Allergic diseases are common in children and may manifest for the first time at preschool or school.¹ They may impair school performance, reduce quality of life, and cause severe reactions.^{2, 3} Parents have frequently concern over the safety of their child at school. Only few studies examine the management of children with allergies at school.¹ In Sweden, a report by the National Board of Health and Welfare (2013), aiming to describe through a systematic review how the school environment is for children with allergy, identified a series of problems, in terms of indoor and outdoor environment, special diets, teaching, and communication with the parents.⁴ In 2015, the Swedish Association for Allergology provided recommendations for the management of anaphylaxis, including written individual healthcare plans (IHP) at school.⁵ Recently, the National Food Agency (2021) updated the national guidelines for preschool/school meals (provided for free to all students), including special diets.⁶ The aim of this survey was to assess routines, level of knowledge, and safety/concern among preschool and school personnel when working with children with all types of allergies, irrespective of severity.

In 2021–2022, the heads of 148 preschools (children aged ≤5 years) and 181 elementary/lower secondary schools (described as schools, 6–16 years) in Stockholm County were contacted and asked to distribute a questionnaire among all personnel. Most of these preschools/schools had at least one student referred to child allergy nurses. The latter are pediatric nurses with specialist competence in allergies, who support preschool/school personnel in Stockholm County, following physician referral of children with allergies. The questionnaire was developed based on clinical experience and current literature by a multidisciplinary team. Personnel from 42 preschools (1–18 from each) and 30 schools (3–58) from 18 of 26 municipalities of Stockholm County agreed to participate. Participation was voluntary and anonymous and was followed by an educational intervention in allergy management. Written informed consent was provided. The study was approved by the Swedish Ethical Review Authority (Dnr 2020–02424).

Ordinal variables (10-point Likert scales) were grouped into low (1–4), medium (5–8), and high (9, 10) response categories due to skewed data distribution. We considered preschool/school locations and classified into low (types 1–3) and high (types 4–5) area socioeconomic status (SES) based on the area socioeconomic index. Differences in responses by preschool/school and area SES were tested by multinomial and ordinal logistic regression as appropriate, considering school clustering. p-value <.05 was considered statistically significant.

Out of 1002 respondents, 35.6% worked in preschools and 64.4% in schools; 86.9% were teachers, 4.8% principals, 3.1% school meal staff, and 1.7% school nurses. They worked in diverse settings; 75.0% in public and 25.0% in private sector; 74.8% in high and 25.2% in low SES area (Table S1).

Out of total, 78.0%, 73.2%, and 86.3% replied that preschools/schools had routines for how to care for children with allergies (physical and psychosocial care), how to manage allergic reactions, and how to manage special diets for children with food allergy, while 5.6%, 6.5%, and 3.3% replied “No,” and 16.4%, 20.4%, and 10.4% replied “Don't know,” respectively (Figure 1).

Responses from 10-point scales are summarized in Table S2. About half (48.9%) gave a high rating regarding how routines for care of children with allergies work, 44.8% regarding the management of allergic reactions, and 63.1% regarding special diets. In contrast, 7.7%, 11.2%, and 5.1% gave a low rating, respectively (Table 1). More than half (range 52.6%–56.9%) rated their level of knowledge about specific allergies as medium and less than 33.0% as high. Additionally, 53.9% and 43.5% rated their knowledge about the management of allergic reactions and special diets as medium, and 20.8% and 40.8% as high, respectively.

More than half rated their security (perceived risk) when taking care of children with allergies and safety (actual risk due to safe environment) when meeting them as medium (56.4% and 55.2%, respectively) and less than 33.0% as high (Figure 2). Moreover, 13.0% reported high anxiety about children getting allergic reactions and 17.5% about children with food allergy getting inappropriate food. About half (48.7%) rated their level of communication with parents of children with allergies as high and 42.1% as medium. When asked how close to an ideal they were at the workplace, 63.7% gave a medium, and 20.9% a low rating. Only 23.4% knew the Student Health Portal (www.elevhalsoportalen.se), a website aiming to support preschool/school personnel with health promotion including the allergy field; out of these, 29.7% were using it at their workplace.

