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

Patterns of adaptation to children's food allergies

BACKGROUND

Families with food allergy (FA) are at risk of reduced quality of life and elevated anxiety. A moderate level of anxiety may be beneficial to sustain vigilance for food avoidance; however, excessive anxiety may increase risk for burden and maladjustment. The current study presents a framework for understanding the patterns of adaptation to FA across families and to identify typologies of families that would benefit from intervention.

METHODS

Participants included 57 children, 6-12 years old with documented FA, and their mothers. Families were assessed using the Food Allergy Management and Adaptation Scale. Families also completed measures of quality of life, anxiety, FA management, and psychosocial impairment.

RESULTS

A hierarchical cluster analysis revealed that 56 of the 57 families of food-allergic children were categorized into four groups that differed on their adequacy of family FA management, levels of anxiety, and balanced psychosocial functioning: balanced responders (n = 23; 41%), high responders (n = 25; 45%), and low responders (n = 3; 5%). The fourth group, anxious high responders (n = 5; 9%), was characterized by extremely high maternal FA anxiety scores and low scores for balanced integration of FA management and psychosocial functioning. Families in clusters differed across illness and psychosocial outcome variables.

CONCLUSION

Families with FA were characterized by patterns of FA management, anxiety, and ability to integrate FA demands into daily life. Identified adaptation patterns correspond with clinical impressions and provide a framework for identifying families in need of intervention.

Multidimensional analysis of food-allergic children and adolescents' self-concept: A comparison with a healthy matched sample

The study investigated self-concept in food-allergic youths and matched healthy controls. Global and domain-specific self-concepts were assessed in 154 participants (9-19 years) using the Multidimensional Self-Concept Scale. Statistical analysis assessed differences between the two samples and effects of asthma, dermatitis, age, and gender among patients. Significant differences were found for Total Scale score and for Competence and Physical scores. Patients showed clinically problematic self-concepts in Global, Competence, and Family domains. Age was found to be associated with the Total score. Health professionals should consider food-allergic patients' personality development. Further studies could examine disease-specific consequences and interventions.

Improving the safety of oral immunotherapy for food allergy

Food allergy is a major public health problem in children, impacting upon the affected individual, their families and others charged with their care, for example educational establishments, and the food industry. In contrast to most other paediatric diseases, there is no established cure: current management is based upon dietary avoidance and the provision of rescue medication in the event of accidental reactions, which are common. This strategy has significant limitations and impacts adversely on health-related quality of life. In the last decade, research into disease-modifying treatments for food allergy has emerged, predominantly for peanut, egg and cow's milk. Most studies have used the oral route (oral immunotherapy, OIT), in which increasing amounts of allergen are given over weeks-months. OIT has proven effective to induce immune modulation and 'desensitization' - that is, an increase in the amount of food allergen that can be consumed, so long as regular (typically daily) doses are continued. However, its ability to induce permanent tolerance once ongoing exposure has stopped seems limited. Additionally, the short- and long-term safety of OIT is often poorly reported, raising concerns about its implementation in routine practice. Most patients experience allergic reactions and, although generally mild, severe reactions have occurred. Long-term adherence is unclear, which rises concerns given the low rates of long-term tolerance induction. Current research focuses on improving current limitations, especially safety. Strategies include alternative routes (sublingual, epicutaneous), modified hypoallergenic products and adjuvants (anti-IgE, pre-/probiotics). Biomarkers of safe/successful OIT are also under investigation.

Quality of life in patients with food allergy

Food allergy has increased in developed countries and can have a dramatic effect on quality of life, so as to provoke fatal reactions. We aimed to outline the socioeconomic impact that food allergy exerts in this kind of patients by performing a complete review of the literature and also describing the factors that may influence, to a greater extent, the quality of life of patients with food allergy and analyzing the different questionnaires available. Hitherto, strict avoidance of the culprit food(s) and use of emergency medications are the pillars to manage this condition. Promising approaches such as specific oral or epicutaneous immunotherapy and the use of monoclonal antibodies are progressively being investigated worldwide. However, even that an increasing number of centers fulfill those approaches, they are not fully implemented enough in clinical practice. The mean annual cost of health care has been estimated in international dollars (I$) 2016 for food-allergic adults and I$1089 for controls, a difference of I$927 (95 % confidence interval I$324–I$1530). A similar result was found for adults in each country, and for children, and interestingly, it was not sensitive to baseline demographic differences. Cost was significantly related to severity of illness in cases in nine countries. The constant threat of exposure, need for vigilance and expectation of outcome can have a tremendous impact on quality of life. Several studies have analyzed the impact of food allergy on health-related quality of life (HRQL) in adults and children in different countries. There have been described different factors that could modify HRQL in food allergic patients, the most important of them are perceived disease severity, age of the patient, peanut or soy allergy, country of origin and having allergy to two or more foods. Over the last few years, several different specific Quality of Life questionnaires for food allergic patients have been developed and translated to different languages and cultures. It is important to perform lingual and cultural translations of existent questionnaires in order to ensure its suitability in a specific region or country with its own socioeconomic reality and culture. Tools aimed at assessing the impact of food allergy on HRQL should be always part of the diagnostic work up, in order to provide a complete basal assessment, to highlight target of intervention as well as to evaluate the effectiveness of interventions designed to cure food allergy. HRQL may be the only meaningful outcome measure available for food allergy measuring this continuous burden.

Sensitization to milk, egg and peanut from birth to 18 years: A longitudinal study of a cohort at risk of allergic disease

BACKGROUND

Longitudinal data on the natural history of food sensitization beyond early childhood are scarce. We aimed to investigate the natural history of milk, egg and peanut sensitization from infancy to 18 years and assess whether early food sensitization predicted adolescent food allergy.

