Factors impacting parental burden in food-allergic children

Pediatric oral food challenges in the outpatient setting: A single-center experience

Background

Oral food challenge (OFC) is the criterion standard for diagnosing food allergy (FA). It is important to have parameters to aid in selecting ideal OFC candidates.

Objective

We sought to characterize outcomes and predictors of OFCs for common food allergens.

Methods

We completed a retrospective chart review of all OFCs for IgE-mediated FA performed at Duke University pediatric allergy clinics from June 2017 through May 2022. Patients were deemed eligible for milk, egg, and nut OFC if testing revealed a specific IgE level not exceeding 2 kU/L and a skin prick test (SPT) resulting in a wheal size not exceeding 5 mm. Different parameters were followed for selecting candidates for baked challenge.

Results

A total of 663 OFCs were conducted on 510 patients (59% male). The most common foods challenged were peanut (26%), plain egg (23%), baked egg (8%), and milk (8%), with pass rates of 84%, 88%, 62%, and 84%, respectively. Of the patients who failed OFC, 84% had objective symptoms, 23% had multisystemic reactions, and 15% required epinephrine. Although the presence of a personal or family history of atopy or prior failed OFC was not associated with outcomes, a history of anaphylaxis (regardless of the trigger) was associated with increased risk of failure.

Conclusion

Although there are no established consensus guidelines, our study provides a benchmark illustrating that cutoffs of a specific IgE level not exceeding 2 kU/L and SPT finding not exceeding 5 mm result in a failure rate of approximately 13% for nonbaked milk, nonbaked egg, and nuts. The high rate of failed baked egg OFCs is likely related to selection bias, but our results illustrate the low negative predictive value of ovomucoid.

Natural course of IgE-mediated food allergy in children

The prevalence of food allergy and food-induced anaphylaxis in children is increasing worldwide. Cow's milk, hen's eggs, and wheat allergies in young children have a more favorable prognosis with a relatively early outgrow, while allergies to peanuts, tree nuts, and seafood are more likely to be persistent. Although our understanding of the mechanism underlying the resolution of food allergy is incomplete, the roles of dendritic cells, regulatory T cells, and regulatory B cells are important. Many past studies on the natural course of food allergy were retrospective analyses of specific study groups, but large-scale population-based prospective studies are now being published. This review summarizes recent studies of the natural course of cow's milk, hen's eggs, wheat, peanuts, tree nuts, soy, sesame, and seafood allergies. The potential factors affecting the natural course of food allergy include symptom severity on ingestion, age at diagnosis, allergic comorbidities, skin prick test reaction size or serum food-specific immunoglobulin (Ig) E levels, changes in sensitization degree, IgE epitope specificity, ratio of food-specific IgE to IgG4, food-specific IgA levels, component-resolved diagnostic profile, diet, gut microbiome, and interventions such as immunotherapy. Since food allergy places a significant burden on patients and their caregivers in daily life, clinicians should be able to provide relevant knowledge on the natural course of food allergy, appropriately evaluate its resolution, and offer therapeutic options whenever possible.

Eosinophil-Associated Gastrointestinal Manifestations During OIT

Gastrointestinal adverse events are common during oral immunotherapy (OIT) for food allergy and range from immediate IgE-mediated reactions to non-anaphylactic clinical presentations. This review aims to summarize recent findings on non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT. Two clinical presentations of non-anaphylactic eosinophil-associated gastrointestinal adverse events during OIT are identified, each with a different paradigm for treatment, and distinguished by their time of onset. In the first clinical entity, characterized by its onset early in the course of treatment, patients present with abdominal pain, nausea, and/or vomiting. The symptoms become evident typically within weeks to months of starting OIT. These symptoms, however, are not temporally related to the time of dose administration, as in the case of immediate IgE-mediated anaphylactic reactions. While esophageal biopsies, when performed, can demonstrate eosinophilic esophagitis (EoE), baseline esophageal eosinophilia has also been observed in food allergic patients prior to OIT. A potential non-invasive biomarker, the peripheral absolute eosinophil count (AEC), often rises during these reactions and subsides after dose reduction and subsequent resolution of symptoms. OIT can usually then be resumed, albeit at a slower pace, without a recurrence of symptoms. Risk factors for development of symptoms early during OIT include a high starting dose and a baseline AEC of greater than 600. The second, and much less frequently encountered, non-anaphylactic gastrointestinal adverse event related to OIT, presents months to years after initiating OIT. In this latter group, patients present with the classical clinical symptoms and endoscopic findings of EoE. In contrast to the acute onset group, peripheral eosinophilia is usually not observed in these cases. This OIT-associated EoE has shown good response to standard EoE treatment approaches of proton pump inhibitors or swallowed steroids. Most patients with eosinophil-associated adverse reactions are able to continue OIT and remain desensitized. Treatment approaches depend on the specific subtype of these reactions and relate to the stages of OIT treatment.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Psychological Distress and Perceived Burden in Parents of Korean Children With IgE-Mediated Food Allergy

