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

Pearls for practice from the 2023 joint task force anaphylaxis practice parameter

PURPOSE OF REVIEW

To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter.

RECENT FINDINGS

The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis.

SUMMARY

The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.

Alterations in Child Feeding Behavior: An Underrecognized Clinical Complication of Food Allergy

BACKGROUND

Food allergy (FA) affects around 5.6 million children in the United States, conferring risk for negative impacts on growth and psychosocial functioning. While evidence suggests a higher prevalence of feeding difficulties in children with FA, the link between FA and feeding dysfunction remains unclear.

OBJECTIVE

To investigate feeding problems in children with parent-reported IgE-mediated FA and/or pediatric feeding disorder (PFD) compared with healthy children in a community-based sample and explore factors associated with feeding problems in children with FA.

METHODS

A matched cross-sectional cohort study used survey data from 352 parents of children aged 6 months to 7 years who reported a diagnosed IgE-mediated FA and/or PFD (50 with FA only, 67 with FA and PFD, and 235 with PFD only). Healthy children were matched based on age, sex, race, and socioeconomic factors. Feeding problems were assessed using the Pediatric Eating Assessment Tool. Matched-pairs generalized linear regressions compared each cohort and explored factors associated with feeding problems in children with FA.

RESULTS

Children with FA exhibited significantly higher feeding problems compared with healthy children. Children with a diagnosed PFD had more severe feeding problems, irrespective of comorbid FA. Factors linked with feeding problems in children with FA included older age, non-White race, increased medical comorbidity, and limited dietary variety.

CONCLUSIONS

This study adds to evidence indicating a higher prevalence of feeding problems in children with FA. Clinicians treating FA patients should routinely screen for feeding and growth concerns and consider referral to multidisciplinary feeding programs as needed.

EAACI guidelines on the management of IgE-mediated food allergy

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

Immunoglobulin E (IgE)-mediated food allergy

Food allergy is defined as an adverse immunologic response to a food. Immunoglobulin E (IgE)-mediated reactions to foods are associated with a broad range of signs and symptoms that may involve any of the following body systems: the skin, gastrointestinal tract, respiratory tract, and cardiovascular system. IgE-mediated food allergy is a leading cause of anaphylaxis. Therefore, timely and appropriate diagnosis and treatment are imperative. A diagnosis of food allergy entails a careful history and diagnostic tests, which may include skin prick tests, serum-specific IgE, and oral food challenge. The goal of food allergy care is to empower patients and caregivers to manage the risk of food-allergic reactions, reduce food allergy-related anxiety, and achieve a sense of control over their condition. This can be achieved in different ways for different patients and across different life stages. This article provides an overview of the epidemiology, pathophysiology, diagnosis, and management of IgE-mediated food allergy.

Primary prevention of food allergy: beyond early introduction

Food allergy typically begins early in life and persists as a lifelong condition. Delayed introduction of allergenic foods followed by years of hesitancy to introduce these foods early may have contributed to the increase in food allergy prevalence in recent decades. Most infant feeding guidelines focus on the importance of early introduction of allergenic foods in infants at around age 4-6 months. However, regular, ongoing ingestion of allergenic foods is also critical for the primary prevention of food allergy. Similarly, intermittent exposure to cow's milk formula (CMF) in early infancy increases the risk of cow's milk allergy (CMA), while regular exposure (if it is introduced) prevents it. Families hesitant to introduce allergenic foods to their infant at home (despite education) should be offered introduction in a primary care clinic. Infants who have failed primary prevention should be referred to an allergist for consideration of early infant oral immunotherapy (OIT).

'You grow with the allergy': a grounded theory study of families' experiences with food allergy risk or diagnosis in early childhood

OBJECTIVE

Childhood food allergy is increasing in western societies. Preventing and managing food allergies is therefore essential for both parents and children. Given the limited previous research on parents' experiences of food allergy prevention in early childhood, this study aimed to develop a grounded theory to understand the experiences and interactions of families whose children are at risk of, or have been diagnosed with, food allergy.

DESIGN

Using a constructivist grounded theory approach, we used initial, focused and theoretical coding, as well as constant comparative analysis and memoing to interpret our data.

SETTING

Thematic interviews were conducted in Germany between March and September 2022.

PARTICIPANT

We included 28 carers (25 mothers and 3 fathers) of children aged 0-3 years diagnosed with food allergy or at risk of food allergy. We recruited participants using snowball and theoretical sampling.

RESULTS

We developed a theory that we named 'negotiating uncertainty in childhood food allergy'. This theory describes the experiences and interactions of families with a child at risk or diagnosed with food allergy with the central phenomena of negotiation uncertainty. Negotiation is used to transform perceived challenges of uncertainty into feelings of competence in relation to (the prevention of) food allergy. Core themes included 'parental roles', 'healthcare', 'childcare', 'informal support' and 'family routines'. To cope with the challenges, parents relied on two main resources: self-efficacy and health literacy.

CONCLUSION

The study highlights the dynamic process of negotiation within families at risk of or coping with paediatric food allergy. Furthermore, our findings highlight the need to promote parental health literacy.

