Longitudinal evaluation of food allergy-related bullying

Food Allergy

Food allergy is a growing health problem affecting both pediatric and adult patients. Food allergies are often immunoglobulin E (IgE) mediated but other food-induced non-IgE-mediated diseases exist. Diagnosis of food allergy relies on the combination of clinical and reaction history, skin and IgE testing as well as oral food challenges. Although oral immunotherapy has been able to achieve sustained unresponsiveness in some patients, no cure for food allergies has been found to date. Avoidance of the inciting food as well as availability of epinephrine autoinjectors remains the mainstay of treatment.

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.

Food Allergy

Food allergy is a growing health problem affecting both pediatric and adult patients. Food allergies are often immunoglobulin E (IgE) mediated but other food-induced non-IgE-mediated diseases exist. Diagnosis of food allergy relies on the combination of clinical and reaction history, skin and IgE testing as well as oral food challenges. Although oral immunotherapy has been able to achieve sustained unresponsiveness in some patients, no cure for food allergies has been found to date. Avoidance of the inciting food as well as availability of epinephrine autoinjectors remains the mainstay of treatment.

Parental Knowledge about Allergies and Problems with an Elimination Diet in Children Aged 3 to 6 Years

Allergic diseases are highly prevalent, and they can exert a significant influence on the patients’ physical and mental well-being, thus affecting the quality of their lives and society as a whole. The aim of this study was to evaluate parental knowledge about allergens, allergy symptoms, and treatment of allergies, and to identify problems with adherence to an elimination diet and the underlying difficulties. Twelve kindergartens and the parents of 1350 preschoolers took part in the first stage of the study. In a screening trial, allergies were diagnosed in 197 children, and their parents participated in the second stage of the study. The child’s age at the onset of the first symptoms was significantly correlated with allergy type. Age was significantly correlated with selected symptoms of an allergic reaction, and skin allergies were more prevalent in younger children. Erythema, skin reddening, and urticaria occurred more frequently in children aged 3−4 years (OR 1.45; 95%CI 1.24−1.77, p < 0.05) and were diagnosed in skin tests (OR 1.36; 95%CI 1.22−1.59, p < 0.05). Allergies to numerous food items were associated with a long-term elimination diet (OR 1.89; 95%CI 1.33−2.19, p < 0.01), as well as problems with preparing safe meals, shopping for food, or dietary adherence when eating out. According to the respondents, lack of support from other family members and compliance with dietary restrictions in kindergartens and when eating out posed the greatest barriers to dietary adherence. Parents do not have sufficient knowledge about environmental allergens and effective strategies for coping with acute allergic reactions, including anaphylactic shock. Children with diagnosed food allergies should enjoy a similar quality of life to their healthy peers, which is why the parents should be educated about diet therapy, duration of treatment, and safe food substitutes.

The Development of Age-Based Food Allergy Educational Handouts for Caregivers and Patients: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

BACKGROUND

Food allergy education is an ongoing process that must address unique safety concerns and psychosocial challenges at each developmental stage. Families require reliable information that is targeted to specific developmental stages to support the integration of food allergy management into daily life.

OBJECTIVE

The purpose of this project was to develop age-specific, evidence-based patient education handouts with practical recommendations for managing and coping with food allergies at different developmental stages.

METHODS

Handout content was based on: (1) practice guidelines for food allergy management; (2) literature addressing psychosocial and educational needs of patients with food allergy and their caregivers; and (3) clinical experience of the project team. Fifty-seven caregivers of patients (aged 0-21 years) with food allergy and 2 young adults with food allergy reviewed a draft of the handouts and completed an online survey to assess handout acceptability and usability and identify areas for improvement. Handouts were revised based on participant feedback.

RESULTS

The majority of participants (79%) rated the amount of information in the age-specific handouts as "just right," versus "not enough" (9%) or "too much" information (12%). Sixty-three percent reported that they would be "very likely" to use the handouts as a resource and 35% "somewhat likely." Almost all participants (88%-100% by item) agreed that the handouts used elements of plain language writing and clear communication.

CONCLUSION

Caregivers rated the age-based food allergy education handouts as understandable and useful. We anticipate that these handouts could be used during health care visits and directly accessed online by families.