BACKGROUND

Food allergy (FA) can have a profound effect on quality of life (QoL), stress, and anxiety in the family. We aimed to validate the Korean version of the Food Allergy Quality of Life-Parental Burden (FAQL-PB) and identify factors related to the parental psychosocial burden of caring for children with FAs.

METHODS

Parents of children aged between 6 months and 17 years with immunoglobulin E (IgE)-mediated FAs from the Pediatric Allergy Department of five university hospitals in Korea were enrolled in the study. Parents were asked to complete the FAQL-PB, Food Allergy Independent Measure-Parent Form (FAIM-PF), Child Health Questionnaire-Parents Form 28 (CHQ-PF28), Beck's Anxiety Inventory, Connor-Davidson Resilience Scale, and Patient Health Questionnaire-9 for depression. Statistical analyses included internal consistency, test-retest reliability, concurrent validity, discriminative validity, and logistic regression analyses.

RESULTS

A total of 190 parents were enrolled. Social activity limitation was the item with the highest FAQL-PB scores. The Cronbach's α for each item was higher than 0.8. The test-retest reliability was good (intra-class correlation coefficient, 0.716; 95% confidence interval [CI], 0.100-0.935). An increase in the FAQL-PB was significantly associated with an increase in the FAIM-PF (β = 0.765, P < 0.001) (concurrent validity). There was a positive correlation between parental burden, anxiety, and depression, while resilience was inversely correlated with parental burden (all P < 0.001). The total FAQL-PB score in parents of children who had experienced anaphylaxis was significantly higher than that in parents of children who did not experience it (P = 0.008). When adjusting for age, sex, and underlying diseases, anaphylaxis (β = 9.32; 95% CI, 2.97 to 15.68), cow's milk (CM) allergy (β = 8.24; 95% CI, 2.04 to 14.44), soybean allergy (β = 13.91; 95% CI, 1.62 to 26.20), higher anxiety (β = 1.05; 95% CI, 0.07 to 1.41), higher depression (β = 2.15; 95% CI, 1.61 to 2.69), and lower resilience (β = -0.42; 95% CI, -0.61 to -0.2) were significantly associated with greater parental burden in children with IgE-mediated FAs.

CONCLUSION

FAQL-PB is a reliable and valid tool for use in Korea. Anaphylaxis, CM or soybean allergies, more anxiety and depression symptoms, and lower resilience are associated with poorer QoL in parents of children with FAs.

Will Oral Food Challenges Still Be Part of Allergy Care in 10 Years' Time?

Oral food challenges (OFCs) are currently the definitive diagnostic procedure in food allergy. Their design has evolved over the decades to maximize safety, optimize convenience, and address several specific clinical questions. However, they are a resource-intensive investigation that carry a risk for severe allergic reaction in which fatal outcomes, although rare, have been reported. In this review, we explore the many roles that OFC fulfil in the clinical and research settings. We also discuss progress that has been made in developing alternative diagnostic tools and how far these have reached in offering a viable replacement to OFC in clinical practice. Finally, we discuss the ongoing importance of research OFC to improve the future diagnostic capabilities of novel diagnostic tools.

Health-related quality of life in food and venom induced anaphylaxis and role of influencing factors

The impact on health-related quality of life (HRQL) plays a key role for patients suffering from allergies and anaphylaxis. In this narrative review we review the HRQL in allergic patients suffering from food and venom allergy, both being the most frequent elicitors of severe allergic, potential life-threatening reactions and provide an overview on the current knowledge and identified gaps. The data show that for food and venom allergy standardized assessment tools to measure HRQL are available and have been successfully applied. Our analysis shows that multiple factors can modulate HRQL in these patient groups. These include sociodemographic data like patients' age and sex, fear of accidental reactions but also external factors like the social environment and the appreciation of the seriousness of the condition by others. External factors may have a significant impact on HRQL and should be considered in patient-related outcome assessments to avoid biased measurements possibly affecting the results. The assessment of the quality of life in the context of specific immunotherapy should consider lifestyle factors and ideally, the individual change in HRQL should be measured. Although there are many data indicating a negative impact on HRQL in food allergic children and their caregivers, limited data are existing from adults with food allergy and venom allergic patients from all age groups. Also, the use of standardized questionnaires should be extended to allow for a better comparability of results between studies. Therefore, translation to additional languages is necessary. Taken together, the eliciting allergen, the severity of the allergic disease but moreover multiple external factors impact the outcome in HRQL and should be considered in HRQL assessment.

