Letter from \"Dr\" to Cam\'s School...Very Interesting!

Posted on: Mon, 03/03/2003 - 7:38am
anonymous's picture
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Joined: 05/28/2009 - 16:42

I am continuing this from my school thread regarding the situation at Cameron's school. I said I would keep you all posted as to what was going on, and feel this letter definately needs pa.com's attention both for informational purposes and for any advice. I will not be giving this letter to the school, it will only create bigger problems than what already exsists.

I just recieved the letter from Cameron's allergist that I requested for the school. The school was not willing to discuss a pnut free classroom and table (which is what I requested), until documentation from his Dr. was provided saying he felt the accomadations were necessary...

I'm first going to post my letter requesting the Dr's since it's contents add to the revelance as to why I'm posting this.

I too want to add that I give credit to RhondaRS for my letter to the Dr. it was derived alot if not mostly by her letter posted here on the boards.

Lana [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

Posted on: Mon, 03/03/2003 - 7:57am
anonymous's picture
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February 6, 2002
Dr. X
xxxx Plaza Drive
City, FL xxxxx
Re: Patient: Cameron XXXXX DOB: X/XX/XX
XXXX Hwy XXX
Perry, FL 32347
Telephone: XXX-XXX-XXXX
E-Mail:
Dear Dr. X,
Cameron will begin Kindergarten in the Fall of this year. Although it is only February we have already contacted the school and had a preliminary meeting with the administration earlier this week, due to the provisions we would like in regards to his allergy to peanuts.
We want to have him protected under Section 504 of the Rehabilitation Act of 1973 for public school. We are doing this so that he is given an Accommodation and Modification Plan which will include an Individualized Emergency and Healthcare Plan. This educational designation will ensure that Cameron is given a

