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

Food allergy and quality of life: what have we learned?

Health-related quality of life (HRQL) has become an emerging focus of interest in food allergy. Food allergy is a disease characterized by low mortality and symptoms which only occur during an allergic reaction. However, food-allergic patients continuously need to be alert when eating in order to prevent potentially severe allergic reactions, which may be fatal. Fear of such reactions and the need to be continuously vigilant may seriously compromise their HRQL. During the last decade, numerous studies have been published on food allergy and HRQL. The development of reliable, valid and responsive instruments for measuring HRQL in food allergic patients has facilitated this research even further. Such instruments have given insight into the specific problems a patient may face and the impact of food allergy-related interventions from the patient's perspective. This paper focuses on the most significant findings regarding this topic since its first appearance in the literature in 2000.

Nutritional behavior and attitudes in food allergic children and their mothers

Background

Avoidance of food allergens requires adapting dietetic habits, changing nutritional approach. A restriction of food choice can result in a monotonous diet and impact social life. This study investigated the impact of food allergy on nutritional behavior and attitudes of patients and their families.

Methods

A survey involving mothers of food allergic children aged 0–16 years was carried out. We primarily studied the variables related to the child (age, gender, clinical history, food and social events attitudes). In addition, Spielberg Trait-Anxiety Inventory (STAI-T) test was applied to the mothers. We assessed separately the associations between characteristics of child-mother pairs and diet monotony, and attendance to social events, by means of proportional odds regression models.

Results

Nearly 10% of the 124 participants completely banned allergenic foods at home and 15.3% consumed their meals separately. More than one fourth attended parties rarely or never. Most of the participants reported a “monotonous diet”. Model results suggested significant associations between child age (p = 0.05), mother age (p = 0.05), number of excluded foods (p = 0.003) and monotony of the diet. The attendance of social events was inversely associated with the number of excluded foods (p = 0.04) and the mother’s STAI-T T-score (p = 0.04).

Conclusions

The results highlighted the impact of food allergy in reducing interest about food and influencing patients’ approach to social life. It is important to support families in managing allergens avoidance.

Duration of a cow-milk exclusion diet worsens parents' perception of quality of life in children with food allergies

BACKGROUND

In Italy, rigorous studies obtained with specific and validated questionnaires that explore the impact of exclusion diets on health-related quality of life (HRQoL) in children with food allergies are lacking. In this cross-sectional study, we wished to validate the Italian version of a disease-specific quality of life questionnaire, and assess the impact of exclusion diets on the HRQoL in a cohort of Italian children with IgE-mediated food allergies.

METHODS

Children on an exclusion diet for ≥1 food were enrolled consecutively, and their parents completed the validated Italian version of the Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF) and Food Allergy Independent Measure (FAIM).

RESULTS

Ninety-six parents of children aged 0-12 years answered the FAQLQ-PF. The validity of the construct of the questionnaire was assessed by correlation between the FAQLQ-PF and FAIM-PF (r = 0.85). The Italian version of the FAQLQ had good internal consistency (Cronbach's α >0.70). Factors that mainly influenced the HRQoL were older age, severity of food allergy, and the duration of the cow milk-exclusion diet.

CONCLUSIONS

The FAQLQ-PF, validated in Italian, is a reliable instrument. Worse QoL scores were observed among older children, those with severe systemic reactions, and those with a prolonged cow milk-free diet. It is very important to consider the QoL assessment as an integral part of food-allergy management. These results emphasize the need to administer exclusion diets only for the necessary time and the importance of assessment of the HRQoL in these patients.

Twenty four-hour helpline access to expert management advice for food-allergy-triggered anaphylaxis in infants, children and young people: a pragmatic, randomized controlled trial

BACKGROUND

Anaphylaxis is a life-threatening emergency. If promptly administered, adrenaline is potentially life-saving. Many food-allergic-children/carers are unsure when to use their adrenaline autoinjectors, contributing to a low quality of life and worse outcomes in the setting of an acute allergic reaction.

OBJECTIVES

The aim of this study was to assess the effectiveness of 24-hour telephone access to specialist clinical advice on disease-specific quality of life.

METHODS

A pragmatic two-arm, parallel-group randomized control trial was conducted. Children/carers (<16 years) with food allergy, trained in adrenaline auto-injector use, were recruited from a hospital-based paediatric allergy clinic. Baseline disease-specific quality of life was ascertained using the validated Food-Allergy-Related Quality-of-Life Questionnaire (FAQLQ), either Parent Form, Child Form or Teenager Form depending on child's age. Participants were then centrally randomized for a 6-month period to 24-hour telephone specialist support line or to usual care. The primary outcome measure was a change in FAQL scores, at one and 6 months postrandomization, compared with baseline. The minimum clinically important difference (MCID) in score is 0.5.

RESULTS

Fifty two children/carers were recruited. FAQL scores remained static in the control group across the three time points. Scores gradually improved in the intervention group, with a significant difference seen at 6 months (T1-T3 Mean difference = -1.5, (CI 0.87-2.25) P < 0.005] Follow-up questionnaires, 6 months after the intervention was removed, T4, showed sustained significant difference between the groups (control M = 3.0; intervention M = 1.1[t = -4.113, P < 0.05]).

CONCLUSION

The 24-hour helpline improved food-allergy-specific quality of life in children. Six-month intervention support resulted in sustained benefits for at least a further 6 months.

Impact of suspected food allergy on emotional distress and family life of parents prior to allergy diagnosis

BACKGROUND

Food allergy is associated with psychological distress in both child and parent. It is unknown whether parental distress is present prior to clinical diagnosis or whether experiences at clinic can reduce any distress present. This study aimed to assess anxiety and depression in parents and the impact of suspected food allergy on the lives of families before and after a visit to an allergy clinic.

METHODS

One hundred and twenty-four parents visiting an allergy clinic for the first time to have their child assessed for food allergy completed a study-specific questionnaire and the Hospital Anxiety and Depression Scale; 50 parents completed these 4-6 wk later in their own home.