Characteristics of patients diagnosed as non-allergic following food allergy oral immunotherapy referral

BACKGROUND

Ascribing food allergy diagnosis to patients who are not allergic is well described, but its implications on oral immunotherapy (OIT) have not been studied. The aim was to study non-allergic patients referred for OIT.

METHODS

All patients who began OIT at Shamir Medical Center between November 2015 and August 2020 were included. Medical records were reviewed, and skin prick tests (SPT) and/or specific IgE were measured. Patients were challenged to the index food. Allergic and non-allergic patients were compared.

RESULTS

A total of 1073 patients were studied (milk, n = 327; egg, n = 41; peanut, n = 272; sesame, n = 130; and tree nuts, n = 303) and 87 (8.1%) were found non-allergic (milk, n = 21; egg, n = 6; sesame, n = 5; peanut, n = 29; tree nuts, n = 26). Predictors of being not allergic were no previous reaction to the index food (OR = 3.3, p = 0.001), not having asthma (OR = 2.4, p = 0.001), or HDM sensitization (OR = 2.0, p = 0.007), male sex (OR = 2.3, p = 0.004), and a smaller SPT wheal size (OR = 1.5, p < 0.001).

CONCLUSIONS

A substantial number of patients referred for OIT are mislabeled with food allergy, suffer from unjustly food limitations and impairments in quality of life, and "take up" OIT places of true allergic patients. Awareness of OIT centers to this phenomenon is important.

IMPACT

A significant number (8.1%) of patients referred for OIT are found not allergic to the food they intended to treat. This study characterizes non-allergic patients referred for OIT (a lack of previous reaction to the index food, a smaller or negative SPT wheal size, and less atopic co-morbidities) and discusses the implications of such referrals. Increased awareness by OIT centers to potential non-allergic patients referred for OIT is required, including screening of patients before treatment initiation, to minimize unnecessary treatments of non-allergic patients.

Children at risk of anaphylaxis: A mixed-studies systematic review of parents' experiences and information needs

Objective

To explore parents' self-reported experiences and information needs regarding recognition and management of pediatric anaphylaxis.

Methods

We searched Ovid Medline, Ovid PsychInfo, CINAHL Plus, the Cochrane Library, and grey literature to identify primary studies in English or French published since 2000. We used a mixed-method appraisal tool and convergent integrated approach to assess quality and synthesize data, respectively.

Results

43 studies were included (22 quantitative, 19 qualitative, and 2 mixed-method); 77% of studies had high methodological quality. Parents' experiences were categorized as: recognizing an anaphylactic reaction; managing and responding to a reaction; emotional impact of caring for a child at risk of anaphylaxis; and interaction with the health system and healthcare providers. Parents' information needs were categorized into themes relating to: gaps in knowledge and information; type of information desired; information sources; and information delivery format.

Conclusion

Negative emotional experiences and a general lack of information were commonly reported by parents of included studies. Provision of relevant and comprehensible information may help parents to make informed decisions and manage reactions promptly.

Innovation

The findings of this review are guiding the development of an innovative knowledge translation tool (KT) as part of a larger initiative of developing a suite of parent-focused KT tools for acute childhood conditions.

Factors associated with parental burden among parents of children with food allergies in China: a cross-sectional study

OBJECTIVE

This study aimed to investigate the factors associated with parental burden among parents of children with food allergies (FA) in China.

DESIGN

Cross-sectional study.

SETTING

The participants were recruited through the internet and one child health centre of a tertiary hospital in Changsha, China.

PARTICIPANTS

A total of 346 parents of children with FA were recruited using a convenience sampling method. After excluding the invalid questionnaires, 330 questionnaires were included for the analysis.

OUTCOME MEASURES

The data of general and disease-specific information of children with FA and their parents, as well as parental burden, social support and coping style of parents, were collected using a self-developed questionnaire and standard measurement tools with good psychometric properties. Univariate analysis and multivariate stepwise regression analysis were used to analyse the data.

