The impact of childhood food allergy on quality of life

Food Allergy, Nutrition, Psychology, and Health

This article explores food allergy and the nascent field of nutritional psychiatry. Individuals with food allergy experience lower levels of "food freedom" than their nonallergic counterparts, which can create cognitive, emotional, social, nutritional, and financial burdens. Patterns of food avoidance may influence neuroinflammatory states and the gut microbiome; these changes may be associated with neuropsychiatric symptoms. Food restriction may promote disruption of the microbiome neuroimmune axis, which has been linked to various allergic diseases. Targeted psychological counseling strategies can provide benefit. Food allergy and restricted diets may impact dietary health benefits.

Food allergy has no negative impact on children's school performance: A Swedish sibling and co-twin control study

Background

Food allergy has been shown to negatively impact children's mental health and quality of life. However, its impact on school performance is unknown.

Objective

We aimed to investigate whether food allergy, severe and nonsevere, is associated with school performance when accounting for measured and unmeasured familial factors.

Methods

This was a register-based cohort study, with sibling controls, including all children born in Sweden 2001-5 (n = 456,164) with food allergy information based on hospital visits and prescriptions, grades, and national test results from all Swedish schools and confounders. Primary exposure was food allergy severity (none, nonsevere, or severe) in school years 7-9, and the primary outcome was total grades from year 9, with secondary exposures/outcomes also at younger ages. The primary outcome was analyzed by linear regression and, for sibling/twin control analyses, fixed effect linear regression. Results were replicated in a twin cohort (n = 31,609).

Results

In unadjusted and analyses adjusted for measured confounders, children with severe food allergy appeared to have better total grades than children without food allergy (βunadjusted = 10.6 [95% confidence interval (CI), 8.6, 12.6] and βadjusted = 5.5 [95% CI, 3.7, 7.4]). When also adjusting for unmeasured confounders shared by siblings, the difference was close to null and statistically nonsignificant (βsibling = 1.6 [95% CI, -1.5, 4.7]; for nonsevere food allergy, βsibling = -0.0 [95% CI, -2.2, 2.1]). The twin cohort results were similar.

Conclusions

We found no consistent evidence of a negative effect of food allergy, either severe or nonsevere, on school performance when adjusting for measured and unmeasured confounders shared by siblings.

Questionnaire-based real-world survey of diagnosing food allergy in children: Utilization of oral food challenge tests and other diagnostic methods

Background

Oral food challenge tests are considered the reference standard for diagnosing food allergies; however, studies on their real-world implementation rates are limited.

Objective

The study aimed to investigate the proportion of school-age children who underwent the oral food challenge test and to understand the motivations behind food elimination and utilization of various health care services.

Methods

The questionnaire-based survey for the parents of the students who submitted the "Certificate for School Life Management (For Allergic Diseases)" was conducted across public elementary and junior high schools in Gifu prefecture, Japan.

Results

The study encompassed parents of 3457 children with food allergies who submitted the certificate. Approximately one third of those eliminating the 3 major allergens-eggs (32.5%), milk (27.6%), and wheat (33.5%)-were diagnosed via oral food challenge tests, and approximately two thirds were diagnosed using a combination of symptoms and blood tests, suggesting most children were diagnosed appropriately. However, many children were diagnosed and eliminated foods based solely on blood tests without any symptoms of other allergens, such as buckwheat (55.8%), peanuts (29.2%), and tree nuts (21.2%), suggesting that it was likely that these children unnecessarily eliminated foods. Elimination of buckwheat because of anxiety was associated with eliminating other foods for the same reason and with eliminating 2 or more foods.

Conclusion

Examination of the real-world application of the proposed recommendations for the accurate diagnosis of food allergies suggests that closely monitoring their practical application should be conducted in each case to avoid unnecessary food elimination from children's diets.

Japanese version of the food allergy quality of life questionnaire 10: An easy-to-use instrument

Background

The health-related quality of life (HRQL) of people with food allergies should be evaluated to provide high-quality medical care. Currently, there is no available easy-to-use and reliable instrument for assessing HRQL clinically in Japan.

Methods

The Food Allergy Quality of Life Questionnaire 10 (FAQLQ10) in English was translated into Japanese, and this was referred to as the Japanese version of the Food Allergy Quality of Life Questionnaire 10 (FAQLQ10-J). Participants aged up to 18 years, who had food allergy, and their parents were instructed to complete the FAQLQ10-J and the Food Allergy Independent Measure, a self-report instrument. For comparison, participants without food allergies were also included in the survey.

Results

The FAQLQ10-J, which included forms for individuals aged 8-12 years, teenagers, and caregivers was developed. The responders completed each form within approximately 3 min. An analysis of responses showed that each form had a good internal consistency, test-retest reliability, construct validity, and discriminant validity. Moreover, based on an examination of the relationship between demographic data and FAQLQ10-J scores, items such as possession of an adrenaline auto-injector, participant age, and number of eliminated foods might influence HRQL.

Conclusions

We developed the FAQLQ10-J, which is a simple, reliable, and effective tool for assessing HRQL among Japanese individuals with food allergy. Its use may provide a more detailed understanding of HRQL among individuals with food allergy in clinical settings and may facilitate the development of more individual-oriented treatments.

Analyzing early childhood allergy prevention motivation of mothers of infants and its predictors using latent class analysis and structural equation modelling

BACKGROUND

Allergic diseases are among the most common chronic diseases in childhood. Early childhood allergy prevention (ECAP) behaviors of those caring for the infant during pregnancy and the first months of life may influence the risk of allergy development over the life course. Motivation and intention to use appropriate primary ECAP measures are thus of critical importance.

AIMS

To characterize parental ECAP motivation, (a) valid indicators will be developed and (b) typical parental characteristics will be identified. (c) According to socio-cognitive models, the predictive value of parental risk perception, control belief and self-efficacy for parental ECAP motivation shall be determined.

METHOD

A sample of N = 343 (expectant) mothers of infants completed a questionnaire on self-reported ECAP motivation, risk perception, control belief, and self-efficacy. The cross-sectional data were analyzed using latent class analysis and structural equation modelling including nominal regression models.

RESULTS

Four typical maternal response profiles (motivated to a customary degree, 70%; motivated to use primary preventive measures, 17.8%; reluctant towards new prevention measures, 6.4%; highly motivated to apply preventive measures in case of an existing allergy, 5.8%) could be identified for the items on ECAP motivation. After splitting the model variables "risk perception" (allergy vs. allergy-associated general health problems) and "self-efficacy" (trust vs. insecurity) a satisfactory model-fit was achieved (CFI = .939; RMSEA = .064). Particularly, increased "risk perception-allergy" (OR = 1.655) and "self-efficacy-insecurity" (OR = 2.013) as well as lower "risk perception-general health" (OR = 0.555) and "control belief" (OR = 0.217), respectively, are associated with higher ECAP motivation.

CONCLUSION

The use of ECAP-measures by parents to protect their newborns from allergies is important, but there are deficiencies in their implementation. Based on a social cognitive model approach, predictive characteristics could be identified, which are associated with increased motivation to implement ECAP-measures. For public health our findings provide a promising basis for conception of behavioral and environmental ECAP prevention measures and their motivated implementation by parents.

Parental knowledge and attitudes toward food allergies: a cross-sectional study on determinants and educational needs

BACKGROUND

Food allergy (FA) may often lead to fatal consequences if it is treated promptly. Parents of children with FA should have adequate knowledge to improve health outcomes and reduce the associated burden. This study aimed to examine the knowledge and attitudes regarding FA among parents of children with FA.

METHODS

This was a cross-sectional study conducted among parents attending a primary healthcare center using convenience sampling. The minimum sample size of 280 was calculated using an equation based on the local prevalence of FA among children, and was increased to account for missing data. The data were collected using a four-section questionnaire that collected data about the parents and their children and included questions about knowledge and attitudes regarding FA. The knowledge score was calculated by summing the number of correct answers, with a maximum of 15 points. The Mann-Whitney and Kruskal-Wallis tests were used to examine the associations between the knowledge score and other variables. Spearman's correlation was employed to test the correlations between the knowledge score and other variables.

