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Warren CM, Bartell TR. Sociodemographic inequities in food allergy: Insights on food allergy from birth cohorts. Pediatr Allergy Immunol 2024; 35:e14125. [PMID: 38656700 DOI: 10.1111/pai.14125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024]
Abstract
A large and growing corpus of epidemiologic studies suggests that the population-level burden of pediatric FA is not equitably distributed across major sociodemographic groups, including race, ethnicity, household income, parental educational attainment, and sex. As is the case for more extensively studied allergic disease states such as asthma and atopic dermatitis epidemiologic data suggest that FA may be more prevalent among certain populations experiencing lower socioeconomic status (SES), particularly those with specific racial and ethnic minority backgrounds living in highly urbanized regions. Emerging data also indicate that these patients may also experience more severe FA-related physical health, psychosocial, and economic outcomes relating to chronic disease management. However, many studies that have identified sociodemographic inequities in FA burden are limited by cross-sectional designs that are subject to numerous biases. Compared with cross-sectional study designs or cohorts established later in life, birth cohorts offer advantages relative to other study designs when investigators seek to understand causal relationships between exposures occurring during the prenatal or postnatal period and the atopic disease status of individuals later in life. Numerous birth cohorts have been established across recent decades, which include evaluation of food allergy-related outcomes, and a subset of these also have measured sociodemographic variables that, together, have the potential to shed light on the existence and possible etiology of sociodemographic inequities in food allergy. This manuscript reports the findings of a comprehensive survey of the current state of this birth cohort literature and draws insights into what is currently known, and what further information can potentially be gleaned from thoughtful examination and further follow-up of ongoing birth cohorts across the globe.
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Affiliation(s)
- Christopher M Warren
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tami R Bartell
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Patrick M. Magoon Institute for Healthy Communities, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Bartha I, Almulhem N, Santos AF. Feast for thought: A comprehensive review of food allergy 2021-2023. J Allergy Clin Immunol 2024; 153:576-594. [PMID: 38101757 PMCID: PMC11096837 DOI: 10.1016/j.jaci.2023.11.918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
A review of the latest publications in food allergy over the past couple of years confirmed that food allergy is a major public health concern, affecting about 8% of children and 10% of adults in developed countries. The prevalence of food allergy varies around the world, with the increase being driven mainly by environmental factors, possibly together with genetic susceptibility to environmental changes. A precise diagnosis of food allergy is extremely important. Both new tests (eg, the basophil activation test) and improved optimization of information provided by existing tests (eg, the skin prick test and measurement of specific IgE level) can contribute to improving the accuracy and patients' comfort of food allergy diagnosis. Understanding the underlying immune mechanisms is fundamental to designing allergen-specific treatments that can be safe and effective in the long term. New discoveries of the immune response to food allergens, including T-cell and B-cell responses, have emerged. Novel therapeutic approaches are being trialed at various stages of development as attempts to allow for more active intervention to treat food allergy. Prevention is key to reducing the increase in prevalence. Early introduction of allergenic foods seems to be the most effective intervention, but others are being studied, and will, it is hoped, lead to modification of the epidemiologic trajectory of food allergy over time.
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Affiliation(s)
- Irene Bartha
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences King's College London, London, United Kingdom
| | - Noorah Almulhem
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Otolaryngology Head and Neck Surgery, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alexandra F Santos
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, School of Immunology and Microbial Sciences King's College London, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences King's College London, London, United Kingdom.
