The urgent need for a harmonized severity scoring system for acute allergic reactions

The accurate assessment and communication of the severity of acute allergic reactions are important to patients, clinicians, researchers, the food industry, and public health and regulatory authorities. Severity has different meanings to different stakeholders with patients and clinicians rating the significance of particular symptoms very differently. Many severity scoring systems have been generated, most focusing on the severity of reactions following exposure to a limited group of allergens. They are heterogeneous in format, none has used an accepted developmental approach, and none has been validated. Their wide range of outcome formats has led to difficulties with interpretation and application. Therefore, there is a persisting need for an appropriately developed and validated severity scoring system for allergic reactions that work across the range of allergenic triggers and address the needs of different stakeholder groups. We propose a novel approach to develop and then validate a harmonized scoring system for acute allergic reactions, based on a data-driven method that is informed by clinical and patient experience and other stakeholders' perspectives. We envisage two formats: (i) a numerical score giving a continuum from mild to severe reactions that are clinically meaningful and are useful for allergy healthcare professionals and researchers, and (ii) a three-grade-based ordinal format that is simple enough to be used and understood by other professionals and patients. Testing of reliability and validity of the new approach in a range of settings and populations will allow eventual implementation of a standardized scoring system in clinical studies and routine practice.

Prenatal maternal psychosocial stress and offspring's asthma and allergic disease: A systematic review and meta-analysis

BACKGROUND

Prenatal maternal stress may influence offspring's atopic risk through sustained cortisol secretion resulting from activation of the hypothalamic-pituitary axis (HPA), leading to Th2-biased cell differentiation in the foetus. We undertook a systematic review and meta-analysis investigating the relationship between prenatal maternal psychosocial stress and risk of asthma and allergy in the offspring.

METHODS

We searched 11 electronic databases from 1960 to 2016, searched the grey literature and contacted experts in the field. Type of stress indicator included mood disorders, anxiety, exposure to violence, bereavement and socio-economic problems occurring during pregnancy, both objectively and subjectively measured. We included all possible asthma and IgE-mediated allergy outcomes. We conducted random-effects meta-analyses to synthesize the data.

RESULTS

We identified 9779 papers of which 30 studies (enrolling >6 million participants) satisfied inclusion criteria. The quality of 25 studies was moderate, 4 were strong, and one was weak. Maternal exposure to any type of stressors was associated with an increased risk of offspring atopic eczema/dermatitis (OR 1.34, 95% CI 1.22-1.47), allergic rhinitis (OR 1.30, 95% CI 1.04-1.62), wheeze (OR 1.34, 95% CI 1.16-1.54) and asthma (OR 1.15, 95% CI 1.04-1.27). Exposure to anxiety and depression had strongest effect compared to other stressors. Exposure during the third trimester had the greatest impact compared to first and second trimesters. The increased risk was stronger for early-onset and persistent than for late-onset wheeze. Bereavement of a child (HR 1.28, 95% CI 1.10-1.48) or a spouse (HR 1.40, 95% CI 1.03-1.90) increased the risk of offspring asthma.

CONCLUSIONS

Exposure to prenatal maternal psychosocial stress was associated with increased risk, albeit modestly, of asthma and allergy in the offspring. The pronounced risk during the third trimester may represent cumulative stress exposure throughout pregnancy rather than trimester-specific effect. Our findings may represent a causal effect or a result of inherent biases in studies, particularly residual confounding.

Eating out with a food allergy in the UK: Change in the eating out practices of consumers with food allergy following introduction of allergen information legislation

BACKGROUND

Strict allergen avoidance is important in day-to-day management of food allergy and avoidance when eating outside the home can present particular difficulties. EU legislation (EU FIC) introduced in December 2014 aimed to improve food allergen information provision for customers by requiring retailers of non-prepacked foods to provide information related to the content of one or more of 14 specified food allergens within their foods.

OBJECTIVES

To investigate the impact of EU FIC on the behaviours, experiences and attitudes of consumers with food allergy when eating out.