RESULTS

Most parents (86.4%) reported suspected food allergy had an impact on their family life prior to clinic attendance; 76% had made changes to their child's diet. 32.5% of parents had mild-to-severe anxiety before their clinic visit; 17.5% had mild-to-moderate depression. Post-clinic, 40% had mild-to-severe anxiety; 13.1% had mild-to-moderate depression. There were no significant differences in anxiety (p = 0.34) or depression scores (p = 0.09) before and after the clinic visit.

CONCLUSIONS

Anxiety and depression is present in a small proportion of parents prior to diagnosis of food allergy in their child and this does not reduce in the short term after the clinic visit. Identification of parents at risk of suffering from distress is needed and ways in which we communicate allergy information before and at clinic should be investigated to see if we can reduce distress.

Food avoidance in children with adverse food reactions: influence of anxiety and clinical parameters

BACKGROUND

Many children in the general population avoid food because of self-reported adverse food reactions (AFR). Food avoidance can have negative consequences for well-being and nutritional status. This study aimed to investigate which factors are related to avoidance behavior in children (10-13 yr old) from the general population.

METHODS

Questionnaires for both mother and child were sent to participants from the Europrevall study: 164 children with self-reported AFR and 170 children without AFRs. Spielberger state anxiety and trait anxiety and clinical parameters, such as severity of the adverse reaction, specific IgE and doctor's diagnosis, were compared between those who have (had) AFR and avoid food (i.e., avoiders) and those who have (had) AFR(s) and do not avoid food (anymore; i.e., non-avoiders).

RESULTS

In total, 59% of the children with AFRs avoided food, of whom 26% had positive specific immunoglobulin E (sIgE). Child's state anxiety about an AFR was higher in avoiders than in non-avoiders, (p < 0.001), whereas child's trait anxiety and maternal state anxiety and trait anxiety were comparable in both groups. Avoiders reported more often severe symptoms (i.e., generalized urticaria, respiratory or cardiovascular symptoms) than non-avoiders, (p = 0.03). Food avoidance was not associated with doctor's diagnosis of food allergy or doctor's advice to avoid food (p = 1.00).

CONCLUSION

Food avoidance is related to child's state anxiety about an adverse food reaction. Food avoidance seems to be independent of a doctor's diagnosis of food allergy and advice on food avoidance.

Development of the scale of psychosocial factors in food allergy (SPS-FA)

BACKGROUND

Food allergy (FA) is a growing condition among children and it's psychological impact over the patients and their caregivers is well known, establishing a vicious circle that perpetuates stress levels. However, psychosocial factors are not commonly included in allergy treatments. Based on the lack of evidence of records about a scale that indicates the level of interaction between biopsychosocial factors in the patient-caregivers dyad for FA, the present research aims to develop a scale with these characteristics as a helpful tool to achieve a more comprehensive system of health care.

METHODS

A preliminary 28-item scale was generated (sample N = 99). The scale was adjusted in contents and language after expert opinion and application on patients. A factor analysis was carried out selecting the items from the final scale.

RESULTS

The final 9-item scale included three areas: impact on quality of life, social impact and conflicts. The scale had a good internal consistency (Cronbach's α = 0.870) and correlated significantly with anxiety and depression measurements. Moreover, it was able to discriminate between study groups (members and non-members of peer support groups) and proved construct validity.

CONCLUSIONS

The SPS-FA is the first scale for the assessment of the interaction of biopsychosocial factors on FA that includes the patient-caregiver dyad. Its application might be relevant for future research, and it can provide the clinician and the researcher with a solid tool to define which type of psychosocial support is required to provide a more comprehensive care in FA.

A pilot study of omalizumab to facilitate rapid oral desensitization in high-risk peanut-allergic patients

BACKGROUND

Peanut allergy is a major public health problem that affects 1% of the population and has no effective therapy.

OBJECTIVE

To examine the safety and efficacy of oral desensitization in peanut-allergic children in combination with a brief course of anti-IgE mAb (omalizumab [Xolair]).

METHODS

We performed oral peanut desensitization in peanut-allergic children at high risk for developing significant peanut-induced allergic reactions. Omalizumab was administered before and during oral peanut desensitization.

RESULTS

We enrolled 13 children (median age, 10 years), with a median peanut-specific IgE level of 229 kU(A)/L and a median total serum IgE level of 621 kU/L, who failed an initial double-blind placebo-controlled food challenge at peanut flour doses of 100 mg or less. After pretreatment with omalizumab, all 13 subjects tolerated the initial 11 desensitization doses given on the first day, including the maximum dose of 500 mg peanut flour (cumulative dose, 992 mg, equivalent to >2 peanuts), requiring minimal or no rescue therapy. Twelve subjects then reached the maximum maintenance dose of 4000 mg peanut flour per day in a median time of 8 weeks, at which point omalizumab was discontinued. All 12 subjects continued on 4000 mg peanut flour per day and subsequently tolerated a challenge with 8000 mg peanut flour (equivalent to about 20 peanuts), or 160 to 400 times the dose tolerated before desensitization. During the study, 6 of the 13 subjects experienced mild or no allergic reactions, 5 subjects had grade 2 reactions, and 2 subjects had grade 3 reactions, all of which responded rapidly to treatment.

CONCLUSIONS

Among children with high-risk peanut allergy, treatment with omalizumab may facilitate rapid oral desensitization and qualitatively improve the desensitization process.

Psychosocial dysfunction in children and adolescents with eosinophilic esophagitis

OBJECTIVE

Children with eosinophilic esophagitis (EoE) experience daily challenges related to coping with symptoms and the psychosocial effect of this chronic disease. The aim of this study was to identify features of psychosocial dysfunction experienced by children with EoE who were evaluated in a tertiary care program.

METHODS

We performed a retrospective review of EoE patients and their families' psychosocial evaluations performed in a tertiary care EoE program. Consecutive evaluations were analyzed to document reports of patients' disease-related pain/discomfort; feeding/appetite symptoms; sleep, social, and school problems; depression, anxiety; and overall psychological adjustment.