RESULTS

Financial affordability regarding their children's FA and parents' social support were key protective factors against parental burden (β=-0.224, p<0.001 and β=-0.226, p<0.001, respectively). This study also found that parents' working conditions, the number of highly suspected food allergens, the number of children's FA-affected systems and whether children took amino acid milk powder were the factors associated with parental burden.

CONCLUSIONS

Health professionals should pay more attention to parents who are not at work and whose children have more highly suspected food allergens and more FA-affected systems because these parents often have a higher parental burden. Furthermore, it is important to improve financial support for children's FA and social support for parents of children with FA to decrease their parental burden.

BSACI guideline for the diagnosis and management of pollen food syndrome in the UK

Pollen food syndrome (PFS) is a highly prevalent food allergy affecting pollen-sensitized children and adults. Sufferers experience allergic symptoms when consuming raw plant foods, due to the homology between the pollen allergens and unstable proteins in these foods. The triggers involved can vary depending on the pollen sensitization, which in turn is affected by geographical location. The British Society of Allergy and Clinical Immunology (BSACI) Standards of Care Committee (SOCC) identified a need to develop a guideline for the diagnosis and management of PFS in the United Kingdom (UK). Guidelines produced by the BSACI use either the GRADE or SIGN methodology; due to a lack of high-quality evidence these recommendations were formulated using the SIGN guidelines, which is acknowledged to be less robust than the GRADE approach. The correct diagnosis of PFS ensures the avoidance of a misdiagnosis of a primary peanut or tree nut allergy or confusion with another plant food allergy to non-specific lipid transfer proteins. The characteristic foods involved, and rapid-onset oropharyngeal symptoms, mean PFS can often be diagnosed from the clinical history alone. However, reactions involving tree nuts, peanuts and soya milk or severe/atypical reactions to fruits and vegetables may require additional diagnostic tests. Management is through the exclusion of known trigger foods, which may appear to be simple, but is highly problematic if coupled with a pre-existing food allergy or for individuals following a vegetarian/vegan diet. Immunotherapy to pollens is not an effective treatment for PFS, and although oral or sublingual immunotherapy to foods seems more promising, large, controlled studies are needed. The typically mild symptoms of PFS can lead to an erroneous perception that this condition is always easily managed, but severe reactions can occur, and anxiety about the onset of symptoms to new foods can have a profound effect on quality of life.

Is oral food challenge useful to avoid complete elimination in Japanese patients diagnosed with or suspected of having IgE-dependent hen's egg allergy? A systematic review

BACKGROUND

IgE-mediated egg allergy is a common food allergy worldwide. Patients with egg allergy are known to easily achieve tolerance compared to other allergens such as nuts. Oral food challenge (OFC) is often performed on patients diagnosed with or suspected of having IgE-mediated food allergy, but whether hen's egg OFC is useful in IgE-dependent egg allergy patients to avoid complete elimination remains unknown.

METHODS

We identified articles in which OFCs were performed in Japanese patients diagnosed with or suspected of having IgE-mediated egg allergy. We evaluated whether the OFCs were useful to avoid the complete elimination of eggs by assessing the following: (1) the number of patients who could avoid complete elimination; (2) the number of patients who experienced serious adverse events (SAEs); or (3) adverse events (AEs); (4) improvement in quality of life (QOL); and (5) immunological changes.

RESULTS

Fifty-nine articles were selected in the study; all the references were case series or case studies in which OFC was compared to pre-challenge conditions. The overall negative ratio against egg OFC was 62.7%, but an additional 71.9% of OFC-positive patients could take eggs when expanded to partial elimination. Of the 4182 cases, 1146 showed AEs in the OFC, and two cases reached an SAE. Two reports showed an improvement in QOL and immunological changes, although the evidence was weak.

CONCLUSIONS

OFCs against eggs may be useful to avoid complete elimination, but medical professionals should proceed with the test safely and carefully.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exacerbating factors and disease burden in patients with atopic dermatitis

The number of patients with atopic dermatitis is on the rise worldwide, and Japan is no exception. According to recent estimates of the percentage of patients with atopic dermatitis in Japan by age, the majority of patients are between 20 and 44 years old. Because the peak age of onset of atopic dermatitis is during infancy, many patients may experience prolonged symptoms from infancy to adulthood. A prolonged clinical course also increases the burden of atopic dermatitis on affected patients. Decreased productivity due to work disruptions, reduced daily activity, higher direct medical costs, fatigue, and daytime sleepiness due to sleep disturbances are typical burdens on patients with atopic dermatitis. In order to reduce these burdens, it is necessary to shorten its clinical course and achieve long-term control without relying on medications, possibly by using avoidance or coping measures of aggravating factors. Typical aggravating factors of atopic dermatitis include irritant dermatitis, food allergy in children, sweating, and psychological stress in adults. Food allergy places a heavy burden on the quality of life of affected patients and their families. The effectiveness of educational interventions for sweating and psychological stress is unclear. We must also evaluate the economic burden and cost-effectiveness of interventions on the patient as aggravating factors to be addressed.

