Feeding disorders in food allergic children

Nutritional and Psychosocial Impact of Food Allergy in Pediatric Age

Treatment of IgE-mediated food allergy involves avoiding the food causing the allergic reaction. In association, an action plan for allergic reactions is indicated, sometimes including self-injectable adrenaline. In addition to these dietary and medical implications, there are two equally important ones: nutritional and psychosocial. From a nutritional point of view, it is known that children suffering from food allergy have a growth delay in height and weight compared to their non-allergic peers. Specifically, this condition is directly related to the specific food excluded from the diet, the number of foods excluded and the duration of the elimination diet. From a psychosocial point of view, the child often cannot eat the foods other guests eat. Children with food allergy may perceive an aura of parental anxiety around their mealtime and may be afraid that what they eat could have harmful consequences for their health. Furthermore, children's and their parents' quality of life appears to be affected. The need to manage the allergy and the nutritional and psychosocial problems positions the pediatric nutritionist and the child neuropsychiatrist as support figures for the pediatric allergist in managing the child with food allergy.

Feeding Characteristics in Children With Food Allergies: A Scoping Review

BACKGROUND

Food allergy (FA) affects approximately 8% of children and may be immunoglobulin E (IgE)-mediated or non-IgE-mediated. It is recognized clinically that children with both subtypes of FA may present with features of pediatric feeding disorder (PFD); however, there is currently a limited detail of presenting characteristics.

OBJECTIVE

The objective of this study was to synthesize the current evidence regarding the feeding characteristics of children with FA, with a focus on the feeding skills and psychosocial domains of PFD.

METHOD

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Papers published between 2001 and 2022 describing feeding characteristics in the feeding skills and psychosocial domains in children with FA/history of FA were included. Papers that focused solely on characteristics from the medical or nutritional domains were excluded. Descriptive information regarding demographics, methodology, allergy profile and history, and the characteristics of PFD observed was extracted using a preconceived data extraction form.

RESULTS

Overall, 40 papers contained descriptions of feeding characteristics of children with non-IgE-mediated FA (n = 22) and IgE-mediated FA (n = 11), while four were nonspecific. In the psychosocial domain, food refusal/aversion, anxiety with eating, and poor intake were the most frequently reported, regardless of FA subtype. Less information was reported regarding feeding skills, although slowness in eating, immature diet, and delays in oral sensory-motor skills were described.

CONCLUSIONS

Children with FA/history of FA may present with a range of characteristics that map across the feeding skill and psychosocial domains of PFD. Systematic research is needed to fully describe the feeding characteristics of children with FA.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24562732.

Factors Associated with Feeding Problems in Young Children with Gastrointestinal Diseases

Feeding problems are associated with the consumption of a limited amount or restricted variety of foods and often occur in children with gastrointestinal diseases. The majority of studies to date do not use valid and reliable measurements to detect feeding problems. The aim of this cross-sectional study was to assess behavioral and skill-based feeding problems in young children with gastrointestinal diseases by using a well-established parent-reported feeding measure and identify demographic, anthropometric, and environmental factors associated with maladaptive feeding behaviors in this pediatric population. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and self-reported questionnaires assessing mealtime environment and parental feeding practices. It was found that 18.6% of the sample had abnormal Total Frequency Score (TFS) (frequency of problematic feeding behaviors) and 39.5% had abnormal Total Problem Score (TPS) (number of behaviors perceived as problematic by parents). Younger children, with lower body mass index, lower birth weight, and only children were more likely to have feeding problems. The study showed that parent-reported feeding problems are increased in young children with gastrointestinal diseases and are associated with specific aspects of mealtime environment and parental feeding practices.

Effect of early childhood cow's milk elimination diet on eating behaviours, nutrition and growth status at age 2-6 years

BACKGROUND

The present study aimed to investigate the eating behaviour, nutritional status and growth of Caucasian children in ages 2-6 years who had a diet because of cow's milk protein allergy (CMA) [immunoglobulin (Ig)E-mediated and/or non-IgE-mediated] in early childhood.