RESULTS

Sixty-four patients received psychosocial evaluation during an 18-month period and were analyzed. Sixty-nine percent of children evaluated experienced some form of psychosocial problems, including social difficulties (64%), anxiety (41%), sleep difficulties (33%), depression (28%), and school problems (26%). Adjustment problems were identified in 44% of the sample. Older children experienced more adjustment difficulties than younger children (P = 0.05). Sleep disturbances and feeding problems predominated in the younger children. Anxious behavior and depressive feelings increased with age. Children with gastrostomy tubes (G-tubes) had more social, school, and psychological adjustment problems than those without.

CONCLUSIONS

The majority of children with EoE who underwent health and behavior evaluation in a tertiary care program experienced psychosocial adjustment and coping problems. Evaluation and management by mental health professionals would likely benefit a majority of patients with this chronic disease.

Health-related quality of life in children with abdominal pain due to functional or organic gastrointestinal disorders

OBJECTIVE

Comparing health-related quality of life (HRQOL) in children suffering from functional and organic gastrointestinal disorders and to identify predictors for HRQOL.

METHODS

Children with functional (n = 70) and organic (n = 100) gastrointestinal disorders, aged 8-18 years and referred to a pediatric gastroenterologist, completed questionnaires assessing pain severity, coping, and HRQOL.

RESULTS

The sample reported low HRQOL scores, even significantly lower compared with reference values of chronically ill children, derived from normative data of KINDL-R, a generic QOL questionnaire. HRQOL was not significantly associated with age, gender, duration of pain, and diagnosis (functional gastrointestinal disorder vs. organic gastrointestinal disorder). Pain severity and catastrophizing were significantly associated with HRQOL, with catastrophizing fully mediating the relationship between pain and HRQOL.

CONCLUSION

The emotional burden associated with chronic abdominal pain-regardless of its cause-is enormous. Interventions should target the children's coping strategies, as catastrophizing seems to be the causal link between pain and HRQOL.

Patients' experience of a regional allergy service

Background

The principle reason for referral to specialist allergy clinics is to establish diagnoses and provide treatment plans to help patients manage their allergy. If patients do not accept, understand, or remember diagnoses or treatment, clinic visits may have been a waste of time. Few specialist allergy clinics follow up patients after diagnosis.

Design and Methods

This was a postal survey to assess patients’ i) perception of usefulness of specialist allergy clinic visits, ii) understanding of their allergy, iii) confidence in managing it, and iv) response to joining a regional online forum. Data for patients with confirmed allergy who attended the Peninsula Allergy Service (PAS) from 1998-2009 were extracted from consultant letters to general practitioners. Postal questionnaires were sent to 933 patients; 39% (336) responded.

Results

Two-thirds (63%) thought their clinic visit useful and resulted in them being more in control of their allergy; 9% thought it useful but they still had problems, 26% thought it had not been much use. One in six (16%, 55) respondents had major differences in their view of their allergy compared to that recorded by PAS. Over half (56%) had had further symptoms since their clinic visit and 120 patients, who were not confident in coping with their allergy, listed aspects of their lives that gave concern.

Conclusions

Specialist clinics need routine feedback from patients if they are to monitor their effectiveness and some better form of follow up for patients is needed to reinforce education and support patients. Public education is important.

Food allergy diagnosis and therapy: where are we now?

Food allergy is a growing worldwide epidemic that adversely effects up to 10% of the population. Causes and risk factors remain unclear and diagnostic methods are imprecise. There is currently no accepted treatment for food allergy. Therefore, there is an imminent need for greater understanding of food allergies, revised diagnostics and development of safe, effective therapies. Oral immunotherapy provides a particularly promising avenue, but is still highly experimental and not ready for clinical use.

Impacts of online peer support for children with asthma and allergies: It just helps you every time you can't breathe well"

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Support was delivered by peer mentors with asthma and allergies and a professional. Weekly support groups were conducted over 8 weeks using Go to Meeting and Club Penguin. Quantitative measures and a qualitative interview were administered. Significant increases in perceived support and support-seeking coping and trends in decreased loneliness emerged at post-test. Participants also reported increased self-confidence and satisfaction with the intervention.

Stress and food allergy: mechanistic considerations

Recent years have seen a marked increase in food allergy prevalence among children, particularly in Western countries, that cannot be explained by genetic factors alone. This has resulted in an increased effort to identify environmental risk factors underlying food allergies and to understand how these factors may be modified through interventions. Food allergy is an immune-mediated adverse reaction to food. Consequently, considerations of candidate risk factors have begun to focus on environmental influences that perturb the healthy development of the emerging immune system during critical periods of development (eg, prenatally and during early childhood), particularly in the gut. Given that psychosocial stress is known to play an important role in other allergic and inflammatory diseases, such as asthma, its potential role in food allergy is a growing area of research. However, research to date has largely focused on animal studies. This review synthesizes relevant animal research and epidemiological data, providing proof of concept for moderating influences of psychological stress on food allergy outcomes in humans. Pathways that may underlie associations between psychosocial stress and the expression of food allergy are discussed.

Mother's and offspring's use of antibiotics and infant allergy to cow's milk

BACKGROUND

Evidence on the association between antibiotics and the risk of food allergies is limited. We explored the associations between mother's and offspring's use of antibiotics and the risk of cow's milk allergy in infancy.

METHODS

We used a national registry to identify all children who were born in 1996-2004 in Finland and diagnosed with cow's milk allergy after 1 month of age by November 2005 (n = 15,672). For each case, we selected one control matched for birth date, sex, and hospital district. Information on antibiotic purchases and putative confounders was obtained from registries. The associations were analyzed using conditional logistic regression.

RESULTS

Maternal use of antibiotics before and during pregnancy was associated with an increased risk of cow's milk allergy in the offspring (odds ratio = 1.26 [95% confidence interval = 1.20-1.33] and 1.21 [1.14-1.28], respectively, adjusting for putative confounders). The risk of cow's milk allergy increased with increasing number of child's antibiotics used from birth to diagnosis (test for trend P < 0.001).

CONCLUSIONS

Both maternal and child's use of antibiotics were associated with an increased risk of cow's milk allergy. Future studies are needed to confirm these novel findings and to explore the potential biologic mechanisms behind the association.