Insights into Microbiome and Metabolic Signatures of Children Undergoing Peanut Oral Immunotherapy

Background: Peanut oral immunotherapy has emerged as a novel, active management approach for peanut-allergic sufferers, but limited data exist currently on the role of the microbiome in successful desensitization. Objective: We examined the oral and gut microbiome in a cohort of 17 children undergoing peanut oral immunotherapy with the aim to identify the microbiome signatures associated with successful desensitization. We also set out to characterize their fecal metabolic profiles after successful therapy. Methods: Participants gradually built up their daily dose from 2 mg (starting dose) to 300 mg (maintenance dose) within approximately 40 weeks. We collected a buccal and stool specimen from each subject at two different time points: at baseline and post-therapy (1 month after reaching maintenance). The oral (buccal) and gut (fecal) microbiome was characterized based on sequencing of 16S rRNA gene amplicons with Illumina MiSeq. Fecal short chain fatty acid levels were measured using liquid chromatography-tandem mass spectrometry. Results: We report increased alpha diversity of the oral microbiome post-therapy and have also identified a significant increase in the relative abundance of oral Actinobacteria, associated with the desensitized state. However, the baseline gut microbiome did not differ from the post-therapy. Additionally, fecal short chain fatty acids increased after therapy, but not significantly. Conclusion: Our research adds to the limited current knowledge on microbiome and metabolic signatures in pediatric patients completing oral immunotherapy. Post-therapy increased trends of fecal fatty acid levels support a role in modulating the allergic response and potentially exerting protective and anti-inflammatory effects alongside successful desensitization. A better understanding of the microbiome-related mechanisms underlying desensitization may allow development of smarter therapeutic approaches in the near future. Clinical implication: The oral microbiome composition is altered following successful peanut oral immunotherapy, with a significant increase in alpha diversity and the relative abundance of phylum Actinobacteria. Capsule summary: Significant microbiome changes in children completing peanut immunotherapy include increase in alpha-diversity and overrepresentation of Actinobacteria in the oral microbiome, and increased trends for fecal short chain fatty acids, suggesting a protective effect against the allergic response.

Living with food allergy: What this means for children

Health-related knowledge, skills and attitudes that translate to behaviours are important foundations for healthy living. However, deficiencies in any one of these factors have the potential to impact quality of life. This study investigates how Australian children perceive and manage their food allergy as they transition through childhood onto adolescence. To measure this, children aged 12 years and under completed an online survey [under 8 years and 8-12 years] on knowledge, skills and attitudes. Although recruitment involved advertisements to over 700 Australian pre-schools, 44 allergy specialists and multiple representations to the patient support group, Allergy & Anaphylaxis Australia, completion relied on parental notification and/or guidance. Of the 139 participants recruited, 114 commenced the survey with 65 participants under 8 years (58%) and 49 between 8 and 12 years. Results showed participants recognised different ways to keep safe with children under 8 years (N = 65) 100% cognisant of the need to check with 'Mum/Dad' or teachers if they could safely eat food as well as the importance of not swapping lunches, while there was a slight change in compliance for those aged 8-12 years as three (6.1%, n = 3/49) children did not see the necessity of asking an adult/teacher if a food item was safe to eat. Older children were also less likely to tell friends about their food allergy even if they thought they were having an allergic reaction, despite children under 8 years more likely to feel different to friends (38%, n = 24/64) compared to those aged 8-12 years (31%, n = 14/45). Although both groups disliked parents' fussing, for children under 8 years, there was a strong association between this and 'feeling different to friends'. Results from this study highlight the importance of normalising food allergy at home and in the community, so children are confident in telling others about their food allergy.

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.

Egg Allergy in Children and Weaning Diet

Eggs are a fundamental food in the human diet, and together with cow’s milk, they are the most common food allergen. This work highlights the main nutritional characteristics of eggs to show how their absence from a child’s diet can constitute a serious deficiency. We then analyze the risk factors that facilitate the onset of egg allergy. The third part of the paper reports possible interventions to lower the appearance of food allergy that have been occurred in trials. The last part of the paper is a synthesis of this research study that has been taken from several of the latest guidelines or from position papers.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Posttraumatic stress and medication adherence in pediatric transplant recipients