RESULTS

A total of 381 parents completed the questionnaires, of whom 71.9% were mothers and 28.1% were fathers. The prevalence of food allergies was 14.22%. Almost one-third had children who had one or more types of FA (32.8%). Most of those patients had received a professional diagnosis of FA (75.3%). The median knowledge score was 7.0 (IQR = 6-8), with variable proportions of correct answers across and within topics. A higher knowledge score was significantly associated with parenting a child with FA (p = 0.006), comorbid asthma or eczema (p = 0.012), the preference to acquire information from professional health agencies (p < 0.001), and higher educational (p = 0.002) and income (p = 0.001) levels. Moreover, the number of discussions held with a healthcare professional regarding FA was significantly correlated with the knowledge score (r = 0.210, p = 0.019). Online resources were the most commonly reported source of information (65.4%). Parents believed that having a child with FA can cause stress in the family (76.1%) and impact siblings' daily lives (66.7%), while only a minority viewed FA as stigmatizing. Additionally, the majority encouraged governmental spending on FA research (92.9%).

CONCLUSIONS

Parenting a child with FA, comorbid asthma or eczema, number of discussions held with healthcare professionals, and education and income levels were significantly associated with a higher knowledge score. Educational interventions targeting parents should blend emotional regulation, medical information, and management skills to increase knowledge about FA and alleviate associated stress.

Addressing common questions on food oral immunotherapy: a practical guide for paediatricians

Food allergy has been increasing in prevalence in most westernised countries and poses a significant burden to patients and families; dietary and social limitations as well as psychosocial and economic burden affect daily activities, resulting in decreased quality of life. Food oral immunotherapy (food-OIT) has emerged as an active form of treatment, with multiple benefits such as increasing the threshold of reactivity to the allergenic food, decreasing reaction severity on accidental exposures, expanding dietary choices, reducing anxiety and generally improving quality of life. Risks associated with food immunotherapy mostly consist of allergic reactions during therapy. While the therapy is generally considered both safe and effective, patients and families must be informed of the aforementioned risks, understand them, and be willing to accept and hedge these risks as being worthwhile and outweighed by the anticipated benefits through a process of shared decision-making. Food-OIT is a good example of a preference-sensitive care paradigm, given candidates for this therapy must consider multiple trade-offs for what is considered an optional therapy for food allergy compared with avoidance. Additionally, clinicians who discuss OIT should remain increasingly aware of the growing impact of social media on medical decision-making and be prepared to counter misconceptions by providing clear evidence-based information during in-person encounters, on their website, and through printed information that families can take home and review.

Efficacy of very-low-dose oral food challenge in children with severe hen egg allergy: A retrospective, single-center case series

BACKGROUND

To avoid complete elimination of hen eggs (HE) from diet, we introduced a very-low-dose (VLD) oral food challenge (OFC) in patients with severe HE allergy in 2019. Herein, we investigated the efficacy of VLD HE OFC for achieving the full dose OFC.

METHODS

Patients with an overt allergic reaction to LD (1/32 HE [≤100 mg]) or less, egg white (EW) protein within 6 months were included. In the VLD group, patients not achieving full-dose OFC (1/2 HE: 1600 mg EW protein) within 2 years were excluded. We retrospectively compared the rate of passing a full-dose OFC between patients who underwent a LD OFC before 2019 (LD group) and those who underwent a VLD OFC (1/100 HE: 32 mg EW protein) after 2019 (VLD group). The period for passing the full-dose OFC was evaluated using Kaplan-Meier survival analysis.

RESULTS

We enrolled 411 and 111 patients in the LD and VLD groups, respectively. The median age at OFC initiation was 2.2 [1.5-3.6] and 2.1 [1.4-3.2] years in the LD and VLD groups, respectively. EW- and ovomucoid-specific IgE levels were 38.3 (12.5-72.9) and 21.0 (8.3-46.2) kUA/L in the LD group and 49.8 [18.8-83.9] and 32.1 [15.6-67.8] kUA/L in the VLD group, respectively. Over 4 years, the LD and VLD groups passed the full-dose OFC at rates of 70 and 95%, respectively, with significant differences (log-rank test, P < 0.001).

CONCLUSIONS

VLD HE OFC may contribute to passing a full-dose OFC in patients with severe HE allergies.

Quality Appraisal of Quality of Life Research in Children and Adolescents with Food Allergy: A Systematic Review

INTRODUCTION

Quality of life (QOL) and health-related quality of life (HRQOL) in children and adolescents with food allergies have been an important and steadily growing field of research for the past 20 years. There seem to be conceptual and methodological challenges that might influence the face validity of QOL and HRQOL research in general health research, but this has not been investigated in pediatric and adolescent food allergy research up until now. The aim of this study was to perform a systematic review of the QOL and HRQOL studies on food allergy in children and adolescents under the age of 18.

METHODS

The systematic review was conducted on studies purporting to measure QOL or HRQOL in children and adolescents with food allergies. The literature search was developed in Ovid MEDLINE and databases used in the review were Embase, Cochrane Database of Systematic Reviews, CINAHL, and Scopus. Studies were evaluated based on a set of face validity criteria developed by Gill and Feinstein in 1994 and refined by Moons et al. in 2004.

RESULTS

Out of 61 studies eligible for the review, 11 (18%) defined QOL or HRQOL and two distinguished QOL from HRQOL. The Food Allergy Quality of Life (FAQLQ) instrument series is the most frequently used HRQOL measurement among the studies included. QOL and HRQOL were employed interchangeably in half of the studies, some of them also using a third term in addition.

CONCLUSION

Our findings lead to the conclusion that the research field investigated contains methodological and conceptual shortcomings regarding QOL and HRQOL. An increased awareness toward the terminology as well as consideration of points to reflect upon will be beneficial, as this will also improve the validity of future studies.

The clinical burden of food allergies: Insights from the Food Allergy Research & Education (FARE) Patient Registry

Background

Food allergies are serious and potentially life-threatening, and often place a large burden on patients and their caregivers, including impacts on quality of life.

Objective

To assess the real-world patient burden of food allergies, using self-reported data available from the Food Allergy Research & Education (FARE) Patient Registry (NCT04653324).

Methods

The FARE Patient Registry is voluntary and captures real-world experiences of adults and pediatric patients in the United States, and their caregivers, through a series of surveys assessing patient health and experiences with food allergies. Self-reported data were descriptively analyzed.

Results

The FARE study cohort included 5587 patients with food allergies; 82% had multiple food allergies and 62% were aged <18 years. About half of the patients were first diagnosed by an allergist/immunologist (53%), most commonly with a skin prick test (71%) or a serum immunoglobulin E test (62%). This analysis found that food allergies (most commonly peanut [66%], tree nuts [61%], egg [43%], and milk [37%]) impart a large clinical burden on patients, many of whom experience food-related allergic reactions and comorbidities. Many patients experienced >1 food-related allergic reaction per year (42%), with 46% experiencing food-induced anaphylaxis. Half of all food-related allergic reactions occurred at home. Accidental exposures to food allergens were experienced by 77% of patients. The most common allergic comorbidities reported by patients with food allergies were atopic dermatitis (48%), asthma (46%), and allergic rhinitis (39%). The clinical burden of food allergies were found to be greater in patients with multiple food allergies, and different for adults versus pediatric patients.

Conclusion

This is the first study to assess patient experience and disease burden information from patients contributing to the FARE Patient Registry, thus providing a unique insight into the lives of patients in the United States with food allergies. These insights may assist clinicians and other public health stakeholders in the management of patients with food allergies.

Efficacy of biological agents combined with oral immunotherapy (OIT) for food allergy: a protocol for a systematic review and meta-analysis

INTRODUCTION

Food allergy affects a large population throughout the world. Recently, oral immunotherapy (OIT) has been reported as an effective treatment for severe food allergy. Although OIT was successful in numerous trials in desensitisation, adverse events including anaphylaxis during OIT frequently occur. Additionally, some patients fail to be desensitised after OIT and the response to treatment is often not sustained. As a further adjunctive therapy to facilitate OIT, the role of biological agents has been identified. For example, efficacy and safety of omalizumab as an adjuvant therapy of OIT has become apparent through some RCTs and observational studies. Interest towards this topic is growing worldwide, and ongoing trials will provide additional data on the biologics in food allergy.We aim to systematically analyse the efficacy and safety of OIT combined with biological agents for food allergy.

METHODS AND ANALYSIS

This paper provides a protocol for a systematic review of the relevant published analytical studies using an aggregate approach following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Two authors will perform a comprehensive search for studies on MEDLINE/PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases. Subsequently, two independent authors will perform abstract screening, full-text screening and data extraction. A meta-analysis will be conducted as appropriate.

ETHICS AND DISSEMINATION

The protocol of this systematic review will be provided in a peer-reviewed journal. As the researchers will not identify the individual patients included in the studies, they do not need to acquire ethics approval.

PROSPERO REGISTRATION NUMBER

CRD42022373015.