METHODS

In this cross-sectional, case-control study, the cow's milk elimination (CME) group comprised children aged 0-2 years who were receiving a CME diet because of CMA, as confirmed by an oral food challenge test, and had reintroduced cow's milk for at least ≥ 3 months. The control group never had a restricted diet. Eating behaviour and children's growth was assessed. A 3-day food record was taken to determine the macronutrient and micronutrient intake of the children. Data on the children's socio-demographic, infant nutrition and family allergy history were collected from their medical records and face-to-face interviews with mothers.

RESULTS

In total, 62 children with a median age of 32 months were recruited for the study. The total scores of food avoidance and satiety responsiveness in the CME group (n:31) were higher than in the controls (n = 31) (p = 0.036 and 0.006, respectively). Weight-for-age and height-for-age are statistically lower in the CME group than in the control group (p < 0.001). A significant difference between groups in terms of dairy intake was recorded (p = 0.011). In the CME group, the current frequency of adequate energy, vitamin B1, folic acid, vitamin C and calcium intake was significantly lower than in the control group (p < 0.05).

CONCLUSIONS

Dietary interventions because of CMA at age 0-2 years can affect children's nutritional habits and parental-reported assessment of children's eating behaviours, resulting in growth restriction with insufficient micro/macronutrients and/or dairy products at the age of 2-6 years.

Strategy for Food Reintroduction Following Empiric Elimination and Elemental Dietary Therapy in the Treatment of Eosinophilic Gastrointestinal Disorders

PURPOSE OF REVIEW

This review presents the available data regarding efficacy of nutritional therapy, highlighting clinical decision points and a strategy for reintroduction of foods following an elemental diet for treatment of eosinophilic gastrointestinal disorders.

RECENT FINDINGS

Elemental and empiric elimination diets are highly effective treatments for eosinophilic gastrointestinal diseases. Standardization in the reintroduction phase, after utilizing the diet for disease remission, is lacking. Clinicians are confronted with multiple challenges regarding the best practice for food reintroduction and identification of potential dietary triggers including order of foods being challenged and duration between endoscopic procedures. Individualization is required for preference and adherence to optimize quality of life and treatment success for this burdensome and life altering immune driven gastrointestinal disorder. Age specific concerns for children, teenagers, and adults should be assessed using a patient centric approach.

Children with diseases of the upper gastrointestinal tract are more likely to develop feeding problems

Feeding problems may give rise to a number of adverse effects with organic, psychological, developmental and social impact. Specific medical conditions, especially diseases of the gastrointestinal system, are known to be associated with feeding problems. We searched databases, including MEDLINE and the Cochrane Library, for papers published in English from 1990 to March 2018. Keywords included "gastrointestinal diseases", "gastroesophageal reflux disease", "eosinophilic esophagitis", "food allergy", "children", "infants", and "feeding problems". We concluded that children with diseases of the upper gastrointestinal tract, especially those with gastroesophageal reflux disease and eosinophilic esophagitis, are more likely to develop feeding problems. However, further epidemiological studies are needed to determine the prevalence and the specific characteristics of feeding problems in children with certain upper gastrointestinal diseases, as well as the exact causal relationship between them.

Growth of Children with Food Allergy

BACKGROUND

The prevalence of food allergy in children is increasing worldwide. Strict avoidance of identified allergens from the diet is still the cornerstone of the management of food allergies. There are widespread concerns that food allergy and elimination diet may predispose children to nutrient deficiencies and growth failure.

AIM

The aim of this paper was to review the current evidence on growth of children suffering from food allergy. Summarised is literature on the effects of the number and type of offending allergens, the child's age and affected organ system, as well as the importance of supervision by a dietician/nutritionist.

CONCLUSION

Children suffering from food allergy are stunted at the time of diagnosis and during the elimination diets, irrespective whether or not their nutritional requirements were fulfilled, and/or were under the control of a dietician. This underscores the need for further studies to obtain more precise insight into and better understanding of the mechanisms contributing to growth failure in children suffering from food allergy.
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Feeding Disorders

Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders.

Crowdsourced Identification of Possible Allergy-Associated Factors: Automated Hypothesis Generation and Validation Using Crowdsourcing Services

Background

Hypothesis generation is an essential task for clinical research, and it can require years of research experience to formulate a meaningful hypothesis. Recent studies have endeavored to apply crowdsourcing to generate novel hypotheses for research. In this study, we apply crowdsourcing to explore previously unknown allergy-associated factors.