METHODS

As part of longitudinal research, participants with food allergy from across the UK took part in either (A) pre and post legislation in-depth interviews, or (B) pre and post legislation surveys. In-depth interviews were carried out with 28 participants pre and post legislation and analysed using the framework approach. Self-report surveys were completed by 129 participants pre and post legislation, and responses were subject to quantitative analyses.

RESULTS

Improvements in allergen information provision and raised awareness of food allergy in eating out venues were reported following introduction of EU FIC. Whilst participants favoured written allergen information, they expressed greater confidence in communicating with eating out staff and in trusting the allergen information that they provided. Improvements were judged to be gradual, sporadic or inconsistent in implementation.

CONCLUSION & CLINICAL RELEVANCE

For many participants, the "ideal" eating out experience was one in which a range of information resources were available and where written allergen information was complemented by proactive and accommodating staff within an allergy-aware environment. Whilst the onus is on legislators and food providers to ensure that adequate allergen information is provided, clinicians play an important role in encouraging patients with food allergy to pursue their legal right to make allergen enquiries to avoid accidental allergen ingestion when eating out.

Green, Yellow, and Red risk perception in everyday life - a communication tool

BACKGROUND

Adolescents have the highest risk for food allergy-related fatalities. Our main aim was to investigate the level of risk in everyday social situations as perceived by adolescents/young adults with peanut allergy, their families, and their friends.

METHODS

The web-based 'Colours Of Risks' (COR) questionnaire was completed by 70 patients (aged 12-23 years), 103 mothers and fathers, 31 siblings (aged 12-26 years), and 42 friends (aged 12-24 years). COR deals with six main contexts (home, school/university, work, visiting/social activities, special occasions/parties, and vacations), each with 1-12 items. Response categories are green (I feel safe), yellow (I feel uncertain), or red (I feel everything is risky).

RESULTS

There was a high level of agreement between participants in defining situations as safe, uncertain, or risky, but female patients and mothers rated fewer situations as safe compared to male patients and fathers. Being with close friends and family, and attending planned parties without alcohol were perceived as situations of low risk. While 94% of patients took an epinephrine auto-injector (EAI) into risky situations, only 65% took it into safe situations. In contrast to the close family, 31% of the friends did not know the patient had an EAI, and fewer knew how to administer the EAI.

CONCLUSION

Young adults with peanut allergy face challenges when moving from the safe home with ready assistance if needed, to independence with unpredictable surroundings and less certain help. Perceived 'safe' situations may in fact be the riskiest, as patients often do not take the EAI with them.

Coping strategies, alexithymia and anxiety in young patients with food allergy

BACKGROUND

Food allergy is major public health concern affecting nearly 15 million Americans and 80 million Europeans. Risk of anaphylaxis and implications for social activities affect patients' quality of life and psychological well-being. We previously found that young patients reported higher levels of alexithymia (difficulty in recognizing and expressing emotions) compared with healthy peers and may influence affect, management style and clinical outcomes. This study aimed to explore links between coping strategies, alexithymia and anxiety among food-allergic adolescents and young adults.

METHODS

Ninety-two patients with IgE-mediated food allergy (mean age 18.6 years) completed Coping Orientation to Problems Experienced Inventory, Toronto Alexithymia Scale and Trait Anxiety subscale of State-Trait Anxiety Inventory. Multivariate analyses of variance assessed differences and associations between subgroups on the scales.

RESULTS

Significant differences found between alexithymia levels in coping style were explained by Avoidance strategies. 'Avoidance' had the highest contribution in explaining alexithymia, followed by trait anxiety, age, anaphylaxis and social support. Respondents with higher alexithymia use avoidance as coping strategy over and above other coping strategies such as problem-solving and positive thinking, are younger, will have experienced anaphylaxis and will have lower social support.

CONCLUSIONS

Recognizing the specific role of affect regulation in health behaviours may constitute an important step in supporting patients to explore more adaptive strategies.