METHODS

Sensitization to cow's milk, hen's egg and peanut was measured by skin prick testing at ages 6 months, 1, 2, 12 and 18 years in a high-risk allergy birth cohort (n = 620). Generalized additive models investigated interactions with sex, eczema and aeroallergen sensitization in infancy. Logistic regression assessed the relationships between early food sensitization and adolescent sensitization and probable food allergy up to 18 years.

RESULTS

The prevalence of egg and peanut sensitization peaked at 12 months, while milk sensitization peaked at both 1 and 12 years. Boys with early eczema had the highest prevalences of milk and egg sensitization throughout follow-ups. However, neither sex nor eczema influenced the prevalence of peanut sensitization over time. New onset food sensitization beyond the age of 2 was observed in 7% of participants. Food sensitization at 12 months was associated with increased risk of adolescent food sensitization and adolescent probable food allergy, with sensitization to more than one food allergen had the strongest predictor.

CONCLUSIONS

Food sensitization prevalence is highest in infancy and declines after 12 months of age. Boys with early-life eczema have the highest prevalence of milk and egg sensitization. Food sensitization at 12 months can predict children at greater risk of adolescent sensitization and probable food allergy at 12 and 18 years.

Clinical management of food allergy

Food allergies are commonly seen by the practitioner, and managing these patients is often challenging. Recent epidemiologic studies report that as many as 1 in 13 children in the United States may have a food allergy, which makes this an important disease process to appropriately diagnose and manage for primary care physicians and specialists alike. Having a understanding of the basic immunologic processes that underlie varying presentations of food-induced allergic diseases will guide the clinician in the initial workup. This review will cover the basic approach to understanding the immune response of an individual with food allergy after ingestion and will guide the clinician in applying appropriate testing modalities when needed by conducting food challenges if indicated and by educating the patient and his or her guardian to minimize the risk of accidental ingestion.

Milk allergy is a minor cause of milk avoidance due to perceived hypersensitivity among schoolchildren in Northern Sweden

AIM

We investigated phenotypes of milk hypersensitivity among schoolchildren aged 11-12 in Northern Sweden.

METHODS

In a population-based cohort, 1824 (98%) children aged 11-12 participated in a questionnaire survey, skin prick testing, interviews on food hypersensitivity and assessment of body mass index (BMI). Of the 265 children reporting milk hypersensitivity, milk avoidance and no coeliac disease, 236 (89%) participated in a structured interview and blood samples for analyses of milk-specific Immunoglobulin E. The children were then categorised into milk hypersensitivity phenotypes according to preset criteria.

RESULTS

In all, 14.5% reported milk hypersensitivity. Of these, 3% were categorised as current milk allergy, 23% as outgrown milk allergy, 40% as probable lactose intolerance and 11% as nondefinable. Furthermore, 23% had discontinued their elimination diet. Milk allergy was associated with other atopic disorders and lower BMI, with an odds ratio of 0.82 and 95% confidence interval of 0.80-0.98. Only 2% had previously undergone an oral challenge.

CONCLUSION

The most common symptom phenotypes among Swedish children aged 11-12 with self-reported milk hypersensitivity and milk avoidance were probable intolerance and outgrown milk allergy, while current milk allergy was uncommon. Children with milk allergy had a lower BMI and most lacked a challenge-proven diagnosis.

Quality of Life in Food Allergy Patients and Their Families

Pediatric food allergy is a growing health problem in the United States that has been found to adversely impact the quality of life of both affected children and their caregivers. This article provides a review of how food allergy affects the quality of life of patients and their families within the domains of school, social activities, relationships, and daily life. Efforts to improve food allergy-related quality of life among caregivers are also discussed.

The Learning Early About Peanut Allergy Study: The Benefits of Early Peanut Introduction, and a New Horizon in Fighting the Food Allergy Epidemic

Observational studies have explored associations between timing of peanut, egg, and milk introduction and food allergy development, noting significant associations with reduced respective rates of milk, egg, and peanut allergy associated with earlier timing of introduction. Interventional studies developed to more definitively explore these outcomes have been published for egg and peanut, and are ongoing for multiple other allergens. This review focuses on the recent publication regarding the LEAP (Learning Early About Peanut Allergy) study, its highly favorable results, the policy implications of its findings, and the horizon for primary prevention as a realistic strategy to prevent food allergy.

Effectiveness of Cognitive Behaviour Therapy for Mothers of Children with Food Allergy: A Case Series

Background: Food allergy affects quality of life in patients and parents and mothers report high levels of anxiety and stress. Cognitive Behaviour Therapy (CBT) may be helpful in reducing the psychological impact of food allergy. The aim of this study was to examine the appropriateness and effectiveness of CBT to improve psychological outcomes in parents of children with food allergy. Methods: Five parents (all mothers) from a local allergy clinic requested to have CBT; six mothers acted as controls and completed questionnaires only. CBT was individual and face-to face and lasted 12 weeks. All participants completed measures of anxiety and depression, worry, stress, general mental health, generic and food allergy specific quality of life at baseline and at 12 weeks. Results: Anxiety, depression and worry in the CBT group significantly reduced and overall mental health and QoL significantly improved from baseline to 12 weeks (all p < 0.05) in mothers in the CBT group; control group scores remained stable. Conclusions: CBT appears to be appropriate and effective in mothers of children with food allergy and a larger randomised control trial now needs to be conducted. Ways in which aspects of CBT can be incorporated into allergy clinic visits need investigation.