The impact of food allergies on quality of life

CME EDUCATIONAL OBJECTIVES 1. Recognize and appreciate the impact of food allergies on psychosocial health. 2. List the factors that have been shown to negatively affect health-related quality of life. 3. Understand how physicians can directly help to improve a child's quality of life while living with food allergies. Food allergy is a serious problem affecting a growing number of children worldwide. There is a large body of evidence supporting the detrimental effects that food allergy can have on a child's quality of life. With validated tools, we can identify these children and focus on how to protect, guide, and help them to live a safe life. Recent research articulates how food allergies impact health-related quality of life (HRQL). There are studies reported from the child's perspective, as well as studies reported from the parent's perspective. With the development of validated disease and age-specific questionnaires, researchers can reliably gather data on the psychological aspect of children with food allergies. The purpose of this article is to provide a review of the literature examining the psycho-social impact of food allergies on children. This article was designed to outline suggestions to help physicians care for the whole child - both mind and body.

Managing murine food allergy with Cissampelos sympodialis Eichl (Menispermaceae) and its alkaloids

Food allergy is a severe human disease with imminent risk of life. Cissampelos sympodialis (Menispermaceae) is a native Brazilian plant used in Brazilian folk medicine for the treatment of respiratory allergies. In this study the experimental model of food allergy induced by ovalbumin (OVA) was used to determine whether the alcoholic extract of the plant (AFL) and its alkaloids match a therapeutic approach for this disease. Animal weight, diarrhea, OVA-specific IgE levels, inflammatory cell and cytokine profiles, mucus production and proportion of T cells on the mesenteric lymph node (MLN) were evaluated. Warifteine (W) or methyl-warifteine (MW) alkaloids slightly improve diarrhea score independently of AFL and all treatments decreased the OVA-specific IgE levels. Stimulated mesenteric lymph node (MLN) cells in the presence of the alkaloids diminished the IL-12p70 levels independently of IFN-γ or IL-13 secretion. The alkaloids increased the number of Treg cells on MLN and reduced the number of eosinophils and mast cells as well as mucus production in the gut. Therefore, the alkaloids modulate the immune response in food allergy by increasing regulatory T cells in MLN independently of Th1 or Th2 profiles.

The psychosocial impact of an activity holiday for young children with severe food allergy: a longitudinal study

BACKGROUND

Food allergy has been shown to severely affect quality of life (QoL) in children and their families. The Anaphylaxis Campaign U.K. supports families with allergic children and as part of that support ran an activity holiday for those with food allergy. This study investigated the effectiveness of this activity holiday for reducing anxiety and improving QoL and food allergy management for these children.

METHODS

Measures were taken at baseline, at the start of the activity holiday, at the end of the holiday, at 3 and 6 months follow-up. Children (n = 24) completed a paediatric food allergy-specific QoL questionnaire (PFA-QL), a generic QoL questionnaire (PedsQL, the Spence Children's Anxiety Scale (SCAS) and the children's health locus of control (CHLC) scale at all stages of the study.

RESULTS

There were significant improvements in social QoL, food allergy-specific QoL, total CHLC and internal locus of control scores over time (p > 0.05). There were significant decreases in powerful others locus of control, total anxiety and obsessive compulsive disorder scores (p < 0.05). Greater anxiety significantly correlated with poorer QoL at all time points; no correlations with locus of control were significant at the 3- and 6-month follow-up.

CONCLUSIONS

The activity holiday was of significant benefit to the children who took part, providing support for the need for activity holidays such as this for children with severe food allergy. Ways in which adaptive locus of control and improved quality of life can be facilitated need to be further explored.

Why do few food-allergic adolescents treat anaphylaxis with adrenaline?--Reviewing a pressing issue

Food allergic adolescents are at higher risk of fatal anaphylaxis than other children. Both allergen avoidance and maintaining access to adrenaline auto-injectors (AAI) are key goals in effective food allergy management, for which written guidance is often supplied. However, adolescents are rarely sufficiently prepared to use adrenaline during anaphylaxis. It is likely that further didactic education would bring limited improvement in management in this population. Focused discussion of each adolescent's perspectives and current management practice may allow more effective behavioural strategies to be adopted. Key areas for appraisal include subjects' experiences after previous allergen exposure with reference to worst response, recognising specific symptoms requiring AAI administration, and appropriate priority being given to timeliness of administering adrenaline. Behavioural strategies should be discussed to increase AAI accessibility. Rigor of allergen avoidance should not be compromised by false reassurance of proximity to emergency medication or medical services. Food allergic adolescents are motivated by the psychological impact of their condition, which often makes them feel different to their peers and may result in bullying. Methods of appropriately empowering adolescents may be considered, such as involvement of close friends and lay organisations to support appropriate management. Open discussion is crucial in engaging with adolescents' reasoning for adopting their chosen management strategies. Further research is warranted to identify cognitive patterns associated with high-risk behaviour, and to design appropriate interventions for the augmentation of adolescent self-management skills.

Online support for children with asthma and allergies

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Children (n = 27) aged 7 to 11 from across Canada participated. GoToMeeting was employed for the support group sessions and Club Penguin for social connections during and between support group meetings. Content included: strategies for coping with asthma and allergies, role playing and games to help children deal with difficult situations, fun and enjoyment, and presentations by positive role models. Participation in the online peer support intervention was high, 86.3% on average over the 8-week intervention. By sharing their experiences, listening to peers' experiences, and role playing, children were introduced to practical skills: problem solving, communicating, seeking support, and self-advocacy.

Validation of the Paediatric Food Allergy Quality of Life Questionnaire (PFA-QL)

BACKGROUND

The Paediatric Food Allergy Quality of Life Questionnaire (PFA-QL) was the first tool to be developed for assessing health-related quality of life (QoL) in children with food allergy. It has been used in a number of published studies, but has not been validated.

OBJECTIVE

The aim of the current study was to validate child (PFA-QL) and parent-proxy (PFA-QL-PF) versions of the scale in a specialist allergy clinic and in parents of children with food allergy.

METHODS

For the clinic sample, a generic QoL scale (PedsQL) and the PFA-QL were completed by 103 children (age 6-16 yrs) with peanut or tree nut allergy; test-retest reliability of the PFA-QL was tested in 50 stable patients. For the non-clinical sample, 756 parents of food allergic children completed the PFA-QL-PF, the Child Health Questionnaire (CHQ-PF50), Food Allergy Quality of Life Parental Burden Scale (FAQL-PB) and a Food Allergy Impact Measure.