Quality of life in childhood, adolescence and adult food allergy: Patient and parent perspectives

BACKGROUND

Studies of children with food allergy typically only include the mother and have not investigated the relationship between the amount of allergen needed to elicit a clinical reaction (threshold) and health-related quality of life (HRQL). Our aims were (i) to compare self-reported and parent-reported HRQL in different age groups, (ii) to evaluate the impact of severity of allergic reaction and threshold on HRQL, and (iii) to investigate factors associated with patient-reported and parent-reported HRQL.

METHODS

Age-appropriate Food Allergy Quality of Life Questionnaires (FAQLQ) were completed by 73 children, 49 adolescents and 29 adults with peanut, hazelnut or egg allergy. Parents (197 mothers, 120 fathers) assessed their child's HRQL using the FAQLQ-Parent form. Clinical data and threshold values were obtained from a hospital database. Significant factors for HRQL were investigated using univariate and multivariate regression.

RESULTS

Female patients reported greater impact of food allergy on HRQL than males did. Egg and hazelnut thresholds did not affect HRQL, but lower peanut threshold was associated with worse HRQL. Both parents scored their child's HRQL better than the child's own assessment, but whereas mother-reported HRQL was significantly affected by limitations in the child's social life, father-reported HRQL was affected by limitations in the family's social life. Severity of allergic reaction did not contribute significantly to HRQL.

CONCLUSION

The risk of accidental allergen ingestion and limitations in social life are associated with worse HRQL. Fathers provide a unique perspective and should have a greater opportunity to contribute to food allergy research.

A new framework for the interpretation of IgE sensitization tests

IgE sensitization tests, such as skin prick testing and serum-specific IgE, have been used to diagnose IgE-mediated clinical allergy for many years. Their prime drawback is that they detect sensitization which is only loosely related to clinical allergy. Many patients therefore require provocation tests to make a definitive diagnosis; these are often expensive and potentially associated with severe reactions. The likelihood of clinical allergy can be semi-quantified from an IgE sensitization test results. This relationship varies though according to the patients' age, ethnicity, nature of the putative allergic reaction and coexisting clinical diseases such as eczema. The likelihood of clinical allergy can be more precisely estimated from an IgE sensitization test result, by taking into account the patient's presenting features (pretest probability). The presence of each of these patient-specific factors may mean that a patient is more or less likely to have clinical allergy with a given test result (post-test probability). We present two approaches to include pretest probabilities in the interpretation of results. These approaches are currently limited by a lack of data to allow us to derive pretest probabilities for diverse setting, regions and allergens. Also, cofactors, such as exercise, may be necessary for exposure to an allergen to result in an allergic reaction in specific IgE-positive patients. The diagnosis of IgE-mediated allergy is now being aided by the introduction of allergen component testing which may identify clinically relevant sensitization. Other approaches are in development with basophil activation testing being closest to clinical application.

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.

Precautionary allergen labelling: perspectives from key stakeholder groups

Precautionary allergen labelling (PAL) was introduced by the food industry to help manage and communicate the possibility of reaction from the unintended presence of allergens in foods. However, in its current form, PAL is counterproductive for consumers with food allergies. This review aims to summarize the perspectives of all the key stakeholders (including clinicians, patients, food industry and regulators), with the aim of defining common health protection and risk minimization goals. The lack of agreed reference doses has resulted in inconsistent application of PAL by the food industry and in levels of contamination that prompt withdrawal action by enforcement officers. So there is a poor relationship between the presence or absence of PAL and actual reaction risk. This has led to a loss of trust in PAL, reducing the ability of consumers with food allergies to make informed choices. The result has been reduced avoidance, reduced quality of life and increased risk-taking by consumers who often ignore PAL. All contributing stakeholders agree that PAL must reflect actual risk. PAL should be transparent and consistent with rules underpinning decision-making process being communicated clearly to all stakeholders. The use of PAL should indicate the possible, unintended presence of an allergen in a consumed portion of a food product at or above any proposed action level. This will require combined work by all stakeholders to ensure everyone understands the approach and its limitations. Consumers with food allergy then need to be educated to undertake individualized risk assessments in relation to any PAL present.