Exploring young adults' experiences with food allergy during their teenage years: A practice research study

INTRODUCTION

Symptoms of anxiety, eating disorders and social isolation are prevalent among teenagers with food allergy compared to peers without. Treatment of teenagers with food allergy focus on preventing anaphylactic reactions, with little attention to promoting social and emotional well-being. The aim of the study was to explore young adults' perspectives on everyday life with food allergy during their teenage years to improve future clinical practice.

METHODS

Critical psychological practice research. During a 2-day camp the perspectives of 10 young adults (18-23 years) were explored through participant observation and informal interviews. Three follow up interviews were conducted. A co-researcher group discussed preliminary results, clinical challenges and ways forward.

RESULTS

Being together with peers with food allergy was crucial, fostering belonging and normalisation. The shift in responsibility of managing the risk feels overwhelming and stressful during teen age. Self-understanding was influenced when managing food allergy in social contexts, inducing feelings of burden and isolation. Acceptance and understanding from social relations became important for all participants, and they all underlined desire for being viewed as individuals rather than being defined by their allergy.

CONCLUSION

Support from other peers with food allergy is crucial for the participants. Transition to independently managing risks introduces uncertainty and social constraints, affecting self-understanding and interactions. Clinicians should prioritise peer support and empower teenagers in managing the risk and psychosocial challenges.

From bite to brain: Neuro-immune interactions in food allergy

Immunoglobulin E (IgE)-mediated food allergies are reported to affect around 3.5% of children and 2.4% of adults, with symptoms varying in range and severity. While being the gold standard for diagnosis, oral food challenges are burdensome, and diagnostic tools based on specific IgE can be flawed. Furthering our understanding of the mechanisms behind food allergy onset, severity and persistence could help reveal immune profiles associated with the disease, to ultimately aid in diagnosis. Alterations to cytokine levels and immune cell ratios have been identified, though further research is needed to fully capture the heterogenous nature of food allergy. Moreover, the existence of such immune alterations also raises the question of potential wider systemic effects. For example, recent research has emphasised the existence and impact of neuro-immune interactions and implicated behavioural and neurological changes associated with food allergy. This review will provide an overview of such food allergy-driven neuro-immune interactions, with the aim of emphasising the importance of furthering our understanding of the immune mechanisms underlying IgE-mediated food allergy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Innate lymphoid cells in immunoglobulin E-mediated food allergy

PURPOSE OF REVIEW

Recognition of the importance of innate lymphoid cells (ILCs) in the immune mechanisms of food allergy has grown in recent years. This review summarizes recent findings of ILCs in immunoglobulin E (IgE)-mediated food allergy. New research on ILCs in the context of the microbiome and other atopic diseases are also considered with respect to how they can inform understanding of the role of ILCs in food allergy.

RECENT FINDINGS

ILCs can mediate allergic and tolerogenic responses through multiple pathways. A novel subset of interleukin (IL)-10 producing ILC2s are associated with tolerance following immunotherapy to grass pollen, house dust mite allergy and lipid transfer protein allergy. ILC2s can drive food allergen-specific T cell responses in an antigen-specific manner. A memory subset of ILC2s has been identified through studies of other atopic diseases and is associated with effectiveness of response to therapy.

SUMMARY

The role of ILCs in food allergy and oral tolerance is relatively understudied compared to other diseases. ILCs can modulate immune responses through several mechanisms, and it is likely that these are of importance in the context of food allergy. Better understanding of theses pathways may help to answer fundamental questions regarding the development of food allergy and lead to novel therapeutic targets and treatment.

Gut microbiome features in pediatric food allergy: a scoping review

Increasing evidence suggests that alterations in the gut microbiome (GM) play a pivotal role in the pathogenesis of pediatric food allergy (FA). This scoping review analyzes the current evidence on GM features associated with pediatric FAs and highlights the importance of the GM as a potential target of intervention for preventing and treating this common condition in the pediatric age. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we searched PubMed and Embase using the keywords (gut microbiome OR dysbiosis OR gut microbiota OR microbiome signatures) AND (food allergy OR IgE-mediated food allergy OR food protein-induced allergic proctocolitis OR food protein-induced enterocolitis OR non-IgE food allergy OR cow milk allergy OR hen egg allergy OR peanut allergy OR fish allergy OR shellfish allergy OR tree nut allergy OR soy allergy OR wheat allergy OR rice allergy OR food sensitization). We included 34 studies reporting alterations in the GM in children affected by FA compared with healthy controls. The GM in pediatric FAs is characterized by a higher abundance of harmful microorganisms (e.g., Enterobacteriaceae, Clostridium sensu stricto, Ruminococcus gnavus, and Blautia spp.) and lower abundance of beneficial bacteria (e.g., Bifidobacteriaceae, Lactobacillaceae, some Bacteroides species). Moreover, we provide an overview of the mechanisms of action elicited by these bacterial species in regulating immune tolerance and of the main environmental factors that can modulate the composition and function of the GM in early life. Altogether, these data improve our knowledge of the pathogenesis of FA and can open the way to innovative diagnostic, preventive, and therapeutic strategies for managing these conditions.

