Racial differences in timing of food allergen introduction

Health disparities in food allergy

Rates of food allergy are rising worldwide, with a disproportionate amount of disease burden found in patients of Black, Asian, and Latinx descent. Recent guidelines have recommended early introduction of allergens as early as 4-months-old to mitigate the development of food allergy. However, non-White children continue to have significantly poorer outcomes with higher rates of food allergy-related emergency department visits for anaphylaxis without having equivalent access to epinephrine auto-injectors. With only half of allergists accepting Medicaid in the United States, and only one-third of Medicaid-enrolled children with food allergies having seen an allergist, underserved populations are less likely to have access to subspecialty care - a major determining factor in allergy health outcomes. In this review, we examine the health disparities that contribute to food allergy as well as possible solutions for physicians to combat inequity in allergy care.

Total Serum IgE in a Cohort of Children With Food Allergy

BACKGROUND

Total serum IgE (TsIgE) has not been examined in children with food allergy.

OBJECTIVE

To evaluate associations of TsIgE with patient, household, environmental, and community-level characteristics among children with food allergy.

METHOD

We used linear mixed-effects models of data from 398 Black and/or African American (B/AA) and White and/or European American (W/EA) children with allergist-diagnosed food allergy from the multicenter, observational cohort FORWARD (Food Allergy Outcomes Related to White and African American Racial Differences); TsIgE (kU/L) was the primary outcome measure.

RESULTS

In univariable analyses of data from all study sites, children's TsIgE was positively associated with older age (P < .001); B/AA race (P < .001); male sex (P = .014); lower household income (P = .005); lower caregiver education (P = .005); higher Area Deprivation Index (P < .001); presence of allergic rhinitis (P < .001), asthma (P < .001), and eczema (P = .024); and a higher number of food allergies (P < .001), but not with tobacco smoke exposure. With covariable adjustment in multivariable analysis, total serum IgE was higher in older versus younger children (P < .001), male versus female children, B/AA versus W/EA children (P < .001), and in children with allergic rhinitis (P = .010), asthma (P < .001), eczema (P = .007), or a higher number of food allergies (P < .001), but not with tobacco smoke exposure or Area Deprivation Index.

CONCLUSIONS

In children with food allergy, age, sex, race, atopic diagnosis, allergic rhinitis, asthma, and eczema are associated with TsIgE. These findings are important when TsIgE values are used in diagnosis and therapies.

Addressing health disparities in food allergy: A Position Statement of the AAAAI Prior Authorization Task Force

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

Food Insecurity and Health Inequities in Food Allergy

PURPOSE OF REVIEW

The intersection of food insecurity among those with food allergy is a growing public health concern. Both food allergy and food insecurity have profound implications on health, social, and economic outcomes. The interaction of social determinants of health, poverty, racism, housing insecurity, and access to care has direct impact on individuals with food allergy.

RECENT FINDINGS

There is increasing evidence that universal screening for food insecurity is vital in the routine care of patients with food allergy. Individuals with food allergy who are also burdened by food insecurity face unique challenges related to the need to maintain dietary modifications often with expensive specialized diets, which are difficult to access. This may lead to limited dietary options, malnutrition, increased financial burden, and social isolation. While there are available resources and support systems that can assist individuals with food allergies in managing food insecurity, there is an increasing need for advocacy and inclusivity in policy frameworks involving multiple stakeholders. Multi-sector efforts involving healthcare providers and advocacy and government agencies are necessary to support policy changes that protect the rights and well-being of individuals affected by food allergy and food insecurity. By increasing awareness, improving access to safe, affordable, allergen-free food, and advocating for policy change, we can work toward ensuring universal access to safe, nutritious food for all individuals, regardless of their food allergy status or socioeconomic background.

Addressing Health Equity in Food Allergy

Social determinants of health can lead to poor health outcomes for food-allergic patients, including limited access to allergen-free foods and specialty care. Housing and transportation limitations can worsen social factors including food insecurity, poor early food introduction, increased reactivity to foods, lower tertiary/allergy care utilization, and increased emergency department utilization. A key component of addressing health equity involves valuing all people with sustained, focused efforts to address social determinants of health. In this clinical commentary, we discuss the current state of heath equity for food-allergic patients, highlighting the disparities in emergency care, food allergy prevention, and food insecurity. Solutions to improve health equity through clinical practice are proposed. Currently available funding opportunities through the National Institutes of Health for health equity initiatives are outlined. Gaps in health equity for food-allergic patients include the lack of documented successful implementation of effective solutions to food insecurity, poor early food introduction uptake, poor access to specialist care, and unequal distribution of educational resources. The availability of research funding and legislative policies supporting access to food and education bolster the impetus to move toward health equity for 20 million people in the United States with food allergy.