Prevalence and burden of coconut allergy in the United States

BACKGROUND

Epidemiologic data on coconut allergy remains sparse in the United States despite the labeling requirement by the Food Allergen Labeling and Consumer Protection Act for products containing coconut.

OBJECTIVE

To provide current estimates of the prevalence, severity, determinants, and distribution of coconut allergy in the United States.

METHODS

A comprehensive food allergy prevalence survey was administered to a nationally representative, probability-based sample of US households between October 1, 2015 and September 30, 2016. Eligible respondents included adults who were able to complete self- and parent-proxy report surveys in English or Spanish by means of web or phone.

RESULTS

Using survey responses from 78,851 individuals, 0.39% (95% confidence interval [CI], 0.33-0.45) of the US general population were categorized as having convincing coconut allergy. Among children, 0.22% (95% CI, 0.16-0.30) were estimated to have coconut allergy compared with 0.43% (95% CI, 0.37-0.51) of adults, whereas only 0.12% (95% CI, 0.08-0.18) of these children and 0.20% (95% CI, 0.16-0.24) of adults with convincing immunoglobulin E (IgE)-mediated coconut allergy reported physician-confirmed diagnoses. A current epinephrine prescription was reported by 40.1% (95% CI, 33.3-47.4) of those with convincing coconut allergy. Reactions involving multiple organ systems were reported by 47.5% (95% CI, 40.1-54.9) of those with convincing coconut allergy.

CONCLUSION

Roughly 1 in 260 Americans report symptoms consistent with an IgE-mediated allergy to coconut, although fewer than half of these individuals report receiving a physician diagnosis. Our data indicate that most individuals with reported coconut allergy meeting symptom-based criteria for convincingly IgE-mediated disease have comorbid FAs, and for many patients, clinical management seems to be suboptimal.

Association of Reaction Symptoms and Eliciting Dose With Health-Related Quality of Life in Children With Peanut Allergy

BACKGROUND

Food allergy adversely affects the health-related quality of life (HRQoL) of patients. It is unclear whether factors such as the reaction eliciting dose (ED) and the nature of allergic reaction symptoms affect HRQoL.

OBJECTIVE

To explore associations between reaction ED or the nature of allergic symptoms and HRQoL among children with peanut allergy.

METHODS

This study was a secondary analysis of baseline data from the PPOIT-003 randomized trial in 212 children aged 1 to 10 years with challenge-confirmed peanut allergy. Children's past reaction symptoms were collected by clinicians during screening. Associations between variables of interest and parent-reported child-proxy HRQoL were examined by univariable and multivariable linear regression.

RESULTS

Mean age of study participants was 5.9 years; 63.2% were male. Children with a low reaction ED of 80 mg peanut protein had significantly poorer HRQoL (β = -0.81; 95% CI, -1.61 to -0.00; P = .049) compared with children with a high ED of 2,500 mg peanut protein. Gastrointestinal symptoms (β = 0.45; 95% CI, 0.03-0.87; P = .037), lower airway symptoms (β = 0.46; 95% CI, 0.05-0.87; P = .030), multisystem involvement (β = 0.71; 95% CI, 0.25-1.16; P = .003), or anaphylaxis (β = 0.46; 95% CI, 0.04-0.87; P = .031) during a previous reaction were associated with worse HRQoL.

CONCLUSIONS

Peanut-allergic children with a lower allergen reaction threshold experienced a greater negative HRQoL impact compared with children with higher reaction thresholds. In addition, specific past allergic reaction symptoms were associated with comparatively worse HRQoL. Children experiencing these symptoms and those with lower reaction ED require increased clinical support to manage the food allergy and are likely to benefit from interventions that can improve HRQoL.

Quality of life in children with food allergies, psychiatric symptoms, and caregiving burden of their mothers

OBJECTIVE

The present study aimed to evaluate the quality of life in children with food allergies, the accompanying depression and anxiety disorders, and caregiving burden of their mothers.

MATERIAL AND METHODS

A total of 168 children with food allergy visiting our clinic and their mothers were included in the study group. The control group included 152 children who visited the healthy child follow-up clinic of our hospital and their mothers. Studying mothers' opinions, the Food Allergy Quality of Life Questionnaire Parent Form (FAQLQ-PF) was used for evaluating children, and the Beck's Depression Inventory, Beck's Anxiety Inventory, Temperament Evaluation of Memphis, Pisa, Paris, San Diego Auto-questionnaire, and Zarit Caregiver Burden Scales were used for evaluating mothers.

RESULTS

No differences were noticed between the study and control group regarding mean age and gender distribution (P > 0.05). In the study, the FAQLQ-PF total and subscale scores of children with food allergies were determined according to the opinions of their mothers, and scores tended to increase with age (P < 0.0001). In addition, it was determined that mothers of children with food allergies had higher levels of anxiety, depression, and caregiving burden than mothers of the control group (P < 0.0001).

CONCLUSION

In order to develop a multidisciplinary approach for children with food allergies, we conceived as appropriate to inform their families about the difficulties of caregiving and psychosocial disorders that could develop over time. They also must be informed to take preventive measures as well as the medical aspects of their children's disease.

Maternal Diet and Infant Risk of Eczema and Food Allergy: A Systematic Review

A significant portion of the pediatric population is affected by allergy diseases, which have become a worldwide public health concern. Could maternal diet during pregnancy or breastfeeding influence allergy outcomes in offspring? If this cause-and-effect relationship exists, it will be simpler to design prevention strategies to reduce the incidence of allergic disorders in children, reduce costs to the public health system and to parents, and improve the quality of life of allergic children and their parents. In this systematic review, we will visit the literature from January 2019 to December 2022 to see if any relationship was found between maternal nutrition and its consequences on children's allergy occurrence. We will focus only on food allergy and eczema outcomes in the offspring. Also, we will summarize what was found to be protective or nonprotective to better control the outcomes if applied in the future.

Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies

BACKGROUND

Chronic diseases involving strict dietary adherence have been associated with an increased risk of eating disorders (EDs). This is the first systematic review investigating the rate of EDs among individuals with food allergies (FAs).

OBJECTIVE

To report the incidence, prevalence, and types of EDs in individuals with FAs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases for studies published to January 2022 that reported the prevalence or incidence of EDs in samples with immunoglobulin E (IgE) or non-IgE-mediated allergy. Risk of bias was assessed and evidence qualitatively synthesized.

RESULTS

From 1,180 papers identified, 9 met inclusion criteria. There were 4,161 adult and pediatric participants with IgE-mediated FAs or eosinophilic esophagitis. Avoidant/Restrictive Food Intake Disorder (ARFID) or anorexia nervosa/bulimia nervosa were the main EDs identified. The prevalence of EDs in samples with FA ranged from 0.8% to 62.9%. Among studies investigating IgE-mediated FA (n = 6), the prevalence of anorexia nervosa and/or bulimia nervosa ranged from 17.6 to 61%, ARFID was 62.9%, and unspecified EDs was 0.8% to 6%. Among samples with eosinophilic esophagitis (n = 3), ARFID prevalence ranged from 4.5% to 51%. Most studies were limited by small sample size, possible selection bias, and lack of diagnostic EDs tools validated for food allergic populations.

CONCLUSIONS

Eating disorders appear prevalent in individuals with FA; however, prevalence estimates varied widely. Large studies with healthy control groups and validated measures to identify EDs in individuals with FA are needed to accurately determine the prevalence of EDs.

Barriers to Healthy Family Dinners and Preventing Child Obesity: Focus Group Discussions with Parents of 5-to-8-Year-Old Children

BACKGROUND

Although numerous physical and mental health benefits for children have been linked to family dinners, many families still do not have regular family meals together. This study sought to identify the barriers that keep families from having dinners together.

METHODS

We interviewed 42 parents of 5-to-8-year-old children in small focus groups to identify barriers and challenges that keep families from having healthy and consistent dinners together.

RESULTS

Parents reported the main barriers were time (e.g., time strain and overscheduling, mismatched schedules, long work hours, etc.), lack of meal planning or failure to follow plans, lack of skills (e.g., cooking skills or nutritional awareness), external factors (e.g., daycare, schools, or extended family, and competing with advertising), and food-related challenges (e.g., picky eating, food allergies). Parents also suggested potential solutions to overcome these barriers.

CONCLUSIONS

Overall, parents had a desire to have family dinners with their children, but they felt that there are many barriers keeping them from establishing or maintaining consistent family mealtimes. Future research, as well as child obesity prevention and intervention efforts, should consider these barriers and suggested solutions in efforts to promote healthy and consistent family meals as a means of lowering the prevalence of childhood obesity.