Predictors of health-related quality of life of European food-allergic patients

BACKGROUND

Although food allergy has universally been found to impair HRQL, studies have found significant differences in HRQL between countries, even when corrected for differences in perceived disease severity. However, little is known about factors other than disease severity which may contribute to HRQL in food-allergic patients. Therefore, the aim of this study was to identify factors which may predict HRQL of food-allergic patients and also to investigate the specific impact of having experienced anaphylaxis and being prescribed an EAI on HRQL.

METHODS

A total of 648 European food-allergic patients (404 adults, 244 children) completed an age-specific questionnaire package including descriptive questions. Multivariable regression analyses were performed to develop models for predicting HRQL of these patients.

RESULTS

For adults, the prediction model accounted for 62% of the variance in HRQL and included perceived disease severity, type of symptoms, having a fish or milk allergy, and gender. For children, the prediction model accounted for 28% of the variance in HRQL and included perceived disease severity, having a peanut or soy allergy, and country of origin. For both adults and children, neither experiencing anaphylaxis nor being prescribed an epinephrine auto-injector (EAI) contributed to impairment of HRQL.

CONCLUSIONS

In this study, food allergy-related HRQL may be predicted to a greater extent in adults than in children. Allergy to certain foods may cause greater HRQL impairment than others. Country of origin may affect HRQL, at least in children. Experiencing anaphylaxis or being prescribed an EAI has no impact on HRQL in either adults or children.

The impact of oral food challenge tests on food allergy health-related quality of life

Food allergy health-related quality of life (FAQOL) has been shown to improve after food challenge, but it is unknown whether this improvement is attributed to the procedure itself. Using the Food Allergy Quality of Life Questionnaire-Parent Form, we assessed FAQOL changes over time for children who underwent food challenges in the only paediatric allergy clinic in Ireland. Of 54 children who had a food challenge between September 2012 and February 2013, 25 were positive (allergic) and 29 were negative (nonallergic). FAQOL improved significantly from 2 months prechallenge to 2 months postchallenge for both groups, but began to decrease at 6 months postchallenge in allergic patients. Our findings confirm the positive therapeutic effect of the food challenge on FAQOL; however, the effect appears to wane between 2 and 6 months postchallenge in those confirmed food-allergic, highlighting the importance of regular contact with families of food-allergic children after the food challenge.

Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.

Disease-specific health-related quality of life instruments for IgE-mediated food allergy

This is one of seven interlinked systematic reviews undertaken on behalf of the European Academy of Allergy and Clinical Immunology as part of their Guidelines for Food Allergy and Anaphylaxis, which focuses on instruments developed for IgE-mediated food allergy. Disease-specific questionnaires are significantly more sensitive than generic ones in measuring the response to interventions or future treatments, as well as estimating the general burden of food allergy. The aim of this systematic review was therefore to identify which disease-specific, validated instruments can be employed to enable assessment of the impact of, and investigations and interventions for, IgE-mediated food allergy on health-related quality of life (HRQL). Using a sensitive search strategy, we searched seven electronic bibliographic databases to identify disease-specific quality of life (QOL) tools relating to IgE-mediated food allergy. From the 17 eligible studies, we identified seven disease-specific HRQL instruments, which were then subjected to detailed quality appraisal. This revealed that these instruments have undergone formal development and validation processes, and have robust psychometric properties, and therefore provide a robust means of establishing the impact of food allergy on QOL. Suitable instruments are now available for use in children, adolescents, parents/caregivers, and adults. Further work must continue to develop a clinical minimal important difference for food allergy and for making these instruments available in a wider range of European languages.

EAACI Food Allergy and Anaphylaxis Guidelines. Food allergy health-related quality of life measures

Instruments have been developed and validated for the measurement of health-related quality of life in patients with food allergy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group. It draws on a systematic review of the literature on quality of life instruments for food allergy and the Appraisal of Guidelines for Research & Evaluation (AGREE II) guideline development process. Guidance is provided on the use of such instruments in research, and the current limitations of their use in clinical practice are described. Gaps in current knowledge as well as areas of future interest are also discussed. This document is relevant to healthcare workers dealing with food-allergic patients, scientists engaging in food allergy research and policy makers involved in regulatory aspects concerning food allergy and safety.

