowledge by facility staff on how to respond effectively to an anaphylactic episode (Boros, Kay & Gold, 2000; Sinacore, Kim, Murthy & Pongracic, 2007).

Until recently, apart from Victoria, Australian ECFs had no compulsory legislation regulating food allergy management for children in their care. Rather, only voluntary state and relevant association guidelines were available to guide practice. This had the potential to place children at risk of a life-threatening food allergy reaction while attending ECFs. This absence of national, compulsory legislation changed from January, 2012, when the National Quality Framework (Education and Care Services National Regulations, 2011), became national legislation. This legislation requires ECFs to become fully accredited, which among other things mandates staff to become competent in the management of food allergies of children in their care.


Following human ethics approval, the research was conducted between June and September, 2007. A mixed-methods research design (Hardy, 1999) using both quantitative data (i.e. a two-part survey and a knowledge quiz), as well as qualitative data (semi-structured one-on-one interviews and small-group interviews) was used to determine staff confidence and perceptions about their management of food allergy among children attending their ECFs. This research design was deemed appropriate for the study because it validates collecting, analysing and mixing both quantitative and qualitative data in a single study (Creswell & Piano Clark, 2007). It also allows the qualitative data collected to build on or explain initial quantitative results and to elicit in-depth information regarding individual experiences, opinions and feelings toward food allergy management. The targeted participants in the present study were volunteering staff members of the invited ECFs.

The study was undertaken in the Illawarra region of New South Wales. Statistically, the Illawarra region is representative of the population age and gender distribution of Australia in general, and thus provides a reliable source for extrapolation of data from this exploratory study (ABS, 2010a; ABS, 2010b). As a central register of ECFs for the region was not available, all facilities listed in the local telephone directory (n = 126) were invited by mail to participate in the study. The ECFs included those providing long day care (centre-based care for children aged 0-5 years) and preschools (structured care for children aged 3-6 years). The ECFs covered the range of management and ownership found in the region, such as government, community or privately run centres, along with a combination of catered and non-catered facilities.


A two-part survey was developed for the study. The first part collected basic demographic data of each ECF: location, type of ECF, funding source, enrolment numbers, staff numbers and level of qualifications, if the facility provided food and numbers of children attending identified as having a food allergy. The second part of the survey sought data on staff training with regard to food allergy management.

The survey was 'pilot' tested by four participants (who were not included in the final study sample) two weeks before distribution, to allow for amendments of the survey questions if required. Results of the 'pilot' test indicated no amendments were needed.

The survey was mailed to all identified ECFs, requesting a senior staff member to complete and return the survey in a pre-paid envelope. A senior staff member was defined as the senior manager of the centre, or a staff member who had a childcare higher degree, direct access and management of the children, and/or the ECF staff.

Food Allergy Knowledge Quiz

To gain further information about the level of staff knowledge and understanding about food allergy management, and especially the management of an anaphylaxis episode, all staff members (both junior and senior) who volunteered to take part in the interviews were asked to individually complete a food allergy knowledge quiz immediately prior to their interview sessions. The quiz (14 knowledge questions: six multiple choice and eight true/false questions about signs, symptoms and management of food allergy) was developed using peer-reviewed literature (Brown, 2006; Douglass & O'Hehir, 2006), as well as from information provided by Anaphylaxis Australia (2006) and the Australian Society of Clinical Immunology and Allergy (ASCIA, 2006). Individual written responses to the quiz were collected prior to the interview sessions and later entered into an Excel spreadsheet for frequency analysis of correct and incorrect responses.


The one-on-one and small group interview sessions were driven by the following interview questions:

* Can you describe a food allergy incident that you have seen or heard about?

* What happened or what would you expect to have happened to the person?

* What was or would your reaction be to this situation ?

* How did or would you feel when responding to this situation?

* What do you believe would help you if this happened again?

A total of 10 one-on-one and small group interviews were held with volunteering staff members (n = 36) from 10 different Illawarra-based ECFs. The interviews were held in the ECF workplace. Each of the interview sessions was recorded digitally and transcribed by the researcher who then analysed the data to identify common themes.


Survey results

Only 24 (19%) of the 126 ECFs returned surveys: 15 were from long day care (LDC) centres, seven from preschools (PS) and two from vacation care centres (VCC) from northern, central and southern parts of the Illawarra region. The poor survey return was not unexpected as it was representative of paper survey methods, which have been found to yield a low response rate often because of the proliferation of junk mail and other paperwork commitments of the sample population (Sax, Gilmartin & Bryant, 2003).

Seventeen of the ECFs (13 LDCs, two PSs and two VCCs) provided food for the children in their care, while seven of the ECFs (two LCCs and five PSs) did not. In total, the 24 facilities cared for 1462 children, 17 (1.2%) of whom had a severe food allergy, 66 (4.5%) of whom had a non-severe food allergy, and employed 170 full- and part-time staff members. The 15 LDCs employed 118 staff members who cared for 855 children, the seven preschools employed 47 staff who cared for 495 children, and the two vacation care centres employed five staff members who cared for 112 children. Of the 170 staff, 29 (17%) had university training, with the majority 102 (60%) having obtained Early Childhood certificates from either Technical and Further Education (TAFE) or other accredited organisations. No relevant qualifications were cited for 39 (23%) of the ECF staff members.