The epidemiology of multifood allergy in the United States: A population-based study

BACKGROUND

Immunoglobulin E (IgE)-mediated food allergies (FAs) are increasingly common among US children and adults. Not only can living with FA impose considerable physical health impacts, but it also imposes economic burden and can negatively affect quality of life. Limited data indicate that allergy to multiple foods (multi-FA) also may be common, but much remains unknown about its distribution and determinants.

OBJECTIVE

To characterize the prevalence, characteristics, determinants, psychosocial burden, and distribution of multi-FA among a large, nationally representative sample of US children and adults.

METHODS

A US population-based survey was administered. Estimates of multi-FA prevalence, conditional frequencies of multi-FA combinations, and associated factors were derived. Latent class analyses were conducted using 9 dichotomized indicators of specific FA prevalence, which were used to determine factors associated with latent class membership and characterize FA-related psychosocial burden within each class.

RESULTS

Surveys were completed for 38,408 children and 40,443 adults. Among children and adults meeting established symptom-report criteria for FA, an estimated 40% and 48% had multi-FA, respectively. Among pediatric and adult populations with convincing FAs, the lifetime reported prevalence of physician-diagnosed atopic comorbidities increased significantly as the number of reported current convincing FAs increased, as did the proportion reporting multi-FA-related health care utilization and higher perceived psychosocial burden. Latent class analyses suggested the existence of the following 4 key latent phenotypes of multi-FA: milk and egg-dominant, seafood-dominant, peanut and tree nut-dominant, and broadly multi-food allergic.

CONCLUSION

The US population-level burden of multi-FA is high among both children and adults, and data indicate the presence of 4 major phenotypes of multi-FA in both populations.

Oral immunotherapy using boiled peanuts for treating peanut allergy: An open-label, single-arm trial

BACKGROUND

Peanut allergy affects 1%-3% of children in Western countries. Boiling peanuts has been demonstrated to result in a hypoallergenic product that may provide a safer way of inducing desensitization in peanut-allergic patients by first inducing tolerance to boiled peanut. We aimed to assess the efficacy and safety of oral immunotherapy (OIT) using sequential doses of boiled peanuts followed by roasted peanuts for treating peanut allergy in children.

METHODS

In this open-label, phase 2, single-arm clinical trial, children aged 6-18 years with a positive history of peanut allergy and positive peanut skin prick test ≥ 8 mm and/or peanut-specific IgE ≥ 15 kU/L at screening underwent OIT involving sequential up-dosing with 12-hour boiled peanut for 12 weeks, 2-hour boiled peanut for 20 weeks and roasted peanut for 20 weeks, to a target maintenance dose of 12 roasted peanuts daily.

PRIMARY OUTCOME

proportion of children passing open-label oral food challenge involving cumulative administration of 12 roasted peanuts (12 g peanuts; approximately 3000 mg peanut protein) 6-8 weeks after reaching the target maintenance dose. Secondary outcomes included treatment-related adverse events and use of medications for treating allergy symptoms.

RESULTS

Between 1 July 2017 and 22 June 2018, 70 participants were enrolled and commenced OIT. Desensitization was successfully induced in 56 of 70 (80%) participants. Withdrawal due to treatment-related adverse events was infrequent (n = 3). Treatment-related adverse events were reported in 43 (61%) participants, corresponding to a rate of 6.58 per 1000 OIT doses. Medication use associated with treatment-related adverse events was infrequent, with rescue epinephrine use reported by three (4%) participants (0.05 per 1000 doses).

CONCLUSION

Oral immunotherapy using boiled followed by roasted peanuts represents a pragmatic approach that appears effective in inducing desensitization and is associated with a favourable safety profile.

Perinatal exposure to foodborne inorganic nanoparticles: A role in the susceptibility to food allergy?

Food allergy (FA) is an inappropriate immune response against dietary antigens. Various environmental factors during perinatal life may alter the establishment of intestinal homeostasis, thereby predisposing individuals to the development of such immune-related diseases. Among these factors, recent studies have emphasized the chronic dietary exposure of the mother to foodborne inorganic nanoparticles (NP) such as nano-sized silicon dioxide (SiO2), titanium dioxide (TiO2) or silver (Ag). Indeed, there is growing evidence that these inorganic agents, used as food additives in various products, as processing aids during food manufacturing or in food contact materials, can cross the placental barrier and reach the developing fetus. Excretion in milk is also suggested, hence continuing to expose the neonate during a critical window of susceptibility. Due to their immunotoxical and biocidal properties, such exposure may disrupt the host-intestinal microbiota's beneficial exchanges and may interfere with intestinal barrier and gut-associated immune system development in fetuses then the neonates. The resulting dysregulated intestinal homeostasis in the infant may significantly impede the induction of oral tolerance, a crucial process of immune unresponsiveness to food antigens. The current review focuses on the possible impacts of perinatal exposure to foodborne NP during pregnancy and early life on the susceptibility to developing FA.

App providing psychosocial and educational supports benefits caregivers of children with newly diagnosed food allergies

Background

Approximately 6 million children in the United States have a diagnosed food allergy, and 32% of caregivers experience significant psychological distress due to the diagnosis. Despite substantial impacts on psychosocial health and quality of life, few interventions aim to help caregivers of newly diagnosed children. There is a clear, unmet need for interventions to address caregiver distress, especially after the initial diagnosis.

Objective

We developed a mobile psychosocial health intervention, the Food Allergy Symptom Self-Management with Technology (FASST) app. Primary end points were to determine the app's feasibility and caregiver satisfaction.

Methods

This was a phase II, randomized controlled, implementation study (4-week duration) in caregivers (N = 30) of children ≤ 18 years of age who were newly diagnosed with a food allergy (≤90 days after the diagnosis). Caregivers (n = 20) were randomized to use the FASST app (intervention group) with access to individualized, self-help symptom relief interventions and food allergy support, and educational resources; or to use a limited app with a basic FASST interface and links to a few educational resources (control group [n = 10]). Ten participants (intervention group, n = 5; control group, n = 5) participated in semistructured interviews at week 4.

Results

Both groups found the app relatively easy to use. The intervention group scores for safety preparedness during social activities increased by 24%, whereas those in the control group experienced a 1% decline. The intervention group participants increased the use of websites to find food allergy information by 17% at week 4 compared with 4% for the control group. Although the intervention group participants showed greater gains than did those in the control group in their confidence to prepare for and prevent allergic reactions, and greater declines in perceived social limitations, more participants in the control group endorsed confidence in their ability to recognize (11% versus 5%, respectively) and treat (10% versus 6%, respectively) allergic reactions.

Conclusion

Analysis of our results suggests that the FASST app may provide a feasible means of delivering psychosocial and educational supports to caregivers of children recently diagnosed with a food allergy.Clinical trial NCT04512924, www.clinicaltrials.gov.

Effectiveness of educational interventions for quality of life of parents and children with food allergy: A systematic review

BACKGROUND

Educational intervention along with medical treatment is important to improve the quality of life of children with food allergies and their parents. This systematic review was designed to investigate the effects of education programs for parents and children with food allergies to provide a direction for developing an intervention program to improve their quality of life.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies published between January 2010 and August 2021 were identified through a systematic search of 5 databases (PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trial, and Psycho Info).

RESULTS

A total of 2351 articles were identified. Of these, 9 met the inclusion criteria after duplicates were removed. Among these, only 2 studies, using the support and handbook provided, showed significant results on quality of life.

DISCUSSION

There is a lack of educational interventions for children with food allergies and their parents. Educational intervention, an essential intervention, can maximize medical treatment and improve overall quality of life. Hence, these interventions should be actively developed and applied in the future.

Anaphyl-Crisis: Rising Rates of Pediatric Anaphylaxis

OBJECTIVES

Anaphylaxis is a serious allergic reaction that has the potential to be life-threatening if not recognized and managed rapidly. Several regional studies have shown increased incidence of anaphylaxis over the past decade. The objectives of this study were to determine rates of pediatric anaphylaxis in southeast Michigan between January 1, 2010, and December 31, 2019, and to describe the epidemiology of pediatric patients presenting to emergency centers in southeast Michigan with anaphylaxis.

METHODS

We performed a retrospective chart review of all pediatric patients aged 0 to 17 years presenting to 2 large emergency centers from 2010 to 2019 with a diagnosis of anaphylaxis using International Classification of Diseases , Ninth and Tenth Revision , Clinical Modification codes. Epidemiological and visit data, including length of stay, use of intravenous medication, and emergency severity index, were extracted and analyzed. Pediatric anaphylaxis rates were calculated based on detected anaphylaxis cases divided by total pediatric emergency department visits to the 2 emergency centers. A Poisson regression model was used to predict rates of anaphylaxis per 100,000 emergency department visits.