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Warren CM, Sehgal S, Sicherer SH, Gupta RS. Epidemiology and the Growing Epidemic of Food Allergy in Children and Adults Across the Globe. Curr Allergy Asthma Rep 2024; 24:95-106. [PMID: 38214821 DOI: 10.1007/s11882-023-01120-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Food allergies are immune-mediated, complex disorders, which are the source of increasing health concern worldwide. The goal of this review is to present an updated summary of the food allergy (FA) burden among children and adults across different populations, focusing on research from the past 5 years. RECENT FINDINGS FAs impact a growing number of global residents-particularly those residing in higher-income, industrialized regions. Moreover, growing epidemiologic evidence suggests that the population health burden of non-IgE-mediated FAs, such as food protein-induced enterocolitis syndrome, may also be higher than previously reported. FA is a complex trait that impacts infants, children, as well as adults across the globe. The population health burden of both IgE- and non-IgE-mediated FAs is likely to grow in the absence of rapid advances and widespread implementation of effective FA prevention and treatment interventions. Systematic epidemiological research initiatives are needed, both nationally and globally, to better understand and reduce the burden of these allergic diseases.
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Affiliation(s)
- Christopher M Warren
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Shruti Sehgal
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Ruchi S Gupta
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Prodinger C, Yerlett N, MacDonald C, Chottianchaiwat S, Goh L, Du Toit G, Mellerio JE, Petrof G, Martinez AE. Prevalence of and risk factors for nutritional deficiency and food allergy in a cohort of 21 patients with Netherton syndrome. Pediatr Allergy Immunol 2023; 34:e13914. [PMID: 36705039 DOI: 10.1111/pai.13914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/16/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Netherton syndrome (NS; OMIM: 256500) is a rare autosomal recessively inherited disease due to SPINK5 mutations. Hair and inflammatory skin involvement are variable along with allergies. Morbidity and mortality are high, particularly in infancy. A detailed clinical analysis of a NS patient cohort should broaden the understanding of nutritional challenges and allergic comorbidities. METHODS In this retrospective monocentric cohort study, medical and dietetic records of pediatric NS patients, presenting between 1999 and 2018, were reviewed. The severity of skin involvement was assessed according to the extent of the body surface area (BSA) affected by erythema. RESULTS We identified 21 patients with NS (median age 11.6 years). Within the first 6 months of life, requirements for fluid and kcals/protein were high for all patients (average 228 ml/kg/day) and infants had an average of 1.9 feed changes (range 0-4) due to food intolerance. Clinical evidence for IgE-mediated food allergy was present in 84.2% (16/19 children, 2 no data) with a range of 1-12 food allergies per patient. In 75%, more than one food had to be avoided. Specific IgE levels were falsely positive in 38.3% and 8/18 patients (44.4%). One-third (5/15; 6 no data) of patients, all with severe disease, had anaphylactic reactions following ingestion of fish (n = 2), sesame (n = 1), cow's milk (n = 1), and both peanut and egg (n = 1). CONCLUSIONS Our data emphasize feeding difficulties in children with NS and reveal an unexpectedly higher prevalence of food allergies that gives evidence to the importance of early coordinated multidisciplinary care for overcoming these challenges in NS.
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Affiliation(s)
- Christine Prodinger
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Natalie Yerlett
- Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Cassie MacDonald
- Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Leanne Goh
- Pediatric Allergy Clinic, University College London Hospital, London, UK
| | - George Du Toit
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Jemima E Mellerio
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gabriela Petrof
- Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anna E Martinez
- Department of Dermatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Jonsson M, Ekström S, Protudjer JLP, Bergström A, Kull I. Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort. Nutrients 2021; 13:nu13072357. [PMID: 34371866 PMCID: PMC8308910 DOI: 10.3390/nu13072357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 01/01/2023] Open
Abstract
Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.
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Affiliation(s)
- Marina Jonsson
- Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden; (S.E.); (A.B.)
- Centre for Occupational and Environmental Medicine, Region Stockholm, Solnavägen 4, 113 65 Stockholm, Sweden
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden;
- Correspondence:
| | - Sandra Ekström
- Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden; (S.E.); (A.B.)
- Centre for Occupational and Environmental Medicine, Region Stockholm, Solnavägen 4, 113 65 Stockholm, Sweden
| | - Jennifer L. P. Protudjer
- Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1S1, Canada;
- George and Fay Yee Centre for Healthcare Innovation, Winnipeg, MB R3E 0T6, Canada
- The Children’s Hospital Research Institute of Manitoba, Winnipeg, MB R3E 3P4, Canada
- The Centre for Allergy Research, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Anna Bergström
- Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden; (S.E.); (A.B.)