Depression and anxiety among parents of phenylketonuria children

OBJECTIVE

To investigate the existence of depression and/or anxiety with underlying risk factors among parents of children with classical phenylketonuria (PKU).

METHODS

This cross-sectional study was conducted in the Division of Pediatric Metabolism, Ankara Children`s Hospital, Dokuz Eylul University, Kirikkale University, and Erzurum Local Research Hospital, Turkey, between January and July 2014. Parents of 61 patients and 36 healthy controls completed the self-report questionnaires. We used Beck Depression Inventory (BDI) to assess the parental depression and State-Trait Anxiety Inventory S-T (STAI S-T) to assess parental anxiety.

RESULTS

Depression and anxiety scores were significantly higher in the case group (BDI: 12.3 ± 9.1; STAI-S: 38.2 ± 9.6; STAI-T: 43.2 ± 6.9) than controls (BDI: 5.4 ± 4.1 p=0.000; STAI-S: 31.8 ± 7.6 p=0.001; STAI-T: 37.0 ± 7.2 p=0.000). Mothers of the patients had higher scores than the other parental groups (BDI: p=0.000, STAI-S: p=0.001 and STAI-T: p=0.000). Logistic regression analysis showed that low educational level of the parent was the only independent factor for depression (OR: 9.96, 95% CI: 1.89-52.35, p=0.007) and state anxiety (OR: 6.99, 95% CI: 1.22-40.48, p=0.030) in the case group.

CONCLUSION

A subset of parents with PKU patients have an anxiety or depressive disorder. Supportive services dealing with the parents of chronically ill children such as PKU are needed in order to reduce the level of anxiety.

Health-related quality of life in children with objectively diagnosed staple food allergy assessed with a disease-specific questionnaire

AIM

Among Swedish children of 0-12 years old, we investigated various food allergy-related exposures associated with health-related quality of life using a food allergy-specific questionnaire among children allergic to the staple foods cow's milk, hen's egg and/or wheat, and contextualised worse food allergy-associated health-related quality of life using a generic questionnaire versus controls.

METHODS

In total, 85 children with objectively diagnosed allergy to the staple foods were included as cases, and 94 children matched for age and sex were included as controls. We administered a food allergy-specific parent-completed questionnaire originally developed by EuroPrevall to cases only, and a generic health-related quality of life questionnaire (EuroQol Health Questionnaire, 5 Dimensions; EQ 5-D); to both cases and controls.

RESULTS

Hen's egg was the most common offending staple food, affecting 76% of cases. Approximately 7% of cases were allergic to all three staple foods. Parent-reported respiratory and cardiovascular symptoms were associated with worse health-related quality of life. Elements of disease severity [previous anaphylaxis (p < 0.001); epinephrine autoinjector prescription (p < 0.003)] were negatively associated with health-related quality of life. Cases had worse health-related quality of life measured by the EQ-5D compared to controls (p < 0.01).

CONCLUSION

The use of a disease-specific questionnaire revealed that disease severity in children with objectively diagnosed allergy to the staple foods cow's milk, hen's egg and/or wheat is associated with worse health-related quality of life. The use of a generic questionnaire confirmed that cases have worse health-related quality of life than controls.

The Role of Skin Barrier in the Pathogenesis of Food Allergy

Food allergy is a serious public health problem with an increasing prevalence. Current management is limited to food avoidance and emergency treatment. Research into the pathogenesis of food allergy has helped to shape our understanding of how patients become sensitized to an allergen. Classically, food sensitization was thought to occur through the gastrointestinal tract, but alternative routes of sensitization are being explored, specifically through the skin. Damaged skin barrier may play a crucial role in the development of food sensitization. Better understanding of how patients initially become sensitized may help lead to the development of a safe and effective treatment for food allergies or better prevention strategies.

Assessment of Allergy to Milk, Egg, Cod, and Wheat in Swedish Schoolchildren: A Population Based Cohort Study

Objectives

Knowledge about the prevalence of allergies to foods in childhood and adolescence is incomplete. The purpose of this study was to investigate the prevalence of allergies to milk, egg, cod, and wheat using reported data, clinical examinations, and double-blind placebo-controlled food challenges, and to describe the phenotypes of reported food hypersensitivity in a cohort of Swedish schoolchildren.

Methods

In a population-based cohort of 12-year-old children, the parents of 2612 (96% of invited) completed a questionnaire. Specific IgE antibodies to foods were analyzed in a random sample (n=695). Children reporting complete avoidance of milk, egg, cod, or wheat due to perceived hypersensitivity and without physician-diagnosed celiac disease were invited to undergo clinical examination that included specific IgE testing, a celiac screening test, and categorization into phenotypes of food hypersensitivity according to preset criteria. Children with possible food allergy were further evaluated with double-blind challenges.

Results

In this cohort, the prevalence of reported food allergy to milk, egg, cod, or wheat was 4.8%. Food allergy was diagnosed in 1.4% of the children after clinical evaluation and in 0.6% following double-blind placebo-controlled food challenge. After clinical examination, children who completely avoided one or more essential foods due to perceived food hypersensitivity were categorized with the following phenotypes: allergy (29%), outgrown allergy (19%), lactose intolerance (40%), and unclear (12%).

Conclusions

There was a high discrepancy in the prevalence of allergy to milk, egg, cod and wheat as assessed by reported data, clinical evaluation, and double-blind food challenges. Food hypersensitivity phenotyping according to preset criteria was helpful for identifying children with food allergy.

