The psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families: a review

Long-term sublingual immunotherapy for peanut allergy in children: Clinical and immunologic evidence of desensitization

BACKGROUND

Peanut sublingual immunotherapy (SLIT) for 1 year has been shown to induce modest clinical desensitization in allergic children. Studies of oral immunotherapy, epicutaneous immunotherapy, and SLIT have suggested additional benefit with extended treatment.

OBJECTIVE

We sought to investigate the safety, clinical effectiveness, and immunologic changes with long-term SLIT in children with peanut allergy.

METHODS

Children with peanut allergy aged 1 to 11 years underwent extended maintenance SLIT with 2 mg/d peanut protein for up to 5 years. Subjects with peanut skin test wheals of less than 5 mm and peanut-specific IgE levels of less than 15 kU/L were allowed to discontinue therapy early. Desensitization was assessed through a double-blind, placebo-controlled food challenge (DBPCFC) with up to 5000 mg of peanut protein after completion of SLIT dosing. Sustained unresponsiveness was further assessed by using identical DBPCFCs after 2 to 4 weeks without peanut exposure.

RESULTS

Thirty-seven of 48 subjects completed 3 to 5 years of peanut SLIT, with 67% (32/48) successfully consuming 750 mg or more during DBPCFCs. Furthermore, 25% (12/48) passed the 5000-mg DBPCFC without clinical symptoms, with 10 of these 12 demonstrating sustained unresponsiveness after 2 to 4 weeks. Side effects were reported with 4.8% of doses, with transient oropharyngeal itching reported most commonly. Side effects requiring antihistamine treatment were uncommon (0.21%), and no epinephrine was administered. Peanut skin test wheals, peanut-specific IgE levels, and basophil activation decreased significantly, and peanut-specific IgG4 levels increased significantly after peanut SLIT.

CONCLUSION

Extended-therapy peanut SLIT provided clinically meaningful desensitization in the majority of children with peanut allergy that was balanced with ease of administration and a favorable safety profile.

Understanding how consumers with food allergies make decisions based on precautionary labelling

BACKGROUND

Understanding consumer perceptions is crucial if effective food safety policy and risk communication are to be developed and implemented. We sought to understand how those living with food allergy assess risk with precautionary allergen labelling (PAL) and their preference in how risks are communicated within a quantitative risk assessment (QRA) framework.

METHODS

The Integrated Approaches to Food Allergen and Allergy Risk Management (iFAAM) labelling online survey was developed for adults and parents of children with food allergy and distributed across Germany, Ireland, Netherlands, Spain and UK via patient support groups.

RESULTS

There were 1560 complete responses. 'This product is not suitable for' was selected as first choice for PAL by 46% overall and 'May contain' was selected as the first choice by 44%. Seventy-three percent reported that it would improve their trust in a product if a QRA process had been used to make a decision about whether to include 'may contain'. Overall, 66% reported that a 'statement + symbol' on the label indicating a QRA, would help them to understand the risk assessment process that had been used by the food manufacturer.

CONCLUSIONS

Consumers want to know what process has actually taken place for the placing of a PAL and/or risk assessment statement on a particular food product. Our findings provide a basis for the development of more informative communication around food allergen risk and safety and support evidence-based policy-making in the context of the legislative requirements of the European Union's Food Information for Consumers Regulation.

Managing Younger Siblings of Food Allergic Children

Current guidelines state that there is insufficient evidence to recommend testing siblings of food allergic children before introduction of potential allergic foods, but the topic continues to remain controversial. Although the proportion of siblings who are sensitized to a food without clinical reactivity is high in comparison to those with a true food allergy, there is still a known increased risk amongst siblings of children with food allergies that has led to much apprehension about management. The appropriateness of testing and further steps for management of sensitization in the absence of history of clinical reactivity should be discussed with parents.

Beyond Avoidance: the Psychosocial Impact of Food Allergies

Over the past few years, the rates of food allergies have dramatically increased. As a result, the lives of patients and their caregivers have been dramatically altered. While most attention surrounding food allergies has focused on treatment, less consideration has been given to the mental health ramifications of living with this condition, among them depression, anxiety, post-traumatic stress, being bullied, and an overall poorer quality of life. At the same time, patients' family lives are often disrupted. Parents of food-allergic children, especially mothers, report anxiety, depression, and a decreased quality of life. Indeed, mental health issues associated with food allergies are likely underrecognized. In this review, we describe not only the psychosocial impacts of food allergies but also survey treatments that can be used to address this burgeoning problem. Interventions include educating members of the greater community about food allergies, camps for food allergic children, and support groups for parents. For physicians, treatment options consist of oral challenges, proximity challenges, oral immunotherapy, and cognitive behavioral therapy. Although the existing research is built on an already strong foundation, ultimately more studies are needed to deepen our understanding of the relationship between food allergies and mental health.

Evaluation of the healthcare resource use and the related financial costs of managing peanut allergy in the United Kingdom

Aims: We aimed to estimate the resource use and associated costs for patients with peanut allergy (PA) compared to matched controls. Methods: This was a retrospective cohort study using data from the UK Clinical Practice Research Datalink and Hospital Episode Statistics. PA patients were matched to two control cohorts: the first (simple-matched) were matched 1:1 on year of birth, general practice, gender and registration year. The second (atopy-matched) were matched on the same characteristics plus presence/absence of an atopic condition. Prescriptions and primary and secondary care contacts were compared between cases and controls. Results: 15,483 peanut-allergic patients were identified: 13,609 (87.9%) were simple-matched and 9,320 (60.2%) atopy-matched. The total per person annual incremental health-care costs associated with PA were £253 (atopy-matched) and £333 (simple-matched). For those with PA and a prior anaphylaxis incremental costs were £662, for those prescribed an epinephrine autoinjector incremental costs were £392. Extrapolated to the U.K. population, total excess costs of PA were between £33 and 44 million in 2015. Conclusions: Patients with PA had increased health-care contacts and consequently increased associated costs compared to controls. Observation bias should be considered in interpretation, but this study suggests that PA presents significant burden to health-care systems.

What makes women with food hypersensitivity do self-management work?

Background

Managing a chronic condition takes work, and it is considered important that patients carry out this work. However, knowledge is lacking on what elements enhance self-management work.

Persons with food hypersensitivity (FH) seem to do self-management work despite the relatively little support they receive. Our aim is to explore what makes women with FH carry out the work of managing their condition. Our research will shed light on the health care needs of women with FH and contribute to the knowledge on self-management among persons with chronic conditions.

Methods

We used the Self-determination theory and the Conservation of resources theory to analyze 16 qualitative individual interviews with women with FH aged 39–67 years.

Results

Our participants reported that eating selected foods resulted in uncomfortable symptoms, and their main motivation for carrying out self-management work was the wish to avoid these symptoms and their consequences.

Participants’ individual resources were crucial to the management of FH, and those who had a social network that included people with relevant competencies clearly benefited from this.

Hindrances to the management of FH included competing priorities and not wanting to break with the social expectation of sharing a meal.