Adolescent transplant recipients may encounter a range of potentially traumatic events (PTEs) pre- and posttransplant, yet little is known about the relationship between posttraumatic stress symptoms (PTSS) and medication adherence in this population. In the present study, adolescent recipients and caregivers completed psychosocial questionnaires at enrollment. Outpatient tacrolimus trough level data were collected over 1 year to calculate the Medication Level Variability Index (MLVI), a measure of medication adherence. Nonadherence (MLVI ≥2) was identified in 34.8% of patients, and most (80.7%) reported ≥1 PTE exposure. Levels of PTSS indicating likely posttraumatic stress disorder (PTSD) were endorsed by 9.2% of patients and 43.7% of caregivers. PTSS and MLVI were significantly correlated in the liver subgroup (r = .30, p = .04). Hierarchical multivariable linear regression analyses revealed overall patient PTSS were significantly associated with QoL (p < .001). PTEs are common in adolescent recipients; a minority may meet criteria for PTSD. PTSS screening to identify nonadherence risk requires further investigation and addressing PTSS may improve QoL. Caregivers appear at greater risk for PTSD and may require their own supports. The study was approved by each participating center's Institutional Review Board.

Food Allergy-Related Bullying Among Children and Adolescents

OBJECTIVE

Food allergy (FA) management requires youth to avoid allergens and carry emergency medication which can impact participation in social activities. Previous research indicates that some youth experience FA-related bullying, but many studies are limited by single-item assessment methods and a narrow definition of bullying. This study describes FA-related bullying among a diverse cohort of youth with FA and evaluates parent-child disagreement and bullying assessment methods.

METHODS

Youth ages 9-15 years (n = 121) diagnosed with an IgE-mediated FA and their primary caregivers were recruited from pediatric FA clinics to complete surveys about their FA-related bullying experiences. Descriptive statistics were conducted to assess overall FA-related bullying and McNemar tests were utilized to assess disagreement among parent-child report and between multi-item and single-item assessment methods.

RESULTS

Seventeen percent and 31% of youth reported FA-related bullying on single-item and multi-item assessments, respectively. Twelve percent of parents reported their child had experienced FA-related bullying. Youth reported overt physical (51%), overt non-physical (66%), and relational FA-related bullying (20%). FA-related bullying was most common among classmates. Assessment method significantly affected the rates of FA-related bullying reported by youth, and parents and youth only agreed on FA-bullying experiences when assessed via the single-item measure.

CONCLUSIONS

A subset of a diverse sample of youth with FA reported FA-related bullying. Clinicians should use multi-item assessment methods and ask both parents and children about their experiences to fully capture the experiences of families managing FA. School policies that facilitate FA safety and social inclusion should be promoted.

CLINICAL TRIAL REGISTRATION

N/A.

Clinical Manifestations of Pediatric Food Allergy: a Contemporary Review

Food allergies (FAs) are an emerging health care issue, and a "second wave of the allergy epidemic" was named. There are extensive data that documented the prevalence rate as high as approximately 10%. FAs are immunological adverse reactions, including IgE-mediated mechanisms, cell-mediated mechanisms, or mixed IgE- and cell-mediated mechanisms. A diagnosis of FA is made by specific symptoms encounter with food, detailed past history, sensitization tests, and oral food challenges (OFCs) if necessary. The component-resolved diagnostics (CRD) test can distinguish true or cross-reaction. "Minimal elimination" from the results of CRD and OFC could avoid unnecessary food restriction. Strict food limitation is harsh and stressful on patients and their families. Children with FAs experience a higher rate of post-traumatic stress symptoms (PTSS) and bullying than others. In the last 20 years, oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT) are treatment strategies. OIT and EPIT are the most two encouraging treatments for FA. This review aims to introduce FAs in diverse clinical disorders, new perspectives, and their practical implications in diagnosing and treating FA.

Addressing Common Misconceptions in Food Allergy: A Review

Background: Food allergies are common, affecting 1 in 13 school children in the United States and their prevalence is increasing. Many misconceptions exist with regards to food allergy prevention, diagnosis and management. Objective: The main objective of this review is to address misconceptions with regards to food allergies and discuss the optimal, evidence-based approach for patients who carry this diagnosis. Observations: Common misconceptions in terms of food allergy prevention include beliefs that breastfeeding and delayed introduction of allergenic foods prevent the development of food allergies. In terms of diagnosis, statements such as ‘larger skin prick tests or/and higher levels of food-specific IgE can predict the severity of food-induced allergic reactions’, or ‘Tryptase is always elevated in food-induced anaphylaxis’ are inaccurate. Additionally, egg allergy is not a contraindication for receiving the influenza vaccine, food-allergy related fatalities are rare and peanut oral immunotherapy, despite reported benefits, is not a cure for food allergies. Finally, not all infants with eczema will develop food allergies and epinephrine auto-injectors may unfortunately be both unavailable and underused in food-triggered anaphylaxis. Conclusions and relevance: Healthcare professionals must be familiar with recent evidence in the food allergy field and avoid common misunderstandings that may negatively affect prevention, diagnosis and management of this chronic disease.