Posted on: Mon, 03/03/2003 - 8:42am
anonymous's picture
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February 23, 2003
XXXXXX County School
District Administrator, Nurses and Teachers
RE: Cameron XXX XXXXX DOB: X/XX/XX
To Whom it may concern:
Cameron XXXXX is an almost four yr old patient who we first saw at the XXXXXXXXX Asthma and Allergy Center on March 19, 2002 for evaluation of allergic rhinitis and asthma.
At that time, he had already been diagnosed as having an anaphylaxis to peanut ingestion and this was confirmed by positive test to peanut in Gainesville, FL. His reaction consistented of geralized urticaria, wheezing, shortnees of breath, and cough and required aggressive intervention, including Epinephrine, antihistamines and steroids to resolve. Since that time, he has had one accidental ingestion of the peanut containing candy bar "Butterfinger" and developed vomiting several hours later.
Because of the risk of possible severe reaction from skin testing in a patient with know peanut allergy, repeat peanut allergy skin testing was not done at his visit in March of 2002, but instead we tested him for inhalant allergens that might be contributing to his problems noted to the
atmospheric mold Fusarium and the pollens from live oak, several different weeds, and feathers. He showed a slight positive skin test reaction to milk, but this was not felt to be clinically significant as he is able to ingest milk without difficulty.
Cameron was diagnosed as having severe peanut allergic hypersensitivity and we felt that it was important that he avoid oral ingestion or physical contact with peanuts. Allergic reactivity from inhalation of aerosolized peanut protein has been occasionally encountered in the most exquisitely severe patients, but in general, this type of reaction is rare and I do not think that it is of consequence in Cameron's situation.
In addition, he was diagnosed with allergic rhinitis, and treatment with Flonase on a daily basis was recommended. He also had evidence of bronchial hyperreactivity, a condition that is similar to mild early asthma, and treatment with Flovent and Albuterol when he had exacerbations of lower
airway symptoms was suggested with the possibility of requiring Flovent as maintenance if asthma symptoms became more sustained or frequent.
Peanut allergy is one of the most severe forms of allergy that have been identified and is similar in its severity to venemous stinging insect reactions such as to yellow jacket, wasp or fire ant. Very small amounts of peanut have been shown in highly allergic patients to lead quickly to severe urticaria and angioedema of the skin as well angioedema (swelling) of the tongue, throat, lungs, as well as dramatic bronchospasm and hypotension (drop in blood pressure) and even shock. It is estimated that in the US at least 20-30 people die from peanut allergy each year that are known and probably many more cases occur that are not poitively identified. For this reason, it is
especially important for children who are allergic to be maintained in such an environment that they do not accidentally ingest and physically contact peanut allergen. It has recently been brought to my attention that new legislation has been passed which strictly prohibits peanut containing foods in daycares (or schools) taking care of children four yrs and under. A parent recently related this to me and stated that a fine was given out at her daycare when peanut containing foods were
inadvertently introduced. Clearly, it is important for children to avoid peanut exposure and often when children are young, this has to be the responsibility of supervising adults. But generally as children get older, somewhere around age six to seven, they can be taught never to ingest a food that they are not sure of what it contains and the responsiility can be made their own. Until a child is old enough to understand the importance of the allergy themselves, we recommend that peanut containing foods never be introduced into thier classroom and that in cafeteria settings, children with peanut allergy should be kept away from any children who may be eating peanut butter at the same table.
Unfortunately, exposure to peanut allergen cannot be completely prevented in a school
environment as peanut butter can easily get on a child's hands or clothes and this can be
transferred to desk or doorknobs or other places where peanut allergic children may then inadvertently either contact or ingest it. For this reason, it is important that suitable emergency intervention is present in the school with adequate training to know how to use it. Epi Pen Jr. injectors should be readily available in a nurses office or teacher's desk so that it can be administered quickly. I do not think that it is necessary to have the Epi Pen injector in the lunchroom, however, and as long as it is injected in the first five to ten minutes, this will nearly always be lifesaving. It should be given at the first sign of respiratory compromise such as wheezing, shortness of breath, difficulty breathing, severe swelling of the tongue or throat, or
alteration in consciousness. Oral Benadryl can be given initially if the reaction seems to be confined to the skin or gastrointestinal tract. The child should be watched carefully if they have ingested peanut for at least one hour after the ingestion to be sure that they are not going to have a delayed reation. The parents should be notifiedof accidental ingestion so that the child can be watched some eight to twelve hours later for a late phase reaction.
It is imperative that an antihistamine such as Benadryl or Hydroxyzine as well as an Epi Pen Jr be readily available to school personnel to administer to a peanut allergic patient if there is accidental exposure. I do not believe that these medications need to be specificall with the adult that is
supervising Cameron at any particular moment in time, but should be where it can be readily accessed withing five to ten minutes.
The parents provided me with a possible emergency plan and I wanted to make these following observations: On page 1 #1, paragraph B, I would change the part after the sentence ending "signs of reaction." to "if patient develops an urticaria reaction at the site of contact and is having
itching, first give Beneadryl. Epinephrine can be used, but should be reserved for symptoms that affect the resipiratory tract such as swelling of the tongue or throat, wheezing, cough, shortness of breath, or obvious alteration in consciousness."
Under paragraph D, I do not agree with immediately administering Epi Pen after ingestion of peanut when there are no symptoms present that are affecting the respiratory tract or blood pressure. Even Cameron himself after ingesting a butterfinger candy bar which does contain
peanuts, only had symptoms of vomitting some three to four hours after ingestion, and clearly, Epinephrine is not needed for these kinds of reactions. I also would not call 911 when the child is not having symptoms involving the respiratory tract or the cardiovascular systems, such as itching, redness, hives or swelling of the skin as this is as far as a milder reaction goes. It is clearly important to be aggressive with the use of Epinephrine if the reaction progresses past the skin, and in that eventuality, the Epinephrine should clearly be given. The decision to transport to the
hospital clearly should be made the emergency personnel who are called to the scene and probably should not be undertaken by school personnel. Gereally, if Epinephrine is given, it is lifesaving at
that point; but if there is a massive ingestion and the reaction continues to progress after the dose of Adrenalin, then a second shot of adrenalin should be administered and the child transported to
an emergency facility.
If there are further questions or concerns, please do not hesitate to contact us.
Sincerely,
Rand XXXXXX, M.D.
[This message has been edited by Cam's Mom (edited March 03, 2003).]