Allergic Diseases and Mental Health

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

Introducing NASN's School Nursing Evidence-Based Clinical Practice Guideline: Allergy and Anaphylaxis CPG and Implementation Toolkit

Clinical Practice Guidelines (CPGs) are statements informed by a systematic review of research/evidence and provide recommendations for clinical practice to improve healthcare quality and patient outcomes. The National Association of School Nurses (NASN) released School Nursing Evidence-Based Clinical Practice Guideline: Students with Allergies and Risk for Anaphylaxis, in 2023, to provide evidence-based recommendations specific to school nursing practice and support the role of the school nurse in providing high-quality care for school-age children with allergies and risk for anaphylaxis. This article will provide an overview of the CPG and Implementation Toolkit. The implementation toolkit is designed to provide school nurses with tools and resources to implement the recommendations into practice. These tools and resources include school policies; nursing assessments and intake; planning, training, implementing, and evaluating care; and data collection. Examples are discussed, including how to customize the toolkit resources to your current practice needs.

Oral Immunotherapy: An Overview

Oral immunotherapy (OIT) is an alternative treatment of IgE-mediated food allergy that has been shown to increase tolerance threshold to many of the top food allergens, although this effect may be dependent on age, dose, frequency, and duration. OIT has been shown to be effective and safe in infants, and early initiation can improve rates of desensitization even for those foods whose natural history favors loss of allergy. Studies looking at protocol modification to improve OIT success are ongoing as is the evaluation of clinical tools to help monitor OIT effects.

An investigation of a novel milk allergy-friendly food supplement program

Introduction

Compared to households not managing food allergy, households managing food allergy are faced with greater direct and indirect costs. To address these cost burdens, we developed and piloted a milk allergy-friendly food supplement program for lower- and middle-income households managing a dairy allergy in a child age <6 years. Herein, we aimed to evaluate to the impact of this program on food costs, food security, and caregiver mental health using a longitudinal design.

Methods

Participants living in or near the city of Winnipeg, in Manitoba, Canada were recruited from January to February 2022 via social media, word-of-mouth, and a database maintained by the principal investigator. Consenting participants took part in a 6-month allergen-friendly food supplement program that provided them with biweekly deliveries of allergen-friendly foods free of charge. To evaluate the impact of the program on food costs, food security, and well-being, participants completed a series of questionnaires at baseline, mid-point, and at the end of the program. Changes in these variables were assessed via a series of Friedman tests.

Results

The final sample was comprised of 8 households. Relative to baseline, participants reported higher total direct food costs at midpoint (+5.6%) and endpoint (+13.5%), but these changes did not reach statistical significance. In contrast, total indirect food costs decreased over the course of the study relative to baseline (midpoint = -28.2%; endpoint = -18.5%), but the changes were not found to be statistically significant. Participants did, however, report a statistically significant decrease in costs related to lost time from work or school as a result of their child's food allergy at endpoint relative to baseline (-100%). Few changes in food security, caregiver well-being, or child food allergy quality of life were noted.

Discussion

The provision of allergen-friendly foods helped keep grocery costs below the pace of inflation. Participants also reported reduced costs associated with missed time from work or school as a result of their child's food allergy. Despite these encouraging findings, a relatively high proportion of the current sample reported experiencing food insecurity throughout the study period, suggesting that additional financial support for families is needed.

Management of food allergy based on oral food challenge

PURPOSE OF REVIEW

Food allergy is a growing health problem that affects both patients and society in multiple ways. Despite the emergence of novel diagnostic tools, such as component-resolved diagnostics (CRD) and basophil activation tests (BAT), oral food challenge (OFC) still plays an indispensable role in the management of food allergies. This review aimed to highlight the indications and safety concerns of conducting an OFC and to provide insights into post-OFC management based on recent findings.

RECENT FINDINGS

Standardized OFC protocols have regional diversification, especially in Japan and Western countries. Recent studies suggested that the interval between doses should be at least more than an hour. Furthermore, applying a stepwise method tailored to the patient's specific immunoglobulin E level and history of anaphylaxis seems to mitigate these risks. Recent surveys have shown that, following a positive OFC, options other than strict avoidance are also selected.

SUMMARY

OFC serves diverse purposes, yet the risks it carries warrant caution. The stepwise protocol appears promising for its safety. Subthreshold consumption following OFC shows potential; however, further research on its efficacy and safety is required. Management following OFC should be tailored and well discussed between clinicians and patients.

Perspectives in the validation of DEFASE: a paradigm shift in food allergy management

PURPOSE OF REVIEW

To explore the groundbreaking international consensus on the DEFASE (DEfinition of Food Allergy Severity) project as a revolutionary grading system for IgE-mediated food allergy severity. Against the backdrop of the growing public health challenge posed by food allergy, this article delves into the importance of validating and implementing DEFASE in real-world clinical settings.

RECENT FINDINGS

With new therapeutic options available for food allergy, including biologics alongside immunotherapy, it is urgent to properly support clinical decision-making in the management of the disease. The DEFASE score is the first international consensus-based grading system of severity associated with food allergy as a whole disease embracing multidisciplinary perspectives from different stakeholders involved. In its current version, this comprehensive scoring system has been developed to be used in research settings.

SUMMARY

The review emphasizes the potential impact of DEFASE on patient outcomes, healthcare management, and resource allocation, underscoring its significance for the allergy scientific community. Future research should focus on internal and external validation of the scoring system, targeting these models to various food allergenic sources, populations, and settings.

Dismantling the myth of "all foods fit" in eating disorder treatment

We call for a reevaluation of the long-standing dogmatic nutritional principle that "all foods fit" for all cases of eating disorders (EDs) and its corollary, "there are no bad foods" (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.