Optimizing Patient Care in Egg Allergy Diagnosis and Treatment

Egg allergy occurs frequently in childhood with a reported prevalence of 1.3-1.6%. Providing optimal care to egg-allergic patients requires knowledge of the most up-to-date developments in both diagnosis and management, as well as effective communication skills, which will engage the patient in the shared decision-making process. This review aims to provide up-to-date information on egg allergy and also serve as a concise guide on optimal patient diagnosis and management. The field of food allergy has seen multiple advances in recent years, including use of component resolved diagnostics, early egg introduction into the infant diet as a way of preventing egg allergy, baked egg introduction and oral immunotherapy as a form of active therapy. Faced with a variety of options and treatment paths, it is important to ensure that patients and families taking part in the decision-making process have fully understood the potential outcomes and trade-offs and can undertake a detailed discussion of all options that are available to them. Shared decision-making remains the cornerstone of optimal patient care.

A Practical, Stepwise Approach to Peanut Oral Immunotherapy in Clinical Practice: Benefits and Risks

Food allergies are common, affecting 6-8% of the children in the United States. There is a significant burden on the quality of life of allergic children and their caregivers, due to multiple dietary, social and psychological restrictions. Peanut allergy affects approximately 2-5% of the school-age children. Despite the recommended dietary avoidance, reactions tend to occur due to unintentional exposures and the fear of accidental ingestions potentially resulting in anaphylaxis and death, which creates a lot of anxiety in peanut-allergic individuals. Peanut oral immunotherapy (POIT) has emerged as a form of active treatment and has shown high efficacy in research trials with the majority of participants achieving desensitization and protection from trace exposures. An improved quality of life has also been noted following successful POIT. The risks of POIT should be balanced against the benefits resulting from successful treatment for each individual. Rates of allergic reactions and anaphylaxis are reported to be higher in individuals pursuing therapy, but most subjects will experience mild or moderate reactions during treatment. The landscape of peanut allergy management is changing and the future offers more options for patients than were previously available. Shared decision-making, which is the process of how to choose between different available options, becomes an ongoing discussion between the clinician and the patient, which will ensure achievement of the best possible outcome for the peanut-allergic child. This is a multistep process that evaluates the benefits and risks of therapy or no therapy, as well as patient and family preferences and we review it in detail in this manuscript with the aim to provide clinicians with a practical approach.

An Approach to the Office-Based Practice of Food Oral Immunotherapy

Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.

Weighing the benefits and risks of oral immunotherapy in clinical practice

Food allergies are common and affect 6-8% of children in the United States; they pose a significant burden on the quality of life of children with allergy and their caregivers due to multiple daily restrictions. Despite the recommended dietary avoidance, reactions tend to occur due to unintentional exposure to the allergenic food trigger. Fear of accidental ingestions with potentially severe reactions, including anaphylaxis and death, creates anxiety in individuals with food allergy. Oral immunotherapy has emerged as a form of active and potentially disease-modifying treatment for common food allergies encountered in childhood. The efficacy of oral immunotherapy is high, with the majority of participants achieving desensitization and, as a result, protection from trace exposures and improved quality of life. The main risk of oral immunotherapy consists of allergic reactions to treatment. In general, rates of allergic reactions and anaphylaxis are reported to be higher in individuals pursuing therapy options, but most subjects who undergo oral immunotherapy will likely experience mild or moderate reactions during treatment. Adverse events tend to reduce in both frequency and number in the maintenance period. The use of immune modulators alongside oral immunotherapy has been suggested, with the aim to improve efficacy and safety, and to facilitate the overall process. It is evident that the landscape of food allergy management is changing and that the future looks brighter, with different options emerging over time. The process of how to choose the appropriate option becomes a discussion between the clinician and the patient, which involves a joint review of the current medical evidence but also the patient's preference for balancing particular attributes of the treatment. By working together, providers and patients will ensure achievement of the best possible outcome for children with food allergies.

