Food Allergy-Related Bullying Among Children and Adolescents

Immune therapies in coeliac disease and food allergies: Advances, challenges, and opportunities

Coeliac disease and food allergy management primarily relies on the strict avoidance of dietary antigens. This approach is challenging to maintain in real-world settings and in food allergy carries the risk of life-threatening anaphylaxis. Despite their distinct pathogenesis, both disorders are driven by maladaptive responses to dietary proteins, creating opportunities for shared treatment strategies. In food allergy, desensitisation therapies such as oral, sublingual, and epicutaneous immunotherapy are well-established, complemented by biologics like omalizumab and dupilumab. However, the induction of sustained tolerance remains challenging. In contrast, therapeutic advancements for coeliac disease are still in their early stages. Current efforts focus on gluten detoxification or modification, immune blockade or modulation, tolerogenic approaches, and barrier restoration. Emerging therapies, including JAK and BTK inhibitors and microbiome-targeted interventions, support further targeted treatment options for both conditions. Biomarkers tracking gluten-specific T cells have emerged as valuable tools for immunomonitoring and symptom assessment in coeliac disease, although standardisation of patient-reported outcome measures and gluten challenge protocols is still needed. Food allergy trials are reliant on double-blind placebo-controlled food challenges to measure allergen reactivity, but these are time-consuming, carry risks, and underscore the need for surrogate biomarkers. The successful development of immune-targeted therapies will require building an immune toolset to optimally assess systemic responses to antigens in both conditions. Clinically, this could lead to better outcomes for patients who might otherwise remain undiagnosed or untreated due to the absence of significant enteropathy or allergen-specific symptoms.

Oral Immunotherapy Should Play a Key Role in Preschool Food Allergy Management

Food allergies pose significant challenges including the risk for severe allergic reactions. This review article highlights the advantages and disadvantages of the historic standard management approach-avoidance and carrying epinephrine in case of accidental ingestion-and argues, based on accumulating evidence, that oral immunotherapy (OIT) should play a key role in preschool food allergy management. Firstly, our review will highlight pitfalls with the 'wait-and-see' approach to natural resolution of food allergies, with recent data pointing to lower resolution than previously thought. For those who do not outgrow their allergies, waiting until school age to offer OIT means missing the window of opportunity where OIT is safest, and prolongs unnecessary dietary restrictions. For those who do outgrow their allergies, research indicates they may not reintroduce the food due to fear and aversion and can become re-sensitised, putting them at risk of severe reactions. Secondly, the risks associated with allergen avoidance are higher than previously believed. Allergen avoidance is imperfect and carries an increased risk of severe reactions when compared with the risk of severe reactions while on OIT, particularly in preschoolers. Although an allergic reaction can be stressful, it is preferable to have this occur during OIT where caregivers are vigilant following a scheduled dose, rather than having this occur at a potentially unexpected time following an accidental exposure. Lastly, there is a growing body of evidence supporting favourable safety and effectiveness of OIT in preschoolers, and preliminary data suggesting higher likelihood of remission in infants. OIT has the potential to significantly improve quality of life, and future research is needed to answer this important question in preschoolers. In summary, while ongoing research will further clarify cost-effectiveness, long-term adherence and psychosocial impacts of OIT, this review suggests that OIT should play a key role in preschool food allergy management.

Food allergy-related bullying: Risk factors and psychosocial functioning

BACKGROUND

Food allergy (FA)-related bullying is common, yet little is known about risk factors for FA-related bullying or the relationship between FA-related bullying and psychosocial wellbeing. This study aimed to (1) identify sociodemographic and clinical factors associated with risk of FA-related bullying in children with FA, and (2) evaluate the psychosocial functioning of children and parents reporting FA-related bullying.

METHODS

This was a cross-sectional survey study of children ages 5-17 years with immunoglobulin E (IgE)-mediated FA and their parents, recruited from Boston Children's Hospital (BCH) and through social media outlets. Children and parents with versus without a history of FA-related bullying were compared on sociodemographic and clinical characteristics and FA-related psychosocial outcomes using validated instruments.

RESULTS

In this cohort of 295 child-parent dyads, the median child age was 8.0 years, 53.2% of children were male, and parent respondents were primarily mothers (96.6%). Reported lifetime prevalence of FA-related bullying was 36.6%. FA-related bullying was associated with certain child characteristics, including coming from a household at risk of food insecurity (FI) (12.0% of bullied children v. 2.2% of not bullied children were from food insecure households, p < .001), having coexisting atopic and mental health conditions-particularly anxiety (30.6% of bullied children v. 8.6% of not bullied children carried an anxiety disorder diagnosis, p < .001)-and having a history of more severe FA reactions. FA-related bullying was associated with elevated concerns in child and parental FA-related psychosocial functioning domains.