Objective

In this study, we aimed to collect and test hypotheses of unknown allergy-associated factors using a crowdsourcing service.

Methods

Using a series of questionnaires, we asked crowdsourcing participants to provide hypotheses on associated factors for seven different allergies, and validated the candidate hypotheses with odds ratios calculated for each associated factor. We repeated this abductive validation process to identify a set of reliable hypotheses.

Results

We obtained two primary findings: (1) crowdsourcing showed that 8 of the 13 known hypothesized allergy risks were statically significant; and (2) among the total of 157 hypotheses generated by the crowdsourcing service, 75 hypotheses were statistically significant allergy-associated factors, comprising the 8 known risks and 53 previously unknown allergy-associated factors. These findings suggest that there are still many topics to be examined in future allergy studies.

Conclusions

Crowdsourcing generated new hypotheses on allergy-associated factors. In the near future, clinical trials should be conducted to validate the hypotheses generated in this study.

Assessment of children's nutritional attitudes before oral food challenges to identify patients at risk of food reintroduction failure: a prospective study

BACKGROUND

Inappropriate dietary eliminations may impair quality of life, affect children's growth and unnecessarily impact on healthcare costs. Previous retrospective studies reported that around 25% of children continue a food-avoidance diet despite a negative oral food challenge (OFC). A definite pattern has not been found yet for patients not reintroducing the food. This study aimed to examine the role of child's nutritional attitudes and maternal anxiety in reintroducing food after a negative OFC.

METHODS

A prospective study was conducted involving 81 mothers of children with IgE-mediated food allergy. They completed a survey on nutritional behaviour and attitudes and the State-Trait Anxiety Inventory on the day of OFC and 6 months later.

RESULTS

In total, 11.1% of children never or rarely ate the food after a negative OFC. Consumption of the reintroduced food is positively correlated to child's interest in tasting new foods before and after OFC and to changes in child's nutritional habits after OFC. It is negatively correlated to monotony of the diet after OFC. No correlations were found with other participants' characteristics or maternal anxiety. State anxiety significantly decreased after the OFC. A correlation was found between trait and state anxiety and the degree of change in nutritional habits after OFC.

CONCLUSIONS

Evaluating child's approach towards food before the OFC is a promising approach to identify patients at risk of food reintroduction failure. Furthermore, it underlined the importance of reassessing food consumption in all patients after a negative OFC and supporting patients in the reintroduction of food.

Mealtime behavior among parents and their young children with food allergy

BACKGROUND

Food allergies are increasingly prevalent in the pediatric population. Balancing allergen avoidance with the promotion of healthy eating behaviors can be challenging for families.

OBJECTIVE

To characterize mealtime behaviors among parents of young children with food allergy.

METHODS

Seventy-four parents of young children with food allergies (≤7 years of age) completed measures of mealtime behavior, perceptions of food allergy risk and severity, pediatric parenting stress, and food allergy-related quality of life. Mealtime behavior reports were compared with published data regarding typically developing children, young children with type 1 diabetes, and children with diagnosed feeding disorders (with or without related medical factors).

RESULTS

Parents of young children with food allergies reported frequent mealtime concerns. Specifically, they reported significantly more mealtime behavioral concerns than typically developing peers, comparable mealtime behavioral concerns to young children with type 1 diabetes, and significantly fewer mealtime behavioral concerns than children with diagnosed feeding disorders. Parental mealtime concerns were positively correlated with other parent perceptions of food allergy, such as risk of allergen exposure, illness-related parenting stress, and food allergy-related quality of life.

CONCLUSION

Young children with food allergy and their parents are more likely to exhibit mealtime behavioral concerns than typically developing peers and their parents. Future research should investigate the effect of food allergies and maladaptive mealtime behaviors on children's nutrition to provide clinical guidelines for parents who may benefit from psychosocial and/or nutritional support.

Food avoidance and restriction in adults: a cross-sectional pilot study comparing patients from an immunology clinic to a general practice

BACKGROUND

With the introduction of avoidant/restrictive food intake disorder (ARFID) in the Diagnostic and Statistical Manual - fifth edition, there is an increased need to understand the prevalence and pattern of food avoidance and restriction in adults. High rates of food allergy and intolerance in immunology clinic populations, and subsequent high rates of elimination diets, place these individuals at a greater risk of developing pathological eating behaviours. This descriptive cross sectional pilot study aims to provide preliminary data on the prevalence and nature of food avoidance and restriction in an adult population, and to explore the reasons for this behaviour.