Becoming the Parent of a Child With Life-Threatening Food Allergies

Food induced anaphylaxis (FIA) is a serious medical event and managing it can place tremendous mental, emotional and financial burdens on parents of children with FIA. Using grounded theory methods, the experiences of parents caring for a child with FIA and the adjustments and strategies used to effectively manage a child's diagnosis were examined. Findings revealed once a child is diagnosed with FIA, parental competency is often severely challenged, calling into question parents' ability to succeed in the parenting role. To regain parental competency, parents engage in a 3 phase process to learn how to parent a child with FIA.

Pediatric Food Allergies and Psychosocial Functioning: Examining the Potential Moderating Roles of Maternal Distress and Overprotection

OBJECTIVES

Identify factors associated with maternal perceptions of health-related quality of life (QoL) among youth with food allergies (FA), and identify maternal factors that may moderate relationships between FA-related challenges and child QoL.

METHODS

In all, 533 mothers of children with FA completed measures assessing characteristics of their child's FA, maternal perceptions of child QoL, maternal psychological distress, and maternal overprotection.

RESULTS

FA severity, maternal psychological distress, and overprotection were significantly associated with maternal reports of poorer child functioning and/or poorer QoL among youth with FA. Hierarchical linear regression analyses showed an FA severity by maternal distress interaction in the prediction of child FA-related anxiety; children of higher stress mothers showed a stronger link between auto-injector use and anxiety than children of lower stress mothers.

CONCLUSIONS

When identifying youth with FA who are at risk for low QoL, it is important to assess history of FA-related challenges, parental psychological distress, and overprotection.

Topical Review: Pediatric Food Allergies Among Diverse Children

OBJECTIVE

To present a brief review of the literature regarding potential racial/ethnic disparities in pediatric food allergy (FA).

METHODS

Topical review considering data regarding FA prevalence, asthma comorbidity, epinephrine access/use, and psychosocial impact (e.g., burden, quality of life).

RESULTS

Methodological variation precludes firm conclusions regarding disparities in prevalence; however, some data suggest Black children may be at particular risk. The comorbidity of FA and asthma among urban populations may increase risk of negative outcomes. There are clear racial/ethnic and socioeconomic disparities in epinephrine access and use. Psychosocial measures are frequently validated on samples that are not racially or ethnically diverse. Studies investigating FA's psychosocial impact are often composed of mostly White, non-Hispanic participants (>85% of study sample).

CONCLUSIONS

Further research is needed to clarify prevalence patterns by race/ethnicity, to investigate the sources of disparity in epinephrine use, and to evaluate the differential impact of FA on diverse children.

Predictors of health-related quality of life of European food-allergic patients

BACKGROUND

Although food allergy has universally been found to impair HRQL, studies have found significant differences in HRQL between countries, even when corrected for differences in perceived disease severity. However, little is known about factors other than disease severity which may contribute to HRQL in food-allergic patients. Therefore, the aim of this study was to identify factors which may predict HRQL of food-allergic patients and also to investigate the specific impact of having experienced anaphylaxis and being prescribed an EAI on HRQL.

METHODS

A total of 648 European food-allergic patients (404 adults, 244 children) completed an age-specific questionnaire package including descriptive questions. Multivariable regression analyses were performed to develop models for predicting HRQL of these patients.

RESULTS

For adults, the prediction model accounted for 62% of the variance in HRQL and included perceived disease severity, type of symptoms, having a fish or milk allergy, and gender. For children, the prediction model accounted for 28% of the variance in HRQL and included perceived disease severity, having a peanut or soy allergy, and country of origin. For both adults and children, neither experiencing anaphylaxis nor being prescribed an epinephrine auto-injector (EAI) contributed to impairment of HRQL.

CONCLUSIONS

In this study, food allergy-related HRQL may be predicted to a greater extent in adults than in children. Allergy to certain foods may cause greater HRQL impairment than others. Country of origin may affect HRQL, at least in children. Experiencing anaphylaxis or being prescribed an EAI has no impact on HRQL in either adults or children.

Children's Food Allergies: Development of the Food Allergy Management and Adaptation Scale

OBJECTIVE

Develop a measure that evaluates effective pediatric food allergy (FA) management, child and parent FA anxiety, and integration of FA into family life.

METHODS

A semistructured family interview was developed to evaluate FA management using a pilot sample (n = 27). Rating scales evaluated eight dimensions of FA management (FAMComposite), child anxiety, parent anxiety, and overall balanced integration (BI). Families of children with IgE-mediated food allergies (n = 60, child age: 6-12) were recruited for interview and rating scale validation.

RESULTS

FAMComposite was correlated with physician ratings for families' food avoidance and reaction response readiness. FA anxiety was correlated with general anxiety measures for children, but not parents. Parents' FA anxiety was correlated with expectations of negative outcomes from FA. Low BI was associated with poor quality of life and negative impact on family functioning.

CONCLUSIONS

Preliminary analyses support Food Allergy Management and Adaptation Scale validity as a measure of family adaptation to pediatric FA.

Mental health and quality-of-life concerns related to the burden of food allergy

As food allergy increases, more research is devoted to its influence on patient and family mental health and quality of life (QoL). This article discusses the effects on parent and child QoL, as well as distress, while appraising the limitations of knowledge given the methods used. Topics include whether QoL and distress are affected compared with other illnesses, assessment of distress and QoL in parents compared with children, concerns about food allergy-related bullying, and the necessity for evidence-based interventions. Suggestions are offered for how to improve QoL and reduce distress on the way to better coping with food allergy.

Randomized trial of peanut consumption in infants at risk for peanut allergy

BACKGROUND

The prevalence of peanut allergy among children in Western countries has doubled in the past 10 years, and peanut allergy is becoming apparent in Africa and Asia. We evaluated strategies of peanut consumption and avoidance to determine which strategy is most effective in preventing the development of peanut allergy in infants at high risk for the allergy.