CONCLUSION

Pediatricians and allergists should screen for FA-related bullying and offer families appropriate guidance around management of FA-related bullying.

"When I became older, I started having to manage that more myself"-Experiences of adolescents with food allergies: A qualitative study

BACKGROUND

It's often caregivers or healthcare professionals' experiences that are studied in the field of allergy, but the adolescents' perspective is crucial to develop interventions that support them in areas they find most challenging. This study aims to explore adolescents' experience of managing food allergies, particularly how they navigate the transition from parental management to self-management.

METHODS

This is an interpretive descriptive qualitative study. Semi-structured interviews were conducted with ten adolescents with food allergies aged 12-16 years. Reflexive thematic analysis was conducted. The Reflexive Thematic Analysis Reporting Guidelines were used.

RESULTS

Four themes were generated, (1) belonging-seeing me, (2) not knowing (3) taking responsibility-"So I guess when I became older, I started having to manage that more myself" and (4) variation in coping strategies. These describe adolescents need for belonging, that their peers acknowledge their food allergies without making them feel like a burden. Adolescents understanding of essential food allergy information was lacking, with some unaware of this lack of knowledge. Adolescents were conscious of the need to take over responsibility from their parents, although this could be difficult. Finally, how adolescents coped with all these aspects of their food allergy could be seen as avoidant due to high anxiety, minimizing of risk, or adaptive, where adolescents are aware of and mitigate risks appropriately, without avoiding life experiences.

CONCLUSION

Adolescents find the transition of responsibility from their parents difficult. A trusted source of allergy information is required, aimed at adolescents, covering both physical allergy management and psychosocial content.

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 Allergy-Related Bullying in Pediatric Patients: A Systematic Review

BACKGROUND

Food allergy (FA)-related bullying is a significant public health concern affecting pediatric patients. This systematic review investigates the prevalence, characteristics, and psychosocial impact of FA-related bullying, as well as current intervention strategies within educational and healthcare settings.

METHODS

A systematic literature search was conducted across the PubMed, Web of Science, and CINAHL databases, covering publications up to February 2024. The review followed PRISMA guidelines and included studies on children and adolescents (0-18 years) diagnosed with FAs. Studies were selected based on eligibility criteria and assessed for quality using the Newcastle-Ottawa Scale.

RESULTS

The initial search identified a total of 260 records (6 from scientific databases and 254 from registries). Twenty-six studies met the inclusion criteria. The findings of these studies reveal that FA-related bullying is prevalent, with rates varying between 17% and 60%, depending on the study population and methods. Bullying often involves verbal teasing, social exclusion, and physical threats using allergens, presenting both psychological and physical risks. Psychological consequences include increased anxiety, depression, and social withdrawal, which persist over time, significantly impacting quality of life for both children and their families. Notably, bullying often occurs in school settings, emphasizing the need for targeted interventions.

CONCLUSION

FA-related bullying profoundly affects mental health and quality of life for affected children and their families. Interventions, such as school-based allergy education programs and policies promoting inclusivity and safety, have shown promise in reducing bullying incidents. A collaborative approach involving healthcare providers, educators, and policymakers is essential to mitigate the impact of FA-related bullying and improve outcomes for affected children.

Canadian Society of Allergy and Clinical Immunology position statement: panel testing for food allergies

This position statement addresses the critical concerns and recommended practices surrounding the use of panel food testing for diagnosing food allergies. Food allergies are a significant public health concern, and the misdiagnosis of food allergies remains a prevalent concern, made worse by the ongoing use of panel food testing. The practice of screening patients for multiple food allergens, regardless of clinical relevance, is commonly referred to as "panel food testing." Fundamentally, a panel food test is not simply a single test; a panel food test is a series of several distinct tests for multiple foods, each with its own variable predictive value. These tests have not been adequately validated as screening tests and carry a considerable false positive rate. The resulting false diagnoses lead to unnecessary dietary restrictions, increased healthcare costs, and significant psychosocial distress for patients and their families.