Conclusions

Women with FH carried out self-management work because they were highly motivated. Important motivators included the uncomfortable symptoms that resulted from consuming some foods, which had negative consequences on their lives or could bring shame. The ability to perform self-management work was dependent on the availability of individual and social resources. Indeed, women with FH who have the individual and social resources necessary to manage their condition may not need health services, whereas those who do not have these resources, or have significant competing priorities, may need assistance from health services.

The desire to avoid uncomfortable symptoms can be a motivator for persons with chronic conditions to do self-management work, while a lack of symptoms can reduce motivation. The competing role of basic needs can take two forms: when fulfilled, these needs may contribute to self-management work; however, people may opt out of self-management in order to fulfil basic needs.

First Real-World Safety Analysis of Preschool Peanut Oral Immunotherapy

BACKGROUND

In 2017, a clinical trial of 37 subjects demonstrated that preschool peanut oral immunotherapy (P-OIT) was safe, with predominantly mild symptoms reported and only 1 moderate reaction requiring epinephrine.

OBJECTIVES

We sought to examine whether these findings would be applicable in a real-world setting.

METHODS

As part of a Canada-wide quality improvement project, community and academic allergists administered P-OIT to preschool-age children who had (1) skin prick test wheal diameter greater than or equal to 3 mm or specific IgE level greater than or equal to 0.35 kU/L and history of reaction and/or positive baseline oral food challenge, or (2) no ingestion history and specific IgE level greater than or equal to 5 kU/L. Over 16 to 22 weeks, patients had biweekly clinic visits for updosing, and consumed the dose daily at home between visits. Target maintenance dose was 300 mg peanut protein. Symptoms were classified using a modified World Allergy Organization Subcutaneous Immunotherapy Reaction Grading System (1 mildest, 5 fatal).

RESULTS

Of 270 patients who started P-OIT in the period 2017 to 2018, 243 reached maintenance, and 27 dropped out (10.0%); 67.8% of patients experienced reactions during buildup: 36.3% grade 1, 31.1% grade 2, and 0.40% grade 4. Eleven patients (4.10%) received epinephrine (10 patients received 1 dose, 1 patient received epinephrine on 2 separate days), representing 2.23% of reactions (12 of 538) and 0.029% of doses (12 of 41,020).

CONCLUSIONS

We are the first group to describe preschool P-OIT in a real-world multicenter setting. The treatment appears to be safe for the vast majority of patients because symptoms were generally mild and very few reactions received epinephrine; however, life-threatening reactions in a minority of patients (0.4%) can still occur.

How to manage food allergy in nursery or school

PURPOSE OF REVIEW

The aim of this review is to describe effective management strategies in nursery or school based upon research findings.

RECENT FINDINGS

The prevalence of food allergy and number of emergency department visits for food-related anaphylaxis are increasing in children and adolescents. As there is currently no cure, the most effective strategy to decrease allergic reactions is food allergen avoidance. However, allergic reactions are inevitable in both food allergic children as well as in first-time reactors. Misconceptions exist on the safety of products with advisory labels and questions remain on whether school-wide bans decrease the risk of allergic reactions in school. Recent legislation has prompted schools to consider requiring unassigned epinephrine autoinjectors to better manage those who have allergic reactions in nursery or school.

SUMMARY

A collective effort is required to keep children with food allergies safe at school. Families, healthcare providers, and school personnel should be informed on food allergen avoidance strategies, symptoms consistent with allergic reactions and anaphylaxis, how to respond to allergic reactions, and the impact the diagnosis of food allergy may have on quality of life for affected children and their families.

Prevalence of food allergy among schoolchildren in Kuwait and its association with the coexistence and severity of asthma, rhinitis, and eczema: A cross-sectional study

BACKGROUND

Food allergy (FA) is a common public health problem that affects both children and adults. Empirical knowledge of the burden of FA in Kuwait is limited. This study sought to estimate the prevalence of FA among schoolchildren in Kuwait and assess associations between FA and the coexistence and severity of asthma, rhinitis, and eczema.

METHODS

Schoolchildren aged 11-14 years (n = 3,864) were enrolled in a cross-sectional study. Parents completed questionnaires regarding their children's early life exposures and clinical history of FA and allergic diseases. Study-defined FA was ascertained by a convincing clinical history. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated.

RESULTS

The 12-month prevalence of study-defined FA was estimated to be 4.1% (154/3,738), with more girls being affected than boys (aPR = 1.44, 95% CI: 1.04-1.99). Egg (2.7%), fish (1.6%), shellfish (1.3%), peanut (1.3%), and tree nut (1.2%) were the most reported offending food allergens. Underweight and adiposity, cesarean section delivery, exposure to household dogs during infancy, and parental history of doctor-diagnosed FA were associated with an increased prevalence of study-defined FA. However, later birth order was associated with a reduced prevalence of study-defined FA. The prevalence of eczema only was higher in children with study-defined FA than in those without study-defined FA (aPR = 3.49, 95% CI: 2.37-5.14). In contrast, this association was not pronounced for children who had asthma only (aPR = 1.56, 95% CI: 0.94-2.57) or rhinitis only (aPR = 1.40, 95% CI: 0.86-2.28). Study-defined FA was associated with a 9.20-fold (95% CI: 4.50-18.78) higher prevalence of coexisting asthma, rhinitis, and eczema. Moreover, study-defined FA was associated with increased severity of symptoms of asthma, rhinitis, and eczema.

CONCLUSIONS

FA affects a considerable proportion of schoolchildren in Kuwait, and the most reported offending food allergens are similar to those reported in Western countries. Study-defined FA was associated with the coexistence and increased severity of asthma, rhinitis, and eczema, indicating that FA may link the comanifestations of allergic diseases and contribute to their chronicity and severity.

Walnut oral immunotherapy for desensitisation of walnut and additional tree nut allergies (Nut CRACKER): a single-centre, prospective cohort study

BACKGROUND

The safety and efficacy of oral immunotherapy for tree nut allergy has not been demonstrated to date, and its effectiveness is complicated by the high prevalence of co-allergies to several nuts. This study aimed to investigate the use of walnut oral immunotherapy in the desensitisation of walnut and additional tree nuts in patients who are co-allergic to several nuts.

METHODS

In a single-centre, prospective cohort study (the Nut Co-Reactivity ACquiring Knowledge for Elimination Recommendations study) at the Institute of Allergy, Immunology, and Paediatric Pulmonology at the Yitzhak Shamir Medical Centre, we recruited patients aged 4 years or older who were allergic to walnut, with or without co-allergy to pecan, hazelnut, and cashew. The diagnosis of each food allergy was based on a positive skin prick test or specific serum IgE (≥0·35 kU_A/L) to the corresponding nut together with a positive oral food challenge, unless an immediate (within 2 h of exposure) reaction in the past year had been documented. Patients with uncontrolled asthma or a medical contraindication to receive adrenaline were excluded. Patients were assigned to walnut oral immunotherapy or the control group (observation and strict dietary exclusion) on the basis of the order of presentation to the clinic. Oral immunotherapy began with a 4-day dose-escalation phase to establish the single highest tolerated dose, which was consumed daily at home for 24 days; subsequent monthly dose escalations were repeated until 4000 mg walnut protein was achieved. Patients who were desensitised to walnut continued to consume 1200 mg walnut protein daily for 6 months as maintenance. The primary outcome was walnut desensitisation (passing an oral food challenge with 4000 mg of walnut protein) at the end of the study, analysed by intention to treat. In patients who were co-allergic to pecan, hazelnut, and cashew, the proportion who achieved cross-desensitisation to these nuts in addition to walnut desensitisation was examined.