Of the 170 staff members, 112 (65.9%) had either completed a Senior First Aid Certificate course (St John Ambulance or Australian Red Cross) or a general first aid course but only 79 (46.5%) had undergone specific anaphylaxis training (St John Ambulance or Australian Red Cross).

Of the 24 ECFs that participated in the survey, 17 (70.8%) reported having a food allergy policy in place, with the remaining seven (29.2%) having no form of food allergy policy in place. Importantly, three of these seven ECFs with no food allergy policy had a child with a severe food allergy enrolled in their facilities. Further, only 14 (58.3%) of the 24 ECFs reported having a craft policy in place to deal specifically with food allergy management as relevant to craft materials. With regard to the most common actions to minimise food allergy reactions in their facilities, 21 (87.5%) of the ECFs asked parents to list their child's food allergies on enrolment; 15 (62.5%) provided general information about food allergies via newsletters, brochures and pamphlets to all parents; and 18 (75%) banned peanuts and nut products from their ECFs.

The six most common allergens for the 17 (1.2%) of children who had a severe food allergy were peanuts, soy, egg, seafood, sesame and dairy (in descending order of prevalence). The six most common allergens among the 66 (4.5%) of children who had non-severe food allergies were dairy, egg, peanut, seafood, sesame and wheat (in descending order or prevalence).

At the completion of this survey, 10 of the 24 facilities indicated they would be willing to provide staff time to participate in the one-on-one or small-group interviews.

Food Allergy Knowledge Quiz results

A total of 36 ECF female staff members (a mixture of junior and senior staff) completed the 'Food Allergy Knowledge Quiz'. Their responses indicated that all 36 (100%) knew about food-induced allergic reactions, recognising that severe food allergies could lead to anaphylaxis and be potentially fatal. All 36 (100%) correctly identified that adrenaline could be used to treat anaphylaxis, with 33 (92%) correctly identifying the site for the adrenaline injection. Twenty-three (65%) did not know that non-severe food allergies did not result in anaphylaxis. Twenty-two (62%) correctly identified the five core elements of an action plan for severe food allergies (1. list of anaphylaxis symptoms; 2. list of instructions on what actions to take; 3. instructions on how to use an EpiPen/ Anapen; 4. child's contact details with photograph; and 5. contact details of child's doctor) (Baumgart et al., 2004). Finally, 17 (47%) staff members correctly identified three of the four symptoms of anaphylaxis according to Anaphylaxis Australia (201 lb) (e.g. itching of palms and soles of feet, swelling of face, difficulty in breathing, hives or red welts on the body).

Interview results

The same 36 ECF female staff members (a mixture of junior and senior staff) who took part in the Food Allergy Knowledge Quiz also took part in the 10 one-on-one and small-group interview sessions. Two of these sessions were conducted as one-to-one interviews, with the remaining eight conducted as small-group interview sessions with numbers varying between two and 10 participants. Thematic analysis of the interviews produced the following three major themes: a 'public' confidence in staff of their ability to respond correctly to an anaphylactic reaction; a 'private' lack of confidence in staff of their ability to respond correctly to an anaphylaxis episode; and a belief in the need for continuing education and training.

In general, staff expressed confidence in their knowledge of how to correctly react to a severe food allergy incident.
   Mostly if it's severe the child would have an ... EpiPen
   and we have done a course on it.

However, this confidence did not always reflect the correct treatment protocol. Nine participants (25%) incorrectly suggested that only calling for an ambulance and not administering adrenaline was the correct response to an emergency anaphylaxis episode.
   The first thing is to ring 000 and get an ambulance ...
   the other thing we would do would be to monitor his
   airways to try and cool him down.

Compounding this, only eight (22%) of the participants described the correct treatment procedure.
   If a child went into an anaphylactic response then one
   of us would go straight and get the EpiPen and put it
   into his thigh.

However, three staff, additional to the eight who described the correct treatment procedure, did recognise the need to use the child's action plan as the source of direction for treating a reaction.
   You would follow his plan ... he would have a plan at
   the school and it would tell you the directions and you
   could follow what the directions say.

Overall, although there was a general 'public' belief of confidence in their responses regarding questions of knowledge and correct action, it was evident that correct knowledge of anaphylaxis treatment was limited in a significant number, nine (25%), of the respondents.

Conflicting with the 'public' statements of confidence was a contrasting lack of individual confidence that could be implied from responses made by participants later in the interviews. Emotional factors, such as anxiety, panic and being scared, emerged to contribute to this lack of confidence.
   The thought of it, doing it, is scary.