- Centre for Occupational and Environmental Medicine, Region Stockholm, Solnavägen 4, 113 65 Stockholm, Sweden
| | - Inger Kull
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 118 83 Stockholm, Sweden;
- Sachs’ Children and Youth Hospital, 118 83 Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW Food allergy remains a disease of global public health significance well known to impact social, emotional, and financial well being. This review aims to summarize the existing literature focused on the direct, indirect, and intangible costs of food allergy at the household and healthcare system levels, and begin to discuss how emerging treatment and prevention strategies may be leveraged to comprehensively care for the food allergic population with the efficient use of health resources. RECENT FINDINGS Food allergy imposes significant costs to multiple stakeholders and largely impact families at the household level. Recent studies elucidate the need to balance the household management of food allergy with the efficient use of health resources. Overall, it remains critical that safe foods and medications remain affordable while further exploring the cost-effectiveness of early introduction, emerging food allergy therapies, and the wider use of stock epinephrine to adequately meet the public health needs of the food-allergic community. SUMMARY Better understanding how the cost of food allergy impacts populations will help to inform more progressive policies aimed at lessening socioeconomic disparities and ultimately improve quality of life for children and adults with food allergies.
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Edvinsson Sollander S, Fabian H, Sarkadi A, Salari R, Fält E, Dahlberg A, Feldman I, Durbeej N. Asthma and allergies correlate with mental health problems in preschool children. Acta Paediatr 2021; 110:1601-1609. [PMID: 33284466 PMCID: PMC8247343 DOI: 10.1111/apa.15709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022]
Abstract
AIM To explore the relations between asthma, allergies and mental health problems in preschool children, aged 3-5 years. METHODS In this cross-sectional Swedish study, we used data on 4649 children in Uppsala municipality whose parents and preschool teachers had responded to questions measuring asthma and allergies, and the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health problems. Logistic regression models were used to explore the relations between asthma and allergies and mental health problems. RESULTS Children with asthma (8.5%) had elevated odds of having emotional symptoms as rated by parents (OR: 1.34; 1.02-1.76) and teachers (OR: 1.44; 1.09-1.91). According to parents' ratings, these children also had elevated odds of showing mental health problems in general according to the SDQ total score (OR: 1.42; 1.05-1.94). Children with food allergies or intolerance (4.4%) only had elevated odds of having emotional symptoms (OR: 1.64; 1.16-2.33), as reported by parents. These results remained significant after adjustment for parental background factors. CONCLUSION Preschool children with asthma and food allergies or intolerance are at risk of having concurrent mental health problems. Mental health problems should be assessed in children with these disorders. Adequate support and/or referral to specialised services should be offered when needed.
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Affiliation(s)
- Sofia Edvinsson Sollander
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Helena Fabian
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Anna Sarkadi
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Raziye Salari
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Elisabet Fält
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Anton Dahlberg
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Inna Feldman
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
| | - Natalie Durbeej
- Child Health and Parenting (CHAP) Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden
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Hurst K, Gerdts J, Simons E, Abrams EM, Protudjer JLP. Social and financial impacts of food allergy on the economically disadvantaged and advantaged families: A qualitative interview study. Ann Allergy Asthma Immunol 2021; 127:243-248. [PMID: 33894341 DOI: 10.1016/j.anai.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/28/2021] [Accepted: 04/16/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Differences in the qualitatively-perceived burden of food allergy based on economic disadvantages have not been previously described. OBJECTIVE To describe the perceptions of food allergy-related social and financial issues of families who have a child with food allergy, considering the similarities and differences between economically advantaged and disadvantaged families. METHODS From March to July 2019, we interviewed parents of children being followed up for food allergy at a tertiary allergy clinic in central Canada. Interviews were recorded, transcribed, and analyzed thematically. Economic groups were categorized on the basis of the national cutoffs for low-income after-tax dollars. RESULTS We interviewed 18 parents (17 [94.4% mothers]) of whom 6 (33.3%) were economically disadvantaged, and who represented 25 children (10 [40.0%] girls) with food allergy. We identified 3 common themes: food allergy had (1) resulted in the need to teach others in addition to contributing to tensions in relationships; (2) increased time costs for food shopping and preparation; and (3) contributed to concerns securing qualified child care. We also identified 2 divergent themes that underscored how this burden was perceived between economic groups: (1) medications and medical appointments are costly or inconvenient; and (2) allergy-friendly food choices: single vs several sources and servings. CONCLUSION Despite some qualitative similarities in the social and financial burdens of food allergy, there are some notable differences between economic groups that underscore the need for further discussions surrounding the related policy.