IgE-Mediated Fish Allergy in Children

Fish allergy constitutes a severe problem worldwide. Its prevalence has been calculated as high as 7% in paediatric populations, and in many cases, it persists into adulthood with life-threatening signs and symptoms. The following review focuses on the epidemiology of Immunoglobulin E (IgE)-mediated fish allergy, its pathogenesis, clinical manifestations, and a thorough approach to diagnosis and management in the paediatric population. The traditional approach for managing fish allergy is avoidance and rescue medication for accidental exposures. Food avoidance poses many obstacles and is not easily maintained. In the specific case of fish, food is also not the only source of allergens; aerosolisation of fish proteins when cooking is a common source of highly allergenic parvalbumin, and elimination diets cannot prevent these contacts. Novel management approaches based on immunomodulation are a promising strategy for the future of these patients.

An update on international practice variation in peanut introduction: conundrums, controversies, and a new direction

PURPOSE OF REVIEW

Introduction of peanut during the first year of life is associated with an 81% relative risk reduction of developing peanut allergy in infants with severe eczema, egg allergy, or both. However, significant international variation exists in risk stratification prior to peanut introduction.

RECENT FINDINGS

A policy-level screening approach, such as the one in the United States, is not practical and is associated with higher costs and more cases of peanut allergy over time, in contrast to international models that recommend universal early introduction without prescreening. In Australia, population-level efforts to introduce peanut early without screening have demonstrated high rates of peanut introduction before 12 months of age and low rates of severe allergic reactions. In contrast, screening prior to peanut introduction in the United States is associated with 'screening creep' - the tendency of clinicians to test populations where screening is not recommended.

SUMMARY

Early peanut introduction can reduce the risk of developing food allergy and is more effective without a risk-based screening approach. In some circumstances, shared clinical decision-making can facilitate food allergy prevention in a manner consistent with family values and preferences.

Allergy to Peanuts imPacting Emotions And Life (APPEAL): the impact of peanut allergy on children, adolescents, adults and caregivers in France

Background

Peanut allergy (PA) has increased in developed countries and can have a dramatic effect on quality of life but data surrounding this is limited in France. Allergy to Peanuts imPacting Emotions And Life study (APPEAL) investigated the experience and impact of living with PA in France.

Methods

Respondents affected by PA directly (children aged 8–12 years, teenagers aged 13–17 years, or adults aged ≥ 18 years) or indirectly (caregiver) completed either an online questionnaire (APPEAL-1, N = 198), or provided in-depth interviews (APPEAL-2, N = 32). Quantitative data was evaluated using descriptive statistics. Qualitative data was analysed thematically, using MAXQDA software.

Results

Of 198 responders in APPEAL-1, 88% stated that PA affects their daily activities, and 74% felt isolated as a result of living with PA. Feelings of worry about exposure to peanuts on social occasions where food is involved was reported by 91%. A total of 44% reported some restrictions in their job options, 85% in socializing. Psychological impact of PA included responders feeling emotions of frustration (89%), uncertainty (87%), and stress (93%) and 93% reporting encountering instances of feeling different due to their PA. Main factors that drove PA impact included social activities and relationships; whereas main coping strategies to avoid peanuts included monitoring, communication and planning.

Conclusion

The analysis of French respondents from the APPEAL study demonstrates the impact and burden of PA on allergic children, teenagers, adults and their caregivers, and highlights the unmet need to be addressed.

Management of Peanut Allergy

Peanut allergy is a growing public health concern in westernized countries. Peanut allergy is characterized as an often severe and lifelong allergy, which can have detrimental effects on quality of life and trigger anxiety. Although multiple therapeutic options are emerging, the focus of current management strategies is strict peanut avoidance and carriage of self-injectable epinephrine. The greatest risk of reacting to peanut comes from direct ingestion, whereas casual skin contact or airborne exposure is highly unlikely to provoke significant symptoms. Patients and families must be educated about how to best execute strict peanut avoidance through careful label reading as well as how to understand and address likely and unlikely risk with regard to peanut exposure in public, in particular when dining outside of the home and for children attending school or child care. This review discusses the risk of exposure in public such as at school or on an airplane and how such risk can be abated, situations and scenarios when dining out of the house that may pose more risks than others, the essentials of US and EU label reading laws with particular emphasis on precautionary labeling and the risk implied by such, quality of life and psychosocial issues that may affect the peanut allergic individual and family, and a discussion of how risk may differ and evolve based on the patient's age.