Global availability and uptake of psychological services for adults, caregivers and children with food allergy

BACKGROUND

Food allergy (FA) is associated with poor health-related quality of life and high levels of psychological distress. Psychological support is extremely important but not always available. As part of the Global Access to Psychological Services for Food Allergy (GAPS) study, we aimed to assess psychological distress and service use among adults, caregivers and children with FA in a global survey.

METHODS

Participants (n = 1329 adults with FA; n = 1907 caregivers of children with FA) from >20 countries were recruited through patient organisations, social media advertisements and online survey panels to complete an online survey. Surveys were available in six languages.

RESULTS

A total of 67.7% of adults and 77.2% of caregivers reported direct experience, and 51.6% of caregivers said their child had experienced FA-related psychological distress. The most commonly reported issue was anxiety about having an allergic reaction. Less than 20% had been assessed for FA-related psychological distress. There were significant differences across countries for levels of distress, screening for distress, seeing a mental health professional and being diagnosed with a FA-related mental health disorder (all p < .001). The United Kingdom, Australia and Brazil had the highest number of participants reporting distress. The most commonly reported barrier to seeing a mental health professional was cost.

CONCLUSIONS

FA-related distress is common across countries, but with substantial country-to-country variability. Allergy providers are encouraged to routinely assess families for psychological distress and provide access to appropriate mental health resources. Development and implementation of evidence-based, patient-informed accessible, affordable FA interventions in multiple languages is urgently needed.

The Lived Experiences of Students With Food Allergies During a Usual Weekday

BACKGROUND

Extant literature indicates students living with food allergies (FA) experience biopsychosocial challenges (eg, social isolation, anxiety). The purpose of this study was to explore the experiences of students living with FA during a usual weekday in a school setting.

METHODS

Phenomenological study with purposive convenience sample from the US states of Florida and Colorado. Students aged 10-14 years who have been managing an IgE-mediated FA for more than 1 year within a school setting. Data collection was guided by a story path process with semi-structured interview, with Interpretive Phenomenological Analysis used to ascribe meaning to their experiences.

RESULTS

Four themes: (1) Living with Restraints: A Way of Life, (2) Managing Exposure, (3) Experiencing Stigma, and (4) Experiencing Lack of Knowledge.

CONCLUSION

Findings underscore unique biopsychosocial challenges faced by students living with FA, highlighting the need for comprehensive approaches beyond traditional biological management in developing strategies, policies, future research, and recommendations in school settings.

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.

Winnipeg-based elementary school teachers' perspectives on food allergy management: a qualitative analysis

BACKGROUND

Food allergy affects 7-8% of children worldwide. Teachers supervise children in school, where most children spend their day. Yet, teachers have variable food allergy-related knowledge.

OBJECTIVE

We aimed to identify how Winnipeg-based elementary school teachers manage food allergy and prevent food-triggered allergic reactions in their classrooms and schools.

METHODS

Kindergarten-Grade 6 public and private school teachers, from Winnipeg, Canada, were interviewed virtually upon providing written informed consent. Interviews were recorded and transcribed verbatim. The study followed a pragmatic framework. Data were analysed via thematic analysis by multiple researchers.

RESULTS

We interviewed 16 teachers, who primarily identified as female (87.5%). Most teachers worked in public schools (87.5%) and, on average, had 5.8 years of teaching experience. We identified four themes within the data. Most teachers (68.9%) had direct or indirect experience with food allergy. Theme 1 described the minimal standardization and inconsistent enforcement of food allergy policies between and within schools. Teachers also had varied food allergy knowledge. Theme 2 reflected teachers' variable confidence/perceived knowledge towards food allergy management, including feeling of stress and anxiety. Theme 3 captured the lack of standardized food allergy education for teachers, and concerns about the adequacy of the current provincial program. Theme 4 described how teachers spoke of relying on other school staff, families and students to have effective communication.

CONCLUSION

Teachers' food allergy management was informed by their knowledge and lived experience, guided by their school policies and individualized students' needs. Teachers identified gaps in knowledge and communication, and desired more training and resources.

Food allergy knowledge, attitudes and beliefs of kindergarten teachers in Kuwait: a cross-sectional study

BACKGROUND

Food allergy (FA) affects up to 10% of children globally, with clinical symptoms varying from mild to severe, and in rare instances, it is life-threatening. Approximately one in five children with FA experience a food-induced allergic reaction in school, leaving teachers as the first line of intervention. This study aimed to assess kindergarten teachers' knowledge, attitudes and beliefs regarding FA.