Food allergy treatment value: Child caregiver and patient perspectives

BACKGROUND

Food allergy is a major health problem that significantly impacts quality of life (QoL). There is growing focus to evaluate food allergy-related QoL and treatment options' value beyond the clinical effectiveness perspective by engaging patients and caregivers. We aimed to identify and prioritize outcomes important to food allergy parents of children and patients allergic to milk, egg, and/or peanut, to guide comparative effectiveness research (CER) that focuses on evaluating food allergy treatment decisions.

METHODS

We conducted a modified 3-round Delphi study to identify and derive consensus on priority treatment outcomes for parents of children and adult patients with diagnosed allergies to at least one of three major allergenic foods (milk, egg, and peanut) from across the United States.

RESULTS

Round 1 yielded 44 statements for round 2, and 39 statements reached the agreement level for round 3 ranking. Statements were organized under 4 sections: 1) food allergy problems, 2) treatment experiences, 3) important treatment outcomes, and 4) value of different treatment options.

CONCLUSION

Food allergy parents and patients face several social, psychological, medical, healthcare, financial, food selection, and awareness challenges. The areas of consensus on important treatment outcomes revealed shared priority for reducing the risk of potentially fatal allergic reactions and having reliable treatments. The most valued treatment options reflect hope for permanent cure and fear of serious allergic reactions.

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.

A scoping review of the caregiver burden of pediatric food allergy

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTIONS

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

RESULTS

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

CONCLUSION

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

Food Allergies: An Example of Translational Research

Food allergies have been rising in prevalence since the 1990s, imposing substantial physical, psychosocial, and economic burdens on affected patients and their families. Until recently, the only therapy for food allergy was strict avoidance of the allergenic food. Recent advances in translational studies, however, have led to insights into allergic sensitization and tolerance. This article provides an overview of cutting-edge research into food allergy and immune tolerance mechanisms utilizing mouse models, human studies, and systems biology approaches. This research is being translated and implemented in the clinical setting to improve diagnosis and reduce food allergy's public health burden.

Quality of life of children aged 8-12 years undergoing food allergy oral immunotherapy: Child and parent perspective

BACKGROUND

Oral immunotherapy (OIT) for food allergy improves the quality of life (QOL) of children from parental perspective but little is known about the child perception.

METHODS

The Food Allergy Quality of Life Questionnaire-Child Form (FAQLQ-CF) was administered to children aged 8-12 years, and the FAQLQ-Parent Form (FAQLQ-PF) was administered to their parents at the start of OIT for milk, egg, peanut, sesame, or tree nuts, at the end of up-dosing, and after 6 months of follow-up. Food-allergic children not undergoing OIT served as controls. Children QOL scores were compared to their parents.

RESULTS

The total FAQLQ-CF score of 103 children undergoing OIT improved significantly from start of OIT (median (IQR); 4.8, 3.8-5.7) to end of up-dosing (3.9, 3-5.2) (P < .001). A greater improvement was noted in the 56 children who reached a follow-up visit, from 5.0 (3.7-5.8) at OIT start to 3.1 (1.8-5.0) on follow-up, (P < .001). In contrast, FAQLQ-CF scores of control patients improved mildly and nonsignificantly between the two time points from 5.3 (4.3-5.7) to 4.8 (3.6-6.0), (P = .13). The improvement in the total FAQLQ-CF scores from OIT start to follow-up was significantly greater compared to the change in control patients during observation (P = .015). Parents reported better QOL scores compared to their children at all stages of OIT (start 4.0, 3.2-5, P = .004; end of up-dosing 2.9, 1.9-4.7, P = .04; follow-up 2.2, 1.6-3.6, P = .003).

CONCLUSIONS

QOL of food-allergic children undergoing OIT improves significantly compared to controls. Parents perceive QOL to be better than the perception of the children.