Food Allergy Management at School in the Era of Immunotherapy

PURPOSE OF REVIEW

Food allergy is increasing in prevalence, and management focuses on strict avoidance of known allergens and appropriately treating reactions. Any reaction has the potential to result in anaphylaxis, which can be fatal. Children spend a significant amount of time in the childcare or school setting, and interactions between families, school personnel, and clinicians are important to ensure the health and safety of children with allergies and asthma.

RECENT FINDINGS

This review examines current food allergy guidelines and legislation, an assessment of allergen-free schools, the importance of written anaphylaxis action plans, training and education of school personnel, emerging treatment options, and the social implications of having food allergies. As the clinical use and research into food allergen immunotherapy continues to expand, an additional level of education and management is required of school personnel and caregivers. Food allergy has both medical and social implications, which are magnified in the school setting.

Quality of life in food allergic children: Results from 174 quality-of-life patient questionnaires

BACKGROUND

Food allergies are becoming a global concern and pose a significant burden on allergic children and their family, with reported physical and emotional effects.

OBJECTIVE

To investigate the effect of food allergy on patients' quality of life (QoL), to identify any characteristics associated with worse QoL, and to directly compare the effect of food allergies on the QoL of adolescents vs younger children.

METHODS

Children 0 to 17 years old with a physician-confirmed food allergy diagnosis were invited to participate by completing the validated Food Allergy Quality of Life Questionnaire (FAQLQ). The FAQLQ form for children 10 to 12 years old was completed by the parent (proxy report), whereas the FAQLQ form for adolescents was completed by the adolescent (self-report). Scores were compared using the Wilcoxon rank sum test. Independent median regressions were used to test association between potential risk factors and QoL outcomes.

RESULTS

In our cohort, the median FAQLQ score was significantly higher (reflecting lower QoL) in adolescents compared with children (4.7 vs 3.5, P = .007). The median social and dietary limitations score (5.2 vs 4, P = .002) and the median emotional impact score (3.8 vs 3.1, P = .02) were also higher in adolescents. Limitations in family activities because of food allergy had a negative effect on QoL.

CONCLUSION

Food allergic adolescents are affected more than younger children (based on parental report) in terms of QoL, with a direct reflection on all areas of their daily life (emotional, dietary, and social). In addition, limitations in family activities because of the child's food allergy significantly worsen the QoL and well being of all family members.

Bullying in Australian children and adolescents with food allergies

BACKGROUND

Food allergy is an increasing concern worldwide. The significant impact of food allergies on quality of life and bullying has been well described in international studies. No studies have yet investigated the occurrence of bullying in children and adolescents with food allergies in the Australian population. This study aimed to characterize and examine the frequency of bullying and describe those most responsible and the effects of the bullying on the victims.

METHODS

Questionnaires were developed based on those used in previous studies and were distributed throughout paediatric allergy clinics. Children and adolescents aged 10-19 with food allergies were recruited to complete the questionnaire independently, whilst parents completed the questionnaire on behalf of their children aged 5-9 with food allergies. The data were tabulated and analysed using descriptive statistics.

RESULTS

Ninety-three questionnaires were completed. Overall, 39 (42%) children experienced some form of bullying. This was higher in the older children and adolescent group, where 53% (18/34) were bullied. In addition, 23% (21/93) of the cohort were bullied or teased specifically because of their allergy. Food allergens had been used in the bullying in 24 cases, but no child reported being forced to eat foods to which they were allergic. Two adolescents experienced allergic reactions.

CONCLUSIONS

This study highlights that those with food allergy are subject to a high degree of bullying. This risk of bullying for children with food allergy indicates a significant social problem that requires addressing to positively assist these children.

Food allergy

Food allergies manifest in a variety of clinical conditions within the gastrointestinal tract, skin and lungs, with the most dramatic and sometimes fatal manifestation being anaphylactic shock. Major progress has been made in basic, translational and clinical research, leading to a better understanding of the underlying immunological mechanisms that lead to the breakdown of clinical and immunological tolerance against food antigens, which can result in either immunoglobulin E (IgE)-mediated reactions or non-IgE-mediated reactions. Lifestyle factors, dietary habits and maternal-neonatal interactions play a pivotal part in triggering the onset of food allergies, including qualitative and quantitative composition of the microbiota. These factors seem to have the greatest influence early in life, an observation that has led to the generation of hypotheses to explain the food allergy epidemic, including the dual-allergen exposure hypothesis. These hypotheses have fuelled research in preventive strategies that seek to establish desensitization to allergens and/or tolerance to allergens in affected individuals. Allergen-nonspecific therapeutic strategies have also been investigated in a number of clinical trials, which will eventually improve the treatment options for patients with food allergy.