Management of anaphylaxis: a systematic review

To establish the effectiveness of interventions for the acute and long-term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series and - only in relation to adrenaline - case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty-five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1-antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long-term management interventions studied were anaphylaxis management plans and allergen-specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom-triggered anaphylaxis.

Twenty four-hour helpline access to expert management advice for food-allergy-triggered anaphylaxis in infants, children and young people: a pragmatic, randomized controlled trial

BACKGROUND

Anaphylaxis is a life-threatening emergency. If promptly administered, adrenaline is potentially life-saving. Many food-allergic-children/carers are unsure when to use their adrenaline autoinjectors, contributing to a low quality of life and worse outcomes in the setting of an acute allergic reaction.

OBJECTIVES

The aim of this study was to assess the effectiveness of 24-hour telephone access to specialist clinical advice on disease-specific quality of life.

METHODS

A pragmatic two-arm, parallel-group randomized control trial was conducted. Children/carers (<16 years) with food allergy, trained in adrenaline auto-injector use, were recruited from a hospital-based paediatric allergy clinic. Baseline disease-specific quality of life was ascertained using the validated Food-Allergy-Related Quality-of-Life Questionnaire (FAQLQ), either Parent Form, Child Form or Teenager Form depending on child's age. Participants were then centrally randomized for a 6-month period to 24-hour telephone specialist support line or to usual care. The primary outcome measure was a change in FAQL scores, at one and 6 months postrandomization, compared with baseline. The minimum clinically important difference (MCID) in score is 0.5.

RESULTS

Fifty two children/carers were recruited. FAQL scores remained static in the control group across the three time points. Scores gradually improved in the intervention group, with a significant difference seen at 6 months (T1-T3 Mean difference = -1.5, (CI 0.87-2.25) P < 0.005] Follow-up questionnaires, 6 months after the intervention was removed, T4, showed sustained significant difference between the groups (control M = 3.0; intervention M = 1.1[t = -4.113, P < 0.05]).

CONCLUSION

The 24-hour helpline improved food-allergy-specific quality of life in children. Six-month intervention support resulted in sustained benefits for at least a further 6 months.

Longitudinal validity and responsiveness of the Food Allergy Quality of Life Questionnaire - Parent Form in children 0-12 years following positive and negative food challenges

BACKGROUND

There are no published studies of longitudinal health-related quality of life (HRQL) assessments of food-allergic children using a disease-specific measure.

OBJECTIVE

This study assessed the longitudinal measurement properties of the Food Allergy Quality of Life Questionnaire - Parent Form (FAQLQ-PF) in a sample of children undergoing food challenge.

METHODS

Parents of children 0-12 years completed the FAQLQ-PF and the Food Allergy Independent Measure (FAIM) pre-challenge and at 2 and 6 months post food challenge. In order to evaluate longitudinal validity, differences between Group A (positive challenge) and Group B (negative challenge) were expected over time. We computed correlation coefficients between change scores in the FAQLQ-PF and change scores in the FAIM. To determine the minimally important difference (MID), we used distributional criterion and effect size approaches. A logistic regression model profiled those children falling below this point.

RESULTS

Eighty-two children underwent a challenge (42 positive; 40 negative). Domains and total score improved significantly at pos-challenge time-points for both groups (all P<0.05). Sensitivity was demonstrated by significant differences between positive and negative groups at 6 months [F(2, 59)=6.221, P<0.003] and by differing improvement on relevant subscales (P<0.05). MID was 0.45 on a seven-point response scale. Poorer quality of life at baseline increased the odds by over 2.0 of no improvement in HRQL scores 6-month time-point. General maternal health (OR 1.252), number of foods avoided (OR 1.369) and children >9 years (OR 1.173) were also predictors. The model correctly identified 84% of cases below MID.

CONCLUSION

The FAQLQ-PF is sensitive to change, and has excellent longitudinal reliability and validity in a food-allergic patient population. The standard error of measurement value of 0.5 points as a threshold for meaningful change in HRQL questionnaires was confirmed. The FAQLQ-PF may be used to identify problems in children, to assess the effectiveness of clinical trials or interventions, and to guide the development of regulatory policies.