RESULTS

One thousand three hundred ninety-one pediatric visits for anaphylaxis were identified during a period between January 1, 2010, and December 31, 2019. There was a significant rate of increase in pediatric anaphylaxis cases over the 10-year study period at both suburban emergency centers, with an annual increase of 21% and 13%. There was no significant change in trends in demographic factors. Most anaphylaxis cases were young, White males with private insurance. Most children did not receive intravenous medications (77%). The median length of stay increased by 1.5 hours over the study period and 92% of patients were discharged home.

CONCLUSIONS

Pediatric emergency center visits and length of stay for anaphylaxis in southeast Michigan have markedly increased over the past 10 years.

A practical focus on milk oral immunotherapy

Cow's milk allergy (CMA) is a common childhood food allergy associated with a significant burden for those children who are affected and their families, including unintentional exposures that result in allergic reactions, severe allergic reactions, and anaphylaxis. In young children, cow's milk is one of the most frequent food triggers in anaphylactic episodes, and fatalities have also been described as a result of unintentional exposures, which reinforces the notion that milk allergy can be severe in some individuals. The natural history of CMA is favorable, with the allergy resolving over time in the majority of individuals, although some will have persistent allergy that does not resolve. The standard management approach for CMA consists of strict avoidance of milk and carriage of emergency medication for use in accidental exposures. Recently, a novel approach has emerged as an alternative option for management in patients with CMA in the form of oral immunotherapy (OIT). The aim of milk OIT is to protect patients from accidental exposures to milk-containing foods and allow patients to introduce larger amounts of milk into their diet. The goal of this article was to review the available evidence, discuss key studies that focused on milk OIT, and provide practical information and useful tips related to this novel treatment.

Early Introduction of Allergenic Foods and the Prevention of Food Allergy

The increasing prevalence of food allergies is a growing public health problem. For children considered high risk of developing food allergy (particularly due to the presence of other food allergies or severe eczema), the evidence for the early introduction of allergenic foods, and in particular peanut and egg, is robust. In such cases, the consensus is clear that not only should such foods not be delayed, but that they should be introduced at approximately 4 to 6 months of age in order to minimize the risk of food allergy development. The early introduction of allergenic foods appears to be an effective strategy for minimizing the public health burden of food allergy, though further studies on the generalizability of this approach in low-risk populations is needed.

Probiotics for the prevention of atopic dermatitis in infants from different geographic regions: a systematic review and meta-analysis

BackgroundAtopic dermatitis (AD) is a common skin disease during infancy, but the preventive effect of probiotics on AD remains unclear.AimTo evaluate the efficacy of probiotic supplementation for the prevention of AD in infants.MethodsPubMed, Cochrane Library, and Embase databases were reviewed for relevant randomized controlled trials (RCTs). Two authors independently extracted the data. The primary endpoint was the risk of AD in infants. Risk ratio (RR) and 95% confidence interval (CI) were calculated.ResultsA total of 20 related articles including 22 studies were included. A significant reduction in AD risk was revealed for the probiotic group compared to the control group (RR 0.76; 95% CI 0.67-0.87). Subgroup analyses by participant receiving intervention revealed that not only probiotics given to mother (RR 0.70; 95% CI 0.57-0.85) or given to mother and infant (RR 0.76; 95% CI 0.61-0.95) were effective in preventing AD in infants, and probiotics given to infants alone (RR 0.76; 95% CI 0.60-0.96) still effectively decreased the risk of AD.ConclusionProbiotic supplementation reduced the risk of developing AD in infants. Furthermore, probiotic supplementation given to mother or to mother and infant could effectively prevent AD in infants.

The burden of food allergy on children and teens: A systematic review

BACKGROUND

Over the last two decades, researchers have placed increasing attention on understanding how food allergy affects the health-related quality of life (HRQL) and psychosocial well-being of children and teens. In response, a number of reviews have been published that aim at synthesizing the literature. However, many of these papers focus narrowly on HRQL or suffer from methodological limitations.

METHOD

The current review aims to fill this gap by providing a comprehensive overview of the burden of pediatric food allergy by synthesizing the quantitative and qualitative literature.

RESULTS

Findings from the present review provide evidence of reduced HRQL among children and teens with food allergy, particularly older children and those with more severe manifestations of the condition. In comparison to HRQL, the link between food allergy and psychosocial functioning is less clear; however, some evidence can be cited linking food allergy to greater levels of psychological distress. Qualitative evidence suggests that the burden of pediatric food allergy largely stems from worries surrounding exposures outside of the home and the social consequences of the condition. The current review also highlights several gaps in the literature, including a paucity of longitudinal research, research focused on predictors of psychological distress among children and teens with food allergy as well as a dearth of studies comparing rates of bullying in food-allergic and non-food-allergic samples.

CONCLUSION

More emphasis should be placed on not only alleviating the social and psychological consequences of food allergy, but also on identifying and assisting those most acutely burdened by the condition.

New and Emerging Concepts and Therapies for the Treatment of Food Allergy

Food allergy is an increasingly common disease that often starts in early childhood and lasts throughout life. Self-reported food allergy has risen at a rate of 1.2% per decade since 1988, and by 2018, the prevalence of food allergy in the United States was estimated to be 8% in children and 11% in adults.^- This prevalence has led to an economic burden of almost $25 billion annually. Despite these staggering statistics, as of the time of this writing, the Food and Drug Administration (FDA) has only approved one treatment for food allergy, which is limited to use in children with peanut allergy. Fortunately, a new horizon of therapeutic interventions, in all stages of development, lay ahead and hold promise for the near future.

The relationship between dietary elimination and maternal psychopathology in breastfeeding mothers of infants with food allergy

BACKGROUND

There has been no study evaluating the psychopathology in breastfeeding mothers of infants with food allergy (FA).

OBJECTIVE

The aim of the study was to investigate the relationship between dietary elimination and maternal psychopathology, specifically anxiety, depression, and mother-to-infant bonding, in breastfeeding mothers of infants with food allergy.

METHODS

Breastfeeding mothers following an elimination diet due to FA in their children aged 1-to-12 months were compared with the healthy controls. The physician-diagnosed FA group was divided into IgE-, non-IgE-mediated, and infants with some minor symptoms which were not enough to make the diagnosis of FA were classified as Indecisive symptoms for FA group. Mothers completed standardized questionnaires including Symptom Checklist 90R, Beck Depression/Anxiety Inventories (BDI/BAI), Postpartum Bonding Questionnaire (Bonding).

RESULTS

Of 179 mother and infants, 64 were healthy, 89 were FA, 16 were indecisive symptoms for FA. The mean age of the mothers and infants were 31.1 ± 4.7 years and 6.3 ± 3.6 months, respectively. The physician-diagnosed FA groups had higher scores for anxiety (p = .008), anger (p = .042), depression (p < .001), obsession (p = .002), phobia (p = .008), somatization (p = .002), general symptom index (GSI) (p = .001), BDI (p < .001), BAI (p = .008), and Bonding (attachment [p = .001], anger [p = .019], and total [p = .036]) than the healthy ones. The indecisive symptoms for FA group had a similar score pattern to physician-diagnosed FA, except interpersonal sensitivity, BDI, and attachment.

CONCLUSION

Breastfeeding mothers of infants with FA were more anxious, with higher depression scores than controls, and had many psychopathologies which affected bonding. Interventions targeting negativity in caregivers' social relationships are urgently needed.

Food-allergy-specific anxiety and distress in parents of children with food allergy: A systematic review

BACKGROUND

Parenting a child with food allergy (FA) can lead to impaired quality of life and family functioning. Anxiety is a critical component of FA-associated distress and a potential target for therapeutic intervention. This systematic review aimed to clarify the concept of FA-specific anxiety (FAA) and its antecedents, consequences, and correlates and to determine the extent to which existing FA-specific outcome measures capture symptoms of parental distress and FAA.

METHODS

MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for qualitative and quantitative studies examining distress or anxiety in parents of children with FA through August 2020. This review was registered with PROSPERO (CRD42020208316) and conducted in accordance with PRISMA guidelines.

RESULTS

Ninety-eight studies were included in the final narrative synthesis. Most participants were mothers, and reporting of demographic data was limited. Parents identified anxiety as the most burdensome form of FA-specific emotional distress. Several allergy-related factors as well as medical and psychosocial interventions were associated with reduced parental anxiety and distress. However, affective, cognitive, and behavioral dimensions of FAA were only partially addressed by existing measures for general anxiety symptoms and FA-specific parental factors.