Differences in the Course, Diagnosis, and Treatment of Food Allergies Depending on Age-Comparison of Children and Adults

Food allergy (FA) has become a common global public health issue, with a growing prevalence in the modern world and a significant impact on the lives of patients, their families, and caregivers. It affects every area of life and is associated with elevated costs. Food allergy is an adverse immune reaction that occurs in response to a given food. The symptoms vary from mild to severe and can lead to anaphylaxis. This is why it is important to focus on the factors influencing the occurrence of food allergies, specific diagnostic methods, effective therapies, and especially prevention. Recently, many guidelines have emphasized the impact of introducing specific foods into a child's diet at an early age in order to prevent food allergies. Childhood allergies vary with age. In infants, the most common allergy is to cow's milk. Later in life, peanut allergy is more frequently diagnosed. Numerous common childhood allergies can be outgrown by adulthood. Adults can also develop new IgE-mediated FA. The gold standard for diagnosis is the oral provocation test. Skin prick tests, specific IgE measurements, and component-resolved diagnostic techniques are helpful in the diagnosis. Multiple different approaches are being tried as possible treatments, such as immunotherapy or monoclonal antibodies. This article focuses on the prevention and quality of life of allergic patients. This article aims to systematize the latest knowledge and highlight the differences between food allergies in pediatric and adult populations.

Interaction Between Baseline Participant Factors and Treatment Effects Following Peanut Oral Immunotherapy

BACKGROUND

The Probiotic Peanut Oral Immunotherapy-003 multicenter randomized trial found that both probiotic peanut oral immunotherapy (PPOIT) and peanut OIT alone (OIT) were effective compared with placebo in inducing clinical remission after 18 months of treatment, and improving health-related quality of life (HRQL) at 12 months after treatment. Understanding treatment effect modifiers can optimize outcomes through precision care.

OBJECTIVES

This post hoc study examined baseline clinical and demographic participant factors that modified treatment effects.

METHODS

The study sample included 201 children (aged 1-10 years) with challenge-confirmed peanut allergy. Exposure variables were baseline clinical and demographic factors. Outcomes were remission (double-blind, placebo-controlled food challenge, cumulative 4,950-mg peanut protein at 8 weeks after treatment) and HRQL (change in Food Allergy Quality of Life Questionnaire-Parent Form score). Interactions between baseline factors and treatment effects on remission and HRQL were explored with regression models.

RESULTS

A higher degree of peanut sensitivity (large peanut skin prick test, high peanut specific IgE, and low reaction-eliciting dose at study entry challenge) and other concurrent allergic conditions (multiple food allergies, asthma, or wheeze) were associated with the decreased likelihood of attaining remission after both PPOIT and OIT treatment. History of anaphylaxis was associated with the reduced likelihood of remission after PPOIT compared with OIT. For the HRQL outcome, there was evidence that sex, history of anaphylaxis, and age modified treatment effects.

CONCLUSIONS

Baseline participant factors modify PPOIT and OIT effects on remission and HRQL. Considering modifiers of treatment effect during participant selection may optimize treatment success and clinical trial design toward specific outcomes, such as the achievement of remission.

Core Outcome Set for IgE-mediated food allergy clinical trials and observational studies of interventions: International Delphi consensus study 'COMFA'

BACKGROUND

IgE-mediated food allergy (FA) is a global health concern with substantial individual and societal implications. While diverse intervention strategies have been researched, inconsistencies in reported outcomes limit evaluations of FA treatments. To streamline evaluations and promote consistent reporting, the Core Outcome Measures for Food Allergy (COMFA) initiative aimed to establish a Core Outcome Set (COS) for FA clinical trials and observational studies of interventions.

METHODS

The project involved a review of published clinical trials, trial protocols and qualitative literature. Outcomes found as a result of review were categorized and classified, informing a two-round online-modified Delphi process followed by hybrid consensus meeting to finalize the COS.

RESULTS

The literature review, taxonomy mapping and iterative discussions with diverse COMFA group yielded an initial list of 39 outcomes. The iterative online and in-person meetings reduced the list to 13 outcomes for voting in the formal Delphi process. One more outcome was added based on participant suggestions after the first Delphi round. A total of 778 participants from 52 countries participated, with 442 participating in both Delphi rounds. No outcome met a priori criteria for inclusion, and one was excluded as a result of the Delphi. Thirteen outcomes were brought to the hybrid consensus meeting as a result of Delphi and two outcomes, 'allergic symptoms' and 'quality of life' achieved consensus for inclusion as 'core' outcomes.

CONCLUSION

In addition to the mandatory reporting of adverse events for FA clinical trials or observational studies of interventions, allergic symptoms and quality of life should be measured as core outcomes. Future work by COMFA will define how best to measure these core outcomes.

The Natural History and Risk Factors for the Development of Food Allergies in Children and Adults

PURPOSE OF REVIEW

This narrative review explores food allergy prevalence and natural history stratified by life stages, especially in context of evolving knowledge over the last few decades.