METHODS

We randomly assigned 640 infants with severe eczema, egg allergy, or both to consume or avoid peanuts until 60 months of age. Participants, who were at least 4 months but younger than 11 months of age at randomization, were assigned to separate study cohorts on the basis of preexisting sensitivity to peanut extract, which was determined with the use of a skin-prick test--one consisting of participants with no measurable wheal after testing and the other consisting of those with a wheal measuring 1 to 4 mm in diameter. The primary outcome, which was assessed independently in each cohort, was the proportion of participants with peanut allergy at 60 months of age.

RESULTS

Among the 530 infants in the intention-to-treat population who initially had negative results on the skin-prick test, the prevalence of peanut allergy at 60 months of age was 13.7% in the avoidance group and 1.9% in the consumption group (P<0.001). Among the 98 participants in the intention-to-treat population who initially had positive test results, the prevalence of peanut allergy was 35.3% in the avoidance group and 10.6% in the consumption group (P=0.004). There was no significant between-group difference in the incidence of serious adverse events. Increases in levels of peanut-specific IgG4 antibody occurred predominantly in the consumption group; a greater percentage of participants in the avoidance group had elevated titers of peanut-specific IgE antibody. A larger wheal on the skin-prick test and a lower ratio of peanut-specific IgG4:IgE were associated with peanut allergy.

CONCLUSIONS

The early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts. (Funded by the National Institute of Allergy and Infectious Diseases and others; ClinicalTrials.gov number, NCT00329784.).

Genome-wide association study identifies peanut allergy-specific loci and evidence of epigenetic mediation in US children

Food allergy (FA) affects 2–10% of U.S. children and is a growing clinical and public health problem. Here we conduct the first genome-wide association study of well-defined FA, including specific subtypes (peanut, milk, and egg) in 2,759 U.S. participants (1,315 children; 1,444 parents) from the Chicago Food Allergy Study; and identify peanut allergy (PA)-specific loci in the HLA-DR and -DQ gene region at 6p21.32, tagged by rs7192 (p=5.5×10⁻⁸) and rs9275596 (p=6.8×10⁻¹⁰), in 2,197 participants of European ancestry. We replicate these associations in an independent sample of European ancestry. These associations are further supported by meta-analyses across the discovery and replication samples. Both single-nucleotide polymorphisms (SNPs) are associated with differential DNA methylation levels at multiple CpG sites (p<5×10⁻⁸); and differential DNA methylation of the HLA-DQB1 and HLA-DRB1 genes partially mediate the identified SNP-PA associations. This study suggests that the HLA-DR and -DQ gene region likely poses significant genetic risk for PA.

Diagnosis and treatment of pediatric food allergy: an update

The prevalence of pediatric food allergy and anaphylaxis has increased in the last decades, especially in westernized countries where this emerging phenomenon was marked as a "second wave" of the allergic epidemic. Over recent years great advances have been achieved in the field of in vitro allergy testing and component-resolved diagnosis has increasingly entered clinical practice. Testing for allergen components can contribute to a more precise diagnosis by discriminating primary from cross-reactive sensitizations and assessing the risk of severe allergic reactions.The basic concept of the management of food allergy in children is also changing. Avoidance of the offending food is still the mainstay for disease management, especially in primary health care settings, but it severely affects the patients' quality of life without reducing the risk of accidental allergic reactions. There is a growing body of evidence to show that specific oral tolerance induction can represent a promising treatment option for food allergic patients. In parallel, education of food allergic patients and their caregivers as well as physicians about anaphylaxis and its treatment is becoming recognized a fundamental need. International guidelines have recently integrated these new evidences and their broad application all over Europe represents the new challenge for food allergy specialists.

Parenting and independent problem-solving in preschool children with food allergy

OBJECTIVE

To examine autonomy-promoting parenting and independent problem-solving in children with food allergy.

METHODS

66 children with food allergy, aged 3-6 years, and 67 age-matched healthy peers and their mothers were videotaped while completing easy and difficult puzzles. Coders recorded time to puzzle completion, children's direct and indirect requests for help, and maternal help-giving behaviors.

RESULTS

Compared with healthy peers, younger (3- to 4-year-old) children with food allergy made more indirect requests for help during the easy puzzle, and their mothers were more likely to provide unnecessary help (i.e., explain where to place a puzzle piece). Differences were not found for older children.

CONCLUSIONS

The results suggest that highly involved parenting practices that are medically necessary to manage food allergy may spill over into settings where high levels of involvement are not needed, and that young children with food allergy may be at increased risk for difficulties in autonomy development.

Review article: the diagnosis and management of food allergy and food intolerances

BACKGROUND

Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public.

AIM

To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children.

METHODS

MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance.

RESULTS

An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4-7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1-2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described.

CONCLUSIONS

Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.

Food and environmental allergies

Immunoglobulin E-mediated allergic responses to food and environmental allergens can cause symptoms ranging from mild allergic rhinitis and rashes to gastrointestinal distress and, most seriously, anaphylaxis. The diagnosis can be difficult, as it relies on complex interplay between patient history and diagnostic tests with low specificity. Adding to the difficulty in confirming the diagnosis is an increased public interest in food intolerances, which can be inappropriately attributed to an allergic response. Treatment of allergic diseases with avoidance strategies and pharmacologic treatments can improve quality of life and control of other chronic conditions, such as asthma and eczema.

Food allergies in school: design and evaluation of a teacher-oriented training action

Background

Food allergies are perceived as a significant problem in school environments; as a result, a teacher’s ability to recognise and deal with allergic reactions is of fundamental importance to protect children’s health. This paper includes the results of a study conducted for the purposes of designing, implementing and monitoring a specific set of teacher-oriented communication actions.

