Design of the Intervention to Reduce Early Peanut Allergy in Children (iREACH): A practice-based clinical trial

BACKGROUND

Introducing peanut products early can prevent peanut allergy (PA). The "Addendum guidelines for the prevention of PA in the United States" (PPA guidelines) recommend early introduction of peanut products to low and moderate risk infants and evaluation prior to starting peanut products for infants at high risk for PA (those with severe eczema and/or egg allergy). Rapid adoption of guidelines could aid in lowering the prevalence of PA. The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) trial was designed to promote PPA guideline adherence by pediatric clinicians.

METHODS

A two-arm, cluster-randomized, controlled clinical trial was designed to measure the effectiveness of an intervention that included clinician education and accompanying clinical decision support tools integrated in electronic health records (EHR) versus standard care. Randomization was at the practice level (n = 30). Primary aims evaluated over an 18-month trial period assess adherence to the PPA guidelines using EHR documentation at 4- and 6-month well-child care visits aided by natural language processing. A secondary aim will evaluate the effectiveness in decreasing the incidence of PA by age 2.5 years using EHR documentation and caregiver surveys. The unit of observation for evaluations are individual children with clustering at the practice level.

CONCLUSION

Application of this intervention has the potential to inform the development of strategies to speed implementation of PPA guidelines.

Potential parental determinants of the pace of evidence-based practice change in children's mental health care

BACKGROUND

Strength of evidence is key to advancing children's mental health care but may be inadequate for driving practice change. The Designing for Accelerated Translation (DART) framework proposes a multifaceted approach: pace of implementation as a function of evidence of effectiveness, demand for the intervention, sum of risks, and costs. To inform empirical applications of DART, we solicited caregiver preferences on key elements.

METHOD

In March-April 2022, we fielded a population-representative online survey in Illinois households (caregivers N = 1,326) with ≥1 child <8 years old. Six hypothetical scenarios based on the DART framework were used to elucidate caregivers' preferences on a 0-10 scale (0 = never; 10 = as soon as possible) for pace of implementation of a family-based program to address mental health concerns.

RESULTS

Caregivers' pace preference scores varied significantly for each scenario. The highest mean score (7.28, 95% confidence interval [95% CI: 7.06, 7.50]) was for a scenario in which the child's provider thinks the program would be helpful (effectiveness) and the caregiver believes the program is needed (demand). In contrast, the lowest mean score (5.13, 95% CI [4.91, 5.36]) was for a scenario in which online information implies the program would be helpful (effectiveness) and the parent is concerned about the program's financial costs (cost). Caregivers' pace preference scores did not vary consistently by sociodemographic factors.

CONCLUSION

In this empirical exploration of the DART framework, factors such as demand, cost, and risk, in combination with evidence of effectiveness, may influence caregivers' preferred pace of implementation for children's mental health interventions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Gut microbiome is associated with asthma and race in children with food allergy

BACKGROUND

The composition of the gut microbiome has been associated with development of atopic conditions such as food allergy (FA) and asthma. African American or Black children with FA have higher rate of asthma compared to their White counterparts.

OBJECTIVE

We sought to investigate whether the diversity and relative abundance (RA) of gut microbiota is different between children with FA from different racial backgrounds living in the same cities. Furthermore, we aimed to understand whether the difference in the gut microbiota is associated with asthma in children with FA.

METHODS

We analyzed and compared the stool microbiome of a cohort of Black and White children with FA by shotgun genomic sequencing.

RESULTS

A total of 152 children with IgE-mediated FA enrolled onto FORWARD (Food Allergy Outcomes Related to White and African American Racial Differences); 30 Black and 122 White children were included. The RA of several bacteria was associated with race and asthma. Most notably the RA of Bacteroides thetaiotaomicron, Chlamydia thrachomatis, Parabacteroides goldsteinii, and Bacteroides eggerthii were significantly higher, while the RA of Bifidobacterium sp CAG:754, Parabacterium johnsonii, Bacteroides intestinalis, and Bifidobacterium breve were significantly lower in stool samples of Black children compared to White children. Asthma was associated with lower RA of B breve, Bifidobacterium catenulatum, Prevotella copri, Veilloella sp CAG:933, and Bacteroides plebius, and higher RA of 3 Bacteroides species.

CONCLUSIONS

The observed variations in the gut microbiota of Black and White children such as differences in the Bacteroides and Bifidobacterium species along with their association to history of asthma in our cohort is indicative of their potential role in the higher rate of asthma observed among Black children with FA.