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Affiliation(s)
- Kim Hurst
- Queen's University, Kingston, Canada
| | | | - Elinor Simons
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Elissa M Abrams
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada; Section of Allergy, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jennifer L P Protudjer
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada; Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.
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Kawada S, Futamura M, Hashimoto H, Ono M, Akita N, Sekimizu M, Hattori H, Goto M, Horibe K, Maeda N. Association between sites and severity of eczema and the onset of cow's milk and egg allergy in children. PLoS One 2020; 15:e0240980. [PMID: 33075082 PMCID: PMC7571679 DOI: 10.1371/journal.pone.0240980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background Cow’s milk allergy (CMA) and egg allergy (EA) are common and can reduce quality of life in children. Infantile eczema is a well-established risk factor for the onset of food allergy via transdermal sensitization; however, various types of infantile eczema have not yet been evaluated. Therefore, we assessed the association between CMA and EA and the sites and the severity of infantile eczema. Methods This retrospective study was based on data from patients aged 2–19 years with atopic disease who were treated between July 2015 and March 2019 in a pediatric allergy clinic in Japan. Data regarding the history of IgE-mediated symptoms, eczema in the first year of life, parental history of atopic diseases, and infantile nutrition were collected. Results A total of 289 patients were included in the study, of which 81 and 111 children had IgE-mediated CMA and EA, respectively. The rates of CMA and EA were higher in the children with infantile eczema than in those without (30% vs. 9% and 42% vs. 21%). The rate of CMA was also higher in children with eczema on the face. Significant differences were noted in the rate of CMA among children with facial eczema of exudation (adjusted odds ratio 2.398; P = 0.017) and papules (adjusted odds ratio 2.787; P = 0.008), using multivariate analysis. Conclusion The rate of IgE-mediated CMA was high among children with atopic disease having severe facial eczema during infancy.
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Affiliation(s)
- Shiori Kawada
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masaki Futamura
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- * E-mail:
| | - Hiroya Hashimoto
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Manabu Ono
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Nobuhiro Akita
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masahiro Sekimizu
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroyoshi Hattori
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Masahiko Goto
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Keizo Horibe
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naoko Maeda
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Abstract
PURPOSE OF REVIEW In recent decades, food allergy has become an increasing concern for families, clinicians, and policymakers. This review aims to summarize what is currently known about the epidemiology and population-level burden of IgE-mediated food allergy, including its effects on quality of life. RECENT FINDINGS Prevalence surveys, healthcare utilization data, and findings from longitudinal cohort studies across the globe indicate that food allergy imposes a growing societal burden. Worryingly, recent data indicate that food allergies may be more prevalent among adult populations than previously acknowledged, with many reported cases of adult-onset allergies. While it remains unclear how much of the current population-level burden of disease results from true, IgE-mediated allergy, as much epidemiological data does not incorporate clinical confirmation of disease prevalence-it is clear that affected individuals suffer impairments in their quality of life and incur substantial economic costs-beyond the physical health burden imposed by anaphylaxis.