Methods

The study involved designing, implementing and assessing five workshops. These workshops were designed on the basis of the analysis of perceptions and information needs investigated by three focus groups (25 teachers). The level of the teachers’ knowledge and appreciation of the workshops was evaluated by using two structured questionnaires (n = 158).

Results

The teachers feel that they are insufficiently informed about food allergies; this knowledge gap is confirmed by an analysis of their knowledge before participating in the workshops. According to the teachers, the information which would be most useful to them has to do with the practical management of allergies in school. They feel that there is a lack of a professional contact person for precise and reliable information on health issues. The workshops seem to be appreciated as an information method. In addition, there appears to be a need to involve all children in awareness raising activities and education projects on this subject.

Conclusions

There is an urgent need for training actions on food allergies in Italian schools, in particular the communication of practical information regarding the management of allergies and emergencies. More communication between the medical and school staff is, in particular, advisable.

Are children and adolescents with food allergies at increased risk for psychopathology?

OBJECTIVE

Living with food allergy is a unique and potentially life-threatening stressor that requires constant vigilance to food-related stimuli, but little is known about whether adolescents with food allergies are at increased risk for psychopathology-concurrently and over time.

METHODS

Data came from the prospective-longitudinal Great Smoky Mountains Study. Adolescents (N=1420) were recruited from the community, and interviewed up to six times between ages 10 and 16 for the purpose of the present analyses. At each assessment, adolescents and one parent were interviewed using the Child and Adolescent Psychiatric Assessment, resulting in N=5165 pairs of interviews.

RESULTS

Cross-sectionally, food allergies were associated with more symptoms of separation and generalized anxiety, disorder, attention deficit and hyperactivity disorder, and anorexia nervosa. Longitudinally, adolescents with food allergy experienced increases in symptoms of generalized anxiety disorder and depression from one assessment to the next. Food allergies were not, however, associated with a higher likelihood of meeting diagnostic criteria for a psychiatric disorder.

CONCLUSION

The unique constellation of adolescents' increased symptoms of psychopathology in the context of food allergy likely reflects an adaptive increase in vigilance rather than cohesive syndromes of psychopathology. Support and guidance from health care providers is needed to help adolescents with food allergies and their caregivers achieve an optimal balance between necessary vigilance and hypervigilance and unnecessary restriction.

Two year effects of food allergen immunotherapy on quality of life in caregivers of children with food allergies

Background

Food allergy (FA) can have serious psychosocial and economic repercussions on food-allergic children and their caregivers and be associated with negative effects on their quality of life. Food allergen immunotherapy (IT) is a promising experimental therapy but can be linked to anxiety. This study investigated the effects of IT on FA-specific health-related quality of life (HRQL) over a 24 month-follow-up in caregivers of children with single and multiple food allergies. We hypothesized that characteristics such as age, asthma at baseline and respiratory allergic reactions during therapy were key characteristics that influenced HRQL scores.

Methods

A validated Food Allergy Quality of Life – Parental Burden Questionnaire (FAQL-PB) was used to assess HRQL. It was randomly distributed to and filled out by caregivers of 57 food-allergic children enrolled in clinical trials of IT. The same parent answered the FABQL-PB questionnaire at baseline and for 6-month, 12- month, 18- month, and 24-month time points on IT.

Results

Caregiver HRQL improved significantly (change < - 0.5, p <0.0001) at each follow-up time point compared to baseline. The percentages of caregivers with improvement in HRQL progressively increased (92% at 24 month-follow-up time point compared to baseline). HRQL improved more in caregivers of participants older than 10 years or desensitized to more than 4 food allergens than those who were not (p <0.0001). Caregivers of participants with pre-existing asthma or dose-related respiratory allergic reactions had less improvement in HRQL than those who did not (p <0.01).

Conclusion

IT lead to improvement in caregiver HRQL. Certain characteristics were associated with greater improvements in caregiver HRQL.

Electronic supplementary material

The online version of this article (doi:10.1186/1710-1492-10-57) contains supplementary material, which is available to authorized users.

Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012

Background

The incidence of anaphylaxis might be increasing. Data for fatal anaphylaxis are limited because of the rarity of this outcome.

Objective

We sought to document trends in anaphylaxis admissions and fatalities by age, sex, and cause in England and Wales over a 20-year period.

Methods

We extracted data from national databases that record hospital admissions and fatalities caused by anaphylaxis in England and Wales (1992-2012) and crosschecked fatalities against a prospective fatal anaphylaxis registry. We examined time trends and age distribution for fatal anaphylaxis caused by food, drugs, and insect stings.

Results

Hospital admissions from all-cause anaphylaxis increased by 615% over the time period studied, but annual fatality rates remained stable at 0.047 cases (95% CI, 0.042-0.052 cases) per 100,000 population. Admission and fatality rates for drug- and insect sting–induced anaphylaxis were highest in the group aged 60 years and older. In contrast, admissions because of food-triggered anaphylaxis were most common in young people, with a marked peak in the incidence of fatal food reactions during the second and third decades of life. These findings are not explained by age-related differences in rates of hospitalization.

Conclusions

Hospitalizations for anaphylaxis increased between 1992 and 2012, but the incidence of fatal anaphylaxis did not. This might be due to increasing awareness of the diagnosis, shifting patterns of behavior in patients and health care providers, or both. The age distribution of fatal anaphylaxis varies significantly according to the nature of the eliciting agent, which suggests a specific vulnerability to severe outcomes from food-induced allergic reactions in the second and third decades.