RECENT FINDINGS

The prevalence of food allergy remains highest in early childhood with common food triggers being cow's milk, soy, hen's egg, wheat, peanut, tree nuts, sesame, fish, and shellfish. This correlates with certain risk factors especially pertinent in the postnatal period which appear to predispose an individual to developing a food allergy. Some allergies (such as milk and egg) were previously thought to be easily outgrown in early life; however, recent studies suggest increasing rates of persistence of these allergies into young adulthood; the reason behind this is unknown. Despite this, there is also evidence demonstrating that food allergies can be outgrown in adolescents and adults. An understanding of the paradigm shifts in the natural history of food allergy allows clinicians to provide updated, age-appropriate, and tailored advice for patients on the management and prognosis of food allergy.

Validity and Reliability of the Korean Versions of the Food Allergy Quality of Life Questionnaire-Child Form and Teenager Form

We aimed to assess the validity and reliability of the Korean versions of the Food Allergy Quality of Life Questionnaire-Child Form (K-FAQLQ-CF) and the Food Allergy Quality of Life Questionnaire-Teenager Form (K-FAQLQ-TF). Patients aged 8-17 years with food allergy (FA) were enrolled and completed the Korean versions of the questionnaires, including the K-FAQLQ-CF, the Food Allergy Independent Measure-Child Form (K-FAIM-CF), and the Pediatric Quality of Life Inventory™ (K-PedsQL™ 4.0) for children and the K-FAQLQ-TF, the Food Allergy Independent Measure-Teenager Form (K-FAIM-TF), and the K-PedsQL™ 4.0 for adolescents. We enrolled 56 children and 23 adolescents in this study. The K-FAQLQ-CF showed a good internal consistency (Cronbach's α coefficient = 0.969) and an excellent test-retest reliability (intraclass correlation coefficient = 0.914, P = 0.011). There was a moderate correlation between the K-FAQLQ-CF and K-FAIM-CF scores (β = 0.736, P < 0.001), indicating construct validity. The K-FAQLQ-CF score was weakly associated with the K-PedsQL™ 4.0 score (β = -0.289, P = 0.031), verifying convergent and discriminant validities. The K-FAQLQ-TF also showed a good internal consistency (Cronbach's α coefficient = 0.966) and test-retest reliability (intraclass correlation coefficient = 0.974, P = 0.005). Construct validity was also established by a moderate correlation with the K-FAIM-TF (β = 0.699, P < 0.001). Our results suggest that the K-FAQLQ-CF and K-FAQLQ-TF are valid and reliable tools to evaluate the quality of life of children and adolescents with FA in Korea.

Psychological support needs for children with food allergy and their families: A systematic review

This systematic review aimed to review the evidence for psychological support for children with food allergies and their families, identify effective psychological interventions, and highlight the support needs for this group. A systematic search was undertaken across six databases (up to October 2023). Articles were checked by three reviewers for inclusion. Study data were extracted, and quality was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was undertaken. A total of 11 papers were included (n = 838 participants). Intervention types were based on cognitive behavioral therapy (CBT; n = 7); psycho-education (n = 1); peer mentoring (n = 1); self-regulation theory (n = 1); and coping (n = 1). Two interventions were for children only, three were for children and parents and six for parents only. Cognitive behavioral therapy-based interventions with highly anxious parents or children or those facilitated by a psychologist showed significant improvements with moderate-to-large effect sizes. The one self-help CBT-based online program showed no effects. Other intervention types reported mainly trends in improvement due to small sample sizes. Most interventions were aimed at supporting children or parents in day-to-day management of food allergy, measuring outcomes such as quality of life, self-efficacy, anxiety, worry, and depression. One intervention was designed to assist with oral immunotherapy outcomes. The majority of the studies had small sample sizes and were feasibility or proof-of-concept studies. Available research evidence points to effectiveness of facilitated CBT-based interventions for those that have high food allergy-related anxiety, but as many studies have small sample sizes and few report effect sizes, no firm conclusions can yet be drawn. A stepped care approach is likely to be useful for this population. Research using large interventional designs, particularly for children and adolescents, are needed.

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.

Diagnostic intervention improved health-related quality of life among teenagers with food allergy

OBJECTIVES

The aim was to examine if a diagnostic intervention set up to assess current food allergy to cow's milk, hen's egg, fish, or wheat among teenagers had an impact on generic and disease specific health-related quality of life (HRQL). The study compared HRQL scoring before and two years after the intervention, and in relation to age matched controls without reported food allergy.

METHODS

The study was performed within the Obstructive Lung Disease in Northern Sweden (OLIN) studies where a cohort study on asthma and allergic diseases among 8-year-old schoolchildren was initiated in 2006. At age 12 years, the 125/2612 (5%) children who reported allergy to cow's milk, hen's egg, fish, or wheat were invited to a diagnostic intervention including clinical examination, blood tests and evaluation by a pediatric allergist. Of 94 participants, 79 completed generic and disease specific HRQL questionnaires. Additionally, a random sample of 200 (62% of invited) children without food allergy from the OLIN cohort answered the generic HRQL questionnaire. The respondents of the HRQL questionnaires were re-examined two years later and 57 teenagers with and 154 without reported allergy participated.

