Development of an innovative curriculum for paediatricians on peanut allergy prevention: How do we address current guidelines?

BACKGROUND

There exists strong evidence for the early introduction of peanut to at-risk infants for the primary prevention of peanut allergy. There is a need for educational initiatives to assist in dissemination and implementation of updated clinical guidelines on peanut allergy prevention.

APPROACH

The aim for this project was to create an innovative curriculum for paediatricians on peanut allergy prevention. The Intervention to Reduce Early Allergy (Peanut) in Childhood (iREACH) study was leveraged to recruit paediatricians for a needs assessment. Materials from the iREACH study, including an educational YouTube video and knowledge survey, were evaluated. Applying findings from the needs assessment, an innovative curriculum was developed, and updated knowledge survey questions were developed.

EVALUATION

The iREACH YouTube video had suboptimal viewing behaviours, and iREACH participants had high baseline knowledge scores that did improve after viewing the video. The majority of respondents to the needs assessment felt that all paediatricians needed access to an effective educational module on peanut allergy prevention, and they wanted a broadly accessible curriculum that incorporated quality media and content segmentation. An online, interactive curriculum was developed that includes clinical cases and games, and updated knowledge questions were created with associated internal structure and reliability evidence, as well as relation to other variables evidence.

IMPLICATION

The next steps of this project will focus on curriculum implementation and evaluation through a randomised, prospective study with the aim to serve as an educational model for how to integrate specialty-specific guidelines into broader clinical practice through education.

Food Allergy Reaction Severity and Management in a Diverse Population

BACKGROUND

Definitive treatment for food allergy reactions including anaphylaxis varies widely by reaction severity and socioeconomic status, but little data exist to characterize the relationship between severity, management, and race and ethnicity.

OBJECTIVE

To analyze the differences in reaction severity, epinephrine use, and emergency room (ER) use by race and ethnicity in a large, diverse, food-allergic cohort.

METHODS

We analyzed intake data from participants in the Food Allergy Outcomes Related to White and African-American Racial Differences cohort on the history of food allergy reactions, severity of the reactions, and management associated with each reaction. We used descriptive statistics as well as mixed-effects logistic and Poisson models to describe the differences in reaction severity, ER visits, and total lifetime epinephrine use by race and ethnicity.

RESULTS

A total of 784 children were included in the analysis: 425 (54.2%) were non-Hispanic White, 282 (36.0%) were non-Hispanic Black, and 77 (9.8%) were Hispanic/Latino. Non-Hispanic Black children had increased odds of more severe reactions (odds ratio, 1.7; 95% CI, 1.2-2.3) and higher odds of going to the ER (odds ratio, 2.8; 95% CI, 1.4-5.4). Both non-Hispanic Black (incidence rate ratio, 0.4; 95% CI, 0.3-0.5) and Hispanic/Latino (incidence rate ratio, 0.3; 95% CI, 0.2-0.5) children had lower rates of total lifetime epinephrine use.

CONCLUSIONS

There are significant disparities in the severity and treatment of food allergy reactions by race and ethnicity, resulting in increased ER use and decreased total lifetime epinephrine use. Equipping parents with resources and tools on management of food allergy reactions may result in decreased disparity in access to definitive care.

Natural Topical Treatment Contributes to a Reduction of Dry Scalp Symptoms in Children

Background

Dry scalp conditions affect a significant portion of the population, including children. Emerging evidence indicates the potential for improvement of atopic symptoms through altering the skin microbiome. Therefore, a topical treatment consisting of probiotic extracts, honey, turmeric, and vitamin B12 was manufactured to improve dry scalp symptomology through sustained balance of the microbiome.

Purpose

This interventional clinical study aims to determine the safety and efficacy of the topical treatment in reducing dry scalp symptomology in children 1-17 years old with dry scalp symptoms.

Methods

Participants applied the topical dry scalp treatment 2-3 times per week for two weeks. Safety and efficacy of the topical treatment was determined through physician assessment using the validated Investigator's Global Assessment (IGA) scale and the Total Severity Scale (TSS) during pre- and post-treatment clinic visits as well as parent reports at baseline, 1-week midpoint, and 2-week exit.