Preschool personnel were more likely to give a high rating regarding routines, and level of knowledge about allergies and their management in comparison with school personnel, the latter being more likely to reply “Don't know” regarding the availability of routines. Preschool personnel were more likely to report high security/safety but also high anxiety. Moreover, personnel in high SES areas were more likely to report a high level of knowledge and high security/safety (Table S3), while school personnel in high SES areas were more likely to give a high rating regarding routines compared with school personnel in low SES areas.

In this study, although most respondents reported that there were routines available, between 10.0% and 20.0% did not know if there are routines, and only about half reported that the routines worked well. Preschools/schools with children at risk of anaphylaxis are recommended to have written personalized care plans and a staff member trained in the use of adrenaline.¹ In Sweden, adrenaline is prescribed individually following a thorough healthcare investigation, and there are currently no available stock adrenaline autoinjectors kept in preschools/schools, but children submit their personal autoinjectors to be stored on site. Moreover, school training is usually offered upon request, which places the responsibility upon the school management.⁷ In this respect, guidelines emphasize the importance of a whole school approach, empowering all personnel to support children while at school.⁸ Therefore, routines involving personnel, health care, children with allergies, and their parents, working within clear school policy, are needed.

Most respondents rated their knowledge about allergies as medium, and less than one out of four were aware of supportive digital tools. Previous studies reported poor knowledge of asthma, food allergy, and anaphylaxis management among school personnel, while personnel working in schools without any child with a known allergic disease were less knowledgeable.^{7, 9-11} However, up to 24% of children with history of anaphylaxis have their first episode at preschool/school.¹

Most respondents rated their safety/security as medium, while about one out of six reported high anxiety about children getting allergic reactions. In a previous study, concern was mostly associated with food allergy, in addition to anxiety, fear, and helplessness.¹² Anxiety and fear may reduce the capability of rational thinking in an emergency and can also lead to unnecessarily restrictive school environments.

Preschool personnel were more likely to reply that routines work well and report not only a high level of knowledge and security/safety but also high anxiety in comparison with school personnel. Age-appropriate measures are an integral component of recommendations, as children can take some responsibility with increasing maturity. Furthermore, personnel working in high SES areas were more likely to report a high level of knowledge and security/safety compared with those working in low.

Some limitations must be acknowledged. Recruitment occurred during the second wave of the COVID-19 pandemic, which probably impacted on the response rate. Nevertheless, the distribution of respondents at group level in sectors and SES areas is largely representative of Stockholm County population. The questionnaire was based on clinical experience and current literature due to lack of a validated tool, and although it was anonymized, respondents had to fill in their e-mail address. However, results are in line with previous studies, and should social desirability bias influence the results, that would mean that the true ratings would be even lower.

In conclusion, knowledge among personnel about prevention and management of allergies needs to be improved and routines need to be well implemented. More actions are needed, such as (i) promotion of school training for all personnel in the management of allergies, (ii) use of digital tools such as the Student Health Portal for health promotion at school, including the allergy field, (iii) national policies, for example, IHP for all children with allergy from the healthcare system, written self-care plans at school, and local policies such as site-wide protocols for the management of allergic reactions, that address the needs of personnel and children and offer implementation support. This study additionally identified differences by preschool/school and area SES, which could guide future studies. Such interventions may reduce anxiety among personnel, improve communication with parents and care for children with allergy so that the latter can eventually obtain the same conditions and development as their peers.