METHODS

This cross-sectional study enrolled kindergarten teachers in Kuwait using stratified cluster sampling. The Chicago Food Allergy Research Survey for the General Public was used to assess teachers' knowledge, attitudes and beliefs regarding FA. The overall FA knowledge score was calculated for each participant. The χ² test was used to assess the differences in the distribution of categorical variables.

RESULTS

Responses were obtained from 882 public kindergarten teachers from 63 kindergartens. Most teachers (81.9%) encountered students with FA in their classrooms. Only 13.5% of the teachers reported receiving training in FA. Overall, participants scored an average of 52.2% on the FA knowledge assessment, with participants receiving prior training in FA scoring on average higher than those with no prior training in FA (55.9% vs 51.6%, p=0.005). A few teachers (10.7%) were aware that lactose intolerance was not equivalent to milk allergy. In terms of attitudes regarding FA, only 14.9% of the participants acknowledged that children with FA are teased/stigmatised due to their condition, and 33.7% recognised that avoidance of allergenic food is difficult. Moreover, only 9.9% of the teachers self-reported their ability to use an epinephrine autoinjector.

CONCLUSIONS

Improved knowledge and awareness of FA among public kindergarten teachers in Kuwait are needed to ensure the safety of children with FA in schools. Teachers should be trained to prevent, recognise and manage FA-related allergic reactions.

A practical toolbox for the effective transition of adolescents and young adults with asthma and allergies: An EAACI position paper

INTRODUCTION

Adolescence is a critical stage of rapid biological, emotional and social change and development. Adolescents and young adults (AYA) with asthma and allergies need to develop the knowledge and skills to self-manage their health independently. Healthcare professionals (HCP), parents and their wider network play an essential role in supporting AYA in this process. Previous work showed significant limitations in transition care across Europe. In 2020, the first evidence-based guideline on effective transition for AYA with asthma and allergies was published by EAACI.

AIM

We herein summarize practical resources to support this guideline's implementation in clinical practice.

METHODS

For this purpose, multi-stakeholder Task Force members searched for resources in peer review journals and grey literature. These resources were included if relevant and of good quality and were pragmatically rated for their evidence-basis and user friendliness.

RESULTS

Resources identified covered a range of topics and targeted healthcare professionals, AYA, parents/carers, schools, workplace and wider community. Most resources were in English, web-based and had limited evidence-basis.

CONCLUSIONS

This position paper provides a valuable selection of practical resources for all stakeholders to support effective transitional care for AYA with asthma and allergies. Future research should focus on developing validated, patient-centred tools to further assist evidence-based transition care.

Psychological Considerations for Food Intolerances: Celiac Sprue, Eosinophilic Esophagitis, and Non-Celiac Gluten Sensitivity

Several chronic digestive conditions are physiologically based on food intolerance, including celiac disease, nonceliac gluten sensitivity, and eosinophilic esophagitis. Patients are expected to follow medically prescribed diets to eliminate identified food triggers to control symptoms. However, the psychological impacts of these dietary approaches are largely unaddressed in clinical practice. Hypervigilance and anxiety regarding food and symptoms, and disordered eating, may emerge and negatively affect outcomes. Clinicians working with pediatric and adult populations with food intolerances should be aware of these psychological comorbidities, and equally emphasize effective ways to help patients manage the mental and physical aspects of their condition.

Food Allergies in Inner-City Schools: Addressing Disparities and Improving Management

OBJECTIVE

Food allergy (FA) affects approximately 8% of children in the United States. Management comprises both preventing and treating allergic reactions, which poses unique challenges in the inner-city school setting. In this article, we review the epidemiology of FA in school-aged children and management challenges and opportunities specific to the inner-city population.

DATA SOURCES

A literature search of the PubMed database was performed to identify published literature on FA epidemiology, FA management, school policies, disparities, inner-city, race, ethnicity, and socioeconomic status.

STUDY SELECTIONS

Relevant articles on FA management best practices and challenges in schools, with a particular emphasis on inner-city schools and populations and socioeconomic, racial, and ethnic disparities, were reviewed in detail.

RESULTS

Disparities in FA prevalence, management, and treatment exist. Additional research is needed to better characterize these disparities and elucidate the mechanisms leading to them. There is a lack of evidence-based interventions for the prevention and treatment of food allergic reactions in schools and specifically in inner-city schools, in which a greater proportion of students may rely on school food.

CONCLUSION

There are opportunities for partnership among health care providers, schools, and communities to address unmet needs in FA management and disparities in the inner-city school setting.