Health-related quality of life of food allergic patients measured with generic and disease-specific questionnaires

BACKGROUND

Health-related quality of life (HRQL) has never been measured with both generic and disease-specific questionnaires in the same group of food allergic patients. The aim of this study was to compare HRQL of food allergic patients as measured with generic and disease-specific questionnaires.

METHODS

Generic questionnaires (CHQ-CF87 and RAND-36) and disease-specific HRQL questionnaires (FAQLQ-CF, -TF and -AF) were completed by 79 children, 74 adolescents and 72 adults with food allergy. Floor and ceiling effects, percentage of agreement and multivariate stepwise regression analysis were used to compare the generic and disease-specific measurements.

RESULTS

The Food Allergy Quality of Life Questionnaires (FAQLQs) showed minimal floor or ceiling effects. The CHQ-CF87 and RAND-36 showed minimal floor effects, but remarkable ceiling effects (> 73%) were found for the scales role functioning-emotional (RE), role functioning-behaviour (RB), role functioning-physical (RP) in children and adolescents and the scale RE (> 79%) in adults. Additionally, we found low percentages of agreement between the generic and disease-specific questionnaires to identify the same food allergic patients with the best or worst HRQL. Only patients with the best disease-specific HRQL also tended to have the best generic HRQL. Finally, the explained variance in HRQL by patient characteristics was higher in the disease-specific questionnaires (30.7-62.8%) than in the generic scales (6.7-31.7%).

CONCLUSION

Disease-specific HRQL questionnaires may be more suitable to measure clinically important impairments in HRQL or HRQL differences over time in food allergic patients. However, generic HRQL questionnaires are indispensable for the comparison between different diseases and are thus complementary.

Development, validity and reliability of the food allergy independent measure (FAIM)

BACKGROUND

The Food Allergy Quality of Life Questionnaire-Child Form, -Teenager Form and -Adult Form (FAQLQ-CF, -TF and -AF) have recently been developed. To measure construct validity in the FAQLQs, a suitable independent measure was needed with which FAQLQ scores could be correlated. However, in food allergy, no appropriate independent measure existed, which could be used for this purpose.

AIMS OF THE STUDY

The aim of this study was to describe the development of a Food Allergy Independent Measure Child-Form, -Teenager Form and -Adult Form (FAIM-CF, -TF and -AF) and to assess their validity and reliability.

METHODS

The FAIMs were developed using previously established methodology to capture the patients' expectation of outcome (EO). Face validity was determined by expert opinion. FAIM questions showing no correlation to any potential items in the FAQLQs were considered irrelevant and eliminated. To measure test-retest reliability, one-hundred and one patients were included and completed the FAIM twice with a 10-14 day interval. The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC) and Bland-Altman plots were used to assess test-retest reliability.

RESULTS

Six FAIM questions were developed and considered relevant for the FAIM-CF and -AF, and five questions were relevant for the FAIM-TF. The FAIMs showed good reliability with ICCs and CCCs above 0.70 and with mean differences all close to zero.

CONCLUSIONS

Food allergy independent measures were developed for children, adolescents and adults and were shown to be valid, relevant and reliable. This supports the suitability of the FAIMs for evaluating construct validity.

Health-related quality of life of food allergic patients: comparison with the general population and other diseases

BACKGROUND

To date no studies have compared generic health-related quality of life (HRQL) of food allergic patients from childhood to adulthood with that of the general population or patients with other chronic diseases. The aim of this study was to compare generic HRQL of food allergic patients with the general population and other diseases.

METHODS

Generic HRQL questionnaires (CHQ-CF87 and RAND-36) were completed by 79 children, 74 adolescents and 72 adults with food allergy. The generic HRQL scores were compared with scores from published studies on the general population and patients with asthma, irritable bowel syndrome (IBS), diabetes mellitus (DM) and rheumatoid arthritis (RA).