RESULTS

The PFA-QL and PFA-QL-PF had good internal consistency (α's of 0.77-0.82), and there was moderate-to-good agreement between the generic- and disease-specific questionnaires. The PFA-QL was stable over time in the clinic sample, and in both samples, girls were reported to have poorer QoL than boys.

CONCLUSIONS

The PFA-QL and PFA-QL-PF are reliable and valid scales for use in both clinical and non-clinical populations. Unlike other available tools, they were developed and validated in the UK and thus provide a culture-specific choice for research, clinical trials and clinical practice in the UK. Validation in other countries is now needed.

The management of situated risk: A parental perspective on child food allergy

Food allergy is an illness that requires constant risk management in everyday life. To date, there is no cure or preventive treatment, and the only way to manage the condition is therefore careful avoidance of the offending foodstuff and treatment of reactions when they occur. This article draws on a socio-cultural approach to explore parents’ understandings and management of child food allergy in the context of everyday life, as ‘situated’ risk. A focus group study was carried out with 31 parents of children diagnosed with food allergy at two children’s hospitals. The analysis of the focus group material reveals how the management of allergy risk seems to permeate most aspects of everyday life as well as how the parents draw on a dominant norm of risk avoidance as well as a counter-discourse of calculated risk taking. The patterns of risk management found in this study are discussed in terms of how risk avoidance and risk taking are intertwined and balanced in the context of moral parenthood.

Pathogenesis of food allergy in the pediatric patient

In the US and other developed countries, food allergy is a growing epidemic in pediatric populations with a substantial impact on health-related quality of life. As such, there are great efforts underway to unravel the mechanisms of oral mucosal tolerance and to better define the factors related to host and allergen exposure that contribute to the aberrant immune response leading to sensitization and clinical food allergy. Although more research is needed to eventually develop targeted treatment and prevention strategies, this review highlights our current understanding of the pathogenesis of IgE-mediated food allergy.

Beyond labelling: what strategies do nut allergic individuals employ to make food choices? A qualitative study

Objective

Food labelling is an important tool that assists people with peanut and tree nut allergies to avoid allergens. Nonetheless, other strategies are also developed and used in food choice decision making. In this paper, we examined the strategies that nut allergic individuals deploy to make safe food choices in addition to a reliance on food labelling.

Methods

Three qualitative methods: an accompanied shop, in-depth semi-structured interviews, and the product choice reasoning task – were used with 32 patients that had a clinical history of reactions to peanuts and/or tree nuts consistent with IgE-mediated food allergy. Thematic analysis was applied to the transcribed data.

Results

Three main strategies were identified that informed the risk assessments and food choice practices of nut allergic individuals. These pertained to: (1) qualities of product such as the product category or the country of origin, (2) past experience of consuming a food product, and (3) sensory appreciation of risk. Risk reasoning and risk management behaviours were often contingent on the context and other physiological and socio-psychological needs which often competed with risk considerations.

Conclusions

Understanding and taking into account the complexity of strategies and the influences of contextual factors will allow healthcare practitioners, allergy nutritionists, and caregivers to advise and educate patients more effectively in choosing foods safely. Governmental bodies and policy makers could also benefit from an understanding of these food choice strategies when risk management policies are designed and developed.

Living with severe allergy: an Anaphylaxis Campaign national survey of young people

Background

The transition to adulthood can be particularly challenging for young people with severe allergies, who must learn to balance personal safety with independent living. Information and support for young people and their families are crucial to successfully managing this transition. We sought to: gather insights into the impact of severe allergies on the lives of young people; explore where young people go for information about anaphylaxis and what information they want and need; identify areas where further support is needed.

Methods

An online questionnaire survey of young people aged 15–25 years with severe allergies in the United Kingdom (UK) was conducted on behalf of the Anaphylaxis Campaign, the main patient support organisation. Participants were recruited mainly from the Anaphylaxis Campaign membership database and also via allergy clinics and social media. The study was funded by the Anaphylaxis Campaign’s In Memoriam Fund.

Results

A total of 520 young people responded to the survey. The majority had lived with severe allergies since they were young children; 59% reported having attended Accident and Emergency units as a consequence of their allergies. Only 66% of respondents reported always carrying their epinephrine auto-injectors; only 23% had ever used these. Few were currently receiving specialist allergy care; younger respondents were more likely to be under specialist care (34%) than those 18 years and above (23%). Respondents wanted more information about eating out (56%), travelling (54%) and food labelling (43%). Almost a quarter of respondents (23%) reported needing more information on managing their allergies independently without parental help. Managing allergies in the context of social relationships was a concern for 22% of respondents.

Conclusions

This survey has identified the information and support needs and gaps in service provision for young people with severe allergies. Healthcare professionals and patient support organisations, with the support of the food industry, can help to meet these needs.

Strategies for living with the risk of anaphylaxis in adolescence: qualitative study of young people and their parents

BACKGROUND

Adolescents with anaphylaxis are at increased risk of fatal outcomes. Gaps in their knowledge of day-to-day and emergency management have been identified. There are also gaps in services available to support adolescents at risk of anaphylaxis.

AIMS

To explore the experiences and healthcare needs of adolescents living with the risk of anaphylaxis; to understand the perspectives of their parents; and to look at how care might be improved.

METHODS

A qualitative study was undertaken using in-depth interviews with adolescents with a recent history of severe allergic reactions and with their parents.

RESULTS

Twenty-six adolescents at risk of anaphylaxis living in Scotland and their parents (n=28) were recruited. Most anaphylactic reactions reported by participants appeared to result from accidents, misinformation, or inexperience. For many, management involved finding a balance between taking their allergies seriously whilst not allowing these concerns to dominate their lives. Risks were often difficult to judge, with reactions sometimes taking place even after careful checking of meal ingredients. Most admitted taking some risks with trace-labelled foods. Appropriate healthcare support for adolescents in learning to manage the risk of anaphylaxis independently and advice and support for their parents was inconsistently provided.