RESULTS

There were no significant differences in generic HRQL scores between teenagers with and without reported food allergy at study entry, or after the intervention. Among those with reported food allergy, we found a significant improvement in disease specific HRQL after the intervention (mean values: 3.41 vs 2.80, p<0.001). Teenagers with only food allergy had better disease specific HRQL compared to those with one, two or three concomitant allergic diseases, both before and after the intervention. Children with only food allergy significantly improved their HRQL after the intervention, 1.84 vs. 2.87 (p<0.001) but this association was not seen in children with one other allergic disorder (3.16 vs. 3.65, p = 0.121) or those with two or more allergic disorders (3.72 vs. 3.90, p = 0.148).

CONCLUSION

The diagnostic intervention showed a long-term improvement of disease specific HRQL but not generic HRQL.

The Finnish versions of food allergy quality of life questionnaires including parent form 10

AIM

Examining health-related quality of life (HRQoL) is important to improve patient care. In this study, we translate and evaluate the Finnish versions of the Food Allergy Specific Quality of Life Questionnaires (FAQLQs) from a Finnish perspective and undertake a detailed evaluation of the 10-question Parent Form Questionnaire (FAQLQ-PF10).

METHODS

This validation study was performed to evaluate the Finnish versions of the FAQLQs. Validation was performed by analysing clinical characteristics, factor loadings and Cronbach's α reliability estimates. The inclusion criteria for participants in this study were having a doctor-diagnosed food allergy or being a parent of a child with a doctor-diagnosed food allergy and being able to answer the questionnaire in Finnish.

RESULTS

Altogether, 247 questionnaires were completed in this study. Most of the respondents had multiple food allergies (77%, 189/247). Spearman's correlations related to the 10-question parent form (FAQLQ-PF10), the 30-question parent form (FAQLQ-PF) and the Food Allergy Severity Measurement-Parent Form (FAIM-PF) were statistically significant (p value = 0.000-0.007). The reliability of the Finnish versions of the FAQLQs measured by Cronbach's α was overall good (0.75-0.981).

CONCLUSION

The Finnish versions of the FAQLQs are reliable and suitable to use, and the FAQLQ-PF10 has good usability.

Anthropological and sociological perspectives on food allergy

This review explores the anthropological and sociological literature on food allergy and identifies four primary areas of research to date. The first explores the relationality and management of risk, uncertainty and stigma among parents and sufferers of food allergies. The second analyses the influence of intersectionality, specifically the effects of class, gender, race/ethnicity and disability on experiences of food allergy. The third discusses diagnostic difficulties and the impact these have on legitimacy and believability, both in the context of clinician-patient relations and in managing food allergies in public spaces. The fourth explores the ethics and uncertainties in food allergy treatments and how scientific knowledge of emerging treatments is constructed. This body of research illustrates that although an individual disease, food allergy experiences are significantly affected by socio-cultural structures, institutions, ideologies and discourses. The review concludes with four primary recommendations. First, there should be more incorporation of anthropological or sociological methodologies and perspectives into studies of food allergy. Second, studies are needed from more countries exploring lived experience of food allergy. Third, research on food allergy needs to incorporate an analysis of intersectional factors such as gender, class and race/ethnicity, and should explore the experiences of minority populations. Fourth, more research is needed on the interactions between biomedicine and local systems of knowledge, as well as the factors that shape what treatments become available, for whom it becomes available, experiences of treatment and aspects (including biases) that influence patient-clinician interactions.

Food allergy-A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review

Following a diagnosis of IgE-mediated food allergy, to secure the best outcome, the patient should receive individualized advice tailored to their specific needs, which considers the type and presentation of the food involved, level of exclusion required, risk of cross-contamination and any variance required for age, ethnicity, financial issues, and lifestyle. Issues such as food labels "may contain" statements, and variation in the threshold of reaction and impact of cofactors should also be considered. Most important is the need to ensure that the diagnosis is robust, especially given the nutritional, psychological, and socioeconomic issues that can affect an individual with a diagnosis of food allergy. Unnecessary exclusion of one or more foods that have not triggered allergic reactions, especially in individuals with allergic comorbidities, can result in severe IgE-mediated reactions on re-exposure. Given that food allergies may change over time, the diagnosis should be reviewed, to determine whether resolution is likely, or new-food triggers are reported. Regular assessment is vital, especially during childhood, to ensure reintroduction occurs at an appropriate time, thus enabling increased diversity of the diet and improvement in the quality of life. For some, an IgE-mediated food allergy may necessitate the life-long exclusion of foods, and for others, a food habitually eaten suddenly triggers an allergic reaction in adult life. People of all ages, ethnicities, and socioeconomic backgrounds deserve individual advice on the management of their food allergy to support a healthy diet and improve quality of life.

The development of the DEFASE project

PURPOSE OF REVIEW

To familiarize the reader with the milestones of the DEFASE (Definition of Food Allergy Severity) project. This World Allergy Organization (WAO) initiative has recently developed the first international consensus-based classification system of severity associated with IgE-mediated food allergy as a whole disease incorporating multidisciplinary perspectives from different stakeholders involved.

RECENT FINDINGS

After a systematic review of current evidence on the definition of severity of food allergy, an e-Delphi methodology has been applied to obtain the consensus/agreement through repeated rounds of survey. This comprehensive scoring system has been developed to be used in research settings in its current version with the scope of stratifying the severity of a clinical situation of food allergy.