Identifying Children at Risk of Growth and Nutrient Deficiencies in the Food Allergy Clinic

BACKGROUND

Food allergies affect growth in children by decreasing the availability of nutrients through decreased dietary intake, increased dietary needs, food-medication interactions, and psychosocial burden. Guidelines on food allergy management frequently recommend nutrition counseling and growth monitoring of children with food allergies.

OBJECTIVE

To provide clear guidance for clinicians to identify children with food allergies who are at nutritional risk and ensure prompt intervention.

METHODS

We provide a narrative review summarizing information from national and international guidelines, retrospective studies, population studies, review articles, case reports, and case series to identify those with food allergy at greatest nutritional risk, determine the impact of nutritional interventions on growth, and develop guidance for risk reduction in children with food allergies.

RESULTS

Children with food allergies are at increased risk of nutritional deficiencies and poor growth. Nutritional assessment and intervention can improve outcomes. Identifying poor growth is an important step in the nutrition assessment. Therefore, growth should be assessed at each allergy evaluation. Interventions to ensure adequate dietary intake for growth include appropriately prescribed elimination diets, breast-feeding support and assessment, supplemental formula, vitamin and/or mineral supplementation, appropriate milk substitutes, and timely introduction of nutrient-dense complementary foods. Access to foods of appropriate nutritional value is an ongoing concern.

CONCLUSION

Nutrition intervention or referral to registered dietitian nutritionists with additional training and/or experience in food allergy may result in improved growth and nutrition outcomes.

Psychosocial Impact of Food Allergy on Children and Adults and Practical Interventions

PURPOSE OF REVIEW

IgE- and non-IgE-mediated food allergies are increasing in prevalence in children and adults worldwide. A food allergy diagnosis can be associated with a sense of overwhelm and stress and commonly has a negative impact on quality of life.

RECENT FINDINGS

While there is an increased recognition of the psychosocial effects of food allergy, the current research reflects the experience of mostly White, well-educated wealthier populations. Some studies have now explored the psychosocial impact among other populations; however, further study is needed. It is important that physicians and allied health professionals screen for the potentially negative psychosocial effects of food allergy and provide education to promote safety and self-efficacy at each visit; however, time may be a limiting factor. Numerous validated questionnaires are now available to help assess the psychosocial impact of food allergies. Allergy-friendly foods are typically more expensive, and thus, it is imperative that physicians screen for food insecurity as well. Educational resources should be offered regarding living well with food allergies at each visit. For patients and families experiencing anxiety or food allergy burden that is difficult to manage, referral to a mental health provider should be considered. Resources regarding programs to help accessing safe foods should also be available. Further research is needed among diverse populations focusing on interventions to best support patients and families with food allergy.

Impact of socioeconomic factors on allergic diseases

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly affected by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including health care access and quality, diagnosis, management, education, and disease prevalence and outcomes. Ongoing research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on health care disparities and outcomes among patients with allergic and immunologic diseases.

Factors influencing age of common allergen introduction in early childhood

Objectives

We evaluated factors influencing the timing of allergen introduction in the U.S., including updated peanut introduction guidelines.

Study design

The Gastrointestinal Microbiome and Allergic Proctocolitis (GMAP) study is a prospective observational cohort in suburban Massachusetts. Infants' caregivers enrolled between 2014 and 2017, and they reported when they introduced common allergens to their child. Multivariable linear and survival regression analyses were used to examine factors influencing time of introduction of allergens.

Results

By 9 months, children old enough to be potentially affected by NIAID's 2017 peanut introduction guidelines were more often introduced to peanut than children enrolled well before guidelines publication [54% vs. 42%, OR: 1.63, CI: (1.03, 2.57), P = 0.03]. At any given time, Black children were 73% [HR: 0.27, CI: (0.11, 0.69), P = 0.006] less likely to be introduced to peanut as early as White children. Asian children were, respectively, 36% [HR: 0.64, CI: (0.47, 0.86), P = 0.003] and 26% [HR: 0.74, CI: (0.55, 0.97), P = 0.03] less likely to be introduced to peanut and egg as early as White children. A first child was 27% [HR: 1.27, CI: (1.04, 1.56), P = 0.02] more likely to have been introduced to peanut earlier than a non-first child. There was no association between age of introduction and sex, gestational age, family history of food allergy, or other allergic comorbidities.

Conclusion

Updated introduction guidelines, race, and birth order all influenced earlier introduction of peanut. Further studies to evaluate current practices for allergen introduction with a focus on potential disparities are needed.

Intake of allergenic foods at 1.5 years and 3 years of age in a general child population in Japan: a cross-sectional study

BACKGROUND

Recent studies indicate that the timing of introduction of potentially allergenic food is crucial for the development of food allergy in children. This cross-sectional study aimed to clarify the reality of allergen food intake in a general population of young children in Japan.

METHODS

A questionnaire survey of caregivers was conducted at health checkups for 1.5-year (18-month)-old and 3-year-old children in the fall of 2020. The caregivers were asked about (1) the presence/absence of allergic disease symptoms based on the ISAAC questionnaire, and (2) foods that caregivers avoided giving their children. Ordinal logistic regression analyses were periformed to determine factors associated with food avoidance.