Incident Kaposi sarcoma during the expansion of antiretroviral therapy eligibility in Nigeria: a retrospective cohort study

INTRODUCTION

The expansion of antiretroviral therapy (ART) eligibility could lead to earlier initiation of Human Immunodeficiency Virus (HIV) treatment and consequently reduce the risk of HIV-associated Kaposi Sarcoma (KS). We investigated the impact of changes in the Nigerian HIV treatment guidelines on KS incidence among adults enrolled in HIV care in Nigeria.

METHODS

We analyzed data of adults who enrolled for HIV care from January 2006 to December 2016 at one of Nigeria's largest HIV treatment centers. Based on changes in HIV treatment guidelines, we classified 2006-2009 as the pre-expansion period and 2010-2016 as the post-expansion period. We used Kaplan Meier curves to compare the incidence of KS in the pre-expansion to the post-expansion period. We used Cox regression models to assess the hazard for incident KS between the two periods after adjusting for potential confounders.

RESULTS

Among 14,479 patients with HIV, the overall KS incidence was 2.35; 95% CI 2.01-2.74/1,000 person-years. The incidence of KS decreased from 2.53 to 1.58 per 1,000 person-years from 2006 to 2009 to 2010-2016. In models adjusting for age, sex, CD4-T cell count, and ART use, the risk for KS remained lower in 2010-2016 compared to 2006-2009. In analyses restricted to time on ART, there was no significant difference in KS incidence between HIV patients who enrolled in 2006-2009 and 2010-2016 after adjusting for age, sex, and CD4 T-cell count.

CONCLUSION

The expansion of ART eligibility was associated with a reduced incidence of HIV-associated KS among adults initiating HIV care in Jos, Nigeria. The reduction was likely driven by earlier enrollment for HIV care and ART initiation.

Early Peanut Introduction Awareness, Beliefs, and Practices Among Parents and Caregivers

BACKGROUND AND OBJECTIVES

The 2017 Prevention of Peanut Allergy Guidelines recommend incorporating peanut protein into infants' diets to prevent peanut allergy. The goal of this study was to explore US caregivers' awareness, beliefs, practices, and outcomes around peanut introduction.

METHODS

A parent-report survey was administered between January and February 2021 to a population-based sample of 3062 US parents/caregivers of a child between age 7 months and 3.5 years. The survey evaluated awareness, beliefs, feeding practices, primary care provider (PCP) interactions, and food reactions.

RESULTS

Overall, 13.3% of parents/caregivers reported Prevention of Peanut Allergy Guidelines awareness. Caregivers who reported being white, 30 to 44 years of age, educated, high income, or cared for a child with food allergy or eczema were more likely to be guideline-aware (P < .001). Among US parents/caregivers, 47.7% believed that feeding peanuts early prevented peanut allergy; 17.2% first offered peanut-containing foods before age 7 months and 41.8% did so between ages 7 and 12 months. Peanut introduction occurred earlier among guideline-aware parents/caregivers: 31% offered it before 7 months (P < .001). Overall, 57.8% of parents/caregivers reported discussing peanut introduction with their PCP. PCP counseling was the most common facilitator for peanut introduction before 7 months (odds ratio 16.26 [9.49-27.85]), whereas fear of reactions was the most common reason for delaying peanut introduction beyond 7 months (32.5%). Actual reactions during peanut introduction were reported by 1.4%.

CONCLUSIONS

Early peanut feeding practices are gaining traction among US parents/caregivers; however, disparities exist. Future efforts to increase guideline adherence need to address disparities, provide support for medical providers, and educate about the true incidence of reactions.

Assessing Disparities in the Prevalence of Atopic Comorbidities Among Food-Allergic Children

BACKGROUND

Previous studies have reported that Black children with food allergy (FA) have higher risk of atopic comorbidities than White children.

OBJECTIVE

Our study sought to understand if disparities in the prevalence of atopic comorbidities among children with FA are driven by individual and community-level socioeconomic status (SES).

METHODS

We analyzed data from a prospective, multicenter cohort investigating the natural history of pediatric atopy: the Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD) study. A validated, multicomponent area deprivation index (ADI) percentile score was tabulated by the census block group for each subject's home address. The association of ADI with atopic comorbidities in FA was assessed via multivariable regression analysis.

RESULTS

Of the 700 children in this study, the mean ADI was 37.7 (95% confidence interval: 35.6-39.7). The mean ADI was higher in children with asthma (43.3) compared with those without asthma (31.8), which remained significant after adjusting for race (P < .0001). Children with allergic rhinitis (AR) had a higher mean ADI (39.1) compared with those without (33.4) (P = .008). ADI was associated with secondhand smoking, parents' education, and household income. Black children had a higher risk for asthma after adjusting for ADI and SES-related factors.