SUMMARY

Notwithstanding the limitations due to the complexity of the matter, the recent developed DEFASE definition will be relevant for establishing the levels of diagnostic, management and therapeutic commitment for the disease in the various geographical contexts. Future research should focus on internal and external validation of the scoring system, tailoring of these models to different food allergenic sources, populations, and settings.

Biologicals in IgE-mediated food allergy

PURPOSE OF REVIEW

A better understanding of the most recent scientific literature in the use of biological therapy in the treatment of patients with IgE-mediated food allergy.

RECENT FINDINGS

A systematic review and meta-analysis demonstrated safety and effectiveness of omalizumab in the treatment of food allergy. The findings support the potential use of omalizumab as a monotherapy or as an adjunct to oral immunotherapy in IgE-mediated cow's milk allergy. The potential use of other biologics in the management of food allergy is subject of speculation.

SUMMARY

Different biological therapies are under evaluation for food allergic patients. The advance in literature will guide for a personalized treatment in the near future. However, additional research is needed to better understand the best candidate for each treatment, the optimal dose and timing.

An online, peer-mentored food allergy education program improves children's and parents' confidence

BACKGROUND

Children with food allergy, and their families experience substantial burdens because of efforts necessary to minimize the risk of anaphylaxis. To this end, peer-to-peer education is paramount. Food Allergy Canada offers an online, peer-to-peer mentoring program. However, the impact of this program has not previously been formally evaluated.

OBJECTIVE

To determine if Allergy Pals, an online, peer-to-peer mentoring program, for children aged 7-11 years, increased child and parental food allergy competency, and confidence. Our secondary aim was to qualitatively describe the experiences of the program.

METHODS

From May 2020-May 2021, children and their parents were invited to participate in an online, anonymous survey about Allergy Pals, at pre-program, and post-program. Primary outcomes, which were described and compared using chi2 or t-tests, as appropriate for the respective variables, included food allergy competence (epinephrine carriage, signs and symptoms of anaphylaxis) and food allergy confidence (e.g. comfort asking other for food allergy-related support). Secondary outcomes included child and parent perceptions of the program, which were analysed thematically.

RESULTS

Overall, 17 children completed the pre-program, and 11 completed the post-program survey. Corresponding numbers for parents were 25 and 23. Food allergy competence was high pre-program, and remained so post-program. Food allergy confidence improved from pre-program to post-program. E.g. Children tended to feel less left out (5/12, 41.7%; 3/10; 30.0%, respectively), a finding that was reflected also in parents' scores. Themes identified for child and parent perceptions further supported improved food allergy confidence.

CONCLUSION

Although food allergy competence was high pre-program, Allergy Pals improved food allergy confidence.

Breast milk microRNAs: Potential players in oral tolerance development

Breast milk is an essential source of nutrition and hydration for the infant. In addition, this highly complex biological fluid contains numerous immunologically active factors such as microorganisms, immunoglobulins, cytokines and microRNAs (miRNAs). Here, we set out to predict the function of the top 10 expressed miRNAs in human breast milk, focusing on their relevance in oral tolerance development and allergy prevention in the infant. The top expressed miRNAs in human breast milk were identified on basis of previous peer-reviewed studies gathered from a recent systematic review and an updated literature search. The miRNAs with the highest expression levels in each study were used to identify the 10 most common miRNAs or miRNA families across studies and these were selected for subsequent target prediction. The predictions were performed using TargetScan in combination with the Database for Annotation, Visualization and Integrated Discovery. The ten top expressed miRNAs were: let-7-5p family, miR-148a-3p, miR-30-5p family, miR-200a-3p + miR-141-3p, miR-22-3p, miR-181-5p family, miR-146b-5p, miR-378a-3p, miR-29-3p family, miR-200b/c-3p and miR-429-3p. The target prediction identified 3,588 potential target genes and 127 Kyoto Encyclopedia of Genes and Genomes pathways; several connected to the immune system, including TGF-b and T cell receptor signaling and T-helper cell differentiation. This review highlights the role of breast milk miRNAs and their potential contribution to infant immune maturation. Indeed, breast milk miRNAs seem to be involved in several pathways that influence oral tolerance development.

Food Allergies and Quality of Life among School-Aged Children and Adolescents: A Systematic Review

Recently, besides the focus on the medical diagnosis and therapeutic interventions for food allergy (FA), the psychosocial aspects of this frequent condition have also been investigated. The current systematic review aimed to explore and synthesize the scientific evidence published from January 2015 to April 2022 on Health-Related Quality of Life (HRQoL) among children and adolescents with FAs. Twenty-eight research studies were included in the review, which was conducted on three databases (PubMed, Scopus and Cochrane Library). In most studies, the scores indicate an average level of HRQoL for children and adolescents with FAs, with girls and older children being more negatively affected than boys and younger ones, respectively. Few studies compared HRQoL between children with FA and healthy children, with 3 of them showing worse HRQoL for children with FAs. Immunotherapy has been found to improve the QoL of children with FAs. Anaphylaxis history, number of FAs, additional allergies, number and severity of symptoms were identified as the main factors with a negative impact on QoL. More comparative studies on the HRQoL of children and adolescents with FAs and healthy populations or children with other chronic diseases are required in order to improve QoL of children with FAs.