FINDINGS

73 patients with a walnut allergy were enrolled between May 15, 2016, and Jan 14, 2018. 49 (89%) of 55 patients in the oral immunotherapy group were desensitised to walnut compared with none of 18 patients in the control group (odds ratio 9·2, 95% CI 4·3-19·5; p<0·0001). Following walnut desensitisation, all patients who were co-allergic to pecan (n=46) were also desensitised to pecan. Additionally, 18 (60%) of 30 patients who were co-allergic to hazelnut or cashew, and 14 (93%) of 15 patients who were co-allergic to hazelnut alone, were either fully desensitised or responded to treatment. 47 (85%) of 55 patients had an adverse reaction (mostly grade 1 or 2) during up-dosing in the clinic; eight patients required intramuscular epinephrine in response to a dose at home. Of 45 patients who had follow-up data for the maintenance phase, all maintained walnut desensitisation and one patient required epinephrine during this period.

INTERPRETATION

Walnut oral immunotherapy can induce desensitisation to walnut as well as cross-desensitisation to pecan and hazelnut in patients who have tree nut co-allergies, with a reasonable safety profile. A low daily dose of the allergen maintains desensitisation.

FUNDING

None.

Food allergy is associated with depression and psychological distress: A web-based study in 11,876 Japanese

BACKGROUND

Although some studies suggest a possible association between food allergy (FA) and depression/psychological distress, empirical data are still scarce. We aimed to examine whether this association exists in a large sample of the Japanese population.

METHODS

This web-based cross-sectional survey included 1000 individuals with self-reported lifetime history of clinical depression (mean age: 41.4 years, 501 men), and the remaining 10,876 subjects served as controls (mean age: 45.1 years, 5691 men). A six-item Kessler scale (K6) test was used to evaluate severe psychological distress. Information on FA was obtained by a self-report checking for 27 specific allergens.

RESULTS

Participants with FA, 2 or more, 3 or more, and 4 or more allergens were more common in the depression group than in the control group (odds ratio [OR] = 1.64, 1.75, 2.02, and 2.27, respectively; p < 0.001). In the allergen analyses, allergies for shrimp, egg, mackerel, crab, kiwi fruit, milk, banana, and squid (nominal, p < 0.05) were more common in the depression group than in the controls. The proportion of individuals who had a K6 test cut-off score ≥ 13 was higher in the FA group than in the non-FA group, in the total sample (OR = 1.32, 1.62, 2.04 and 2.51; 1, 2, 3, and 4 or more allergens, respectively; p < 0.001).

LIMITATIONS

The identification of FA and depression was based on self-reports.

CONCLUSIONS

Our data suggest that FA is a risk factor for depression and severe psychological distress, which depends on the number of allergens.

Health-related quality of life worsens by school age amongst children with food allergy

Background

Food allergy is negatively associated with health-related quality of life (HRQL). Although differences exist between parents and children, less is known about age-specific differences amongst children. As such, we aimed to identify if age, as well as other factors, are associated with food allergy-specific HRQL in an objectively defined population of children.

Methods

Overall, 63 children (boys: n = 36; 57.1%) with specialist-diagnosed food allergy to 1 + foods were included. Parents/guardians completed the Swedish version of a disease-specific questionnaire designed to assess overall- and domain-specific HRQL. Descriptive statistics and linear regression were used.

Results

The most common food allergy was hen’s egg (n = 40/63; 63.5%). Most children had more than one food allergy (n = 48; 76.2%). Nearly all had experienced mild symptoms (e.g. skin; n = 56/63; 94.9%), and more than half had severe symptoms (e.g. respiratory; 39/63; 66.1%). Compared to young children (0–5 years), older children (6–12 years) had worse HRQL (e.g. overall HRQL: B = 0.60; 95% CI 0.05–1.16; p < 0.04.). Similarly, multiple food allergies, and severe symptoms were significantly associated with worse HRQL (all p < 0.05) even in models adjusted for concomitant allergic disease. No associations were found for gender or socioeconomic status.

Conclusion

Older children and those with severe food allergy have worse HRQL.

Electronic supplementary material

The online version of this article (10.1186/s13601-019-0244-0) contains supplementary material, which is available to authorized users.

Next-Generation Approaches for the Treatment of Food Allergy

PURPOSE OF REVIEW

IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance.

RECENT FINDINGS

Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options. This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.

Preliminary psychometric analyses and clinical performance of a caregiver self-efficacy scale for food allergy self-management

BACKGROUND

Food allergy health-related quality of life has been defined, but self-efficacy is poorly described.

OBJECTIVE

To examine the preliminary reliability, validity, and clinical performance of a novel food allergy self-efficacy index.

METHODS

An 8-item Food Allergy Self-Efficacy Questionnaire (FASEQ) was adapted for food allergy-related themes and coadministered with the Food Allergy Quality of Life Parental Burden (FAQL-PB) index to caregivers self-reporting a food allergic child (group A) and those with children followed up at a food allergy referral center clinic (group B). FASEQ split-half reliability, 2-week recall, factor analysis, and construct and discriminative validity were assessed. Multiple linear regression was used to explore predictive associations between the FAQL-PB and the FASEQ.

RESULTS

Among 2,308 caregivers, the mean FASEQ score was 2.69 (95% CI, 2.66-2.73) and was lower (better) among group A (mean FASEQ score, 2.52; 95% CI, 2.49-2.56) vs group B (mean FASEQ score, 3.75; 95% CI, 3.66-3.84; P < .001). The FASEQ Cronbach α was 0.87, and the 2-week intraclass correlation coefficient (ICC) was 0.75. Total and 6 of 8 individual FASEQ domain scores were significantly lower among caregivers with children having anaphylaxis or epinephrine use vs none and peanut or tree nut allergy vs milk or egg allergy, demonstrating good discriminative validity. Total FASEQ score was associated with FAQL-PB score (ICC, 0.13; 95% CI, 0.06-0.19; P < .001), with 6 of 8 FASEQ individual domains significantly associated (ICC range, -0.17 to 0.3; P < .01 for all). Factor analysis revealed 2 domains (medical care and social functioning) with construct validity.

CONCLUSION

We present preliminary evidence the FASEQ is a valid tool to assess caregiver food allergy self-efficacy. Self-efficacy is a distinct but related concept that captures aspects of self-management that are an important companion to health-related quality of life.