过敏性疾病在儿童中很常见，可能在学前班或学校首次出现。¹它们可能会损害学校表现、降低生活质量并引起严重反应。^{2, 3}家长经常担心孩子在学校的安全。只有很少的研究调查了学校里过敏儿童的管理。¹在瑞典，国家卫生和福利委员会的一份报告（2013 年）旨在通过系统审查来描述过敏儿童的学校环境，发现了一系列问题，包括室内和室外环境、特殊环境等。饮食、教学以及与父母的沟通。⁴ 2015 年，瑞典过敏学会提供了过敏反应管理建议，包括学校书面个人医疗保健计划 (IHP)。⁵最近，国家食品局 (2021) 更新了国家学前班/学校膳食指南（免费向所有学生提供），包括特殊饮食。⁶这项调查的目的是评估学前班和学校工作人员在处理患有各种过敏症（无论严重程度如何）的儿童时的常规、知识水平和安全/担忧。

2021-2022年，我们联系了斯德哥尔摩县148所幼儿园（≤5岁儿童）和181所小学/初中（称为学校，6-16岁）的校长，并要求向所有人员分发调查问卷。大多数幼儿园/学校至少有一名学生被转介给儿童过敏护士。后者是在过敏方面具有专业能力的儿科护士，他们在医生转诊过敏儿童后为斯德哥​​尔摩县的学前班/学校人员提供支持。该调查问卷是由多学科团队根据临床经验和当前文献制定的。来自斯德哥尔摩县 26 个市镇中 18 个市镇的 42 所幼儿园（每所 1-18 所）和 30 所学校（3-58 所）的工作人员同意参加。参与是自愿和匿名的，随后进行了过敏管理的教育干预。提供了书面知情同意书。该研究得到了瑞典伦理审查局的批准（Dnr 2020-02424）。

由于数据分布不均匀，序数变量（10 点李克特量表）被分为低（1-4）、中（5-8）和高（9、10）响应类别。我们考虑了学前班/学校地点，并根据地区社会经济指数将其分为低（1-3 类）和高（4-5 类）地区社会经济地位 (SES)。考虑到学校集群，通过适当的多项式和序数逻辑回归来测试学前班/学校和地区社会经济地位的反应差异。p值<.05被认为具有统计显着性。

在 1002 名受访者中，35.6% 在幼儿园工作，64.4% 在学校工作；86.9%是教师，4.8%是校长，3.1%是学校供餐人员，1.7%是学校护士。他们在不同的环境中工作；公共部门为 75.0%，私营部门为 25.0%；高 SES 区域为 74.8%，低 SES 区域为 25.2%（表 S1）。

其中，78.0%、73.2%和86.3%的受访者回答说，幼儿园/学校有如何照顾过敏儿童（身体和心理护理）、如何管理过敏反应以及如何管理过敏儿童的特殊饮食的常规。回答“不”的人分别为5.6%、6.5%和3.3%，回答“不知道”的人分别为16.4%、20.4%和10.4%（图1）。

表 S2 总结了 10 分制的回答。大约一半 (48.9%) 的受访者对过敏儿童的日常护理给予高度评价，44.8% 的受访者对过敏反应的管理给予高度评价，63.1% 的受访者对特殊饮食给予高度评价。相比之下，7.7%、11.2%和5.1%的人分别给出了较低的评级（表1）。超过一半（范围 52.6%–56.9%）的人认为自己对特定过敏的了解程度为中等，不到 33.0% 的人认为自己对特定过敏的了解程度为高。此外，53.9%和43.5%的人认为自己对过敏反应管理和特殊饮食的了解为中等，20.8%和40.8%的人分别为高。

超过一半的人将照顾过敏儿童时的安全性（感知风险）和与过敏儿童见面时的安全性（安全环境带来的实际风险）评为中等（分别为 56.4% 和 55.2%），不到 33.0% 的人将其评为高（图2）。此外，13.0%的人对儿童出现过敏反应感到高度焦虑，17.5%的人对食物过敏的儿童吃到不适当的食物感到高度焦虑。大约一半（48.7%）的人认为自己与过敏儿童家长的沟通程度为“高”，42.1%的人认为“中等”。当被问及他们与理想工作场所的距离有多远时，63.7% 的人给出了中等评价，20.9% 的人给出了低评价。只有 23.4% 的人知道学生健康门户网站 (www.elevhalsoportalen.se)，该网站旨在支持学前班/学校人员进行健康促进，包括过敏领域；其中，29.7% 的人在工作场所使用它。