CONCLUSION

The independent association of ADI with asthma and AR, regardless of race, suggests a role of neighborhood-level socioeconomic deprivation in the development of these conditions among children with FA. Black children with FA remained at higher risk for asthma after adjusting for SES-related variables, which can indicate an independent risk for asthma in these children.

Accelerating Food Allergy Research: Need for a Data Commons

Food allergy is a significant health problem affecting approximately 8% of children and 11% of adults in the United States. It exhibits all the characteristics of a "complex" genetic trait; therefore, it is necessary to look at very large numbers of patients, far more than exist at any single organization, to eliminate gaps in the current understanding of this complex chronic disorder. Advances may be achieved by bringing together food allergy data from large numbers of patients into a Data Commons, a secure and efficient platform for researchers, comprising standardized data, available in a common interface for download and/or analysis, in accordance with the FAIR (Findable, Accessible, Interoperable, and Reusable) principles. Prior data commons initiatives indicate that research community consensus and support, formal food allergy ontology, data standards, an accepted platform and data management tools, an agreed upon infrastructure, and trusted governance are the foundation of any successful data commons. In this article, we will present the justification for the creation of a food allergy data commons and describe the core principles that can make it successful and sustainable.

Achieving Racial Representation in Food Allergy Research: A Modified Delphi Study

BACKGROUND

The overrepresentation of White participants in food allergy research contributes to the development of research questions and interventions not driven by those disproportionately affected by the condition. This ultimately limits the generalizability of research findings and affects the development of knowledge about food allergy and food allergy management.

OBJECTIVE

To develop recommendations to combat inequitable research paradigms and increase participation of racially underrepresented populations in food allergy research.

METHODS

This study used a modified consensus development method, known as a Delphi method, to assemble the expertise of food allergy clinicians, advocacy leaders, community-engaged researchers, and patients.

RESULTS

Findings resulted in 18 recommendations within four domains: community partnership, intentional engagement and messaging, recruitment activities, and dissemination.

CONCLUSIONS

Findings from this study provide food allergy researchers with specific recommendations for examining their efforts more critically toward recruiting and engaging with racially underrepresented populations, effectively transitioning from a research-on to a research-with relationship with individuals and families living with food allergy.

Racial, ethnic, and socioeconomic disparities in COVID-19 and influenza vaccination in pediatric food allergy

Background

Current COVID-19 and influenza vaccination-related knowledge, attitudes, and behaviors remain poorly understood among US children with food allergy-and particularly those from non-Hispanic Black, Latinx, and lower income backgrounds who bear a disproportionate burden by allergic disease. These data are especially relevant due to historical vaccine hesitancy in children with food allergy and an initial contraindication for those with severe allergic reactions to be vaccinated against COVID-19.

Objective

We sought to characterize COVID-19 and influenza vaccination-related knowledge, attitudes, and behaviors in a racially, ethnically, and socioeconomically diverse longitudinal cohort of caregiver-child dyads with IgE-mediated food allergy.

Methods

We leveraged the NIH-supported FORWARD cohort, consisting of non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx children diagnosed with food allergy to assess COVID-19 testing, vaccination, and influenza vaccine concern and utilization through administering a one-time IRB-approved survey.

Results

Non-Hispanic Black participants were less likely than Non-Hispanic White participants to be vaccinated (OR=0.25, 95%CI:0.08-0.75) or tested (OR=0.33, 95%CI:0.13-0.85) for COVID-19 and have the intention to vaccinate their children for influenza (OR=0.42; 0.18-0.98). Over one third of participants reported that they believe their child is at greater risk of complications from COVID-19 vaccination due to food allergy. There were racial/ethnic disparities in the belief that COVID vaccines contain allergenic ingredients such that more Hispanic/Latinx (37%) and Black (37%) participants than White (22%) participants reported this belief (p=.02).

Conclusion

The present findings of disparities in vaccination-related knowledge, attitudes, and behaviors across racial/ethnic, and household income strata suggest that initial reports of COVID-19 vaccination hesitancy within the population with food allergy may be further exacerbated by well-documented, racial, ethnic, and socioeconomic differences in vaccine hesitancy, potentially leading to a greater infectious disease burden in these vulnerable populations. This highlights a need for targeted education and outreach among members of these communities who are living with food allergy.