The Allergist's Role in Anaphylaxis and Food Allergy Management in the School and Childcare Setting

Anaphylaxis and food allergy management in childcare facilities and schools are growing challenges. An increasing number of children experience severe allergic reactions on school grounds as evidenced by reports of epinephrine use. Data also suggest that the prevalence of food allergy may be increasing, with a large percentage of school-aged children at risk for anaphylaxis. Moreover, anaphylaxis may occur for the first time in a previously undiagnosed child at school or childcare setting, suggesting that general preparedness is essential. Management includes strategies for minimizing the risk of reactions and allergen exposures as well as readiness to recognize and treat allergic reactions of any severity. The primary objective of this report is to offer health care providers an overview of relevant evidence, resources, and expert opinion to assist with developing interprofessional collaborative counsel on school food allergy management and anaphylaxis preparedness with families, schools, and childcare settings. We present the current evidence base, suggest resources, and highlight areas of current controversy that warrant further study.

Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management

This review provides general information to serve as a primer for those embarking on understanding food allergy and also details advances and updates in epidemiology, pathogenesis, diagnosis, and treatment that have occurred over the 4 years since our last comprehensive review. Although firm prevalence data are lacking, there is a strong impression that food allergy has increased, and rates as high as approximately 10% have been documented. Genetic, epigenetic, and environmental risk factors are being elucidated increasingly, creating potential for improved prevention and treatment strategies targeted to those at risk. Insights on pathophysiology reveal a complex interplay of the epithelial barrier, mucosal and systemic immune response, route of exposure, and microbiome among other influences resulting in allergy or tolerance. The diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges, but emerging use of component-resolved diagnostics is improving diagnostic accuracy. Additional novel diagnostics, such as basophil activation tests, determination of epitope binding, DNA methylation signatures, and bioinformatics approaches, will further change the landscape. A number of prevention strategies are under investigation, but early introduction of peanut has been advised as a public health measure based on existing data. Management remains largely based on allergen avoidance, but a panoply of promising treatment strategies are in phase 2 and 3 studies, providing immense hope that better treatment will be imminently and widely available, whereas numerous additional promising treatments are in the preclinical and clinical pipeline.

Patient-Centered Outcomes in Food Allergy

PURPOSE OF REVIEW

Food allergy prevalence is increasing very rapidly, causing a significant disease burden. The threat of severe allergic reactions occurring unexpectedly and in settings that are not equipped to recognize and treat anaphylaxis is a constant source of worry for individuals and families with food allergies. Inadequate knowledge and understanding in the community significantly impairs the overall quality of life of these individuals and families. Additionally, families face challenges in finding and affording appropriate allergen-free foods.

RECENT FINDINGS

Advancements have been made in understanding the impact of food allergies on patient-centered outcomes such as quality of life and economic impact, and attempts have been made to develop tools to assess patient-centered variables. Innovative national and regional initiatives are helping to spread awareness of the disease condition and to create resources, including access to allergen-free foods. While there is a growing momentum toward recognition of food allergic disorders as a condition that profoundly impacts activities of daily living, greater effort needs to be expounded to develop validated tools and interventions that can adequately address these issues.

Doctor, my child is bullied: food allergy management in schools

PURPOSE OF REVIEW

Studies suggest that food allergies have increased in prevalence, resulting in most school classrooms having more than one child affected. Children with food allergies are vulnerable for experiencing potentially life-threatening allergic reactions, as well as social consequences such as bullying. Management recommendations for food allergies in schools should incorporate knowledge of both issues.

RECENT FINDINGS

Current recommendations for food allergy management in schools focus on appropriate avoidance measures and prompt recognition and treatment of allergic reactions. Guidelines focus upon a school-wide approach, with comprehensive involvement of many stakeholders, but individual students require specific emergency action plans. Special risk groups include young children who need additional supervision and adolescents who may take risks. Based on the observation that anaphylaxis can occur in persons without a prior diagnosis, having epinephrine available for prompt first-aid management of any student in need is now recommended. To promote socialization, avoidance measures should minimize separation of children with food allergies from their peers. Parents and schools need to be aware of bullying and implement intervention and prevention measures.

SUMMARY

Management recommendations for food allergies in schools should ensure the safety of the child, address bullying, and avoid unnecessary isolation.