CONCLUSIONS

FAA contributes to distress and functional impairment among parents of children with FA. Current FA-specific parent measures fail to adequately capture dimensions of FAA, suggesting that further work is needed to improve the assessment and monitoring of FAA and its impacts. Characterization of this construct represents an initial step in developing standardized methods for assessing and monitoring FAA in clinical populations.

Health-related quality of life of food-allergic children compared with healthy controls and other diseases

BACKGROUND

Food allergy is a potentially life-threatening disease, affecting up to 10% of the pediatric population.

OBJECTIVE

The aim of our study was to assess the health-related quality of life (HRQL) of food-allergic patients compared with the general population and patients with other chronic diseases with dietary or allergic burden, in a cross-sectional study.

METHODS

We recruited patients aged 8-17 years diagnosed with food allergy and matched healthy controls recruited in schools. We also included patients with asthma, inflammatory bowel disease, celiac disease, diabetes, obesity, and eating disorders. We used the CHQ-CF87 questionnaire for generic HRQL assessment. Food allergy HRQL was also assessed using specific questionnaires: Food Allergy Quality of Life Questionnaire (FAQLQ) and Food Allergy Independent Measure (FAIM).

RESULTS

One hundred and thirty-five food-allergic children, 255 children with chronic diseases, and 463 healthy controls were included in the analyses. Food-allergic patients had a better HRQL than healthy controls in the Behavior (BE), Bodily Pain (BP), Family Activities (FA), and Mental Health (MH) domains and a worse HRQL in the General Health Perception (GH) domain (p = .048). Food-allergic patients exhibited a better HRQL than patients affected by other chronic diseases, notably diabetes. Although an epinephrine autoinjector had been prescribed to 87.4% of the food-allergic children, only 54.2% of them carried it at all times.

CONCLUSION

Food-allergic patients display overall good HRQL compared with the general population and those with other diseases with daily symptoms and treatments, in line with recent improvements in food allergy management.

The Interplay of Nutriepigenomics, Personalized Nutrition and Clinical Practice in Managing Food Allergy

Food allergy in children has been a common issue due to the challenges of prescribing personalized nutrition with a lack of nutriepigenomics data. This has indeed further influenced clinical practice for appropriate management. While allergen avoidance is still the main principle in food allergy management, we require more information to advance the science behind nutrition, genes, and the immune system. Many researchers have highlighted the importance of personalized nutrition but there is a lack of data on how the decision is made. Thus, this review highlights the relationship among these key players in identifying the solution to the clinical management of food allergy with current nutriepigenomics data. The discussion integrates various inputs, including clinical assessments, biomarkers, and epigenetic information pertaining to food allergy, to curate a holistic and personalized approach to food allergy management in particular.

Adaptation, Translation and Validation of the Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF): The Malay Version

Food allergy has a significant impact on the quality of life (QoL) of children and can be measured using The Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF). This study aimed to adapt, translate the FAQLQ-PF into Malay and determine the validity and reliability of the translated version. This cross-sectional questionnaire validation study was conducted among parents of children (0 to 12 years old) with food allergies across five sites in Selangor and Kuala Lumpur, Malaysia. The FAQLQ-PF-Malay underwent cross-cultural adaptation, translation, validation (content, face and construct) and reliability assessment. Exploratory factor analysis, internal consistency and test-retest reliability analyses were used to examine its construct validity and reliability. Out of 150 children, the majority were between the age of 7 to 12 years old (41%) and were female (81%). Three subscales were identified, which were: (i) social and dietary implication, (ii) food anxiety and (iii) emotional and physical impact. Four items were eliminated because of weak factor loadings. The Cronbach's alpha for each subscale ranged from 0.88 to 0.94, with an overall Cronbach's alpha of 0.95. The intra-class correlation coefficient ranged from 0.54 (95% CI: 0.10-0.77) to 0.97 (95% CI: 0.90-0.99). The 26-item FAQLQ-PF-Malay retained the three-factor structure of the original FAQLQ-PF. The FAQLQ-PF-Malay is a valid and reliable tool to assess the QoL of Malaysian children with food allergies.

A scoping review of the caregiver burden of pediatric food allergy

OBJECTIVE

Although a number of articles have described the psychosocial impact of raising a child with a food allergy, recent attempts at synthesizing this literature have been narrow in focus or methodologically limited. Consequently, this study aimed to synthesize both the quantitative and qualitative literature to achieve a better understanding of the psychosocial and financial burdens faced by families who raise children with food allergy.

DATA SOURCES

Searches were performed on PubMed, Scopus, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature databases for articles related to the psychosocial and financial burden experienced by individuals who care for a child with food allergy.

STUDY SELECTIONS

English language, original research articles were included in this review.

RESULTS

A total of 54 articles were deemed eligible for review. Results from the quantitative literature revealed that parents of children with food allergy (ie, food allergy and food protein-induced enterocolitis, proctocolitis, and enteropathy) consistently reported lower quality of life than their comparison groups. Within-group analyses suggest that this burden is increased for parents who manage multiple food allergies, severe food allergy, and comorbid allergic conditions. Thematic synthesis of the qualitative literature suggests that the psychosocial burden shouldered by parents of children with food allergy stems, in part, from the unpredictable threat of exposure and the practical and social burdens of managing a food allergy. In addition to psychosocial burdens, a small but growing body of literature suggests that families with food allergy also incur greater financial costs.

CONCLUSION

Findings suggest that pediatric food allergy imposes considerable burdens on parents both quantitatively and qualitatively.

Combining Anti-IgE Monoclonal Antibodies and Oral Immunotherapy for the Treatment of Food Allergy

Immunoglobulin E (IgE)-mediated food allergy is a real public health problem worldwide. The prevalence of food allergy is particularly high in children. Patients with food allergy experience high morbidity with a change in quality of life due to the risk of severe anaphylaxis. Current treatment options are poor. Allergen avoidance is widely recommended but exposes patients to accidental ingestion. Oral immunotherapy is also used in patients with food allergies to the most common allergens. Oral immunotherapy consists of a daily administration of small, gradually increasing amounts of allergens to induce desensitisation. This procedure aims at inducing immune tolerance to the ingested food allergens. However, some patients experience adverse reactions and discontinue oral immunotherapy.Given that IgE plays a crucial role in food allergy and anti-IgE are effective in allergic asthma, the use of anti-IgE therapeutic monoclonal antibodies (mAbs) such as omalizumab has been assessed in food allergy patients. The use of omalizumab as a monotherapy in food allergy has not been extensively studied but looks promising. There is more published evidence regarding the effect of omalizumab and oral immunotherapy in food allergy. Given the promising results of oral immunotherapy regarding sustained tolerance in clinical trials and the potential capacity of omalizumab to reduce symptoms in case of accidental exposure, a strategy combining oral immunotherapy with omalizumab pre-treatment has been suggested as a safer option in patients with severe food allergy compared to isolated therapy. Omalizumab seems useful in ensuring safer administration of oral immunotherapy with the oral immunotherapy maintenance dose being reached more rapidly. Quality-of-life improvement is greater with oral immunotherapy + omalizumab compared to oral immunotherapy alone. Moreover, sustained unresponsiveness is achieved more frequently with omalizumab. Considering that precision medicine and personalised therapy are major goals for allergic diseases, predictive biomarkers are crucial in order to identify food allergy patients more likely to benefit from anti-IgE therapies.

A systematic review of infant feeding food allergy prevention guidelines - can we AGREE?