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Affiliation(s)
- Christopher M Warren
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 60611, USA.,Sean N. Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, California, USA
| | - Jialing Jiang
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 60611, USA
| | - Ruchi S Gupta
- Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, 60611, USA. .,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
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11
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Höglund P. Immunotherapy of food allergy: Are combinations the way forward? Scand J Immunol 2019; 91:e12859. [PMID: 31884730 DOI: 10.1111/sji.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Calcium Intake in Children with Eczema and/or Food Allergy: A Prospective Cohort Study. Nutrients 2019; 11:nu11123039. [PMID: 31842448 PMCID: PMC6950300 DOI: 10.3390/nu11123039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 01/24/2023] Open
Abstract
Eczema and food allergy may impact diet. Using data from a cohort of Manitoba children born in 1995, we examined calcium intake, defined as the frequency and quality of calcium products consumed (with the exception of cheese), amongst Manitoba adolescents (12-14 years) with eczema or food allergy in childhood (7-8 years) or adolescence. At both ages, children were assessed by a physician for eczema and food allergy. Adolescents completed food frequency questionnaires. Calcium intake was defined as 1+ vs. <1 weekly. Linear and logistic regression was used as appropriate, with adjustments for confounders. Overall, 468 adolescents were included, of whom 62 (13.3%) had eczema only in childhood, 25 (5.3%) had food allergy only, and 26 (5.6%) had eczema and food allergy. Compared to children without eczema, those with eczema only had poorer calcium intake in adolescence (β -0.44; 95%CI -0.96; 0.00). Girls, but not boys, with eczema in childhood had poorer calcium intake in adolescence than girls without eczema (β -0.84; 95%CI -1.60; -0.08). These patterns persisted even if children experienced transient vs. persistent eczema to adolescence. Similar but non-significant trends were found for food allergy. Childhood eczema is associated with significantly lower calcium intake and consumption in adolescence. These differences persist to adolescence, even if a child "outgrows" their allergic condition.
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Wai HM, Middelveld R, Thörnqvist V, Ballardini N, Nilsson E, Strömquist J, Nilsson L, Ahlstedt S, Protudjer JLP. Pediatric food allergy-related household costs are influenced by age, but not disease severity. World Allergy Organ J 2019; 12:100061. [PMID: 31641409 PMCID: PMC6796906 DOI: 10.1016/j.waojou.2019.100061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/24/2019] [Accepted: 07/30/2019] [Indexed: 12/01/2022] Open
Abstract
Objective The economic burden of food allergy on households is poorly understood. We evaluated the household costs associated with specialist-diagnosed pediatric food allergy, with focus on age and disease severity. Study design A cross-sectional study of 70 Swedish case-control pairs (59% boys) was conducted using Food Allergy Economic questionnaire. Household costs were analyzed between age- and gender-matched cases (children aged 0–17 years, with specialist-diagnosed food allergy) and controls (non-food allergic households). Results Parents were predominantly university-educated and employed full-time. Most cases had parent-reported previous anaphylaxis. Mean total annual household costs were comparable between cases and controls. However, compared to controls, cases had significantly higher direct medical-, and non-medical related costs; higher indirect medical-related costs, and higher intangible costs (all p < 0.05). In a sensitivity analyses of only cases aged 0–12 years, direct household costs, including lost earnings due to child's hospitalization, were significantly higher than controls. Results from only children with severe disease paralleled those of all cases vs. controls. Conclusions Although pediatric food allergy is not associated with higher total annual household costs, these households have significantly higher direct medical-related, indirect and intangible costs vs. non-food allergic households. Higher household costs were identified amongst younger children, but not disease severity.