Posted on: Mon, 03/03/2003 - 9:44am
synthia's picture
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Joined: 10/05/2002 - 09:00

OMG Lana you have got to E-mail me you must be going crazy right now.
What are you going to do?
My heart goes out to you.
Hang in there.
I have a sug I give you by E_mail
Love this site
Synthia

Posted on: Mon, 03/03/2003 - 9:51am
arachide's picture
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Joined: 08/16/2000 - 09:00

Lana,
I can see why you do not wish to submit the allergist's letter to the school... [img]http://uumor.pair.com/nutalle2/peanutallergy/frown.gif[/img]
Obviously, this has been the hard way of finding out your allergist and you are not on the same wavelength.
Why did he take it upon himself to refute some of the safety measures you outlined in your emergency plan? I'm thinking particularly about the need for an epi-pen with Cam at all times and his statement that 911 need not be contacted unless signs of respiratory distress occur --amongst others!
Is this an allergist who has had to write this kind of letter before? Is there perhaps some hidden agenda to foster a certain non-committal professional stance towards the school?
The biggest problem with the doctor's letter, imo, is that it isn't specific to Cameron, but rather focuses on this particular allergist's views regarding pa (which are arguably inconsistent with what alot of members here have learnt to be true).
Too late for another allergist?

Posted on: Mon, 03/03/2003 - 9:54am
Going Nuts's picture
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Joined: 10/04/2001 - 09:00

As Ricky Ricardo would say, "Ay yi yi yi yi".
I'm just sitting here shaking my head. Not only do I disagree with many of his points, but if he did not want to follow your suggestions, didn't he at least owe you the courtesy of a phone call to discuss it?
Are you happy with this doctor in other respects? Are there any alternatives near you?
So sorry you are going through this. I wish I had some great ideas for you. [img]http://uumor.pair.com/nutalle2/peanutallergy/frown.gif[/img]
Amy

Posted on: Mon, 03/03/2003 - 9:56am
Zoie's picture
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Joined: 03/03/2003 - 09:00

what about the emergency plan?
[This message has been edited by Zoie (edited March 03, 2003).]

Posted on: Mon, 03/03/2003 - 9:59am
anonymous's picture
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Joined: 05/28/2009 - 16:42

This is part of the emg. plan I attached to my letter for his approval. There are a couple more pages, but I only included the first part which is where he corrected.
A POSSIBLE EMERGENCY PLAN
1. The following medication administration plan has been developed in conjuction with instructions from the child

Posted on: Mon, 03/03/2003 - 10:04am
anonymous's picture
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Joined: 05/28/2009 - 16:42

Your letter was amazing to the doctor - his response was heartbreaking to read, from right after the 2nd paragraph.
I'm so hoping, as posted above, that it's not too late for another allergist to see Cameron that is alittle more hard-line in your corner, on what constitutes a safe environment for your son.
You're in our thoughts and maybe someone posting here can get you a referral to an allergist in your area that is more in line with your views on having a safe educational environment for Cameron.
Warm regards,

Posted on: Mon, 03/03/2003 - 10:32am
Sandra Y's picture
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Joined: 08/22/2000 - 09:00

I can't believe he would quibble with your request that the school call 911 in case of a reaction. He wants teachers to sit around observing for signs of respiratory distress? I can just see the teachers all hyperventilating until they put themselves in respiratory distress as they try to figure out if it's "bad enough" to call 911. I mean, c'mon, people call 911 when they see an unfamiliar car drive slowly through their neighborhood. Calling 911 is not like calling out the National Guard, what's the big deal?

Posted on: Mon, 03/03/2003 - 10:39am
Gail W's picture
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Joined: 12/06/2001 - 09:00

Lana,
I urge you to set up an appointment with him to address these concerns. There is time, right? I know the school has a schedule, but that can altered. There is ample medical litturature that supports your requests that you can share with him.
1. Regarding transporting ot the hospital after epi is administered:
[url="http://www.aaaai.org/members/academynews/1998/10/positionstatement.stm"]http://www.aaaai.org/members/academynews/1998/10/positionstatement.stm[/url]
position statement from the American Academy of Allergy Asthma & Immunology on anaphylaxis in schools:
"immediately transport children who have been given epinepherine to a hospital, even if symptoms resolve."
2. Use the Sampson article on "Fatal and Near Fatal Reactions" where two students who died at school had NO HIVES or other skin symptoms. I'll find it and post the link.
You can do this Lana. If this doctor doesn't change his letter upon your introducing this information, ask him if he has a partner or recommend another allergist who he thinks would work with you on this.
Gail

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