Food allergy is a significant issue worldwide, particularly in Westernised countries. There is no clear explanation why food allergy appears to have increased so rapidly in recent years, particularly in young children, hence ongoing research to identify effective primary prevention strategies. Food allergy prevention guidelines for health professionals have been developed based on existing clinical trial evidence for effective translation and implementation. As these guidelines underpin clinical practice, it is important to ensure robust processes of development. We conducted a systematic review to identify food allergy prevention guidelines for health professional use; to compare the recommendations made by the identified guideline documents; and to assess the quality of the identified guideline documents. We searched Medline, EMBASE, CINAHL, Scopus, Global Health and Guidelines International Network for the period 1990 to 13 August 2019, to identify articles referring to English-language food allergy prevention guidelines or the guidelines themselves. A grey literature search of Google Scholar and reference checking was also undertaken. The guidelines were compared for recommendation similarities and differences. An Appraisal Guidelines for Research and Evaluation (AGREE II) appraisal was undertaken to assess guideline quality. The electronic database search yielded 1121 publications and reference checking identified an additional 16 publications. After title, abstract and full text screening, data extraction was undertaken on 156 publications and with additional reference checking, 28 food allergy prevention guidelines and advice documents were identified. Comparison of the recommendations within the guidelines and advice documents indicated the greatest variation in recommendations related to exclusive breastfeeding and timing of solid food introduction. Eight of the 10 guidelines and none of the 18 advice documents met the quality threshold set by the reviewers. Overall, documents specifically termed "guidelines" scored better than advice documents when assessed using the AGREE II tool. Variation in recommendations may create confusion for health professionals and result in inconsistent advice being provided to parents, and less translation of the evidence into actual food allergy reduction in the population. Appraisal using the AGREE II tool identified that there is considerable room for improvement in the development of guidelines and advice documents for food allergy prevention. The AGREE II appraisal identified common areas of poorer quality development and/or documentation of processes to inform future guideline development. Based on this study, we recommend the use of validated guideline development tools, to direct food allergy prevention guideline review or development. Use of the AGREE II tool, to direct the review and development of guidelines, is very likely to improve guideline quality.

AAAAI Work Group Report: Trends in Oral Food Challenge Practices Among Allergists in the United States

The oral food challenge (OFC) is the criterion standard for diagnosing food allergy, but prior studies indicate many allergists may not be using OFCs for various reasons. To better understand current OFC trends, practices, and barriers, the American Academy of Allergy Asthma and Immunology (AAAAI) Adverse Reactions to Foods Committee subcommittee updated a 19-item survey (previously administered in 2009) and sent it to AAAAI and American College of Allergy, Asthma, and Immunology (ACAAI) membership. There were a total of 546 respondents who represented approximately a 10% response rate. Among the 546 respondents, compared with 2009, significantly more providers offer OFCs (95% vs 84.5%), offer >10 OFCs per month (17% vs 5.6%), obtain informed consent (82.2% vs 53.6%), and performed OFCs in fellowship (71% vs 45%) (all P < .001). Fellowship OFC training was limited, with 56% performing <10 OFCs in fellowship and 29% performing none. Although 94% see patients <12 months of age, 35.5% do not offer OFCs for early peanut introduction. Although 79% dedicate a supervising medical provider (MD, NP, PA) and 86% have a written OFC protocol, only 60% had a standardized reaction treatment protocol and 56% prepared emergency medications before OFC. Compared with 2009, there was significant worsening of perceived barriers to performing OFCs, including time (65.6% vs 55%), space (55.3% vs 27.1%), staffing (59.6% vs 44.3%), experience (16.9% vs 11.5%), and hospital proximity (10.9% vs 7.9%), though reimbursement as a barrier improved (45.9% vs 53.7%) (all P < .01). Compared with 2009, although more providers offer OFCs, multiple perceived barriers to performing OFCs have worsened. Hesitancy to challenge infants and emergency preparedness issues are emerging potential concerns.

Food Allergy in Restaurants Work Group Report

Individuals with food allergy are at risk for accidental exposures, potentially resulting in allergic reactions that may cause significant morbidity and mortality. Dining out, including restaurants or take-out, account for a large proportion of severe reactions. Errors due to gaps in knowledge or miscommunication can easily occur on behalf of food-allergic individuals or restaurant staff, resulting in accidental exposures and allergic reactions. Improved legislation, training of restaurant staff, and practitioner-guided education are recommended to reinforce patient safety and prevent severe allergic reactions. This Work Group Report provides guidance with specific practices that practitioners may recommend, and that patients and restaurant staff may employ, for prevention and treatment of food-allergic reactions in restaurants.

Peanut oral immunotherapy in a pediatric allergy clinic: Patient factors associated with clinical outcomes

BACKGROUND

Additional information is needed to inform optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy (OIT).

OBJECTIVE

To provide insight into the optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy by analyzing a real-world peanut OIT cohort.

METHODS

Records were reviewed for 174 children undergoing peanut OIT at a pediatric allergy clinic. Patient age, peanut skin prick test results, and peanut-specific immunoglobulin E (sIgE) results, with inclusion of additional foods in OIT, were analyzed for correlations with OIT outcomes.

RESULTS

To date, 144 patients have achieved maintenance dosing, 50 of whom transitioned to ad lib twice-weekly peanut ingestion. A total of 30 discontinued OIT. In addition, 47 patients who underwent multifood OIT had no significant difference in reactions (FDR-adjusted P = .48) or time-to-reach maintenance (FDR-adjusted P = .48) compared with those on peanut OIT alone. Age at initiation inversely correlated with achievement of maintenance: 92% of patients 0.5 to less than 5 years, 81% of those 5 to less than 11 years, and 70% of those 11 to less than 18 years reached and continued maintenance (P = .01). Baseline peanut-sIgE level positively correlated with number of reactions during updosing (P < .001) and maintenance (P = .005), though it was not significantly different in patients achieving successful maintenance vs those who discontinued OIT (P = .09). Furthermore, 66% of patients experienced greater than or equal to 1 adverse reaction during OIT. Of those on ad lib peanut ingestion, 2 reported mild reactions after lapses in peanut consumption.

CONCLUSION

Clinical peanut OIT has similar outcomes to research protocols. OIT can be successful in older children and those with high peanut-sIgE levels, though these factors affect outcomes. Clinical and laboratory criteria can guide successful transition to intermittent ad lib peanut consumption.

Food Allergy Symptom Self-Management With Technology (FASST) mHealth Intervention to Address Psychosocial Outcomes in Caregivers of Children With Newly Diagnosed Food Allergy: Protocol for a Pilot Randomized Controlled Trial

Background

Approximately 2.4 million children in the United States suffer from food-induced anaphylaxis, a condition that is annually responsible for over 200 deaths and 200,000 emergency room visits. As a result, caregivers of children newly diagnosed with severe and life-threatening food allergic reactions experience clinically significant symptoms of psychological distress, including fatigue, anxiety, depressed mood, social isolation, and substantially reduced quality of life. Despite this recognition, there is a lack of caregiver-centered self-management interventions to address these concerns.

Objective

In this protocol, we propose to develop and conduct feasibility testing of a technology-enhanced, self-management, mobile health, smartphone app intervention called Food Allergy Symptom Self-Management with Technology for Caregivers (FASST) designed to meet the psychosocial health needs of caregivers of children with a new diagnosis of food allergy.

Methods

This pilot study uses qualitative work (Phase I) to inform a 4-week longitudinal randomized controlled trial (Phase II). In Phase I, 10 caregivers of children (≤18 years old) with established food allergy (≥1 year from diagnosis) will participate in semistructured interviews to inform the development of the FASST app. In Phase II, 30 caregivers of children (≤18 years old) with a newly diagnosed food allergy (≤90 days from diagnosis) will be randomized 2:1 to receive the FASST intervention (n=20) or control condition (basic app with educational resources; n=10). Process measures include feasibility, caregiver acceptability, adherence, and satisfaction. Outcome measures include caregiver fatigue, anxiety, depression, sleep, self-efficacy, and quality of life measured at baseline, week 4, and 3 months post study completion.

Results

Phase I study activities have been completed, and Phase II participant enrollment into the randomized controlled trial is expected to commence in 2021.

Conclusions

With limited readily available resources at their disposal, the results from this study have the potential to provide caregivers of children with a newly diagnosed food allergy a tool to help them self-manage and mitigate negative psychosocial factors during a critical time period in the caregiving/condition trajectory.

Trial Registration

ClinicalTrials.gov Identifier NCT04512924: https://clinicaltrials.gov/ct2/show/NCT04512924

International Registered Report Identifier (IRRID)

DERR1-10.2196/25805

Preventing Atopic Diseases During Childhood - Early Exposure Matters

Atopic diseases in childhood are a major burden worldwide and there is still a lack of knowledge about treatable causes. In industrialized countries such as Germany, almost every second child is sensitized to at least one common allergen. Recent studies show that although the predisposition to allergies is inherited, the adaptive immune system of neonates and infants follows a developmental trajectory and whether an allergy actually occurs depends also on timing of allergen exposure including diet as well as environmental factors. New recommendations are far from being rigid of allergen avoidance; it is rather moving toward conditions that stand for more biodiversity. The observation that introduction of peanuts or eggs early in life significantly reduced the development of a later allergy will change our recommendations for the introduction of complementary foods. This is consistent with the hygiene hypothesis that early provocation shapes the developing immune system so that it reacts appropriately. Therefore, promoting the development of tolerance is at the heart of sensible allergy prevention - and this begins with the last trimester of pregnancy. In light of this concept, actual recommendations are discussed.