Psychosocial Mediators of Change and Patient Selection Factors in Oral Immunotherapy Trials

Health-related quality of life (HRQL) is influenced by physiological, psychological, and environmental variables and can be best understood by considering the interactions of factors that cut across multiple levels. One of the most important issues relating to treatment in food allergy is to identify, describe, and define predictors that may contribute to modify HRQL outcomes. The research presented demonstrates that measures of HRQL are able to distinguish key features of known groups (e.g. relating to reaction severity, treatment, allergen type/number, expectation of outcome) and delineate impact on hitherto unknown groups (e.g. relating to personality types and coping styles). This heterogeneity may explain why HRQL or other patient-related outcomes may differ in individuals during, or following any treatment or intervention. Patient-reported outcomes are relatively poorly defined to date. Since HRQL has only been studied in relatively few oral immunotherapy trials to date, primarily looking at caregiver HRQL, it is unclear which factors, measures, or subscales are most predictive of short- and/or long-term treatment outcomes for which type of patient, and which time points for measurement are most informative. A standardised protocol that incorporates HRQL and other relevant patient-related outcome measures and agreed definitions of outcomes would allow for the comparison of efficacy of food allergy treatments between centres, trials, or countries. Further evidence-based research aimed at exploring the effects of interventions on outcomes in food allergy is needed, including the influence of patient and parent factors on protocol design. To this end, it is vital that patient-related outcomes such as improved HRQL are seen as a primary outcome and are measured at multiple intervals during the trial duration and beyond. The creative use of methods and designs (both qualitative and quantitative) to better understand the role of HRQL in immunotherapy treatment trials will enable improved modelling of the costs, risks, and benefits of any treatment. Systematic analysis and modelling of antecedent factors, mediators, and outcomes will be important to boost intervention effects and to maximise the overall benefits of treatment.

Reduced Final Height and Inadequate Nutritional Intake in Cow's Milk-Allergic Young Adults

BACKGROUND

Growth impairment was previously described in milk-allergic children but was not examined in adults on reaching final height.

OBJECTIVES

To investigate the dietary intake and final stature of young adults with IgE-mediated cow's milk allergy (IgE-CMA) as compared with nonallergic controls.

METHODS

Eighty-seven patients with IgE-CMA, median age 19.5 years (interquartile range [IQR], 17.3-22.7), and 36 control participants without food allergies, median age 22.7 years (IQR, 18.9-26.1), were studied. Anthropometric and nutritional data were collected. Age and gender z-scores were determined according to the Centers for Disease Control and Prevention growth charts. Nutrient intake assessment was based on dietary records. Individuals with conditions or treatments affecting bone metabolism or growth, other than asthma, were excluded.

RESULTS

Mean values of height z-scores were significantly reduced in CMA subjects compared with controls (-0.64 ± 0.9 vs -0.04 ± 0.7, P = .001). In contrast, no differences were found between the 2 groups in weight and body mass index z-scores. Patients with CMA had significantly lower intake of protein, and several essential vitamins (A, B12, and riboflavin) and minerals (calcium, potassium, phosphorus, magnesium, and zinc) compared with controls (P < .05), but the intakes of calories, carbohydrate, and fat were not significantly different between the 2 groups. Differences between actual and expected (based on midparental height) height z-scores were comparable in CMA subjects with or without asthma and between those with and without additional food allergies.

CONCLUSIONS

Young adults who have CMA from infancy are at risk of not reaching their growth potential. Growth and nutritional monitoring and appropriate dietary intervention are of particular importance in these at-risk individuals.

Comparing the eating out experiences of consumers seeking to avoid different food allergens

Background

Eating outside the home is challenging for consumers with food allergy (FA) and intolerance (FI) and lack of allergen information provision in eating out venues can lead to unnecessary restrictions. Following European legislation (2014) designed to improve allergen information provision, little is known about differences in information provision experienced by consumers seeking to avoid particular allergens, or how this impacts on their eating out experiences. This study compared the information provision that consumers with FA/FI to different allergens experience when eating out.

Methods

Using mixed methods, participants were recruited from across the UK and took part in self-report surveys or in-depth interviews. Surveys were completed by 232 participants avoiding either gluten (n = 66), nuts (peanuts/tree nuts) (n = 94), or milk (n = 74), and responses were subject to quantitative analyses. Interviews were carried out with 49 participants avoiding either gluten (n = 13), nuts (n = 14), milk (n = 13) or a combination of these allergens (n = 9), and analysed using the framework approach.

Results

Although general improvements in information provision following the legislation were reported, variations in provision between allergen groups led participants seeking to avoid milk to conclude that their dietary needs were less well-understood and seen as less important. These perceptions were reflected in a reluctance to involve eating out venue staff in deliberations about the potential for milk-free meal options.

Conclusions

The provision of visual indicators of the presence of milk and of staff trained in allergen-awareness would improve the eating out experiences of consumers seeking to avoid milk. Medical professions can play a key role in encouraging these patients to pursue their right to make enquiries about allergens in order to avoid accidental milk ingestion when eating out.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6117-y) contains supplementary material, which is available to authorized users.

A general strategy for de novo immunotherapy design: the active treatment of food allergy

INTRODUCTION

IgE-mediated food allergy (FA) has been emerging as a public health priority. It is a potentially life-threatening condition with negative impact on the quality of life of patients and their family and its prevalence is increasing in westernized countries in the recent two decades. The current standard approach to FA consists of the strict avoidance of the triggering food. However, an elimination diet may be difficult and frustrating, above all for those foods (e.g. milk and egg) that are pivotal in the common diet. Oral immunotherapy (OIT) may increase the amount of food that the patient can intake without reaction and reduce the risk of potential life-threatening allergic reactions. It is currently considered the most promising treatment for FA. However, many gaps are still unsolved. Areas covered: The aim of this review is to shed light on the current evidence and the main needs in OIT in order to stimulate the development of longitudinal, prospective, and well-designed studies with the final goal of a 'precision medicine.' Expert commentary: Clinical trials for OIT conducted so far are extremely heterogeneous. The aim in the near future is to identify the most suitable candidates to OIT and algorithms for treatments tailored on well-characterized subpopulations of patients.

The future outlook on allergen immunotherapy in children: 2018 and beyond

Allergen immunotherapy (AIT) is the only currently available immune-modifying and aetiological treatment for patients suffering from IgE-mediated diseases. In childhood, it represents a suitable therapeutic option to intervene during the early phases of respiratory allergic diseases such as rhino-conjunctivitis and asthma, which is when their progression may be more easily influenced. A growing body of evidence shows that oral immunotherapy represents a promising treatment option in children with persistent IgE- mediated food allergy. The efficacy of AIT is under investigation also in patients with extrinsic atopic dermatitis, currently with controversial results. Furthermore, AIT might be a strategy to prevent the development of a new sensitization or of a (new) allergic disease. However, there are still some methodological criticisms, such as: a) the regimen of administration and the amount of the maintenance dose are both largely variable; b) the protocols of administration are not standardized; c) the description and classification of side effects is variable among studies and needs to be standardized; d) quality of life and evaluation of health economics are overall missing. All these aspects make difficult to compare each study with another. In addition, the content of major allergen(s) remains largely variable among manufacturers and the availability of AIT products differences among countries. The interest and the attention to AIT treatment are currently fervent and increasing. Well-designed studies are awaited in the near future in order to overcome the current gaps in the evidence and furtherly promote implementation strategies.

Quality of Life of Food-Allergic Patients Before, During, and After Oral Immunotherapy

BACKGROUND

Oral immunotherapy (OIT) for food allergy is demanding but data on patients' quality of life (QOL) throughout the process are limited.

