A mother calls the pediatrician’s office to request an excuse note for her child who missed several school days due to asthma. The asthma episodes have been managed at the emergency department and the office. However, the child infrequently uses the prescribed controller or rescue inhaler due to parental work hours, alternating weeks between households and other social challenges. How can you improve this patient’s medication use?
School nurses and other staff members share pediatricians’ goals for improving students’ health so youth can attend school regularly and participate in extracurricular activities. School health teams can be allies in ensuring medication is accessible and administered safely at school.
Understanding the roles within local school health teams can help pediatricians collaborate more effectively on school medication orders and administration so that youth can thrive in school regardless of disability, health condition or socioeconomic conditions.
The updated AAP policy statement Safe Administration of Medication in School offers evidence-based guidance to pediatric teams, clinical and nonclinical school staff, and policymakers to promote safe medication ordering, storage and administration. The policy, from the Council on School Health and the National Association of School Nurses, is available at https://doi.org/10.1542/peds.2024-066839 and will be published in the June issue of Pediatrics.
How medications are administered in schools
School nurses manage many medications, including insulin, selective serotonin reuptake inhibitors, epinephrine and cannabinoids approved by the Food and Drug Administration (FDA). However, the number of school nurses assigned to individual school buildings has not always kept pace with students’ needs. Therefore, many school districts designate unlicensed assistive personnel (UAP) such as teachers, administrative staff, paraprofessionals and coaches to administer specific medications.
Community prescribers are responsible for writing orders so medications are administered safely and effectively. Therefore, they should contact the school nurse to learn which team members may administer specific medications and how the nurse trains and supervises these staff members. UAP cannot make clinical decisions, so they may be unable to carry out PRN orders such as “inhale every four hours for wheezing.”
Prescribers also should include parents and youth in medication planning to reinforce safe administration.
A table in the policy statement provides a framework for safe medication administration in the school setting. It lists several “rights,” including verifying that the right medication is being given to the right student, in the right dose, using the right route and at the right time.
Another table lists resources to manage specific medical conditions, including asthma, diabetes, epilepsy and substance use overdose, in schools.
The policy also summarizes considerations school nurses use to assess the developmental ability of students to self-carry and self-administer medications. Pediatricians can get feedback from school nurses on whether a patient is self-administering medication successfully and reinforce training during office encounters.
Evolving challenges
The policy acknowledges the challenges of addressing school medication safety when new therapeutic substances are introduced frequently. For example, school health teams may be asked to create policies on school administration of cannabis products that may be legal in their jurisdiction but are not regulated by the FDA.
Although the AAP opposes the use of “medical marijuana” outside the FDA’s regulatory process, the interdisciplinary teams caring for students may look to pediatricians for guidance on best practices if states were to approve school administration of non-FDA-regulated cannabis products. The policy encourages school health teams to develop and implement administration policies for cannabis products using the same safety lens applied to all school-based medications and require school nurses to store, sign out and track these products.
The policy statement also notes that developing and implementing policies and procedures on orders, family consent, safe packaging and labeling, and self-administration assessment for over-the-counter (OTC) and prescribed medications will create an environment of safety for the student and school community.
Key actions and recommendations
The policy statement includes the following recommendations for practice and advocacy:
- Consider the risks and benefits of school medication administration before sending an order to school, including ideal and feasible dosing intervals, the family’s ability to administer required medications at home before or after school, and potential adverse medication effects.
- Understand local school health staffing when writing orders and collaborating on medication management, particularly for students with chronic medical conditions.
- Standardize medical home workflows to review all school medication orders at annual preventive care visits and complete applicable school forms for any new or updated medication orders.
- Collaborate with state departments of health and education to advocate for appropriate and evidence-based school staffing workloads, school nurse oversight of medication administration and role-specific training of all school health staff to promote student safety.
Dr. Miotto is a lead author of the policy statement and a member of the AAP Council on School Health.