Results

Use of the topical treatment was associated with reduced symptoms of itchiness, dryness, irritation, and flakiness in children. The average IGA score was 3.0 at baseline and 2.0 after treatment, corresponding to a score difference of 1.0 (p < 0.001, 95% CI: 0.7, 1.2). The TSS score difference was 1.9 (p < 0.001, 95% CI: 1.4, 2.4). The total parent-reported scalp severity score decreased from 16.6 (95% CI: 14.8, 18.4) to 12.4 (p < 0.001, 95% CI: 11.0, 13.7) at 2-week exit.

Discussion

Study results mirror those reported in a study conducted in adults and point to the safety and efficacy of this natural topical treatment in reducing dry scalp symptomology in children. Based on our data, the combination of probiotic extracts and other anti-inflammatory ingredients appears to improve overall scalp health and appearance, though further studies will need to be conducted to further elucidate the link between clinical improvement and a balanced scalp microbiome.

Food allergen introduction patterns in the first year of life: A US nationwide survey

BACKGROUND

Prevention guidelines have changed over the past decade and now recommend the earlier introduction of peanut and egg without delaying the introduction of other food allergens. This paper explored caregiver practices regarding the introduction of food allergens during infancy.

METHODS

A survey was administered (2021) to a US population-based sample of 3062 caregivers (children 7 months - 3.5 years). Demographics and feeding practices were collected. Weighted frequencies and proportions were calculated using the svyr package in R 4.1. Survey-weighted chi-square statistics and covariate-adjusted, survey-weighted logistic regression models were used for statistical inference.

RESULTS

Cow's milk, wheat, and soy were the top three allergens introduced. Peanut and egg were introduced by 17.2% and 15.5% of caregivers before 7 months and 58.8% and 66.4% before 1 year, respectively. The age of peanut and egg introduction differed significantly by race/ethnicity (p < .001) and caregiver age (p < .001). Peanut and egg introduction before 7 months was significantly associated with the increased introduction of other allergenic foods before 1 year (p = <.001; peanut and p = < .001; egg). Caregivers who introduced peanut and egg before 7 months infant age fed an additional mean of 5.4 and 4.5 food allergens, respectively, before 1 year. Few caregivers (0.9%) reported feeding an "early food allergen introduction product" ≥ 3 times, which was significantly associated with parental food allergy (OR = 2.2) and previously seen an allergist (OR = 6.7).

CONCLUSION

More than half of the caregivers are not introducing peanut by age of one year and one-third are not introducing egg, though an observed shift toward earlier peanut and egg introduction was seen in the past 5 years. Peanut and egg introduction seem to co-occur and are associated with increased intake of other food allergens.

Identifying Contextual Factors and Strategies for Practice Facilitation in Primary Care Quality Improvement Using an Informatics-Driven Model: Framework Development and Mixed Methods Case Study

BACKGROUND

The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives.

OBJECTIVE

This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study.

METHODS

We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study.

RESULTS

The proposed framework was used to organize and analyze different stakeholders' perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs.

CONCLUSIONS

Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.

Food Insecurity in the Food Allergic Population: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.

Access to Allergen-Free Food Among Black and White Children with Food Allergy in the FORWARD Study

BACKGROUND

Racial differences in access to allergen-free food have not been fully described among children with food allergy (FA).

OBJECTIVE

To examine access to allergen-free foods among Black and White children with FA.

METHODS

Black and White children with FA were enrolled in Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD), a multisite prospective cohort study at 4 urban US centers. Caregivers completed questionnaires regarding access to allergen-free foods. Univariable statistics described demographics. Bivariable statistics evaluated crude associations with access to allergen-free foods. Multivariable logistic regression evaluated the adjusted effect of race on access to allergen-free foods. Geospatial analyses examined the distribution of race, socioeconomic status, and food desert residence.