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

Background

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

Methods

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

Results

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

Conclusions

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

A Study of Dietary and BMI Changes Over Time in Mothers of Children with Food Allergies

Few follow-up surveys have been conducted with regard to the changes in diet of mothers of children with food allergy. We examined changes in food and BMI over time in the mothers of children with food allergies. A total of 146 mothers completed a diet survey twice, with the first conducted in 2013-2016 and the second in 2018, and the dietary changes were examined. Furthermore, among the 120 mothers who eliminated eggs from their diet in the first survey, 98 continued to eliminate eggs and 22 reintroduced eggs during the second survey, and the change over time was examined. Additionally, factors related to BMI were analyzed. We observed a change in the amount of egg intake over time within each group. As the number of children who consumed eggs as the causative food declined, the amount of eggs consumed by the concerned mothers significantly increased (median: 7.8 g/1,000 kcal→12.7 g/1,000 kcal) (p<0.01), even in children who continued to not consume eggs. We found a negative correlation between BMI in mothers of children with FA and vegetable protein. The mothers indicated that their awareness on food allergy improved, which we believe led to increased consumption of foods that had been restricted thus far. BMI was believed to be related to synchronization with the elimination-substitution diet.

Epidemiology and Burden of Food Allergy

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.

Association Between Lifestyle Characteristics and Body Mass Index of Mothers of Children With Allergic Diseases

Background

For mothers of children with allergic diseases, the amount of physical activity involved in childcare increases owing to factors, such as the need for diet therapy and environmental improvements. Reportedly, the body mass index (BMI) of mothers of children with food allergies (FAs) is significantly lower than that of those of children without allergies (non-FA mothers). The aim of this study was to evaluate the characteristics of diet and physical activity in FA mothers and to clarify their effects on BMI.

Methods

To investigate the association between lifestyle characteristics and BMI in 69 mothers of children with FA, bronchial asthma and atopic dermatitis, their diets and physical activity pattern (using a three-axis accelerometer) were investigated; dietary and physical activity patterns (every hour) were extracted using principal component analysis, and multiple regression analyses were performed.

Results

Multiple regression analyses revealed a significant positive correlation (P = 0.037) between BMI and the third principal component of dietary patterns (positive correlation with cereals and negative correlation with sweets), a significant negative correlation (P = 0.004) between BMI and FA and the total daily duration of performing low- and moderate-intensity physical activity (P = 0.031) and a significant positive correlation (P = 0.008) between FA and the first principal component of physical activity expenditure patterns (patterns of ongoing physical activity throughout the day). In FA mothers (n = 51), a significant positive correlation (P = 0.042) was observed between the third principal component of dietary patterns and BMI.

Conclusion

Low BMI in FA mothers may be related to reduced cereal intake, increased sweets intake and prolonged and continuous low- and moderate-intensity physical activity.

Reduced Final Height and Inadequate Nutritional Intake in Cow's Milk-Allergic Young Adults

BACKGROUND

Growth impairment was previously described in milk-allergic children but was not examined in adults on reaching final height.

OBJECTIVES

To investigate the dietary intake and final stature of young adults with IgE-mediated cow's milk allergy (IgE-CMA) as compared with nonallergic controls.

METHODS

Eighty-seven patients with IgE-CMA, median age 19.5 years (interquartile range [IQR], 17.3-22.7), and 36 control participants without food allergies, median age 22.7 years (IQR, 18.9-26.1), were studied. Anthropometric and nutritional data were collected. Age and gender z-scores were determined according to the Centers for Disease Control and Prevention growth charts. Nutrient intake assessment was based on dietary records. Individuals with conditions or treatments affecting bone metabolism or growth, other than asthma, were excluded.

RESULTS

Mean values of height z-scores were significantly reduced in CMA subjects compared with controls (-0.64 ± 0.9 vs -0.04 ± 0.7, P = .001). In contrast, no differences were found between the 2 groups in weight and body mass index z-scores. Patients with CMA had significantly lower intake of protein, and several essential vitamins (A, B12, and riboflavin) and minerals (calcium, potassium, phosphorus, magnesium, and zinc) compared with controls (P < .05), but the intakes of calories, carbohydrate, and fat were not significantly different between the 2 groups. Differences between actual and expected (based on midparental height) height z-scores were comparable in CMA subjects with or without asthma and between those with and without additional food allergies.

CONCLUSIONS

Young adults who have CMA from infancy are at risk of not reaching their growth potential. Growth and nutritional monitoring and appropriate dietary intervention are of particular importance in these at-risk individuals.