与学校工作人员相比，学前班工作人员更有可能对日常活动、过敏及其管理知识水平给予较高评价，而学校工作人员更有可能对日常活动的可用性回答“不知道”。学前班人员更有可能表现出高度的安全感，但也表现出高度的焦虑。此外，高 SES 地区的人员更有可能报告高水平的知识和高安全性（表 S3），而高 SES 地区的学校人员与低 SES 地区的学校人员相比，更有可能对日常事务给予高评价。 SES 领域。

在这项研究中，虽然大多数受访者表示有可用的例程，但有 10.0% 至 20.0% 的人不知道是否有例程，只有约一半的受访者表示这些例程效果良好。建议有过敏反应风险的儿童的学前班/学校制定书面个性化护理计划，并配备接受过肾上腺素使用培训的工作人员。¹在瑞典，肾上腺素是在彻底的医疗保健调查后单独开具的，目前幼儿园/学校没有可用的肾上腺素自动注射器，但儿童将其个人自动注射器提交到现场存放。此外，学校培训通常是根据要求提供的，这将责任归于学校管理层。⁷在这方面，指导方针强调了全校办法的重要性，授权所有人员在学校期间为儿童提供支持。⁸因此，需要在明确的学校政策范围内开展涉及人员、医疗保健、过敏儿童及其家长的日常工作。

大多数受访者将他们对过敏的了解评为中等，不到四分之一的人知道支持性数字工具。此前的研究表明，学校工作人员对哮喘、食物过敏和过敏反应管理知之甚少，而在没有已知患有过敏性疾病的孩子的学校工作的人员知识也较少。^{7, 9-11}然而，高达 24% 有过敏反应史的儿童在学前班/学校首次发作。¹

大多数受访者将其安全性评为中等，而大约六分之一的受访者表示对儿童过敏反应高度焦虑。在之前的一项研究中，除了焦虑、恐惧和无助之外，担忧主要与食物过敏有关。¹²焦虑和恐惧可能会降低紧急情况下的理性思考能力，也可能导致学校环境受到不必要的限制。

学前班工作人员更有可能回答说，与学校工作人员相比，日常工作进行得很好，不仅知识水平高，安全/安全水平高，而且焦虑程度高。适合年龄的措施是建议的一个组成部分，因为随着年龄的增长，儿童可以承担一些责任。此外，与低社会经济地位地区工作的人员相比，在高社会经济地位地区工作的人员更有可能报告高水平的知识和安全/安全。

必须承认一些限制。招募发生在第二波 COVID-19 大流行期间，这可能会影响响应率。尽管如此，受访者在部门和社会经济地位区域的群体层面的分布在很大程度上代表了斯德哥尔摩县的人口。由于缺乏经过验证的工具，该调查问卷是基于临床经验和现有文献，虽然是匿名的，但受访者必须填写他们的电子邮件地址。然而，结果与之前的研究一致，如果社会期望偏差影响结果，那就意味着真实的评分会更低。

总之，人员过敏预防和管理知识有待提高，日常工作有待落实。需要采取更多行动，例如（i）促进对所有人员进行过敏管理方面的学校培训，（ii）使用学生健康门户等数字工具在学校促进健康，包括过敏领域，（iii）国家政策，例如医疗保健系统针对所有过敏儿童的国际健康计划、学校书面自我保健计划以及地方政策，例如管理过敏反应的全站点协议，以满足工作人员和儿童的需求，提供实施支持。这项研究还确定了学前班/学校和地区社会经济地位的差异，这可以指导未来的研究。这些干预措施可以减少工作人员的焦虑，改善与家长的沟通以及对过敏儿童的照顾，使后者最终获得与同龄人相同的条件和发展。