Socioeconomic Determinants of Food Allergy Burden-A clinical introduction

OBJECTIVE

This review characterizes what is currently known about how prevalence, severity, distribution, and management of food allergy (FA) differs across socioeconomic strata and provides guidance for practicing clinicians about how to improve equity in research participation, healthcare delivery, and patient outcomes through a deeper understanding of the socioeconomic determinants of FA.

DATA SOURCES

Epidemiological and biomedical literature published prior to April 2022.

RESULTS

Socioeconomic status (SES) is a complex concept that not only encompasses economic resources (e.g., income, wealth) but also a person's social, economic and political power and standing, each of which can impact health. However, in many studies of individuals and families with FA, assessment of SES has been limited and often a respondent's membership within a racial and ethnic group is utilized as a proxy for low SES. As a whole, findings from US-population-based studies indicate a consistent trend: those who self-identify as non-Hispanic Black, and to a lesser extent other subpopulations who identify as being of non-White race and ethnicity, experience a greater burden of food-allergic sensitization and disease including higher rates of emergency health care utilization and food-induced anaphylactic fatality as compared to those identifying as White.

CONCLUSION

Reports of FA management and outcomes highlight inequities among specific low SES populations in the US. Clinicians can and should act to reduce inequities by engaging more diverse populations in clinical research, equitably implementing FA risk screening and prevention, thoughtfully utilizing emerging technologies to ameliorate disparities based on SES in healthcare delivery and outcomes, and advocating for social change.

Development of Food Allergy Data Dictionary: Toward a Food Allergy Data Commons

BACKGROUND

Food allergy (FA) data lacks a common base of terminology and hinders data exchange among institutions.

OBJECTIVE

To examine the current FA concept coverage by clinical terminologies and to develop and evaluate a Food Allergy Data Dictionary (FADD).

METHODS

Allergy/immunology templates and patient intake forms from 4 academic medical centers with expertise in FA were systematically reviewed, and in-depth discussions with a panel of FA experts were conducted to identify important FA clinical concepts and data elements. The candidate ontology was iteratively refined through a series of virtual meetings. The concepts were mapped to existing clinical terminologies manually with the ATHENA vocabulary browser. Finally, the revised dictionary document was vetted with experts across 22 academic FA centers and 3 industry partners.

RESULTS

A consensus version 1.0 FADD was finalized in November 2020. The FADD v1.0 contained 936 discrete FA concepts that were grouped into 14 categories. The categories included both FA-specific concepts, such as foods triggering reactions, and general health care categories, such as medications. Although many FA concepts are included in existing clinical terminologies, some critical concepts are missing.

CONCLUSIONS

The FADD provides a pragmatic tool that can enable improved structured coding of FA data for both research and clinical uses, as well as lay the foundation for the development of standardized FA structured data entry forms.

Analyses of Kaposi Sarcoma trends among adults establishing initial outpatient HIV care in Nigeria: 2006-2017

Background

The incidence of Human Immunodeficiency Virus (HIV)-associated Kaposi Sarcoma (KS) in the pre-antiretroviral therapy (ART) population remains high in several countries in sub-Saharan Africa. We examined trends of KS prevalence in adults, establishing initial outpatient HIV care from 2006 to 2017 in Nigeria.

Methods

We analyzed data of 16,431 adults (age ≥ 18 years) enrolled for HIV care from January 1, 2006, to December 31, 2017, in a large clinic in Jos, Nigeria. KS at enrollment was defined as KS recorded in the electronic health record within 30 days of clinic enrollment. Time trends were compared among four periods: 2006–2008, 2009–2011, 2012–2014, and 2015–2017 using logistic regression models. Annual trends were analyzed using join point regression and restricted splines.

Results

The study population had a mean age 35.1 (standard deviation, SD 9.5) years, and were 65.7% female (n = 10,788). The mean CD4 cell count was 220 (95% CI 117–223). The overall KS prevalence at entry was 0.59% (95% CI 0.48–0.72). Compared to 2006–2008, KS prevalence was significantly higher in 2009–2011 (adjusted odds ratio 5.07 (95% CI 3.12–8.24), p < 0.001), but remained unchanged in subsequent periods. Male sex and low CD4 T-cell count independently increased odds for KS.

Conclusions

Despite ART expansion, KS at enrollment showed no significant decline. The low CD4 cell count, across all periods, indicates delay in enrollment for HIV care, which increases KS risk. Interventions aimed at early HIV diagnosis and linkage to ART is critical to KS risk reduction in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13027-022-00424-4.