Quality of Life of Food-Allergic Patients Before, During, and After Oral Immunotherapy

BACKGROUND

Oral immunotherapy (OIT) for food allergy is demanding but data on patients' quality of life (QOL) throughout the process are limited.

OBJECTIVE

To characterize changes in QOL of food-allergic patients during and after OIT.

METHODS

In a prospective cohort study, the Food Allergy Quality of Life Questionnaire-Parental Form (FAQLQ-PF) was administered to parents of 191 consecutive children aged 4 to 12 years undergoing OIT for food allergy. Questionnaires were administered at OIT initiation, mid up-dosing, upon reaching maintenance, and after 6 months of follow-up. Age- and sex-matched food-allergic children (n = 48) not undergoing OIT served as controls.

RESULTS

FAQLQ-PF scores had significantly improved (decreased) from OIT initiation to reaching full maintenance (emotional impact [EI], 3.66-3.32, P = .001; food anxiety [FA], 3.90-3.32, P < .001; social and dietary limitation [SDL], 3.50-2.94, P < .001; and total score, 3.69-3.19, P < .001) and partial maintenance, whereas no change was noted in control patients. Worse baseline QOL, single food allergy, and a younger age predicted greater QOL improvement. Of the 85 (88.5%) patients who completed the FAQLQ-PF at mid up-dosing and for whom QOL deteriorated, a significant improvement was noted upon reaching maintenance. Additional significant improvement in QOL was observed in the 95 (88.8%) patients who completed the FAQLQ-PF 6 months after reaching maintenance (EI, 3.414-2.993, P = 0.049; FA, 3.37-2.593, P = .001; SDL, 2.989-2.264, P = .001; and total score, 3.266-2.614, P = .001).

CONCLUSION

The QOL of food-allergic children improves significantly upon reaching OIT maintenance, with additional improvement 6 months later. The detrimental effect of OIT on some patients' QOL during up-dosing is reversed upon reaching maintenance.

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.

Changes in patient quality of life during oral immunotherapy for food allergy

BACKGROUND

Quality of life (QOL) is impaired in patients with food allergy and improves following oral immunotherapy (OIT). However, the treatment itself is prolonged and demanding. We examined changes in patient QOL during OIT for food allergy.

METHODS

The FAQLQ-PF was administered to children aged 4-12 years undergoing OIT for milk, peanut, or egg allergy, at the beginning and after 4 months of treatment. Patients were categorized as improved, unchanged, or diminished FAQLQ-PF (>0.5 point decrease, a change of ≤0.5 points, or >0.5 increase, respectively) and compared. Food-allergic patients not undergoing OIT served as controls.

RESULTS

The Food Anxiety, Social and Dietary Limitation, and total FAQLQ-PF scores improved significantly during the study period (P=.001, P=.018, and P=.01, respectively) in treated but not in control patients, while the Emotional Impact did not. The change in the FAQLQ-PF was independent of the maximal tolerated dose at baseline or following four months of treatment, the pace of dose increase, or the number or severity of reactions experienced. The total FAQLQ-PF score was inversely associated with the score at baseline on multivariate analysis (regression coefficient=-0.56, P<.001). That was driven primarily by improvement in QOL scores in patients with high score (worse QOL) at baseline. Some patients with low FAQLQ-PF score (better QOL) at baseline deteriorated.

CONCLUSIONS

QOL of patients with food allergy improves in some but deteriorates in others during OIT. Patients with impaired QOL at baseline improve significantly despite the treatment burden. Some patients with better QOL at baseline might deteriorate during OIT.

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.

Quality of Life Among Food Allergic Patients and Their Caregivers

Food allergy is increasing in prevalence worldwide. This review summarizes progress made studying relationships between food allergy and quality of life (QOL), with an emphasis on recent work in the field. Early work examining QOL among food allergy patients established that stress and anxiety associated with continuous allergen avoidance and the looming threat of anaphylaxis were associated with significantly impaired food allergy quality of life (FAQOL) for children with food allergy and their caregivers. Recent clinical studies suggest that undergoing oral food challenge to confirm food allergy and oral immunotherapy to treat food allergy may each improve FAQOL among both patients and their caregivers. Other intervention modalities, such as nurse-facilitated counseling and educational workshops, also hold promise, but additional work is needed. Future work must strive to recruit more representative, population-based samples, including adult patients, in order to improve the generalizability and clinical relevance of findings.