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Affiliation(s)
- Hay Mar Wai
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Health Economics, Policy and Management, Karolinska Institutet, Stockholm, Sweden
| | - Roelinde Middelveld
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Health Economics, Policy and Management, Karolinska Institutet, Stockholm, Sweden
| | - Victoria Thörnqvist
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Natalia Ballardini
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Lung Clinic, Södersjukhuset, Stockholm, Sweden
| | - Evalill Nilsson
- Institutionen för Medicin och Hälsa, Linköpings Universitetet, Linköping, Sweden
| | | | - Lennart Nilsson
- Pediatric Allergy, Linköpings Universitetet, Linköping, Sweden
| | - Staffan Ahlstedt
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Jennifer Lisa Penner Protudjer
- Institute for Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada.,George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
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14
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Protudjer JLP, Middelveld R, Dahlén SE, Ahlstedt S. Food allergy-related concerns during the transition to self-management. Allergy Asthma Clin Immunol 2019; 15:54. [PMID: 31507642 PMCID: PMC6727333 DOI: 10.1186/s13223-019-0370-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/28/2019] [Indexed: 01/02/2023] Open
Abstract
Background Compared to non-allergic individuals, food allergic individuals have impaired health-related quality of life (HRQL). However, effects of gender and age are unclear. The objective of our study was to describe associations between allergies to common foods and HRQL with consideration to gender and age. Methods Adolescents and adults (N = 137; 49.6% males) with specialist-diagnosed allergy to milk, egg and/or wheat completed age-appropriate versions of the Food Allergy Quality of Life Questionnaire (FAQLQ). We pooled common questions and calculated overall- and domain-specific HRQL in association with number and severity of symptoms and time elapse since worst reaction. Results In the entire study population, HRQL was not affected by gender or age, whereas gender-specific age categories affected HRQL among males only. For example, males 18–39 years had worse overall- (β = 0.77; 95% CI 0.08–1.45) and domain-specific HRQL vs. males < 18 years. Among participants with 1–3 food allergy symptoms, no associations were found. Among participants with 4–6 symptoms, the domain allergen avoidance and dietary restrictions was worse among older participants (e.g. 40+ years: β = 0.71; 95% CI 0.05–1.37 vs. < 18 years), and males 18–39 vs. < 18 years. Among participants with severe symptoms, females vs. males, and participants 18–39 vs. < 18 years had worse HRQL. At least 4 years since worst reaction was associated with worse HRQL for participants 40+ years vs. < 18 years, and older males vs. males < 18 years. Nearly all differences exceeded the clinical relevance threshold of ≥ 0.5. Conclusions Associations between allergies to common foods and HRQL are affected by gender and age. Most affected are males 18–39 years. Among females, HRQL is more stable across age groups.
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Affiliation(s)
- Jennifer Lisa Penner Protudjer
- 1Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,2Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada.,George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada.,4The Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Roelinde Middelveld
- 1Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,5The Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Sven-Erik Dahlén
- 1Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,5The Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Ahlstedt
- 1Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,5The Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
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15
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Protudjer JLP, Middelveld R, Ballardini N, Wai HM, Ahlstedt S, Nilsson L, Kivistö JE. Epinephrine dispensings, allergy hospitalizations and the elimination of co-payments in Sweden. Allergy 2019; 74:1197-1200. [PMID: 30697761 DOI: 10.1111/all.13733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer L. P. Protudjer
- Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
- Centre for Allergy Research; Karolinska Institutet; Stockholm Sweden
- Department of Pediatrics and Child Health; University of Manitoba; Winnipeg Canada
- George and Fay Yee Centre for Healthcare Innovation; Winnipeg Canada
- The Children's Hospital Research Institute of Manitoba; Winnipeg Canada
| | - Roelinde Middelveld
- Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
- Centre for Allergy Research; Karolinska Institutet; Stockholm Sweden
| | - Natalia Ballardini
- Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
- Sachs’ Children and Youth Hospital; Södersjukhuset; Stockholm Sweden