Relationship between Food Allergy and Endotoxin Concentration and the Toleration Status at 2 Years: The Japan Environment and Children's Study

Changes in household endotoxin concentration may affect the prognosis of food allergy (FA), but data on the association between household endotoxin concentration and an already-developed FA are scarce. Thus, we investigated the association between environmental endotoxin exposure and tolerance to hen's egg (HE) and cow's milk (CM) using data from children participating in the Japan Environment and Children's Study who had HE allergies (n = 204) and CM allergy (n = 72) in their first year of life. We grouped the endotoxin results into quartiles 1-4 (Q1-Q4). In children with HE allergy and with CM allergy, there was no significant difference in the prevalence of tolerance to HE and CM at 2 years old when comparing endotoxin levels of the children in Q1 with those in Q2, Q3, and Q4, respectively. However, subgroup analyses by the presence of eczema and causal foods revealed that children in Q1 had a lower prevalence of tolerance to foods in some subgroup analyses and lower causal allergen-specific immunoglobulin G4 levels. Although an individually based approach against endotoxin according to background characteristics, such as eczema and causal foods, is necessary, preventing excessive endotoxin removal might contribute to FA resolution in some children.

Oral Immunotherapy

Oral immunotherapy (OIT) is an alternative treatment of IgE-mediated food allergy that has been shown to increase tolerance threshold to many of the top food allergens, although this effect may be dependent on age, dose, frequency, and duration. OIT has been shown to be effective and safe in infants, and early initiation can improve rates of desensitization even for those foods whose natural history favors loss of allergy. Studies looking at protocol modification to improve OIT success are ongoing as is the evaluation of clinical tools to help monitor OIT effects.

Intake of allergenic foods at 1.5 years and 3 years of age in a general child population in Japan: a cross-sectional study

BACKGROUND

Recent studies indicate that the timing of introduction of potentially allergenic food is crucial for the development of food allergy in children. This cross-sectional study aimed to clarify the reality of allergen food intake in a general population of young children in Japan.

METHODS

A questionnaire survey of caregivers was conducted at health checkups for 1.5-year (18-month)-old and 3-year-old children in the fall of 2020. The caregivers were asked about (1) the presence/absence of allergic disease symptoms based on the ISAAC questionnaire, and (2) foods that caregivers avoided giving their children. Ordinal logistic regression analyses were periformed to determine factors associated with food avoidance.

RESULTS

Questionnaires were distributed to 1720 caregivers, and 1603 (93%) responded. The responders consisted of 771 and 832 caregivers who participated in 1.5-year-old and 3-year-old checkups, respectively. The prevalence of allergic diseases was comparable to recent epidemiological studies in Japan, indicating that the population may be representative. At 1.5 years old, more than 50% of the children were not exposed to peanuts, tree nuts, fish eggs, shellfish, and buckwheat. At 3 years old, the avoidance rates of the foods had decreased but were still between 18.8% and 32.0%. On the other hand, the avoidance rates of chicken egg and cow's milk, the top 2 common allergenic foods in Japan, were much lower at 2.8% and 1.5% at 1.5 years, and they decreased to 1.4% and 0.7% at 3 years old, respectively. Ordinal logistic analysis showed that avoidance of chicken egg, cow's milk, and wheat was associated with food allergy diagnosis and chicken egg avoidance with eczema, but avoidance of other foods showed no associations with any risk factors for food allergy.

CONCLUSION

Caregivers avoided giving various foods, independent of allergy risk factors, to their young children. Since delayed introduction of an allergenic food has been reported to increase the risk of developing an allergy to the food, the results warrant future investigation of the development of food allergies in relation to current eating habits and recommendations.

Management of IgE-mediated food allergy in the 21st century

The 21st century has seen the propulsion of research in the field of food allergy, which has driven real changes in the clinical approach. Allergen immunotherapy has been recommended for the active management of food allergy. Data have shown promising additional methods of treatment, including biologics. Efforts have been devoted to the risk stratification of food allergy and the standardization of the assessment of food-allergic severity. Alternative routes of administration of epinephrine are under investigation to minimize any mechanical issue and the fear of injections. Evidence-based guidelines have been published by the main international societies in the field of anaphylaxis and food allergy management and new updates are in preparation. In the coming years, treatment options that are currently in pre-clinical or early clinical evaluation will hopefully lead to safe and effective disease-modifying therapies for food allergy in clinical practice. The identification of reliable biomarkers and the standardization of definitions and measurement approaches, alongside a shared decision-making with patients and families, will be key for the development of personalized care and to help minimize the substantial burden of food allergy.

Social disparities in early childhood prevention and management of food allergy

Food allergy (FA) affects 8% of US children. Navigating and managing FA permeates across multiple facets of childhood. In this article, we review research on social disparities in feeding practices, managing meals, and selecting childcare and schools. Key highlights include the following: (1) although preference for breast-feeding or formula feeding does not reduce FA risk, there are disparities in access to formula that may affect children with FA; (2) disparities likely exist in the early introduction to allergenic foods, though additional research is needed to identify barriers to following the most recent consensus guidelines on early introduction; (3) families with limited income face challenges in providing safe meals for their children; (4) disparities exist in early childcare options for preschool-age children, though there is a lack of research on FA practices in these settings; and (5) there is evidence that schools with different student demographics implement different types of FA policies. Further research is needed to better understand and characterize social disparities in FA prevention and management in early childhood and to develop evidence-based strategies to reduce them.