Patient quality of life following induction of oral immunotherapy for food allergy

BACKGROUND

Patient quality of life improves following successful completion of oral immunotherapy (OIT), but the process itself might have undesirable effects. We aimed to evaluate patient quality of life following OIT initial induction.

METHODS

The Hebrew version of the Food Allergy Quality of Life Questionnaire-Parental Form (FAQLQ-PF) was validated and administered to the parents of children following the first week of OIT for food allergy (n = 119). Patient demographics and clinical history as well as the course of initial induction week were reviewed.

RESULTS

Pre-OIT severity of food allergy, defined as severity of reactions due to accidental exposure to the allergenic food (anaphylactic reactions, p = 0.017; epinephrine use, p = 0.049; emergency room referrals p = 0.003; and hospital admissions, p = 0.015) and a lower number of tolerated doses during initial induction, reflective of a lower maximal tolerated dose for the different allergens (p = 0.011) were associated with worse total FAQLQ-PF scores. The number of tolerated doses during induction and pre-OIT emergency room referrals remained significantly associated with worse total score of the FAQLQ-PF on multivariate analysis (p = 0.016 and p = 0.005, respectively). The correlation between the number of tolerated doses and quality of life scores was moderate-strong primarily in children aged 6-12 years (Total score, r = -0.41, p = 0.001; Emotional Impact r = -0.42, p = 0.001; Food Anxiety, r = -0.38, p = 0.002; Social and Dietary Limitations, r = -0.33, p = 0.009).

CONCLUSIONS

Pre-OIT reaction severity affects quality of life in both preschool and school-aged food-allergic children. In contrast, a lower maximal tolerated dose during OIT induction is associated with worse indices of quality of life primarily in children aged 6-12 years.

Cardiovascular Risk Factors in Parents of Food-Allergic Children

Previous studies suggest that chronic stress may induce immune system malfunction and a broad range of adverse health outcomes; however, the underlying pathways for this relationship are unclear. Our study aimed to elucidate this question by examining the relationship between parental cardiovascular risk factors including systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), and waist-to-hip ratio (WHR) and maternal psychological stress score (MPSS) relative to the severity of the child's food allergy (FA) and number of affected children. SBP, DBP, BMI, and WHR were measured and calculated at the time of recruitment by trained nurses. MPSS was obtained based on self-report questionnaires covering lifestyle adjustments, perceived chronic stress, and quality of life. General linear models examined whether caregiver chronic stress was associated with FA. For mothers with children under age 5 years, SBP, DBP and number of affected children had strong and graded relationships with severity of the child's FA. MPSS was also significantly and positively associated with child FA severity (P < 0.001). However, no relationships were found between FA severity, BMI, or WHR for either parent. This was also the case for paternal SBP, DBP, and number of affected children of any age. There is a strong and graded link between cardiovascular risk and perceived stress in mothers of food-allergic children under age 5. Findings may have important implications for family-centered care of FA, may generalize to caregivers of children with chronic conditions, and extend the literature on allostatic load.

The compliance and burden of treatment with the epinephrine auto-injector in food-allergic adolescents

BACKGROUND

Food-allergic patients at high risk of potential fatal anaphylaxis should carry an epinephrine auto-injector (EAI) at all times. This treatment may be perceived as burdensome and this may affect compliance and health-related quality of life (HRQL). The aims of the study were (1) to determine the burden of treatment (BoT) of an EAI, (2) to examine the relationship between this burden and compliance, and (3) to analyze which factors contribute to the BoT of the EAI as perceived by food-allergic adolescents and their parents.

METHODS

Dutch food-allergic adolescents prescribed an EAI, and their parents completed a questionnaire package (n = 55). Relationships between BoT and HRQL, illness severity and perception, and anxiety measures were investigated.

RESULTS

Food-allergic adolescents and their parents were (extremely) positive about the EAI (54.5%; 72.7%, respectively) (=low BoT). The BoT measure showed a significantly greater burden in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times than adolescents who reported they did. The BoT scores of both adolescents and their parents were not associated with HRQL, illness severity and perception, or trait anxiety.

CONCLUSIONS

The majority of food-allergic adolescents and their parents were positive about the EAI (=low BoT). However, the BoT was significantly associated with self-reported compliance with carrying the EAI. The BoT was higher in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times. The BoT measure seems to be a useful tool to study compliance with carrying an EAI. The BoT of an EAI is not associated with HRQL. The BoT measures a distinct concept related to compliance behavior.