Associations of Food Allergy-Related Dietary Knowledge, Attitudes, and Behaviors Among Caregivers of Black and White Children With Food Allergy

BACKGROUND

The increasing prevalence of pediatric food allergy (FA) in the United States has disproportionately affected non-Hispanic Black youth. However, racial and other socioeconomic disparities in FA management among caregivers of children with FA remain unclear.

OBJECTIVE

To determine associations between socioeconomic, clinical, and health care factors and FA-related knowledge, attitudes, and behaviors among caregivers of Black and White children with FA.

DESIGN

Cross-sectional survey analysis from the Food Allergy Outcomes Related to White and African American Racial Differences Study.

PARTICIPANTS/SETTINGS

Longitudinal cohort of caregivers of 385 Black and White children with FA ages birth to 12 years residing in Chicago, Illinois, Cincinnati, Ohio, and Washington, DC from 2017 to March 2021.

MAIN OUTCOME MEASURES

There were 3 primary outcomes of interest: (1) FA knowledge assessed by scores from the Knowledge Survey, (2) FA-related attitudes assessed by newly developed survey, and (3) food-related behaviors assessed by the FORWARD Diet and Purchasing Habit Surveys completed 6 months postenrollment.

ANALYSES

Multivariable linear and logistic regression.

RESULTS

The overall response rate to the 6-month postenrollment survey was 51.3% (385 of 751). White caregivers represented 69.4% of the participants. Black race was associated with a 1.5-point mean decrease in FA knowledge score (95% CI: -2.2 to -0.7) compared with White caregivers, and a graduate degree or bachelor's degree was associated with associated with a 1.7-point mean increase (95% CI: 0.8-2.7) and 1.1-point mean increase (95% CI: 0.2-2.0) in FA knowledge score, respectively, compared with caregivers who had less than a bachelor's degree. Multiple FAs and ever visited the emergency department for a food-related allergic reaction were also associated with higher levels of FA knowledge. Ever visited the emergency department for FA was also associated with higher odds of 2 measures of FA attitudes reflecting parental anxiety. Greater FA knowledge scores were consistently associated with lower odds of several FA-related food purchasing and eating behaviors assumed to have elevated risk of FA. Eating food prepared at school was the only FA behavior associated with race. Compared with White children, Black children were 2.5 times more likely to eat school-prepared foods (95% CI: 1.2-5.6).

CONCLUSIONS

Findings from this study identified socioeconomic, racial, and clinical factors associated with caregivers' FA-related knowledge, attitudes, and behaviors, but further research is warranted to better understand these relationships.

African American Children Are More Likely to Be Allergic to Shellfish and Finfish: Findings from FORWARD, a Multisite Cohort Study

BACKGROUND

Despite major differences in health profiles and rates of health care utilization between African American and White children with food allergy (FA), the detailed phenotypic variables that can potentially impact these outcomes have not been thoroughly studied.

OBJECTIVE

We aimed to characterize phenotypic differences such as allergies to different foods and allergic comorbidities between African American and White children with FA enrolled in the Food Allergy Outcomes Related to White and African American Racial Differences study.

METHODS

Our active, prospective, multicenter cohort study is currently enrolling African American and White children aged 0 to 12 years diagnosed with FA and followed by allergy/immunology clinics at 4 urban tertiary centers in the United States. To evaluate associations between race and phenotypic variables, we used multivariable logistic regression, adjusting for important demographic and confounding factors, as well as potential household clustering.

RESULTS

As of May 2020, there were 239 African Americans and 425 Whites with complete intake information enrolled in the study. In comparison with Whites, we found that African Americans had significantly higher adjusted odds of allergy to finfish (odds ratio [OR]: 2.54, P < .01) and shellfish (OR: 3.10, P < .001). African Americans also had higher adjusted odds of asthma than Whites (asthma prevalence of 60.5% in African Americans and 27.2% in Whites; OR: 2.70, P < .001). In addition, shellfish allergy was associated with asthma, after controlling for race.

CONCLUSION

Among a diverse cohort of children with physician-diagnosed FA, we observed that African American children had higher odds of allergy to shellfish and finfish, and higher rates of asthma. Interestingly, having asthma was independently associated with allergy to shellfish, after controlling for race.

Characterizing Biphasic Food-Related Allergic Reactions Through a US Food Allergy Patient Registry

BACKGROUND

Understanding about patient-reported biphasic food-related allergic reactions is currently sparse.

OBJECTIVE

To characterize patient-reported biphasic food-related allergic reactions among a national food allergy registry.