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 (OIT) might be an optional treatment, through desensitization to egg allergen.

OBJECTIVES

We aimed to assess the successful desensitization and development of tolerance to egg protein and the safety of egg 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 unpublished trials using a combination of subject headings and text words (the last search was on 5 December 2013).

SELECTION CRITERIA

Randomized controlled trials (RCTs) were included. All age groups with clinical egg allergy were to be included.

DATA COLLECTION AND ANALYSIS

We retrieved 83 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%).

MAIN RESULTS

We included four RCTs with a total of 167 recruited individuals (OIT 100; control 67 participants), all of whom were children (aged four to 15 years). One study used a placebo and three studies used an avoidance diet as the control. Each study used a different OIT protocol. Thirty nine per cent of OIT participants were able to tolerate a full serving of egg compared to 11.9% of the controls (RR 3.39, 95% CI 1.74 to 6.62). Forty per cent of OIT participants could ingest a partial serving of egg (1 g to 7.5 g; RR 5.73, 95% CI 3.13 to 10.50). Sixty nine per cent of the participants presented with mild-to-severe adverse effects (AEs) during OIT (RR 6.06, 95% CI 3.11 to 11.83). Five of the 100 participants receiving OIT required epinephrine. We cannot comment on whether over- or under-reporting of AEs was a concern based on the available data. Overall there was inconsistent methodological rigour in the trials.

AUTHORS' CONCLUSIONS

The studies were small and the quality of evidence was low. Current evidence suggests that OIT can desensitize a large number of egg-allergic patients, although it remains unknown whether long-term tolerance develops. A major difficulty of OIT is the frequency of AEs, though these are usually mild and self-limiting. The use of epinephrine while on OIT seems infrequent. There are no standardized protocols for OIT and guidelines would be required prior to incorporating desensitization into clinical practice.

Support and negativity in interpersonal relationships impact caregivers' quality of life in pediatric food allergy

PURPOSE

This study examined interpersonal relationship processes as they relate to health-related quality of life (HRQL) in caregivers of food-allergic children. Research questions explored the relative contributions of social support and social negativity to caregivers' adaptation as well as mechanisms of moderation, mediation, and moderated mediation through which these influences affect the association of time since children's food allergy diagnosis to caregivers' HRQL.

METHODS

Caregivers (N = 299) of food-allergic children were recruited from parent groups associated with a food allergy nonprofit organization. Participants completed web-based questionnaires assessing demographics and child allergy characteristics, the extent of support and negativity experienced in their social relationships related caregiving, and their HRQL. Multiple regression analyses were used to examine relations among time since diagnosis, interpersonal relationship processes, and caregiver HRQL.

RESULTS

Social negativity was directly related to diminished caregiver HRQL and was a stronger predictor of caregiver HRQL than social support. The effect of time since diagnosis on caregiver HRQL was indirect through social support, and this mediating effect did not depend on caregivers' experience of social negativity.

CONCLUSIONS

Interpersonal relationship processes appear influential in the adaptation of caregivers in the context of pediatric food allergy. Psychosocial interventions targeting support and negativity in caregivers' social relationships may help improve their HRQL.

Quality of life in the setting of anaphylaxis and food allergy

The diagnosis of a food allergy generally has a considerable impact on patients. Not does it result in dietary restrictions, it is often also associated with a constant threat scenario, given the risk of sudden allergic reactions, including life-threatening anaphylaxis. It is essential for patients to receive training on how to deal with emergency situations and make the correct decision regarding the use of emergency medication. Severe allergic reactions occur only rarely if patients are well informed. However, the fear of allergic reactions results in a significant impairment in quality of life (QoL).

In recent years, numerous studies have been carried out on QoL in food-allergy and anaphylaxis patients. These studies provide insight into patient behaviour in everyday life. More importantly, by means of targeted and specific counselling, they also make it possible to reduce adverse effects on QoL and improve avoidance behaviour and compliance in terms of the requisite emergency measures.

The present article summarizes the available data and formulates recommendations aimed at improving the care of food-allergy patients in terms of QoL and compliance.

High incidence and remission of reported food hypersensitivity in Swedish children followed from 8 to 12 years of age - a population based cohort study

BACKGROUND

Few population-based cohort studies have examined reported food hypersensitivity longitudinally. We investigated prevalence, incidence and remission of perceived food hypersensitivity among schoolchildren from 8 to 12 years of age, and risk factors associated with incidence and remission.

METHODS

A population-based cohort including all 7-8 year-old children in three Swedish towns was recruited in 2006. A total of 2,585 (96% of invited) children participated in a parental questionnaire. The children in two of the towns, n = 1,700 (90% of invited) also participated in skin-prick-testing with airborne allergens. The cohort was followed using the same methods at 11-12 years of age. At study follow up, specific IgE to foods was analyzed in a randomized subset of children (n = 652).

RESULTS

The prevalence of perceived food hypersensitivity increased from 21% at 8 years to 26% at 12 years of age. During this four-year-period, the cumulative incidence of food hypersensitivity was high (15%), as was remission (33%). This pattern was particularly evident for hypersensitivity to cow´s milk, while the incidence of hypersensitivity to other foods was lower. Female sex, allergic heredity, current rhinitis and allergic sensitization were associated with the incidence of food hypersensitivity and allergic sensitization was negatively associated with remission. Risk-factor-patterns for both incidence and remission were different for hypersensitivity to milk compared with hypersensitivity to other foods. Generally, the agreement between reported food hypersensitivity and IgE-sensitization to the implicated food was poor.