RESULTS

Food allergic children and adolescents reported fewer limitations in school work due to behavioural problems (P < or = 0.013), but food allergic adolescents and adults reported more pain (P = 0.020), poorer overall health (P < 0.001), more limitations in social activities (P < 0.001) and less vitality (P = 0.002) than individuals from the general population. Food allergic patients reported poorer generic HRQL than patients with DM, but better generic HRQL than patients with RA, asthma and IBS.

CONCLUSION

HRQL is impaired in food allergic adolescents and adults, compared to the general population, and it is intermediate in magnitude between DM and RA, asthma and IBS. Children show the least impact on generic HRQL from food allergy.

Development and validation of the Food Allergy Quality of Life Questionnaire - Adult Form

BACKGROUND

Health-related quality of life (HRQL) may be affected by food allergy. Presently, no disease-specific HRQL questionnaire exists for food allergic adults. Therefore, we developed and validated the Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) in the Dutch language.

METHODS

Twenty-two food allergic patients (> or =18 years) were interviewed and generated 180 HRQL items. The most important items were identified by 54 food allergic patients using the clinical impact method resulting in the FAQLQ-AF containing 29 items (score range 1 'not troubled' to 7 'extremely troubled'). The FAQLQ-AF, the Food Allergy Independent Measure (FAIM) and a generic HRQL questionnaire (RAND-36) were sent to 100 other food allergic adults for cross-sectional validation of the FAQLQ-AF.

RESULTS

Cross-sectional validity was assessed by the correlation between FAQLQ-AF and FAIM (rho = 0.76, P < 0.001). The FAQLQ-AF had excellent internal consistency (Cronbach's alpha = 0.97). The FAQLQ-AF discriminated between patients who differ in severity of symptoms (anaphylaxis vs no anaphylaxis, total FAQLQ-AF score 4.9 vs 4.1; P = 0.041) and number of food allergies (>3 food allergies vs< or =3 food allergies, total FAQLQ-AF score 5.2 vs 4.2; P = 0.008). The total FAQLQ-AF score was correlated with one RAND-36 scale (convergent/discriminant validity).

CONCLUSIONS

The FAQLQ-AF is the first disease-specific HRQL questionnaire for food allergic adults and reflects the most important issues that food allergic patients have to face. The questionnaire is valid, reliable and discriminates between patients with different disease characteristics. The FAQLQ-AF is short and easy to use and may therefore be a useful tool in clinical research.

Developmental pathways in food allergy: a new theoretical framework

BACKGROUND

To date, there is no model of psychosocial development based on empirical food allergy (FA) research. This limits the ability of clinicians, researchers and policy-makers to predict and evaluate the real impact of FA on the child, with implications for prevention, treatment, intervention and health policy.

OBJECTIVES

To provide an integrated conceptual framework to explain the onset, development and maintenance of FA-related cognitions, emotions and behaviour, with particular attention to transition points.

METHOD

Fifteen focus groups meetings were held with 62 children (6-15 years). Developmentally appropriate techniques were designed to stimulate discussion, maintain interest and minimize threat to children's self-esteem. Data were analysed using grounded theory.

RESULTS

FA impacts directly on children's normal trajectory of psychological development in both an age- and disease-specific manner. Six key themes emerged from the analysis: 'meanings of food'; 'autonomy, control and self-efficacy'; 'peer relationships'; 'risk and safety'; 'self/identity'; and 'coping strategies'.

CONCLUSIONS

Coping with FA is more than simply a strategy, it is a cumulative history of interactive processes (age, gender and disease specific) that are embedded in a child's developmental organization.

CLINICAL IMPLICATIONS

The early recognition and incorporation of an FA-specific developmental framework into a treatment plan is essential and sets the stage for an effective medical care and the eventual transition from paediatric to adult care.

CAPSULE SUMMARY

This study represents a first attempt to provide an integrated developmental framework to explain the onset, development and maintenance of FA-related cognitions, emotions and behaviour.