OBJECTIVE

To characterize changes in QOL of food-allergic patients during and after OIT.

METHODS

In a prospective cohort study, the Food Allergy Quality of Life Questionnaire-Parental Form (FAQLQ-PF) was administered to parents of 191 consecutive children aged 4 to 12 years undergoing OIT for food allergy. Questionnaires were administered at OIT initiation, mid up-dosing, upon reaching maintenance, and after 6 months of follow-up. Age- and sex-matched food-allergic children (n = 48) not undergoing OIT served as controls.

RESULTS

FAQLQ-PF scores had significantly improved (decreased) from OIT initiation to reaching full maintenance (emotional impact [EI], 3.66-3.32, P = .001; food anxiety [FA], 3.90-3.32, P < .001; social and dietary limitation [SDL], 3.50-2.94, P < .001; and total score, 3.69-3.19, P < .001) and partial maintenance, whereas no change was noted in control patients. Worse baseline QOL, single food allergy, and a younger age predicted greater QOL improvement. Of the 85 (88.5%) patients who completed the FAQLQ-PF at mid up-dosing and for whom QOL deteriorated, a significant improvement was noted upon reaching maintenance. Additional significant improvement in QOL was observed in the 95 (88.8%) patients who completed the FAQLQ-PF 6 months after reaching maintenance (EI, 3.414-2.993, P = 0.049; FA, 3.37-2.593, P = .001; SDL, 2.989-2.264, P = .001; and total score, 3.266-2.614, P = .001).

CONCLUSION

The QOL of food-allergic children improves significantly upon reaching OIT maintenance, with additional improvement 6 months later. The detrimental effect of OIT on some patients' QOL during up-dosing is reversed upon reaching maintenance.

Life-Threatening Allergies: Using a Patient-Engaged Approach

BACKGROUND

Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community.

INTRODUCTION

Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic.

METHODS

This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions.

RESULTS

Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The median (range) demonstration score was 6 (5-6) for the video training module group and 4.5 (3-6) for the label group (p < 0.001).

DISCUSSION

Results suggest that the use of this novel m-health application can improve anaphylaxis symptom recognition and increase the likelihood of choosing the appropriate treatment. In addition, performing EAI steps in conjunction with the video training resulted in more accurate medication delivery with fewer missed steps compared to the use of written instructions alone.

CONCLUSION

The results suggest that mobile health decision support technology for anaphylaxis emergency preparedness may support traditional methods of training by providing improved access to anaphylaxis training in the community setting.

Food Allergy Management

The management of food allergies requires the cooperation of the food allergic person, physician, family, and social contacts. For children, school management of food allergies is a key component of the overall approach. Recognition of the signs and symptoms of allergic reactions and preparation to administer the appropriate treatment of mild and severe symptoms in the event of accidental exposure is necessary. Avoidance of food allergens is facilitated by label reading and dietary guidance is extremely important to minimize nutritional deficiencies. Medications and vaccines with food-derived excipients generally do not need to be avoided because, in most cases, they contain little food protein.

Food-Induced Anaphylaxis: an Update

PURPOSE OF REVIEW

This review aims to provide an update of recent advances in the epidemiology, clinical features and diagnosis, and management of food-induced anaphylaxis (FIA).

RECENT FINDINGS

Food allergy prevalence and FIA rates continue to rise, but FIA fatalities are stable. Basophil and mast cell activation tests promise more accurate identification of food triggers. Oral, sublingual, and epicutaneous immunotherapy can desensitize a significant portion of subjects. Epinephrine use for FIA remains sub-optimal. As the burden of food allergy continues to increase, it appears that the corresponding increase in research focused on this epidemic is beginning to bear fruit. The stable number of FIA fatalities in the face of an ongoing epidemic indicates lives have already been saved. The emergence of new diagnostic tests and interventional therapies may transform the management of FIA in the coming years.

Food Allergy Perceptions and Health-Related Quality of Life in a Racially Diverse Sample

This study examined caregiver perceptions of risk of food allergen exposure, and food allergy severity, worry, and health-related quality of life, and identified variations by race/ethnicity. Given the lack of data on racial/ethnic background in research on the psychosocial impacts of food allergy, this study meets a pressing need for research regarding food allergy-related experiences among diverse populations. This study found there were significant differences in perceived risk of allergen exposure among racial/ethnic groups with Asian Americans reporting significantly higher perceived risk of allergen exposure than Hispanic, Caucasian, and African American caregivers. There were no significant differences in food allergy severity, food allergy worry, or health-related quality of life among racial/ethnic groups; however, variability among racial/ethnic groups was apparent. Data may inform screening, counseling, and education practices for families from diverse backgrounds and aid in hypothesis generation for future research.

Tweeting and Eating: The Effect of Links and Likes on Food-Hypersensitive Consumers' Perceptions of Tweets

Moving on from literature that focuses on how consumers use social media and the benefits of organizations utilizing platforms for health and risk communication, this study explores how specific characteristics of tweets affect the way in which they are perceived. An online survey with 251 participants with self-reported food hypersensitivity (FH) took part in an online experiment to consider the impact of tweet characteristics on perceptions of source credibility, message credibility, persuasiveness, and intention to act upon the presented information. Positioning the research hypotheses within the framework of the Elaboration Likelihood Model and Uses and Gratifications Theory, the study explored motivations for using social media and tested the impact of the affordances of Twitter—(1) the inclusion of links and (2) the number of social validation indicators (likes and retweets). Having links accompanying tweets significantly increased ratings of the tweets’ message credibility, as well as persuasiveness of their content. Socially validated tweets had no effect on these same variables. Parents of FH children were found to utilize social media for social reasons more than hypersensitive adults; concern level surrounding a reaction did not appear to alter the level of use. Links were considered valuable in obtaining social media users to attend to useful or essential food health and risk information. Future research in this area can usefully consider the nature and the effects of social validation in relation to other social media platforms and with other groups.

Current trends in food allergy-induced anaphylaxis management at school

OBJECTIVE

To review the evidence and current policies regarding the use of epinephrine at schools and child care centers DATA SOURCES AND STUDY SELECTIONS: A narrative review was performed based on the result of conference proceedings of a group of interprofessional stakeholders who attended the USAnaphylaxis Summit 2017 presented by Allergy & Asthma Network.

RESULTS

Anaphylaxis is a well-recognized medical emergency that requires prompt treatment with intramuscular epinephrine. Anaphylaxis can be associated with poor quality of life. There is renewed recent focus on anaphylaxis management in schools. This interest has been spurred by an increase in the number of children with food allergy who are attending school, data that support up to 25% of first-time anaphylactic events occurring on school grounds, and a well-publicized fatality that helped to initiate a movement for stock, undesignated, non-student-specific epinephrine. Stock epinephrine is now available in 49 states, with an increasing number of states instituting mandatory reporting for use of such devices. Nursing efforts are paramount to support and implement stock epinephrine programs. Many states do not have clarity on delegation of authority for who can administer stock epinephrine, and there is evidence of variability in storage of stock devices. Few states have outcomes data that support successful implementation of stock epinephrine programs.