METHODS

We used two patient registry surveys established by Food Allergy Research and Education. Variables were described with proportions and 95% confidence intervals (CIs); unadjusted results were stratified by respondent type. Multivariable logistic regression evaluated the adjusted odds of reporting a biphasic reaction.

RESULTS

The incidence of reported biphasic reactions was 16.4% (95% CI, 15.3-17.7). A total of 12.8% of parent or guardian respondents (95% CI, 12.5-14.3) and 21.8% of self-respondents (95% CI, 19.7-23.8) indicated a biphasic reaction during their most recent food-allergic reaction. Among respondents with a mild initial reaction, 7.4% reported a biphasic reaction, compared with 30% with a very severe initial reaction. When the initial reaction was mild, 69.6% of parent or guardian respondents (95% CI, 47.2-85.4) and 52.0% of self-respondents (95% CI, 38.0-35.7) with a biphasic reaction reported a mild secondary reaction. When the initial reaction was very severe, 36.3% of parent or guardian respondents (95% CI, 26.4-47.5) and 42.9% of self-respondents (95% CI, 31.1-55.5) with a biphasic reaction reported a very severe secondary reaction. Female sex, Black race, reaction age 5-12 and 26-66 years, initial moderate, severe, or very severe reaction, and one or more annual reactions were associated with increased odds of a biphasic reaction.

CONCLUSIONS

This study characterizes the incidence of patient-reported biphasic reactions and provides valuable information on the probable severity of a biphasic food-related allergic reaction. Further research is necessary to understand the epidemiology of food-related biphasic reactions.

Racial and Ethnic Differences in Managed Care Enrollment Among US Children

This survey study uses data from the 2018 Medical Expenditure Panel Survey Household Component to compare rates of health maintenance organization (HMO) enrollment, by race and ethnicity, for children with commercial and public coverage.

Addressing the social needs of individuals with food allergy and celiac disease during COVID-19: A new practice model for sustained social care

COVID-19 has led to high rates of food insecurity. Food insecure patients with food allergy and celiac disease are especially vulnerable during the pandemic when foods become limited. This paper describes a practice innovation implemented by a community-based organization, Food Equality Initiative (FEI), whose mission is improving health and ending hunger among individuals with food allergy and celiac disease. FEI responded to the pandemic by converting their in-person pantries to a contactless delivery of safe foods. The practice innovation is discussed in relation to three system-level elements necessary to sustain the integration of social care into the delivery of healthcare.

Guideline-informed care among Medicaid-enrolled children with food allergy

OBJECTIVES

To describe food allergy (FA)-related service utilization and identify factors associated with guideline-informed care among Medicaid-enrolled US children with FA.

STUDY DESIGN

Retrospective cohort study.

METHODS

We used the 2012 Medicaid Analytic eXtract files to identify children with an FA diagnosis. FA-related services including outpatient allergist visits, emergency department (ED) visits, epinephrine autoinjector prescription fills, and diagnostic testing were identified. Factors associated with services were assessed using logistic regression. Kaplan-Meier survival curves evaluated the time to guideline-informed care, and proportional hazard models determined associated socioeconomic characteristics.

RESULTS

There were 64,276 Medicaid-enrolled children younger than 20 years who had at least 1 claim with an FA diagnosis in 2012. Minority children and those living in a high-poverty county were less likely to have visited an allergist for FA or received diagnostic testing but more likely to have an FA-related ED visit compared with White children and those not living in a high-poverty county. Survival analyses found that of children seen for FA-related primary care or an ED visit, rates of allergist follow-up visits were 21% and 17%, respectively, and rates of epinephrine autoinjector prescription fills were 39% and 41%. Significant associations with guideline-informed care were found by race/ethnicity, dense population, and high-poverty counties.

CONCLUSIONS

Although guideline-informed FA care includes follow-up with an allergist and epinephrine autoinjector prescription, this study finds low probabilities of timely service utilization after medical visits, as well as socioeconomic disparities in care.

Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but there was no disparity for Latinx children. Black and Asian children received more school-based services than white children. Disparities in case management/care coordination services were largest and present in each minority group. Geographic variation in receipt of services suggests targets for policy intervention to improve access for minorities with ASD.

Assessment of Pediatrician Awareness and Implementation of the Addendum Guidelines for the Prevention of Peanut Allergy in the United States

Importance

The 2017 Addendum Guidelines for the Prevention of Peanut Allergy in the United States recommend that pediatricians assess infant peanut allergy risk and introduce peanut in the diet at age 4 to 6 months. Early introduction has the potential to prevent peanut allergy development.