CONCLUSIONS

Adolescents tend to see their risk management strategies as 'good enough', but these strategies were often inconsistent with clinical best practice and, in some cases, had not prevented reactions. Building on adolescents' existing skills and knowledge and the use of Internet and associated social media resources may help to support more effective self-management among adolescents.

An assessment of the mental health care needs and utilization by families of children with a food allergy

The present study aimed to examine whether caretakers of children with a food allergy experience distress and to determine their family’s mental health-care needs and utilization. An anonymous survey was given to a sample of 454 caretakers during conferences hosted by the Food Allergy & Anaphylaxis Network. Overall, 32 percent of caretakers reported above threshold levels of distress while 70 percent stated that mental health support would have been helpful, but only 23 percent sought it. Even when mental health support was desired and available, few received it. Routine discussion of mental health needs with families receiving medical care may help address barriers to utilization.

Maternal intolerance of uncertainty, anxiety, and adherence with food challenge referrals

Anxiety regarding food challenges may serve an important role in parents’ decisions to adhere to their child’s food challenge referrals. This study examined the role of intolerance of uncertainty in food challenge referral adherence by assessing state/trait anxiety among mothers whose children were referred for a food challenge. Mothers whose children passed a food challenge reported significant decreases in anxiety regarding allergic reactions, but intolerance of uncertainty did not predict adherence. Trust in the physician was a primary reason mothers attended the food challenge, suggesting that physicians should consider the impact of the physician–patient relationship when treating these families.

Validation of the Food Allergy Quality of Life-Parental Burden Questionnaire in the UK

PURPOSE

Food allergy can have a profound effect on quality of life (QoL) of the family. The Food Allergy Quality of Life-Parental Burden Questionnaire (FAQL-PB) was developed on a US sample to assess the QoL of parents with food allergic children. The aim of this study was to examine the reliability and validity of the FAQL-PB in a UK sample and to assess the effect of asking about parental burden in the last week compared with parental burden in general, with no time limit for recall given.

METHODS

A total of 1,200 parents who had at least one child with food allergy were sent the FAQL-PB and the Child Health Questionnaire (CHQ-PF50); of whom only 63% responded.

RESULTS

Factor analysis of the FAQL-PB revealed two factors: limitations on life and emotional distress. The total scale and the two sub-scales had high internal reliability (all α > 0.85). There were small to moderate but significant correlations between total FAQL-PB scores and health and parental impact measures on the CHQ-PF50 (p < 0.01). Significantly greater parental burden was reported for the no-time limited compared with the time-limited version (p < 0.01).

CONCLUSIONS

The FAQL-PB is a reliable and valid measure for use in the UK. The scale could be used in clinic to assess the physical and emotional quality of life in addition to the impact on total quality of life.

Effect of oral immunotherapy to peanut on food-specific quality of life

BACKGROUND

Peanut allergy is an increasingly common problem for which the only available treatment is avoidance. Oral immunotherapy has shown promise for increasing tolerance of peanut in allergic children. Food allergy has an effect on the quality of life of children and adolescents.

OBJECTIVE

To measure the effect of oral immunotherapy to peanut on food-specific quality of life in children and adolescents.

METHODS

One hundred patients (5-18 years of age) were enrolled in an open trial of peanut oral immunotherapy. Parents of children 5 to 12 years old, children 8 to 12 years old, and teenagers completed validated, age-specific, food-related quality-of-life surveys before and after peanut oral immunotherapy.

RESULTS

Ninety patients (76 children 5-12 years old and 14 adolescents 13-18 years old) achieved the maintenance daily dose of 450 mg of peanut protein. A significant improvement in quality of life was found in all survey domains (allergen avoidance, dietary restriction, risk of accidental exposure, emotional impact, food-related anxiety, and social and dietary limitations) with the exception of the emotional impact domain on the adolescents' survey. Quality of life significantly improved (P < .02) on all 30 questions when parents assessed their children 5 to 12 years old. When children (8-12 years old) and teens assessed themselves, quality of life improved (P < .05) on 22 of 24 questions and 12 of 18 questions, respectively.

CONCLUSION

Peanut oral immunotherapy significantly improves food-specific quality of life.

Parent perceived quality of life is age-dependent in children with food allergy

BACKGROUND

Food allergy in children significantly affects their quality of life. Its impact can be analyzed by quality of life questionnaires.

OBJECTIVES

The aim of our study was to validate the French version of disease-specific questionnaires and to evaluate the quality of life in children with IgE-mediated food allergy.

METHODS

Two validated food allergy-specific questionnaires for quality of life, the parent's and children's forms (FAQLQ-PF and FAQLQ-CF), were translated from English to French and submitted to children with food allergy and their parents. Questionnaires were analyzed in terms of emotional impact, food anxiety, and social and food limitations. NCT 01480427.

RESULTS

Sixty-two parents of children aged 0-12 yrs answered the FAQLQ-PF, and 32 children aged 8-12 yrs the FAQLQ-CF. Construct validity of both questionnaires was assessed by correlation between the FAQLQs and FAIM (r = 0.85 and 0.84, respectively). Both FAQLQs had good internal consistency (Cronbach's α = 0.748 and 0.67, respectively). Young children (0-3 yrs old) showed better quality of life scores than older children (FAQLQ-PF global score: p = 0.02). Worse scores were also shown among children with previous severe systemic reactions (FAQLQ-PF global score: p = 0.039), the ones with an allergic mother (FAQLQ-PF global score: p = 0.002), or allergic siblings (FAQLQ-PF emotional impact score: p = 0.034), the ones with multiple food allergy (more than 1 food) (FAQLQ-PF anxiety score: p = 0.04) and among the girls (FAQLQ-CF global score: p = 0.031).

CONCLUSION

Older children, the ones with severe systemic reactions, or with mothers or siblings also affected by allergies, as well as girls, and children with multiple food allergies show worse quality of life scores.

