February 2000
Medications for treating asthma are the most frequently dispensed medications in the Philadelphia school system, and in this era of strict anti-drug policies in schools, this can sometimes lead to trouble. However, many schools have adapted policies for the benefit of the students' health.
"A few years ago, there was a furor over the medications given for attention deficit hyperactivity disorder, like Ritalin [methylphenidate, Novartis]," said Constance Williams, RN, MSN, CRNP, health advisor for the Philadelphia school district. "We did a survey of what drugs we were giving in the school setting. It turned out that asthma medications were the largest group of medications."
This probably isn't surprising to most pediatricians, considering approximately one-third of the 10.4 million physician office visits each year are for children younger than 18 years with asthma, according to statistics from the American Academy of Allergy, Asthma and Immunology.
Policy on how asthma medications are dispensed in schools varies from district to district. For the most part, a permission and instruction form must be completed by a child's parents and pediatrician, and returned to the school nurse.
"Having asthma medications in schools will save children from having severe episodes and keep their asthma under better control," said Paul Y. Qaqundah, MD, chairman of the school health committee of the American Academy of Pediatrics and a practicing pediatrician in Orange County, Calif.
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The Philadelphia school district's permission and instruction form requires that the student's pediatrician include a detailed description of the medication and how it should be used. There is a section on the form that asks about any special evaluations or monitoring that needs to be completed throughout the school day, including monitoring for any side effects associated with the medication.
"The doctor completes the form, indicating the dosage of the medication, the name of the medication, why it's being given, when and what route it should be given. This is really giving us a rationale as to why [the medication] needs to be given out during the school day," said Williams.
In the Chicago public schools, the children also have to return forms to the school nurse. "They have to have a written doctor's order, and they have to have written permission from their parents that it's okay to administer medication in school," said Myrna Garcia, director of student health services for Chicago public schools.
The primary contact for the permission slips and medication is designated by the principal, which is usually the nurse. The medication must be stored in a locked cabinet or drawer, and the principal and nurse are responsible for the key at all times.
In Philadelphia, the parents are instructed to give the nurse the medication with proper pharmacy labeling to identify the name of the medication, the name of the student and the dosage, according to Williams. She also said that parents are instructed to check that the medication is not expired.
Allowing children to keep their medications with them throughout the school day may be more beneficial than keeping the medication locked in the school nurse's office.
"I am personally in support of letting children carry their medication with them. Sometimes you put [the medication] in a locker, the child is wheezing, and by the time you get to it, the nurse is not there, and it becomes a problem," Qaqundah said. "These children are knowledgeable on how to use and when to use their medication, and if they are not, they can be easily taught."
The Philadelphia school system allows children to carry their own medications and self-medicate, providing that they can handle the responsibility. It does not depend on the age of the student, but rather the child's maturity level.
"If the doctor wants self-administration ... then we have a competency checklist and training that we do with the child," Williams said. Also, the child will be observed and monitored by the school nurse to decide whether the child is mature enough to handle the responsibility.
However, "If a child is able to self-administer, that is still under the jurisdiction of the nurse," Williams said. "We don't just turn the child loose. At some point, we still maintain monitoring."
There is some flexibility in the Chicago school system's policy on self-carrying and self-medicating, which depends on the comfort of the student. "Sometimes children feel better if they keep it with a classroom teacher, in the same classroom with them. Or sometimes it's in their book bag or their desk. But it's within reach," said Garcia.
However, age is a factor in Chicago. "For preschoolers and kindergartners, it's usually kept with a classroom teacher," Garcia said.
Not all schools have a full-time nurse to assist children with their medication. "Some schools don't even have a full-time nurse. So, they can't require that the child keep their medication there. They have to come up with some other system," said Bonnie Fass-Offit, MD, a pediatrician in private practice in suburban Philadelphia.
In Philadelphia schools, the school principal will normally designate an additional contact person, in case the nurse is not available. "We usually have an emergency plan," said Williams. "Or we always have a care plan in place for the child if they have any medical problems."
In Chicago, "The initial contact is the nurse," Garcia said. "The nurse initiates what is necessary: the forms, the procedure and the process. The nurse is not in the building every day, so there is a principle designee that carries on after the nurse orients that person."
In addition, there has been some concern that medications carried by an asthmatic student could fall into the hands of non-asthmatic children. Even over-the-counter asthma medications, such as epinephrine inhalers (Primatene Mist, American Home Products), could present a risk to other students.
However, Qaqundah said that other students' safety will not be a concern. "This is a life-saving medication, not a drug," he said. "To me, a drug is marijuana and other illicit drugs, this is a medication prescribed by a physician. Postponing its use can be detrimental to the asthmatic and can put his or her life in danger."
Another problem is that some children may carry their own medication without the knowledge of the school. "I think a lot of parents of older kids will just put an inhaler in their pocket," Fass-Offit said.
Overall, the Chicago public school system has not run into many problems with their school medication policy, according to Garcia. The biggest concern is implementation of the policy, and re-educating faculty regarding the policy.
"We still need a lot of awareness and orientation and re-education," Garcia said. "So far, the only problems that we've encountered are new principals who worry about the process. And then the implementation - we really need to push it," Garcia said.
To ease the implementation problem, the Chicago public schools are releasing an asthma manual that will attempt to increase awareness of the disease and educate the faculty regarding the medication policy.
According to Garcia, "The end goal is to have communication established between the school, the students, the family and the provider. It's a worthy goal."
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