CONCLUSIONS

In this longitudinal, population-based cohort-study perceived food hypersensitivity was common among children between ages 8 and 12, often transient and not well correlated with food-specific IgE. While these findings suggest an overestimated prevalence of food hypersensitivity, the public-health-significance remains high as they reflect the perceived reality to which the children adapt their life and food intakes.

Oral food challenge and food allergy quality of life in caregivers of children with food allergy

BACKGROUND

Food allergy is associated with diminished patient and caregiver quality of life (QoL). Although oral food challenge (OFC) improves QoL of individuals with food allergy, its effects on caregiver QoL are unknown.

OBJECTIVES

To determine if differences in caregiver QoL exist based on their child undergoing OFC.

METHODS

Caregivers of individuals with food allergy who underwent OFCs between 2001 and 2012 at the University of Michigan Food Allergy Center completed the Food Allergy Quality of Life-Parental Burden index and a questionnaire that assessed details of the most-severe reaction by an individual with food allergy. Results were compared with 305 caregivers of individuals with food allergy who were unchallenged. All questionnaire data regarding the characteristics of the reactions of individuals with food allergy were verified through chart review.

RESULTS

A total of 115 caregivers of individuals with food allergy who were undergoing OFC completed the QoL assessment. Caregivers of individuals with food allergy who were undergoing OFC had a significantly lower (better) QoL score than controls who were not challenged (1.5 vs 1.88; P = .02). Furthermore, within the challenged cohort, there was no significant difference in QoL score between those with a passing OFC (eg, non-reactive) and a failing OFC (eg, reactive) (1.42 vs 1.34; P = .83). In an adjusted linear regression model, the QoL score was significantly better among caregivers of individuals with food allergy who were undergoing OFC and with an income >$50,000 but significantly worsened for caregivers with multiple individuals with food allergy or if the individual with food allergy had atopic dermatitis.

CONCLUSION

The caregiver QoL score is better with individuals with food allergy who underwent OFC versus controls who were unchallenged but not significantly different based on OFC outcome. QoL is, in addition, moderated by income, the presence of atopic dermatitis, and having multiple individuals with food allergy. OFC is associated with better caregiver QoL, irrespective of challenge outcome.

International consensus on (ICON) anaphylaxis

ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction. They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice. For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences. ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available. ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research. IN ADDITION TO CONFIRMING THE ALIGNMENT OF MAJOR ANAPHYLAXIS GUIDELINES, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.

Impact of primary food allergies on the introduction of other foods amongst Canadian children and their siblings

Background

Food-allergic children frequently avoid other highly allergenic foods. The NIAID 2010 guidelines state that individuals with an IgE-mediated food allergy should avoid their specific allergens and physicians should help patients to decide whether certain cross-reactive foods also should be avoided. Patients at risk for developing food allergy do not need to limit exposure to foods that may be cross-reactive with the major food allergens. The purpose of this study was to determine if parents of food-allergic children are given advice regarding introduction of allergenic foods; if these foods are avoided or delayed; if there is anxiety when introducing new foods; and if introducing other allergenic foods leads to any allergic reaction. The study also determined if there was a similar pattern seen amongst younger siblings.

Methods

An online survey was administered between December 2011 and March 2012 via Anaphylaxis Canada’s website, available to Canadian parents and caregivers who are registered members of the organization and who have a child with a food allergy.

Results

644 parents completed the online survey. 51% of families were given advice regarding the introduction of other allergenic foods. 72% were told to avoid certain foods, and 41% to delay certain foods. 58% of parents did avoid or delay other highly allergenic foods, mainly due to a fear of allergic reaction. 69% of children did not have an allergic reaction when these foods were subsequently introduced. 68% of parents felt moderate or high levels of anxiety when introducing other foods. A similar pattern was seen amongst the younger siblings.

Conclusions

Canadian parents and caregivers of children with food allergies receive varied advice from health care professionals regarding the introduction of new allergenic foods, and feel moderate to high levels of anxiety. A similar pattern may be seen amongst younger siblings. While the majority of children in our study did not have an allergic reaction to a new food, a significant proportion of children did react. A more consistent approach to the advice given by health care professionals may decrease parental anxiety. Further research to support the 2010 NIAID guidelines may be necessary to clarify recommendations.

An exploratory investigation of food choice behavior of teenagers with and without food allergies

BACKGROUND

Understanding food choice behavior in adolescence is important because many core eating habits may be tracked into adulthood. The food choices of at least 2.3% of teenagers living in the United Kingdom are determined by food allergies. However, the effect of food allergies on eating habits in teenagers has not yet been studied.

OBJECTIVE

To provide an understanding of how teenagers with food allergies make food choice decisions and how these differ from those of non-food-allergic teenagers.

METHODS

One focus group discussion with non-food-allergic teenagers (n = 11) and 14 semistructured interviewers (7 with food-allergic and 7 with non-food-allergic teenagers) were performed (age range, 12-18 years). The focus group discussion and interviews were audiorecorded, transcribed verbatim, and analyzed using thematic content analysis.

RESULTS

Teenagers from both groups (food-allergic and non-food-allergic) named sensory characteristics of foods as the main reason for choosing them. Some food-allergic teenagers downplayed their allergy and frequently engaged in risk-taking behavior in terms of their food choices. However, they reported difficulties in trying new foods, especially when away from home. Parental control was experienced as protective by those with food allergies, whereas non-food-allergic teenagers felt the opposite. Most teenagers, including food-allergic ones, expressed the wish to eat similar foods to their friends. Other themes did not vary between the 2 groups.

CONCLUSION

Food-allergic teenagers strive to be able to make similar food choices to their friends, although differences to non-food-allergic teenagers exist. It is important to address these differences to improve their dietary management.