RESULTS

Questionnaires were distributed to 1720 caregivers, and 1603 (93%) responded. The responders consisted of 771 and 832 caregivers who participated in 1.5-year-old and 3-year-old checkups, respectively. The prevalence of allergic diseases was comparable to recent epidemiological studies in Japan, indicating that the population may be representative. At 1.5 years old, more than 50% of the children were not exposed to peanuts, tree nuts, fish eggs, shellfish, and buckwheat. At 3 years old, the avoidance rates of the foods had decreased but were still between 18.8% and 32.0%. On the other hand, the avoidance rates of chicken egg and cow's milk, the top 2 common allergenic foods in Japan, were much lower at 2.8% and 1.5% at 1.5 years, and they decreased to 1.4% and 0.7% at 3 years old, respectively. Ordinal logistic analysis showed that avoidance of chicken egg, cow's milk, and wheat was associated with food allergy diagnosis and chicken egg avoidance with eczema, but avoidance of other foods showed no associations with any risk factors for food allergy.

CONCLUSION

Caregivers avoided giving various foods, independent of allergy risk factors, to their young children. Since delayed introduction of an allergenic food has been reported to increase the risk of developing an allergy to the food, the results warrant future investigation of the development of food allergies in relation to current eating habits and recommendations.

Social disparities in early childhood prevention and management of food allergy

Food allergy (FA) affects 8% of US children. Navigating and managing FA permeates across multiple facets of childhood. In this article, we review research on social disparities in feeding practices, managing meals, and selecting childcare and schools. Key highlights include the following: (1) although preference for breast-feeding or formula feeding does not reduce FA risk, there are disparities in access to formula that may affect children with FA; (2) disparities likely exist in the early introduction to allergenic foods, though additional research is needed to identify barriers to following the most recent consensus guidelines on early introduction; (3) families with limited income face challenges in providing safe meals for their children; (4) disparities exist in early childcare options for preschool-age children, though there is a lack of research on FA practices in these settings; and (5) there is evidence that schools with different student demographics implement different types of FA policies. Further research is needed to better understand and characterize social disparities in FA prevention and management in early childhood and to develop evidence-based strategies to reduce them.

A pragmatic approach to infant feeding for food allergy prevention

Early introduction of allergenic foods into an infant's diet is currently the most promising strategy to prevent food allergy, with infant guidelines around the world shifting from promoting avoidance to actively encourage the introduction of allergenic foods in the infant diet. Infant feeding guidelines vary according to regional public health priorities, and knowledge gaps remain, resulting in ongoing challenges for clinicians and families to translate guidelines into practical strategies for the introduction of complementary foods for food allergy prevention. Evidence from Australia demonstrates high community support and uptake of revised guidelines with most parents introducing allergenic foods in the first year of life, although this has not had the expected impact on substantially reducing food allergy prevalence. To uptake of guidelines from other countries is less clear, and several barriers have been noted in infant feeding RCTs, which may warrant intervention strategies. Further research is needed to understand additional strategies for food allergy prevention, particularly in infants who develop food allergy prior to when they are developmentally ready to commence solids. Several RCTs are underway investigating preventative strategies that target the window before allergen ingestion, such as vitamin D supplementation, emollient use, and immunizations that prime the immune response away from a Th2-driven allergic phenotype. Further research is also needed to understand the role of the environment and the host environment in the development of tolerance to foods.

Burden of allergic disease among ethnic minority groups in high-income countries

The COVID‐19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene–environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high‐income countries. In conjunction with standards of care, it is prudent that a multi‐pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.

Health disparities in pediatric food allergy

OBJECTIVE

To review the current literature regarding the health disparities in the prevalence, diagnosis, and management of pediatric food allergy and discuss possible interventions.

DATA SOURCES

Literature search of PubMed and Google Scholar databases regarding pediatric food allergy and health disparities.

STUDY SELECTIONS

Original research articles, reviews, and guidelines on health disparities in pediatric food allergy were included in this review.

RESULTS

The overall prevalence of food allergy appears to be increasing and disproportionately affecting minority groups. Racial and socioeconomic disparities are evident across all aspects of food allergy care: diagnosis, prevention, acute management (eg, access to epinephrine autoinjectors, visits to emergency department), and long-term management (eg, oral immunotherapy). Children of minority populations and those of low socioeconomic status are at a greater risk of food insecurity, which is further exacerbated by the high cost of allergen-free foods and limited support from food assistance programs.

CONCLUSION

Racial, ethnic, and socioeconomic disparities in food allergy among children in the United States are evident and negatively affect the outcomes of children with food allergies. Active efforts to decrease racial and socioeconomic disparities, through education, research, and advocacy, will be important to help improve health outcomes in food allergy for all children, regardless of their race, ethnicity, or socioeconomic status.