Developmental trajectories in food allergy: a review

Increasing recognition of the importance of the relationships between perceptions, emotions, behaviors and health has changed the way health and disease are portrayed and researched. A chronic condition may affect and/or interact with already existing normative demands and changes in socialization. Although the prevalence of food allergy and anaphylaxis have been reportedly increasing, the emotional and social impact of growing up with food allergy has received little emphasis. In this paper, we present current findings on the biopsychosocial impact of food allergy on children in order to gain insight into the food allergy experience, from the perspective of the child, teen, and parent living with food allergy, with particular attention to developmental aspects. Due to the scarcity of publications on the psychosocial dimensions of food allergy, we also draw on selected literature on children's and parent's experience of, and coping with chronic disease that may inform research into food allergy. To this end, we review some general developmental mechanisms that may underpin and explain normative age-graded shifts in patterns of coping across childhood and adolescence. We also highlight gaps in the literature and assess implications of current research in food allergy and other chronic diseases for intervention and prevention of negative short and long term outcomes.

Development and validation of a self-administered Food Allergy Quality of Life Questionnaire for children

BACKGROUND

Having a food allergy may affect health-related quality of life (HRQL). Currently, no validated, self-administered, disease-specific HRQL questionnaire exists for children with food allergy.

OBJECTIVE

The aim of this study was to develop and validate the Food Allergy Quality of Life Questionnaire--Child Form (FAQLQ-CF) in the Dutch language.

METHODS

Interviews with food-allergic children (n=13, 8-12 years) generated 139 HRQL items. The most important items were identified by 51 food-allergic children using the clinical impact method. This resulted in the FAQLQ-CF containing 24 items (total score range 1 'not troubled' to 7 'extremely troubled'). The FAQLQ-CF, the Food Allergy Independent Measure (FAIM) and a generic HRQL questionnaire (CHQ-CF87) were sent to 115 food-allergic children for cross-sectional validation of the FAQLQ-CF.

RESULTS

Construct validity was demonstrated by the correlation between the FAQLQ-CF and the FAIM (rho=0.60, P<0.001). The FAQLQ-CF had an excellent internal consistency (Cronbach's alpha=0.94) and discriminated between children who differed in number of food allergies (>2 food allergies vs. < or =2 food allergies; total FAQLQ-CF score, 4.3 vs. 3.6; P=0.036), but did not discriminate between reported anaphylaxis or not. The total FAQLQ-CF score correlated with 8 of the 11 CHQ-CF87 sub-scales which demonstrated convergent/discriminant validity.

CONCLUSION

The FAQLQ-CF is the first self-administered disease-specific HRQL questionnaire for food-allergic children. This questionnaire has a strong internal consistency and cross-sectional validity. It discriminates between children who differ in number of food allergies, and it was short and easy to use in the population studied. Therefore, the FAQLQ-CF may be a useful tool in clinical research.

A framework for measuring the social impact of food allergy across Europe: a EuroPrevall state of the art paper

This state of the art paper has been developed through EuroPrevall, a European multicentre research project funded by the European Union which aims to improve quality of life for food allergic individuals. Food allergy (whether clinically diagnosed or self-perceived) represents a major health issue in Western societies and may have a considerably greater impact on society than was previously believed. However, the social impact of food allergy has never been systematically investigated using validated instruments. Combining the information from studies on health-related quality of life (HRQoL) with epidemiological data on prevalence will ultimately give some indication of the magnitude of the social impact of food allergy in Europe. HRQoL can be assessed with disease-specific questionnaires, which are being developed in EuroPrevall. These instruments will be used to identify HRQoL problems associated with food allergy, and to assess the effectiveness of interventions and to guide the development of regulatory policies.

Incorporating a gender dimension in food allergy research: a review

Sex and gender are the major determinants of health and disease in both men and women. The aim of this review paper was to examine differences in gender and sex in relation to the prevalence and effects of food allergy. There are still major gaps in our knowledge about the kinds of processes which shape men's and women's perceptions and experiences of food allergy. The expression and experience of health and illness may be moderated by variables such as biological vulnerability, exposure to health risks, perception of symptoms, evaluation of risk, information processing and role expectations. This review highlights the complex links between biological sex, gender, and health in general and offers a synthesis of how these may interact to produce sex and gender differences in biopsychosocial manifestations of food allergy. Implications for research and public health practice are discussed.