Immunological mechanisms for desensitization and tolerance in food allergy

Food allergy is a major public health concern in westernized countries, estimated to affect 5 % of children and 3-4 % of adults. Allergen-specific immunotherapy for food allergy is currently being actively evaluated, but is still experimental. The optimal protocol, in terms of the route of administration of the food, target maintenance dose, and duration of maintenance therapy, and the optimal patient for these procedures are still being worked out. The mechanisms underlying successful food desensitization are also unclear, in part, because there is no standard immunotherapy protocol. The mechanisms involved, however, may include mast cell and basophil suppression, development of food-specific IgG4 antibodies, reduction in the food-specific IgE/IgG4 ratio, up-regulation and expansion of natural or inducible regulatory T cells, a skewing from a Th2 to a Th1 profile, and the development of anergy and/or deletion in antigen-specific cells. Additional studies are required to elucidate and understand these mechanisms by which desensitization and tolerance are achieved, which may reveal valuable biomarkers for evaluating and following food allergic patients on immunotherapy.

The strategies that peanut and nut-allergic consumers employ to remain safe when travelling abroad

BACKGROUND

An understanding of the management strategies used by food allergic individuals is needed as a prerequisite to improving avoidance and enhancing quality of life. Travel abroad is a high risk time for severe and fatal food allergic reactions, but there is paucity of research concerning foreign travel. This study is the first to investigate the experiences of, and strategies used by peanut and tree nut allergic individuals when travelling abroad.

METHODS

Thirty-two adults with a clinical history of reaction to peanuts or tree nuts consistent with IgE-mediated allergy participated in a qualitative interview study.

RESULTS

Travel abroad was considered difficult with inherent risks for allergic individuals. Many participants recounted difficulties with airlines or restaurants. Inconsistency in managing allergen avoidance by airlines was a particular risk and a cause of frustration to participants. Individuals used a variety of strategies to remain safe including visiting familiar environments, limiting their activities, carrying allergy information cards in the host language, preparing their own food and staying close to medical facilities.

CONCLUSIONS

Participants used a variety of allergen avoidance strategies, which were mostly extensions or modifications of the strategies that they use when eating at home or eating-out in the UK. The extended strategies reflected their recognition of enhanced risk during travel abroad. Their risk assessments and actions were generally well informed and appropriate. A need for airline policy regarding allergy to be declared and adhered to is needed, as is more research to quantify the true risks of airborne allergens in the cabin. Recommendations arising from our study are presented.

Impact and Oral Immunotherapy on Quality of Life in Children with Cow Milk Allergy: A Pilot Study

Quality of life is negatively affected in children with food allergy. Oral immunotherapy is an approach to food allergy that leads to patient desensitization by administering gradually increasing amounts of a given food allergen. The aim of this pilot study is to evaluate how oral immunotherapy affects quality of life in children allergic to cow milk proteins. Thirty children (aged 3–12 years) with cow milk allergy were recruited. Their parents were provided with a validated disease specific quality of life questionnaire (the food allergy quality of life questionnaire – parent form, FAQLQ-PF) before and again 2 months after completing an oral immunotherapy protocol with cow milk. A significant improvement in all the investigated domains - emotional impact, food anxiety and social and dietary limitations - was found. The separate analysis of the different age groups demonstrated that the emotional impact and the food-related anxiety improved in children older than 4, while the social domains improved in each age group. In this pilot experience, oral immunotherapy significantly improves quality of life in children with cow milk allergy. The improvement seems particularly evident in children over 4 years old, who are most likely to benefit from the oral immunotherapy approach. Further placebo-controlled studies are needed to confirm these preliminary results.

The predictive value of skin prick testing for challenge-proven food allergy: a systematic review

Immunoglobulin E-mediated (IgE) food allergy affects 6-8% of children, and the prevalence is believed to be increasing. The gold standard of food allergy diagnosis is oral food challenges (OFCs); however, they are resource-consuming and potentially dangerous. Skin prick tests (SPTs) are able to detect the presence of allergen-specific IgE antibodies (sensitization), but they have low specificity for clinically significant food allergy. To reduce the need for OFCs, it has been suggested that children forgo an OFC if their SPT wheal size exceeds a cutoff that has a high predictability for food allergy. Although data for these studies are almost always gathered from high-risk populations, the 95% positive predictive values (PPVs) vary substantially between studies. SPT thresholds with a high probability of food allergy generated from these studies may not be generalizable to other populations, because of highly selective samples and variability in participant's age, test allergens, and food challenge protocol. Standardization of SPT devices and allergens, OFC protocols including standardized cessation criteria, and population-based samples would all help to improve generalizability of PPVs of SPTs.

What factors affect the carriage of epinephrine auto-injectors by teenagers?

Background

Teenagers with allergies are at particular risk of severe and fatal reactions, but epinephrine auto-injectors are not always carried as prescribed. We investigated barriers to carriage.

Methods

Patients aged 12-18 years old under a specialist allergy clinic, who had previously been prescribed an auto-injector were invited to participate. Semi-structured interviews explored the factors that positively or negatively impacted on carriage.

Results

Twenty teenagers with food or venom allergies were interviewed. Only two patients had used their auto-injector in the community, although several had been treated for severe reactions in hospital. Most teenagers made complex risk assessments to determine whether to carry the auto-injector. Most but not all decisions were rational and were at least partially informed by knowledge. Factors affecting carriage included location, who else would be present, the attitudes of others and physical features of the auto-injector. Teenagers made frequent risk assessments when deciding whether to carry their auto-injectors, and generally wanted to remain safe. Their decisions were complex, multi-faceted and highly individualised.

Conclusions

Rather than aiming for 100% carriage of auto-injectors, which remains an ambitious ideal, personalised education packages should aim to empower teenagers to make and act upon informed risk assessments.

Immunology in the Clinic Review Series; focus on allergies: immunotherapy for food allergy

There is no approved therapy for food allergy. The current standard of care is elimination of the triggering food from the diet and accessibility to epinephrine. Immunotherapy is a promising treatment approach. While desensitization to most foods seems feasible, it remains unclear if a permanent state of tolerance is achievable. The research team at Duke is pioneering immunotherapy for food allergies. Work here has evolved over time from small open-label pilot studies to larger randomized designs. Our data show that immunological changes associated with immunotherapy include reduction in mast cell reactivity, decreased basophil responses, decreased specific-immunoglobulin (Ig)E, increased IgG4 and induction of regulatory T cells. Immunotherapy has generated much excitement in the food allergy community; however, further studies are needed before it is ready for clinical use.