CONCLUSION

Additional data are needed to demonstrate successful implementations of stock epinephrine programs and their outcomes. Such programs should include support for school nursing and clearer delineation of authority for medication administration as well as standards for where and how devices are stored.

Oral and sublingual immunotherapy for egg allergy

BACKGROUND

Clinical egg allergy is a common food allergy. Current management relies upon strict allergen avoidance. Oral immunotherapy might be an optional treatment, through desensitization to egg allergen.

OBJECTIVES

To determine the efficacy and safety of oral and sublingual immunotherapy in children and adults with immunoglobulin E (IgE)-mediated egg allergy as compared to a placebo treatment or an avoidance strategy.

SEARCH METHODS

We searched 13 databases for journal articles, conference proceedings, theses and trials registers using a combination of subject headings and text words (last search 31 March 2017).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing oral immunotherapy or sublingual immunotherapy administered by any protocol with placebo or an elimination diet. Participants were children or adults with clinical egg allergy.

DATA COLLECTION AND ANALYSIS

We retrieved 97 studies from the electronic searches. We selected studies, extracted data and assessed the methodological quality. We attempted to contact the study investigators to obtain the unpublished data, wherever possible. We used the I² statistic to assess statistical heterogeneity. We estimated a pooled risk ratio (RR) with 95% confidence interval (CI) for each outcome using a Mantel-Haenzel fixed-effect model if statistical heterogeneity was low (I² value less than 50%). We rated the quality of evidence for all outcomes using GRADE.

MAIN RESULTS

We included 10 RCTs that met our inclusion criteria, that involved a total of 439 children (oral immunotherapy 249; control intervention 190), aged 1 year to 18 years. Each study used a different oral immunotherapy protocol; none used sublingual immunotherapy. Three studies used placebo and seven used an egg avoidance diet as the control. Primary outcomes were: an increased amount of egg that can be ingested and tolerated without adverse events while receiving allergen-specific oral immunotherapy or sublingual immunotherapy, compared to control; and a complete recovery from egg allergy after completion of oral immunotherapy or sublingual immunotherapy, compared to control. Most children (82%) in the oral immunotherapy group could ingest a partial serving of egg (1 g to 7.5 g) compared to 10% of control group children (RR 7.48, 95% CI 4.91 to 11.38; RD 0.73, 95% CI 0.67 to 0.80). Fewer than half (45%) of children receiving oral immunotherapy were able to tolerate a full serving of egg compared to 10% of the control group (RR 4.25, 95% CI 2.77 to 6.53; RD 0.35, 95% CI 0.28 to 0.43). All 10 trials reported numbers of children with serious adverse events (SAEs) and numbers of children with mild-to-severe adverse events. SAEs requiring epinephrine/adrenaline presented in 21/249 (8.4%) of children in the oral immunotherapy group, and none in the control group. Mild-to-severe adverse events were frequent; 75% of children presented mild-to-severe adverse events during oral immunotherapy treatment versus 6.8% of the control group (RR 8.35, 95% CI 5.31 to 13.12). Of note, seven studies used an egg avoidance diet as the control. Adverse events occurred in 4.2% of children, which may relate to accidental ingestion of egg-containing food. Three studies used a placebo control with adverse events present in 2.6% of children. Overall, there was inconsistent methodological rigour in the trials. All studies enrolled small numbers of children and used different methods to provide oral immunotherapy. Eight included studies were judged to be at high risk of bias in at least one domain. Furthermore, the quality of evidence was judged to be low due to small numbers of participants and events, and possible biases.

AUTHORS' CONCLUSIONS

Frequent and increasing exposure to egg over one to two years in people who are allergic to egg builds tolerance, with almost everyone becoming more tolerant compared with a minority in the control group and almost half of people being totally tolerant of egg by the end of treatment compared with 1 in 10 people who avoid egg. However, nearly all who received treatment experienced adverse events, mainly allergy-related. We found that 1 in 12 children had serious allergic reactions requiring adrenaline, and some people gave up oral immunotherapy. It appears that oral immunotherapy for egg allergy is effective, but confidence in the trade-off between benefits and harms is low; because there was a small number of trials with few participants, and methodological problems with some trials.

The familial aggregation of atopic diseases and depression or anxiety in children

Background

Children with asthma and atopic diseases have an increased risk of depression or anxiety. Each of these diseases has strong genetic and environmental components; therefore, it seems likely that there is a shared liability rather than causative risk.

Objective

To investigate the existence and nature of familial aggregation for the comorbidity of atopic diseases and depression or anxiety.

Methods

Participants came from the Childhood and Adolescent Twin Study in Sweden (CATSS), n = 14 197. Current and ever asthma, eczema, hay fever and food allergy were reported by parents. Internalizing disorders were identified using validated questionnaires. Familial co‐aggregation analysis compared monozygotic (MZ) twins and same‐sex dizygotic (DZ) twins for atopic disease in 1 twin with internalizing disorder in the other to test for genetic liability. Several familial liability candidates were also tested including parental education, recent maternal psychological stress, childhood family trauma and parental country of birth.

Results

Familial co‐aggregation analysis found that if 1 twin had at least 1 current atopic disease the partner twin was at risk of having an internalizing disorder regardless of their own atopic status (adjusted OR 1.22 (95% CI 1.08, 1.37). Similar results were found for each atopic disease ever and current. MZ associations were not higher than DZ associations, suggesting that the liability is not genetic in nature. Including other familial candidates to the models made little difference to effect estimates.

Conclusions and Clinical Relevance

Atopic diseases and depression or anxiety tend to occur together in families; therefore, when treating for 1 disease, the physician should consider comorbidity in both the individual and the individual's siblings. We did not find evidence to support a genetic explanation for comorbidity, and further exploration is needed to disentangle the environmental and epigenetic reasons for familial aggregation.

Circadian profiling reveals higher histamine plasma levels and lower diamine oxidase serum activities in 24% of patients with suspected histamine intolerance compared to food allergy and controls

Background

Histamine intolerance is thought to trigger manifold clinical symptoms after ingesting histamine‐rich food due to reduced activity of diamine oxidase (DAO). No study has hitherto systematically assessed daily fluctuations of histamine levels and DAO activities in symptomatic patients. The aim of the study was to investigate the presence of histamine intolerance, to therefore establish day profiles of histamine levels and DAO activities, and to compare the results between patients with suspected histamine intolerance, food allergy and healthy controls.

Methods

We determined day profiles of histamine plasma levels and DAO serum activities in 33 patients with suspected histamine intolerance, in 21 patients with proven food allergy and in 10 healthy control patients. Clinical symptoms, food intolerances and further clinical and laboratory chemical parameters were evaluated.

Results

Twenty‐four percent (8 of 33) suspected histamine‐intolerant patients showed elevated histamine levels during the day. That might be caused by constantly and significantly reduced DAO activities in these patients compared to food‐allergic and control patients. The remaining 25 patients presented normal histamine levels and DAO activities, but an increased prevalence of multiple food intolerances compared to the other subgroup of suspected histamine‐intolerants. There was no correlation between subjective complaints and serological histamine parameters in patients with suspected histamine intolerance.

Conclusions

We determined by daily profiling that decreased DAO activities correlated with elevated histamine levels in a subgroup of suspected histamine‐intolerants. This finding discriminates these patients from food intolerant individuals with similar clinical symptoms and strongly suggests the presence of histamine intolerance.