METHOD

A self-administered questionnaire was designed and distributed to adults presenting to an immunology clinic and a general practice over the course of 6 months to describe the prevalence and nature of avoidant and restrictive eating behaviours in this population. Pearson's chi square test was used to examine the strength of a potential link to a formal diagnosis of avoidant restrictive food intake disorder in these patients.

RESULTS

A total of 102 completed questionnaires were used for data analysis. Food avoidance or restriction was detected in 81 respondents (79%), with rates not significantly higher in the immunology clinic group compared to the general practice group (p = .242). Food allergy and intolerance were the most common reasons for disturbed eating patterns. Life impact secondary to food avoidance and restriction was reported by 26% of respondents, with significantly higher rates observed in the immunology clinic cohort compared to the general practice (p = .011).

CONCLUSIONS

Eating disturbances similar to those characteristic of ARFID are very common in adults. Food avoidance and restriction due to perceived food allergy and intolerance are significant reasons for such disordered eating patterns, particularly in an immunology clinic population. Further investigation is needed to determine if such eating behaviours are pathological and whether they qualify for a diagnosis of ARFID.

Fussy eating and feeding difficulties in infants and toddlers consuming a cows' milk exclusion diet

BACKGROUND

Cows' milk allergy (CMA) is the most common infant food allergy in the United Kingdom, requiring a strict exclusion diet. Feeding difficulties and fussy eating are also very common problems in young children and can negatively influence feeding and dietary intake in an infant with CMA. The aim of this study was to compare the levels of fussy eating and feeding difficulties in two groups of young children: a group consuming an exclusion diet for CMA and a control group of children consuming an unrestricted diet.

METHOD

Participants were recruited from allergy and health visitor clinics on the Isle of Wight. Parents completed a number of questionnaires about their child's feeding behaviour.

RESULTS

One hundred and twenty-six participants (mean age 13 months) were recruited. Participants consuming an exclusion diet for CMA had significantly higher scores for both fussy eating and feeding difficulties (p < 0.05), although overall both groups were within the normal range. A number of symptoms were found to be positively moderately correlated with higher feeding difficulty score (p < 0.05). A higher consumption of milk/milk substitute consumed per day was positively correlated to both feeding difficulties and fussy eating (p < 0.05).

CONCLUSION

Participants consuming an exclusion diet for CMA have higher scores for feeding difficulties and fussy eating than those consuming an unrestricted diet; however, the majority of participants' scores were within the normal range and did not affect the growth.

Monitoring the impact of cow's milk allergy on children and their families with the FLIP questionnaire--a six-month follow-up study

BACKGROUND

Many children with cow's milk allergy (CMA) develop tolerance, but, challenges in daily life may remain. Using the Food hypersensitivity famiLy ImPact questionnaire (FLIP), we sought to monitor changes in the impact of CMA over time.

METHODS

Families of children with CMA, who participated in the validation of the FLIP, were re-approached 6 months later for follow-up. Change in reported difficulties was assessed by paired sample t-test and mixed models, stratifying by outgrown vs. persistent CMA.

RESULTS

Impact on families with children who had outgrown CMA (n = 20) decreased in the FLIP's total score (p = 0.0001) and in two subscales; Health and Emotions (p = 0.0001) and Everyday Life (p = 0.0001). In contrast, no significant improvements were registered in nutritional concerns. Impact on the group with persistent CMA (n = 57) was unchanged at follow-up except for more impact on Everyday Life (p = 0.001). In the final analysis comparing longitudinal changes in the groups, the strongest differences were observed for the subscales Health & Emotions and Everyday Life; for the Nutrition subscale, the between-group changes also differed, but to lesser extent.

CONCLUSIONS

We have documented the varying impact of CMA on parents and children over time. Families who were still affected continued to experience impact in daily life. Despite development of tolerance, families who were no longer affected revealed continuing nutritional concerns. Follow-ups should be offered even after outgrown CMA to encourage progression to unrestricted diet, to prevent eating disorders and to promote healthy growth.