Objectives

To measure the rates of guideline awareness and implementation and to identify barriers to and factors associated with implementation among US pediatricians.

Design, Setting, and Participants

This population-based study survey used a 29-item electronic survey instrument that was administered to pediatricians practicing across the United States from June 1, 2018, to December 1, 2018. Invitations to complete a survey were emailed to all pediatricians in the American Academy of Pediatrics vendor database. Eligible participants were nonretired US-based pediatricians providing general care to infants aged 12 months or younger.

Main Outcomes and Measures

The primary outcome was the prevalence of guideline implementation, which was measured by 1 survey item about awareness followed by a second item about implementation. Secondary outcomes included identification of guidelines-focused services provided by pediatricians, knowledge of the guidelines (measured with 3 clinical scenarios), barriers to guideline implementation, need for training, and facilitators of guideline implementation.

Results

A total of 1781 pediatricians were eligible to participate and completed the entire survey. Most respondents self-identified as white (1287 [72.5%]) and female (1210 [67.4%]) individuals. Overall, 1725 (93.4%; 95% CI, 92.2%-94.5%) pediatricians reported being aware of the guidelines. Of those pediatricians who had knowledge of the guidelines, 497 (28.9%; 95% CI, 26.8%-31.1%) reported full implementation and 1105 (64.3%; 95% CI, 62.0%-66.6%) reported partial implementation. Common barriers to implementation included parental concerns about allergic reactions (reported by 575 respondents [36.6%; 95% CI, 34.3%-39.1%]), uncertainty in understanding and correctly applying the guidelines (reported by 521 respondents [33.2%; 95% CI, 30.9%-35.6%]), and conducting in-office supervised feedings (reported by 509 respondents [32.4%; 95% CI, 30.1%-34.8%]). Many pediatricians (1175 [68.4%; 95% CI, 66.1%-70.5%]) reported a need for further training on the guidelines.

Conclusions and Relevance

This survey found that most pediatrician respondents appeared to know of the 2017 guidelines, but less than one-third of respondents reported full implementation. Results of this study may inform future efforts to eliminate barriers to guideline implementation and adherence, thereby reducing the incidence of peanut allergy in infants.

Prevalence of Special Health Care Needs Among Foster Youth in a Nationally Representative Survey

This analysis of a nationally representative cohort examines the association of foster care status with prevalence of special health care needs and specific categories of health disorders in children.

Effectiveness of Clinical Decision Support Tools on Pediatrician Adherence to Peanut Allergy Prevention Guidelines

This study assesses the adherence to guidelines on peanut allergy assessment in infants aged 4 to 6 months in a clinic supplied with clinical decision support tools vs a comparator clinic.

Economic burden of food allergy: A systematic review

OBJECTIVE

To assess the economic burden of food allergy (FA) worldwide.

DATA SOURCES

PubMed MEDLINE, Embase, and Cochrane Central Register of Controlled Trials on the Wiley platform were searched to identify literature that assessed direct, out-of-pocket, and opportunity costs of FA. All databases were searched back to their inception, and no language or date limits were applied.

STUDY SELECTIONS

We included primary studies that examined direct medical, out-of-pocket, or opportunity costs and/or lost labor productivity in food allergic adults and/or children and their families.

RESULTS

Eleven papers met our inclusion criteria, of which ed7 addressed direct medical, 7 addressed out-of-pocket, and 5 addressed opportunity costs. Estimates were based on data that reflected costs for a patient with FA (individual level) or costs for a household with a food allergic patient (household level). The mean individual-level direct medical costs ($2081) were much higher than the mean household-level costs ($806). The mean individual-level out-of-pocket ($1874) and opportunity ($1038) and opportunity cost were lower than the mean household-level out-of-pocket ($3339) and opportunity ($4881) costs. Household-level estimates of lost opportunity costs imposed the largest economic burden attributable to FA.

CONCLUSION

Most of the economic burden studies reviewed measured components of economic burden that are unique to individuals with FA but did so in noncomparable ways. Addressing cost burdens and measuring them using standardized instruments and methods will be critical to better understand the economic burden of FA globally.