"Ne nnipadua mmpe" (the body hates it): Exploring the lived experience of food allergy in Sub-Saharan Africa

Allergic diseases have closely followed the rise of non-communicable diseases (NCDs) especially in western societies. As prevalence of NCD is increasing in sub-Saharan Africa (SSA), researchers are hinting that the same future may hold for (food) allergic disease in this world region. Already, researchers are beginning to record prevalence, though with little attention to the social experience of individuals and parents with food allergic children. This paper presents the first qualitative analysis of the daily realities of adults and parents of children with allergies in SSA using Ghana as a case study. Drawing on political ecology of health, this study contextualizes the psychological (e.g. anxiety and fear), social (e.g. stigmatization, social exclusion), and economic (e.g. impact on work & household expenditures) wellbeing of affected persons within the broader sociocultural environment. By exploring the sociocultural environment, the results provide insights into the likely structures (e.g. the lack of familiarity, absence of local discursive repertoire on food allergy, infrastructure deficit) which interact to shape anxiety, and social exclusion of people with allergy. The case study provides evidence suggesting food allergies do have a global reach, and policy makers must heed the message to integrate food allergy into the broader chronic disease prevention agenda.

IL-33 promotes gastrointestinal allergy in a TSLP-independent manner

Atopic dermatitis (AD) often precedes asthma and food allergy, indicating that epicutaneous sensitization to allergens may be important in the induction of allergic responses at other barrier surfaces. Thymic stromal lymphopoietin (TSLP) and interleukin (IL)-33 are two cytokines that may drive type 2 responses in the skin; both are potential targets in the treatment of allergic diseases. We tested the functional role of IL-33 and the interplay between IL-33 and TSLP in mouse models of atopic march and gastrointestinal (GI) allergy. IL-33-driven allergic disease occurred in a TSLP-independent manner. In contrast, mice lacking IL-33 signaling were protected from onset of allergic diarrhea in TSLP-driven disease. Epithelial-derived IL-33 was important in this model, as specific loss of IL-33 expression in the epithelium attenuated cutaneous inflammation. Notably, the development of diarrhea following sensitization with TLSP plus antigen was ameliorated even when IL-33 was blocked after sensitization. Thus, IL-33 has an important role during early cutaneous inflammation and during challenge. These data reveal critical roles for IL-33 in the "atopic march" that leads from AD to GI allergy.

The longitudinal impact of probiotic and peanut oral immunotherapy on health-related quality of life

BACKGROUND

We previously reported that probiotic and peanut oral immunotherapy (PPOIT) was effective at inducing sustained unresponsiveness compared with placebo in a double-blind, placebo-controlled randomized trial. This study evaluated the impact of PPOIT on health-related quality of life (HRQL).

METHOD

Fifty-one participants (PPOIT 24; placebo 27) from the PPOIT trial completed Food Allergy Quality of Life Questionnaire (FAQLQ-PF) and Food Allergy Independent Measure (FAIM) at pre-treatment, end-of-treatment and 3 months after end-of-treatment. A total of 42 participants (20 PPOIT; 22 placebo) completed measures at 12 months post-treatment. Changes over time in PPOIT and placebo groups were examined by repeated-measures analysis of variance and paired t tests.

RESULTS

Probiotic and peanut oral immunotherapy was associated with significant improvement in FAQLQ-PF (F = 3.63, P = .02), with mean difference 0.8 at 3 months post-treatment (P = .05) and 1.3 at 12 months post-treatment (P = .005), exceeding the 0.5 minimal clinically important difference for FAQLQ-PF. For FAIM, mean difference was 0.5 (P = .03) at 3 months and 0.4 (P = .04) at 12 months post-treatment. In placebo group, post-treatment FAQLQ and FAIM remained unchanged from pretreatment. Improvement in FAQLQ-PF and FAIM scores related specifically to acquisition of sustained unresponsiveness rather than to receiving PPOIT treatment or participation in the trial.

CONCLUSIONS

Probiotic and peanut oral immunotherapy has a sustained beneficial effect on psychosocial impact of food allergy at 3 and 12 months after end-of-treatment. Treatment was not associated with reduced HRQL relative to baseline in either PPOIT or placebo groups, indicating that PPOIT was well tolerated and psychological well-being was not negatively impacted. Improved HRQL was specifically associated with acquisition of sustained unresponsiveness.

Paediatric food-induced anaphylaxis hospital presentations in New Zealand

AIM

Globally, rates of paediatric food-induced anaphylaxis (FIA) are increasing. Little data is available regarding the epidemiology of FIA among New Zealand (NZ) children. This study investigated the incidence of paediatric (0-14 years) FIA hospital presentations in NZ over a 10-year period.

METHODS

Ministry of Health public hospital discharge data from 2006 to 2015 were analysed using FIA-related International Classification of Diseases codes (T78.0 - anaphylactic shock due to adverse food reaction and T78.2 - anaphylactic shock unspecified and free text qualifier) to identify acute hospital presentations.

RESULTS

The overall annualised FIA hospital presentation rate was 16.2 per 100 000 children. Subgroup analysis indicated a significantly higher rate in males (19.1/100 000) than in females (13.1/100 000), and among children aged less than 2 years of age (50.5/100 000) compared with older children. Rates among Asian and Pacific children were higher than Māori and NZ European children. In 67.7% of cases, a single specific allergen was suggested by the information provided; among these cases, nuts (48%), specifically peanuts (26%), were the most commonly reported allergen, followed by cow's milk (21%). Time trend analysis showed a 2.8-fold increase in the overall annualised rate for the 10-year period.

CONCLUSION

These findings are consistent with other international studies indicating increasing rates of FIA in children. These data will provide information for a review of NZ paediatric allergy services to ensure current international standards with regard to the equitable delivery of timely, appropriate and accessible care are being met. Reasons for differences by gender, age and ethnicity require further investigation.

ImmunoCAP® ISAC and Microtest for multiplex allergen testing in people with difficult to manage allergic disease: a systematic review and cost analysis

BACKGROUND

Allergy is a form of immune-mediated exaggerated sensitivity (hypersensitivity) to a substance that is either inhaled, swallowed, injected or comes into contact with the skin. Foreign substances that provoke allergies are called allergens. It has been claimed that multiplex allergen testing may help in diagnosing the cause of symptoms in patients with an unclear cause of allergy or who are allergic to more than one substance.

OBJECTIVES

To evaluate multiplex allergen testing [devices that can measure the presence of multiple immunoglobulin E (IgE) antibodies in a patient's blood at the same time], by assessing (1) clinical effectiveness (allergy symptoms, incidence of acute exacerbations, mortality, adverse events of testing and treatment, health-care presentations or admissions, health-related quality of life); (2) effects on treatment (diet, immunotherapy medications, other potential testing); (3) any additional diagnostic information provided by multiplex allergen testing; and (4) cost-effectiveness (cost of different assessment strategies).