- St John's Institute of Dermatology; King's College London; London UK
| | - Hay Mar Wai
- Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
- Health Economics, Policy and Management; Karolinska Institutet; Stockholm Sweden
| | - Staffan Ahlstedt
- Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
- Centre for Allergy Research; Karolinska Institutet; Stockholm Sweden
| | - Lennart Nilsson
- Paediatric Allergy; Linköpings Universitetet; Linköping Sweden
| | - Juho E. Kivistö
- Allergy Centre; Tampere University Hospital; Tampere Finland
- Tampere Centre for Child Health Research; University of Tampere; Tampere University Hospital; Tampere Finland
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16
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Bilaver LA, Chadha AS, Doshi P, O'Dwyer L, Gupta RS. Economic burden of food allergy: A systematic review. Ann Allergy Asthma Immunol 2019; 122:373-380.e1. [PMID: 30703439 DOI: 10.1016/j.anai.2019.01.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/11/2019] [Accepted: 01/11/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the economic burden of food allergy (FA) worldwide. DATA SOURCES PubMed MEDLINE, Embase, and Cochrane Central Register of Controlled Trials on the Wiley platform were searched to identify literature that assessed direct, out-of-pocket, and opportunity costs of FA. All databases were searched back to their inception, and no language or date limits were applied. STUDY SELECTIONS We included primary studies that examined direct medical, out-of-pocket, or opportunity costs and/or lost labor productivity in food allergic adults and/or children and their families. RESULTS Eleven papers met our inclusion criteria, of which ed7 addressed direct medical, 7 addressed out-of-pocket, and 5 addressed opportunity costs. Estimates were based on data that reflected costs for a patient with FA (individual level) or costs for a household with a food allergic patient (household level). The mean individual-level direct medical costs ($2081) were much higher than the mean household-level costs ($806). The mean individual-level out-of-pocket ($1874) and opportunity ($1038) and opportunity cost were lower than the mean household-level out-of-pocket ($3339) and opportunity ($4881) costs. Household-level estimates of lost opportunity costs imposed the largest economic burden attributable to FA. CONCLUSION Most of the economic burden studies reviewed measured components of economic burden that are unique to individuals with FA but did so in noncomparable ways. Addressing cost burdens and measuring them using standardized instruments and methods will be critical to better understand the economic burden of FA globally.
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Affiliation(s)
- Lucy A Bilaver
- Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Avneet S Chadha
- Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Priyam Doshi
- Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Linda O'Dwyer
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ruchi S Gupta
- Center for Community Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois.
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17
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Fyhrquist N, Werfel T, Bilò MB, Mülleneisen N, Gerth van Wijk R. The roadmap for the Allergology specialty and allergy care in Europe and adjacent countries. An EAACI position paper. Clin Transl Allergy 2019; 9:3. [PMID: 30697418 PMCID: PMC6345018 DOI: 10.1186/s13601-019-0245-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/04/2019] [Indexed: 01/27/2023] Open
Abstract
The high prevalence of allergic diseases warrants for sufficient health care provisions available to patients with allergic diseases. Allergy care should be delivered by well-trained specialists. However, the current status of allergy care is not well documented. For this reason a survey among European and a few non-European countries was launched by the National Allergy Society Committee from the European Academy of Allergy and Clinical Immunology and the Union Européenne des Médecins Spécialistes section and board of Allergology. The survey shows that in the vast majority of countries allergy care services are available. However, a substantial heterogeneity is reported regarding recognition of the full specialty, the number of practicing specialists or subspecialists, and training aspects. Growth but also decline of specialty and subspecialties is reported. In addition, the survey gives insight in strengths, weaknesses, opportunities and threats in this field. It appears that the recognition of the full specialty determines strength as well as weakness. Aging of specialists combined with a decline in the number of trainees form a major threat. Opportunities are seen in creating awareness for allergy, focus on attracting young physicians. The conclusion is that harmonization of allergy services across Europe is needed. Investment in young doctors, creating new opportunities and lobbying for the full specialty is required.