Maternal awareness to the timing of allergenic food introduction in Saudi infants: A cross-sectional study

Background

Current guidelines recommend the introduction of allergenic foods as early as 4–6 months of age to decrease the risk of food allergy. However, caregivers’ knowledge about such practices and adherence to them is ambiguous.

Objectives

The purpose of this study was to evaluate the timing of introduction of potentially allergenic foods into children’s diet and the level of maternal awareness about and degree of compliance with current recommendations.

Materials and methods

We conducted a cross-sectional study from May 2019 to January 2020 at Imam Mohammad Ibn Saud Islamic University Medical Center, Riyadh, Saudi Arabia. Data were collected through questionnaire-based surveys, and a total of 405 mothers were enrolled in the study. The eligibility criteria included mothers of children between the ages of 12 and 36 months.

Results

Most mothers in this study had initiated allergenic foods, and the average time of introduction was 9.84 ± 3.16 months for eggs, 14.6 ± 5.78 months for peanuts, and 13.6 ± 5.37 months for fish. Around one-quarter (n = 102, 25.2%) of the children were identified as being in the high-risk group. Most mothers did not know or disagreed that the timing of introducing allergenic foods might help in preventing food allergy, but there was no difference between the risk groups (33.8% and 26.2%, respectively). Moreover, only 18.6% and 13.2% of the high- and low-risk groups, respectively, received correct information from their health care providers (P = .004). Mothers with only one child were less likely to start eggs at an early age (odds ratio [OR] = 0.5 and P = .005). Furthermore, children at a high risk of food allergy were two times more likely to start eggs at an earlier age (OR = 2.12 and P = .003).

Conclusion

In this study, the allergenic food feeding practices being followed for infants and young children were found to be suboptimal. Parental education level and the number of siblings were identified as potential barriers to the implementation of and adherence to recent guidelines. There is a need for corrective measures to ensure safe and appropriate feeding practices in the Saudi community.

Patients' Perspectives and Needs on Novel Food Allergy Treatments in the United States

PURPOSE

Food allergy management places a daily psychosocial burden on patients and their caregivers. New food allergy treatments may positively impact their lives, but also introduce new stressors. The purpose of this paper is to provide an overview of the current state of the literature regarding patients' and caregivers' food allergy experiences and needs within the United States as well as a set of recommendations regarding how best to proceed with patient-centered development and evaluation of new food allergy treatments.

RECENT FINDINGS

The first pharmaceutical-grade product for peanut oral immunotherapy was approved in the United States for children aged 4-17 years following a successful international Phase 3 trial. This new treatment is only the first of several food allergy treatments currently under development. Patients will soon be presented with multiple options for food allergy treatment and will need to make decisions about what treatment is best for them.

SUMMARY

Allergy researchers and providers are encouraged to consider patients' perspectives and needs when developing and evaluating new food allergy treatments. Recommendations regarding next steps include the development of new patient-reported outcome tools, focus on psychosocial support, health disparities, and financial implications, and research harmonization and interdisciplinary collaboration.

Antigen-Presenting Cells in Food Tolerance and Allergy

Food allergy now affects 6%-8% of children in the Western world; despite this, we understand little about why certain people become sensitized to food allergens. The dominant form of food allergy is mediated by food-specific immunoglobulin E (IgE) antibodies, which can cause a variety of symptoms, including life-threatening anaphylaxis. A central step in this immune response to food antigens that differentiates tolerance from allergy is the initial priming of T cells by antigen-presenting cells (APCs), primarily different types of dendritic cells (DCs). DCs, along with monocyte and macrophage populations, dictate oral tolerance versus allergy by shaping the T cell and subsequent B cell antibody response. A growing body of literature has shed light on the conditions under which antigen presentation occurs and how different types of T cell responses are induced by different APCs. We will review APC subsets in the gut and discuss mechanisms of APC-induced oral tolerance versus allergy to food identified using mouse models and patient samples.

Efficacy, safety, and parental anxiety in a randomized trial of two dietary instruction methods for children with suspected hen's egg allergy

BACKGROUND

Little has been reported on how to introduce hen's egg into the diet of children with suspected egg allergy. We compared the efficacy, safety, and parental anxiety of two different dietary instruction methods to introduce egg.

METHODS

Eligible participants were children aged 1-4 years who were positive for egg white IgE, and ovomucoid IgE <3.5 kUA/L. Participants were either naïve in egg consumption or had a history of an immediate, but non-anaphylactic, allergic reaction to egg. After a negative result of baseline 2 g boiled egg white oral food challenge (OFC), participants were randomly assigned to the step-up OFC testing (SOFT) or home incrementing group. The primary outcome was the proportion of participants who were able to ingest 20 g of boiled egg white 6 months after initiation. This study is registered with the University Hospital Medical Information Network clinical trial registry (UMIN000024192).

RESULTS

Between September 2016 and August 2018, we randomly allocated 55 participants to the SOFT (n = 33 [60%]) and home incrementing (n = 22 [40%]) groups and analyzed 51 patients. Four patients were excluded because they were lost to follow-up. Thirty-one (96.9%) of 32 participants in the SOFT and 12 (63.2%) of 19 in the home incrementing group achieved the primary outcome (p = 0.003). No serious adverse reactions were observed in either group. Parental anxiety significantly improved during treatment in both groups.

CONCLUSIONS

The SOFT method was more effective than home incrementing as dietary instruction to introduce egg in children with suspected egg allergy.

A High Proportion of Canadian Allergists Offer Oral Immunotherapy but Barriers Remain

BACKGROUND

Limited data on clinical implementation of oral immunotherapy (OIT) have been reported with incomplete evaluation of barriers.

OBJECTIVE

To survey Canadian allergists on their current practice of OIT and barriers to implementation and expansion of OIT.

METHODS

A survey investigating current practice and logistical and clinical barriers to offering or expanding OIT was distributed to all Canadian Society of Allergy and Clinical Immunology allergists.

RESULTS

Of 90 responding allergists, 52.2% reported offering OIT, most commonly to peanut. Food sublingual immunotherapy was offered by 7% of allergists. Having received training for OIT was associated with currently performing OIT (P = .008); 44.7% of allergists offering OIT had received training on OIT, and 81.4% not offering OIT had no training. A total of 87% of allergists performing OIT reported lack of efficacy data and lack of support staff and clinic space, and concerns about increased oral challenges (84%) were "moderately" to "extremely" important barriers to expanding OIT. For clinicians not offering OIT, concerns about safety (95%), after-hours support (95%), efficacy (93%), medicolegal risk (93%), and long-term practice implications (93%) were prioritized as significant barriers. Qualitative assessment suggested concerns about the practical challenges associated with OIT, the need for increased safety and efficacy data, and a desire for OIT guidelines and training.

CONCLUSION

The implementation of OIT faces many barriers, both clinical and logistical. Increasing high-quality safety and efficacy data may support those hesitant to offer OIT, and improving funding may address the practical infrastructure challenges. In addition, training will help expand access for allergists interested in performing OIT.

Psychosocial and productivity impact of caring for a child with peanut allergy

Background

Limited previous research has assessed the psychosocial burden and productivity impact of caring for a child with peanut allergy and factors associated with burden. The objective of this research was to explore caregiver burden in terms of psychosocial and productivity impact of caring for a child with peanut allergy, the influence of caregiver and child gender on caregiver burden, and factors predicting caregiver burden in peanut allergy.

Methods

A cross-sectional survey of caregivers of children with peanut allergy was conducted in the United Kingdom, and included sociodemographic and clinical questions, EQ-5D, Hospital Anxiety and Depression Scale, Food Allergy Quality of Life-Parental Burden, Food Allergy Independent Measure, and productivity questions.

Results

One hundred caregivers (55% female) of children with peanut allergy (aged 4-15 years) completed the survey. Male and female caregivers reported mean levels of anxiety significantly higher than United Kingdom population norms. Caregivers of children with severe peanut allergy reported significant impacts on their careers and health-related quality of life. Neither caregiver nor child gender impacted burden, indicating that male and female caregivers are equally anxious and suffer the same level of negative career, productivity, and health-related quality-of-life impact due to their child's peanut allergy. Caregivers' perceived risk of outcomes related to their child's peanut allergy (e.g., death or severe reaction) as measured by the Food Allergy Independent Measure independently predicted burden.

Conclusions

Caregivers of children with peanut allergy in the United Kingdom experience health-related quality-of-life, psychosocial, and productivity burden; this study demonstrates the high levels of anxiety reported by both male and female caregivers.