Prevalence and Correlates of Educational Intervention Utilization Among Children with Autism Spectrum Disorder

This study examined the prevalence and correlates of educational intervention utilization among U.S. preschool aged children with autism spectrum disorder (ASD) prior to recent policy changes. The analysis was based on a nationally representative longitudinal survey of children receiving special education services during the 2003-2004 school year. All children with parent or teacher identified ASD over a 3-year study period were analyzed. Outcomes included utilization of speech therapy, occupational therapy, behavior therapy, and mental health services by service sector. The analysis revealed low rates of behavioral therapy and mental health services. Parents reported that the overwhelming majority of services were received inside school only. This study identified gaps in the provision of services for young children with ASD.

Socioeconomic Disparities in the Economic Impact of Childhood Food Allergy

OBJECTIVES

We compared direct medical costs borne by the health care system and out-of-pocket costs borne by families for children with food allergy by socioeconomic characteristics.

METHODS

We analyzed cross-sectional survey data collected between November 2011 and January 2012 from 1643 US caregivers with a food-allergic child. We used a 2-part regression model to estimate mean costs and identified differences by levels of household income and race or ethnicity.

RESULTS

Children in the lowest income stratum incurred 2.5 times the amount of emergency department and hospitalization costs as a result of their food allergy than higher-income children ($1021, SE ±$209, vs $416, SE ±$94; P < .05). Costs incurred for specialist visits were lower in the lowest income group ($228, SE ±$21) compared with the highest income group ($311, SE ±$18; P < .01) as was spending on out-of-pocket medication costs ($117, SE ± $26, lowest income; $366, SE ±$44, highest income; P < .001). African American caregivers incurred the lowest amount of direct medical costs and spent the least on out-of-pocket costs, with average adjusted costs of $493 (SE ±$109) and $395 (SE ±$452), respectively.

CONCLUSIONS

Disparities exist in the economic impact of food allergy based on socioeconomic status. Affordable access to specialty care, medications, and allergen-free foods are critical to keep all food-allergic children safe, regardless of income and race.

Impact of state mental health parity laws on access to autism services

OBJECTIVES

This study examined the effect of state mental health parity laws on family financial burden, satisfaction with health insurance, and receipt of needed mental health services for privately insured children ages three to 17 with autism spectrum disorder (ASD).

METHODS

Data came from the 2005-2006 wave of the National Survey of Children With Special Health Care Needs. An econometric approach with instrumental variables was used to control for the nonrandom selection of states according to their mental health parity laws. The study analyzed data for 949 youths with ASD and private health insurance. Six outcome variables were examined, including several measures of family financial burden, satisfaction with health insurance, and receipt of needed mental health services.

RESULTS

Families of children needing mental health services and living in a state with a strict parity law had a 61% higher probability of reporting out-of-pocket spending >$1,000 compared with those not living in a strict parity state. Compared with families of children living in a strict parity state that did not specify ASD, those living in a strict parity state that specified ASD had a 92% higher probability of reporting unreasonable out-of-pocket spending. All other results were statistically insignificant.

CONCLUSIONS

In contrast with previous research, this study did not find strong evidence that state mental health parity laws positively affected service access for children with ASD. Future research on the effect of autism insurance reform will provide a more precise test of the impact of insurance mandates on improving access to treatment services for children with ASD.

Expanded medical home model works for children in foster care

The Illinois Child Welfare Department implemented a statewide health care system to ensure that children in foster care obtain quality health care by providing each child with a medical home. This study demonstrates that the Medical Home model works for children in foster care providing better health outcomes in higher immunization rates.These children used the health care system more effectively and cost-effective as reflected in the higher utilization rates of primary care and well-child visits and lower utilization of emergency room care for children with chronic conditions.

Improving access to health care for foster children: the Illinois model

Children in foster care have lower health status than do their peers and limited access to health care. The Illinois Department of Children and Family Services developed HealthWorks, a separate primary care preferred provider system for children in foster care. This study compared claims data for children in HealthWorks with children not enrolled in HealthWorks and with children in Aid to Families with Dependent Children (AFDC) who had never entered foster care. Children enrolled in HealthWorks were more likely than were other children to receive all of the services except general inpatient hospitalizations. They had greater odds of receiving general exams and physicians' services and were more likely to visit the emergency room than children who were not enrolled. They were more likely to receive all of the measured services when compared with children receiving Medicaid through AFDC.

The child welfare response to serious nonaccidental head trauma

Serious nonaccidental head trauma (NHT) can leave permanent neurological damage in children who survive abuse. This study reports on child welfare's handling of NHT cases compared with cases of physical abuse and head trauma due to neglect with regard to placement in foster care, reunification with family, and safety issues. The results show that workers placed children with NHT in foster care immediately after the abuse but treated them no differently than other physically abused children regarding reunification.