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Affiliation(s)
- N Fyhrquist
- 1Unit of Systems Toxicology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - T Werfel
- 2Department of Dermatology and Allergy, Hannover Medical University, Hannover, Germany
| | - M B Bilò
- 3Allergy Unit, Department of Internal Medicine, University Hospital Ospedali Riuniti, Ancona, Italy
| | | | - R Gerth van Wijk
- 5Section of Allergology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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18
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Growth Pattern, Resting Energy Expenditure, and Nutrient Intake of Children with Food Allergies. Nutrients 2019; 11:nu11020212. [PMID: 30678148 PMCID: PMC6412797 DOI: 10.3390/nu11020212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 01/27/2023] Open
Abstract
Growth impairment has been reported in children with food allergies (FA). However, the available data on the dietary intake of FA children are controversial, and no data are available on their resting energy expenditure (REE). The aim of this study was to test whether REE differs between FA and healthy children. In this study, 30 FA children were matched by sex and age, with 31 healthy controls using coarsened exact matching (CEM). Their REE was measured by indirect calorimetry (IC). Energy and macronutrient intake were evaluated using a three-day dietary record. Between-group comparisons were performed by robust median regression using CEM-related weights. The association of REE with allergies was also evaluated using robust median regression models. Anthropometric measurements, REE, and nutrient intake were similar in FA children and matched controls. Taking into account the association of REE with gender and age, a statistically significant but biologically negligible association was detected between median REE and allergy status (+9% in FA children). In conclusion, we did not find any biologically relevant difference in REE, anthropometry, and dietary intake in children with FA compared to healthy children.
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19
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Venkataraman D, Erlewyn-Lajeunesse M, Kurukulaaratchy RJ, Potter S, Roberts G, Matthews S, Arshad SH. Prevalence and longitudinal trends of food allergy during childhood and adolescence: Results of the Isle of Wight Birth Cohort study. Clin Exp Allergy 2018; 48:394-402. [PMID: 29315919 DOI: 10.1111/cea.13088] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 12/06/2017] [Accepted: 12/15/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prevalence and time trends of food allergy change during childhood depending on the age of the child and the type of food. OBJECTIVE To study prevalence and longitudinal trends in food allergy from birth to 18 years in an unselected birth cohort in the Isle of Wight. METHOD Information on food allergy was collected at ages 1, 2, 4, 10 and 18 years from the Isle of Wight Birth Cohort (n = 1456). Skin prick testing (SPT) was performed at the age of 1 and 2 years in symptomatic children. At 4, 10 and 18 years of age, participants were tested to a panel of food and aeroallergens. Food allergy was diagnosed based on the criteria: symptoms suggestive of a typical IgE-mediated reaction and reaction <4 hours following exposure to a known food allergen. McNemar's test was used to determine significance of changes in prevalence over time. RESULTS The prevalence of food allergy remained relatively constant in early childhood (5.3%, 4.4% and 5.0% at 1, 2 and 4 years, respectively), with significant decline at 10 years (2.3%, P < .001 vs 4 years) followed by significant rise at 18 years (4%, P = .02 vs 10 years). Cow's milk (1.6%-3.5%) and egg (1.1%-1.4%) were the most common allergens in the first 10 years with peanut (1%) and tree nuts (0.5%) becoming more prevalent beyond 10 years. Fruit and wheat allergy were less common at 10 years, and shellfish and kiwi emerged during adolescence. The prevalence of food allergy plus positive SPT was 1.3%, 0.8%, 0.8%, 0.9% and 2.2% at 1, 2, 4, 10 and 18 years, respectively. CONCLUSION Food allergy is highly prevalent in infancy with partial resolution during late childhood. However, a number of children acquire new food allergy during adolescence resulting in a relatively higher prevalence at 18 years.
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Affiliation(s)
- D Venkataraman
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - M Erlewyn-Lajeunesse
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - R J Kurukulaaratchy
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
| | - S Potter
- The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
| | - G Roberts
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
| | - S Matthews
- The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
| | - S H Arshad
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
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20
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Peura S, Fall T, Almqvist C, Andolf E, Hedman A, Pershagen G, Helmersson-Karlqvist J, Larsson A. Normal values for calprotectin in stool samples of infants from the population-based longitudinal born into life study. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:120-124. [DOI: 10.1080/00365513.2017.1420216] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Sari Peura
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
- Department of Forest Mycology and Plant Pathology, Science for Life Laboratories, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Tove Fall
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Unit of Paediatric Allergy and Pulmonology at Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ellika Andolf
- Department of Clinical Sciences, Division of Obstetrics and Gynaecology, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Anna Hedman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Göran Pershagen
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
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