Anaphylaxis in children: a nine years retrospective study (2001-2009)

BACKGROUND

Anaphylaxis is an acute multisystemic and potentially fatal reaction, resulting from the rapid release of inflammatory mediators. Its exact prevalence is unknown. In children, foods are the most significant triggers for IgE-mediated anaphylaxis.

OBJECTIVES

To characterise the cases of anaphylaxis evaluated in an Allergy Division of a Central Paediatric Hospital.

MATERIAL AND METHODS

A review of all cases of anaphylaxis evaluated from 2001 to 2009. Anaphylaxis was defined according to Sampson's 2006 criteria.

RESULTS

Seventy-three children had anaphylactic reactions (47 male), of which 64% had history of atopy. Age at time of reaction ranged between 17 days and 15 years old (median: four years). Food was the most frequently identified cause (n=57), followed by drugs (n=8), hymenoptera venom (n=2), and cold (n=1). In five cases there was no identifiable cause. Among foods, cow's milk was the culprit agent in 27 children. The most severe reaction was a cardiorespiratory arrest. The most frequent symptoms were respiratory and cutaneous in 51 cases. Hypotension was present in nine cases. There were no fatalities. Most acute reactions were treated with corticosteroids and/or antihistamines. Adrenaline was used in only about one quarter of children.

CONCLUSIONS

The most important causes of anaphylaxis in our study were foods, and the most common symptoms were respiratory and cutaneous. The prevalence of anaphylaxis was higher in males and, in two thirds of patients there was a history of atopy. Despite being the primary and most important treatment for anaphylaxis, adrenaline is still used in only a minority of these cases.

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.

Adolescent-parent disagreement on health-related quality of life of food-allergic adolescents: who makes the difference?

BACKGROUND

Food-allergic adolescents are at highest risk for food allergy fatalities, which may be partly due to compromised self-management behavior. Such behavior may be negatively influenced by conflictual situations caused by adolescent-parent disagreement on the adolescent's health-related quality of life (HRQL). Comparisons of adolescent-self-reported and parent-proxy-reported HRQL of food-allergic adolescents have never extensively been studied. The aims of this study were to investigate disagreement in adolescent-self-reports and parent-proxy-reports on the HRQL of food-allergic adolescents and to investigate the factors influencing adolescent-parent disagreement.

METHODS

Teenager Form (TF) and Parent Form (PFA) of the Food Allergy Quality of Life Questionnaire (FAQLQ), Food Allergy Independent Measure (FAIM), and Brief-Illness Perception Questionnaire (Brief-IPQ) were sent to food-allergic Dutch adolescents (13-17 years) and their parents. ICCs, t-tests, and Bland-Altman plots were used to investigate adolescent-parent disagreement. Participant characteristics, illness expectations, and illness perceptions influencing adolescent-parent disagreement were studied using regression analysis.

RESULTS

Seventy adolescent-parent pairs were included. There were a moderate correlation (ICC = 0.61, P < 0.001) and no significant difference (3.78 vs 3.56, P = 0.103) between adolescent-self-reported and parent-proxy-reported HRQL at group level. However, Bland-Altman plots showed relevant differences (exceeding the minimal important difference) for 63% of all adolescent-parent pairs. Adolescent's age (> 15 years), poorer adolescent-reported illness comprehension (Brief-IPQ-TF, coherence), and higher adolescent-reported perceived disease severity (Food Allergy Independent Measure-Teenager Form & -Parent Form) were associated with adolescent-parent disagreement.

CONCLUSIONS

Adolescent-parent disagreement on the adolescent's HRQL was mainly associated with adolescents' rather than parents' perceptions and characteristics. Illness comprehension of the adolescent may be an important target for intervention aimed at reducing adolescent-parent disagreement.

Parental perceptions and dietary adherence in children with seafood allergy

BACKGROUND

Allergy to seafood (fish, mollusc and crustacean) is increasing and is now a leading cause of food anaphylaxis, but there is only limited data on the impact of seafood allergy on affected children and their families.

METHODS

We assessed dietary adherence and perceptions of seafood allergy amongst the parents of 94 children presenting to a specialist allergy clinic with proven seafood allergy, by means of a postal questionnaire and cross-referencing the data obtained to clinical records.

RESULTS

One-quarter of parents were unable to correctly recall the dietary advice provided. Nonetheless 89% of parents implemented a safe diet, but over half followed a more stringent elimination than that recommended. One-fifth of the children had subsequent allergic reactions to seafood after diagnosis, and these were generally a result of accidental rather than intentional exposure or cross-contamination. Provision of an adrenaline auto-injector device was associated with increased adherence to dietary advice. Oral food challenges had a beneficial effect on parental perceptions and were helpful to parents in managing their child's allergy.

CONCLUSIONS

Seafood allergy has a significant adverse effect on anxiety and stress in the families of affected children. Parental recall of dietary advice is variable and many tend to impose more stringent dietary avoidance than that recommended. Despite this, subsequent accidental reactions are common. Thus, the avoidance of seafood in children may be more difficult than often presumed.

Anaphylaxis: a history with emphasis on food allergy

In the century since Paul Portier and Charles Richet described their landmark findings of severe fatal reactions in dogs re-exposed to venom after vaccination with sea anemone venom, treatment for anaphylaxis continues to evolve. The incidence of anaphylaxis continues to be difficult to measure. Underreporting due to patients not seeking medical care as well as failure to identify anaphylaxis affects our understanding of the magnitude of the disease. Treatment with intramuscular epinephrine continues to be the recommended first-line therapy, although studies indicate that education of both the patients and the medical community is needed. Adverse food reactions continue to be the leading cause of anaphylaxis presenting for emergency care. Current therapy for food-induced anaphylaxis is built on the foundation of strict dietary avoidance, rapid access to injectable epinephrine, and education to recognize signs and symptoms of anaphylaxis. Investigation into therapy with oral and sublingual immunotherapy as well as other modalities holds hope for improved treatment of food-induced anaphylaxis.