Critical Issues in Food Allergy: A National Academies Consensus Report

The National Academies of Sciences, Engineering, and Medicine convened an expert, ad hoc committee to examine critical issues related to food allergy. The authors of the resulting report, "Finding a Path to Safety in Food Allergy: Assessment of the Global Burden, Causes, Prevention, Management, and Public Policy," evaluated the scientific evidence on the prevalence, diagnosis, prevention, and management of food allergy and made recommendations to bring about a safe environment for those affected. The committee recommended approaches to monitor prevalence, explore risk factors, improve diagnosis, and provide evidence-based health care. Regarding diagnostics, emphasis was placed on utilizing allergy tests judiciously in the context of the medical history because positive test results are not, in isolation, diagnostic. Evidence-based prevention strategies were advised (for example, a strategy to prevent peanut allergy through early dietary introduction). The report encourages improved education of stakeholders for recognizing and managing as well as preventing allergic reactions, including an emphasis on using intramuscular epinephrine promptly to treat anaphylaxis. The report recommends improved food allergen labeling and evaluation of the need for epinephrine autoinjectors with a dosage appropriate for infants. The committee recommended policies and guidelines to prevent and treat food allergic reactions in a various settings and suggested research priorities to address key questions about diagnostics, mechanisms, risk determinants, and management. Identifying safe and effective therapies is the ultimate goal. This article summarizes the key findings from the report and emphasizes recommendations for actions that are applicable to pediatricians and to the American Academy of Pediatrics.

Bullying and quality of life in children and adolescents with food allergy

Food allergy is an increasing phenomenon in Australia, with most recent reports of food allergy occurring in 1 in 12 children. A number of studies have demonstrated that children and adolescents with food allergies experience a decreased quality of life across a number of domains. More recent evidence suggests that this population also experiences an increased occurrence of bullying compared to similar school-aged children. Some individuals have reported being bullied because of their allergies, whilst others have reported specific allergy-related-bullying, such as being touched with foods that they are allergic to or having their food being intentionally contaminated with an allergen. Where there may be a risk of severe anaphylaxis, this is of great concern. This article reviews the current literature on bullying in populations of children and adolescents with food allergies. Several papers worldwide have investigated this, providing evidence of its occurrence in North America, Canada, Italy and Japan.

Clinical Management of Psychosocial Concerns Related to Food Allergy

Current estimates indicate that 4% to 8% of children in the United States are diagnosed with food allergy, and more than 40% of US children with food allergy experience severe allergic reactions. Families trying to avoid foods that may trigger an allergic reaction and ensure adequate treatment of allergic reactions that do occur face numerous challenges. The rise in the number of children diagnosed with food allergies underscores the importance of food allergy-related interventions to address elevated psychosocial concerns, such as parenting stress, anxiety, and worries about bullying. This review provides an overview of common psychosocial concerns among children with food allergy and their families across the developmental spectrum, and offers guidance to medical providers regarding the identification and treatment of food allergy-related psychosocial challenges.

Quality of Life in Food Allergy Patients and Their Families

Pediatric food allergy is a growing health problem in the United States that has been found to adversely impact the quality of life of both affected children and their caregivers. This article provides a review of how food allergy affects the quality of life of patients and their families within the domains of school, social activities, relationships, and daily life. Efforts to improve food allergy-related quality of life among caregivers are also discussed.

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2014

This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2014. Studies on food allergy suggest worrisomely high rates of peanut allergy and food-induced anaphylaxis-related hospitalizations. Evidence is mounting to support the theory that environmental exposure to peanut, such as in house dust, especially with an impaired skin barrier attributed to atopic dermatitis (AD) and loss of function mutations in the filaggrin gene, is a risk factor for sensitization and allergy. Diagnostic tests are improving, with early studies suggesting the possibility of developing novel cellular tests with increased diagnostic utility. Treatment trials continue to show the promise and limitations of oral immunotherapy, and mechanistic studies are elucidating pathways that might define the degree of efficacy of this treatment. Studies have also provided insights into the prevalence and characteristics of anaphylaxis and insect venom allergy, such as suggesting that baseline platelet-activating factor acetylhydrolase activity levels are related to the severity of reactions. Advances in drug allergy include identification of HLA associations for penicillin allergy and a microRNA biomarker/mechanism for toxic epidermal necrolysis. Research identifying critical events leading to skin barrier dysfunction and the polarized immune pathways that drive AD have led to new therapeutic approaches in the prevention and management of AD.