   I have never done it, if I was to come across it I
   wouldn't know how to, I would have to read the
   instructions first or hope from word of mouth that I
   am doing it right.

Paradoxically, this conflict between 'public' and 'private' confidence was acknowledged through the recognition by the participants of their desire for regular education and training sessions which they believed would assist them to deal effectively with a severe food allergy reaction.
   I think there should be a refresher course once a year
   and just be re-shown how to use the EpiPen again
   'cause it was many years ago that we did it.

This training was reported as being provided and undertaken. The quality of the training being received did vary, however, from formal accredited organisations (Australian Red Cross, St John Ambulance) to informal information provided by parents of the anaphylactic children.
   When we got the child with anaphylaxis, straight
   away the Red Cross gave us training.

   I think I would be pretty comfortable with it, I mean
   with the little girl here I got the mother to re-show me
   and re-show me every time she brings it up I have
   said, 'this is how I do it, isn't it?'


Overall, while the ECF staff indicated confidence in their knowledge and understanding of the management of both severe and non-severe food allergies, an underlying feeling of unease was evident. Interestingly, even though it was recognised that severe food allergies could potentially lead to life-threatening anaphylaxis episodes and the critical importance of administering an adrenaline injection, staff generally maintained that they would rather call an ambulance than perform the injection. This indicated that staff were not confident in actually responding to an incident, reflecting a general theme of fear, unease and anxiety that permeated the discussions.

The majority of the ECF staff were TAFE-trained and had completed a senior first aid certificate course or a general first aid course. However, only 79 (46.5%) of the 170 staff were reported to have received specific anaphylaxis training, ranging from information supplied by parents of anaphylactic children to formal accreditation courses run by certified organisations. This does not comply with ASCIA guidelines (ASCIA, 2006), which recommend all staff receive accredited training to understand, recognise and treat an anaphylaxis episode, while reflecting research of facility staff lacking knowledge in both preventative and proactive strategies (Boros et al., 2000; Sinacore et al., 2007).

Undertaking accredited anaphylaxis training, available from, for example, Australian Red Cross or St John Ambulance, is essential to improve knowledge and reduce risk of mortality (Baumgart et al., 2004; Watura, 2002). This should therefore be an essential component of regular education and training sessions provided to ECF staff. The need for regular education and training sessions is evidenced in the current study because as many as 1.2 per cent and 4.5 per cent of the children in their care were identified as having severe food allergies or non-severe food allergies respectively. One-third of the staff members, however, could not identify the five core elements of an action plan and almost half could not correctly identify the signs and symptoms of anaphylaxis (Anaphylaxis Australia, 2011b). As action plans are essential for best practice in reducing the risk of allergen exposure (Hourihane, 2001), this deficiency needs to be addressed. On a national scale, this finding is of major concern. As already established, there is an increasing trend in parents using ECFs (ABS, 2011). Therefore, a similar percentage of children nationally may be facing the potential risk of experiencing an anaphylactic episode in an ECF which has staff inadequately trained to either prevent a reaction or to assist them successfully if a reaction does occur.

Although a limited number of ECFs took part in this study, the majority had a food allergy policy and/or a craft policy in place. It should be noted, however, that three of the 24 facilities who cared for children with severe food allergies did not have a food allergy policy in place. Also, it is significant that, while many of the facilities asked parents to list their child's allergies on enrolment and distributed written food allergy information to all parents, in most cases they were likely to ban only peanuts and nut products from their ECFs, even though children attending the facilities may also have had severe allergies to dairy, egg, seafood and soy products (Anaphylaxis Australia, 2011a).

Overall, the findings in this study highlight the possibility that children with severe and non-severe food allergies are still being placed at risk of a reaction and potential death in ECF environments in Australia. In this particular study, Illawarra ECFs were either adopting their own policies that are insufficient and vary greatly or choosing not to adopt any food policies at all. The introduction of the National Quality Framework in 2012 should correct this situation, with every ECF which seeks accreditation needing to provide evidence of both a workable food allergy policy and staff trained to meet minimum standards in food allergy care.


There were several limitations to the study. The response rate for the survey was poor, hence the sample may not be truly representative of Australian ECFs.


This study highlights that levels of staff knowledge and confidence vary significantly when dealing with children attending Australian ECFs who experience food-induced allergies, and in particular severe food-induced allergies.

The compulsory implementation of the Education and Care Services National Regulations, with its requirement of trained staff members, should minimise this risk substantially and answer Anaphylaxis Australia's (2006) call for universal minimum standards of food allergy management across Australia. However, it is still imperative that ECF staff members have access to continued and regular ongoing food allergy management training.


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Judy Mullan

Warren Rich

Irene Kreis

University of Wollongong

Catharine Fleming

University of New South Wales
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Author:Mullan, Judy; Rich, Warren; Kreis, Irene; Fleming, Catharine
Publication:Australasian Journal of Early Childhood
Article Type:Essay
Geographic Code:8AUST
Date:Mar 1, 2013
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