METHODS

Fifteen databases were searched from 2005 to April 2015, including MEDLINE (via OvidSp), MEDLINE In-Process Citations, MEDLINE Daily Update, PubMed (National Library of Medicine), EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Science Citation Index (SCI), Conference Proceedings Citation Index-Science (CPCI-S), BIOSIS Previews, Latin American and Caribbean Health Sciences Literature (LILACS), National Institute for Health Research (NIHR) HTA programme, and the US Food and Drug Administration (FDA); supplementary searches of conference proceedings and trials registries were performed. Review methods followed published guidance from the Cochrane Collaboration and the Centre for Reviews and Dissemination, University of York, UK. The methodological quality of included studies was assessed using appropriate published tools or a review-specific tool designed by the project team. Studies were summarised in a narrative synthesis. Owing to a lack of data on the clinical effectiveness of multiplex allergen testing, no long-term cost-effectiveness model was developed. A conceptual model structure was developed and cost analyses were performed to examine the short-term costs of various possible diagnostic pathways.

RESULTS

Fifteen studies were included in the review. The very limited available data indicated that the addition of multiplex allergen testing [ImmunoCAP(®) Immuno Solid-phase Allergen Chip (ISAC), Thermo Fisher Scientific/Phadia AB, Uppsala, Sweden] to standard diagnostic work-up can change the clinicians' views on the diagnosis, management and treatment of patients. There was some indication that the use of ImmunoCAP ISAC testing may be useful to guide decisions on the discontinuation of restrictive diets, the content of allergen-specific immunotherapy (SIT) prescriptions, and whether or not patients should receive SIT. However, none of the studies that we identified reported any information on clinical outcomes subsequent to changes in treatment or management. There was some evidence that ImmunoCAP ISAC may be useful for discriminating allergens that are structurally similar and are recognised by the same IgE antibody (cross-immunoreactive). No data were available for Microtest (Microtest Matrices Ltd, London, UK). Detailed cost analyses suggested that multiplex allergen testing would have to result in a substantial reduction of the proportions of patients receiving single IgE testing and oral food challenge tests in order to be cost-saving in the short term.

CONCLUSIONS

No recommendations for service provision can be made based on the analyses included in this report. It is suggested that a consensus-based protocol for the use of multiplex allergen testing be developed. The clinical effectiveness and cost-effectiveness of the proposed protocol should then be assessed by comparing long-term clinical and quality of life outcomes and resource use in patients managed using the protocol with those managed using a standard diagnostic pathway.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015019739.

FUNDING

This project was a Diagnostic Assessment Report commissioned by the NIHR HTA programme on behalf of the National Institute for Health and Care Excellence.

Eating out with a food allergy in the UK: Change in the eating out practices of consumers with food allergy following introduction of allergen information legislation

BACKGROUND

Strict allergen avoidance is important in day-to-day management of food allergy and avoidance when eating outside the home can present particular difficulties. EU legislation (EU FIC) introduced in December 2014 aimed to improve food allergen information provision for customers by requiring retailers of non-prepacked foods to provide information related to the content of one or more of 14 specified food allergens within their foods.

OBJECTIVES

To investigate the impact of EU FIC on the behaviours, experiences and attitudes of consumers with food allergy when eating out.

METHODS

As part of longitudinal research, participants with food allergy from across the UK took part in either (A) pre and post legislation in-depth interviews, or (B) pre and post legislation surveys. In-depth interviews were carried out with 28 participants pre and post legislation and analysed using the framework approach. Self-report surveys were completed by 129 participants pre and post legislation, and responses were subject to quantitative analyses.

RESULTS

Improvements in allergen information provision and raised awareness of food allergy in eating out venues were reported following introduction of EU FIC. Whilst participants favoured written allergen information, they expressed greater confidence in communicating with eating out staff and in trusting the allergen information that they provided. Improvements were judged to be gradual, sporadic or inconsistent in implementation.

CONCLUSION & CLINICAL RELEVANCE

For many participants, the "ideal" eating out experience was one in which a range of information resources were available and where written allergen information was complemented by proactive and accommodating staff within an allergy-aware environment. Whilst the onus is on legislators and food providers to ensure that adequate allergen information is provided, clinicians play an important role in encouraging patients with food allergy to pursue their legal right to make allergen enquiries to avoid accidental allergen ingestion when eating out.

Food allergy: Children's symptom levels are associated with mothers' psycho-socio-economic variables

BACKGROUND

Allergies affect children's health as well as their quality of life, stress levels, and family budget. The available literature suggests that family, social and psychological factors are affected by allergic pathologies such as rhinitis, asthma and atopic dermatitis. However, few studies have focused on quantifying such association in child food allergy. This study aims to enhance the understanding of the associations between caregiver variables and children's Food Allergy (FA).

METHODS

The study involved 206 participants: 103 mothers plus 103 children with IgE mediated FA. The analyses excluded two outliers comprising 101 subjects. For statistical analyses, each dyad -mother/child- was considered to be one subject unity. A between-subjects one-way ANOVA determined the association of children's cutaneous, gastric and respiratory symptoms with anxiety, depression, perceived social support and socioeconomic factors in the mothers.

RESULTS

There are significant associations between children's allergic symptoms (gastric and cutaneous) and mothers' psychological state (anxiety and depression); family budget; social interactions (with friends, family and partner); understanding of health care required by their child; and sleep disorders. Respiratory symptoms did not show any significant associations with the dependent variables.

CONCLUSION

FA is a process in which children's symptoms are significantly associated with socioeconomic and psychological variables of the mothers. The presence or absence of some specific symptoms is directly associated with specific impacts on the mothers. An understanding of such dynamics supports the consideration of a comprehensive and multidisciplinary therapeutic approach to offer more ecological healthcare for "families living with FA."

Changes in patient quality of life during oral immunotherapy for food allergy

BACKGROUND

Quality of life (QOL) is impaired in patients with food allergy and improves following oral immunotherapy (OIT). However, the treatment itself is prolonged and demanding. We examined changes in patient QOL during OIT for food allergy.

METHODS

The FAQLQ-PF was administered to children aged 4-12 years undergoing OIT for milk, peanut, or egg allergy, at the beginning and after 4 months of treatment. Patients were categorized as improved, unchanged, or diminished FAQLQ-PF (>0.5 point decrease, a change of ≤0.5 points, or >0.5 increase, respectively) and compared. Food-allergic patients not undergoing OIT served as controls.

RESULTS

The Food Anxiety, Social and Dietary Limitation, and total FAQLQ-PF scores improved significantly during the study period (P=.001, P=.018, and P=.01, respectively) in treated but not in control patients, while the Emotional Impact did not. The change in the FAQLQ-PF was independent of the maximal tolerated dose at baseline or following four months of treatment, the pace of dose increase, or the number or severity of reactions experienced. The total FAQLQ-PF score was inversely associated with the score at baseline on multivariate analysis (regression coefficient=-0.56, P<.001). That was driven primarily by improvement in QOL scores in patients with high score (worse QOL) at baseline. Some patients with low FAQLQ-PF score (better QOL) at baseline deteriorated.

CONCLUSIONS

QOL of patients with food allergy improves in some but deteriorates in others during OIT. Patients with impaired QOL at baseline improve significantly despite the treatment burden. Some patients with better QOL at baseline might deteriorate during OIT.