RESULTS

Among participants (n = 336), White caregivers (88.1%) were more likely to report access to allergen-free foods than Black caregivers (59%) (P < .001). White caregivers were more likely to purchase allergen-free foods online (35.2%) than Black caregivers (12%) (P < .001). Although Black children were more likely to live in a food desert, access to allergen-free food was not related to food desert residence. In the unadjusted analysis, White children were 5.2 times as likely to have access than Black children (P < .001); after adjusting for demographics, this increase in access was no longer significant (P = .08). Other predictors of access to allergen-free foods included online food purchasing, annual household income, respondent education level, milk allergy, and child age >5 years.

CONCLUSION

In the FORWARD cohort, Black children have less access to allergen-free foods than White children, but much of the difference is accounted for by socioeconomic status and other participant characteristics.

Kaposi sarcoma among adults enrolling for HIV care in a large HIV clinic in Nigeria: 2006-2017

e18539

Background: Expanded access to antiretroviral therapy (ART) has led to a dramatic decline in Kaposi sarcoma (KS) among people initiating HIV care globally. In Nigeria, the country with the second-largest global HIV population, ART coverage increased from 11% in 2006 to 57% by 2017. The impact of Nigeria’s ART expansion of KS risk is unclear. We examined trends in KS risk among patients enrolled for HIV care in a large clinic in Nigeria from 2006-2017. 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 three periods: 2006-2009, 2010-2013, and 2014-2017 (Mean national ART coverage 16%, 33%, and 50% respectively), using the Chi-test trend test and logistic regression models to identify factors independently associated with KS. The study was approved by the local institutional Institutional Review Board (IRB) and ruled exempt by the IRBs of Northwestern University and Harvard School of Public Health. 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 median first CD4 cell count was 192 (IQR 84-320), 215 (IQR 98-344), and 222 (IQR 94-353) in 2006-2009, 2010-2013, and 2014-2017, respectively. The overall KS prevalence at entry was 0.59 % (95% CI 0.48-0.72). KS prevalence was lowest for patient entering care during 2006-2009 (0.39%, 95% CI 0.29-0.53), increased to 1.12% (95% CI 0.82-1.52) in 2010-2013 and declined to 0.72% (95% CI 0.42-1.20) from 2014-2017 (Chi2 for trend, 12.14, p<0.01). Adjusting for age, sex, and CD4 T-cell count KS prevalence was significantly higher in 2010-2013 compared to 2006-2009 (Table). 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 are critical to KS risk reduction in this population.

Factors associated with Kaposi sarcoma at HIV care enrollment in Jos, Nigeria (2006-2017).[Table: see text]

Food allergy-related bullying and associated peer dynamics among Black and White children in the FORWARD study

BACKGROUND

The experiences of Black children with food allergy (FA) are not well characterized, particularly with respect to bullying victimization and other psychosocial outcomes.

OBJECTIVE

To evaluate bullying experiences of Black and White children with FA, including associations with peer relationships, anxiety, and school policies.

METHODS

Surveys were administered to parents of 252 children with physician-diagnosed FA enrolled in the multisite FORWARD cohort. The surveys assessed demographics, atopic disease, bullying victimization, and school FA management practices and policies. Descriptive statistics of bullying by race were compared by χ² tests. Multiple logistic regression analyses adjusting for race, age, parental education, household income, child sex, and multi-FA compared adjusted probabilities of bullying victimization by school policies.

RESULTS

Nearly 20% of school-aged children were bullied for FA with no substantial racial differences overall, though for children ages 11 years and up, White children reported higher rates of bullying. However, Black children experienced non-FA-related bullying twice as frequently as White children (38.6% vs 17.7%; P = .002). Most of the caregivers (85.7%) who intervened in their child's bullying reported that it was helpful. Among parents, 17.3% reported that they were teased or bullied owing to their child's FA. More than half of the respondents (54.8%) reported that some allergens are banned from their child's school, most typically peanut. In schools banning peanuts, FA-related bullying was less frequently reported by all students who have food allergy.

CONCLUSION

Bullying owing to FA is common, and caregivers, medical professionals, and school administrators can help reduce bullying by screening for bullying and supporting and educating school policies.

Understanding Food-Related Allergic Reactions Through a US National Patient Registry

BACKGROUND

Although previous studies have focused on unintentional food-related allergic reactions, few have explored the motivation of intentional exposure to a known food allergen, independent of oral food challenges and/or oral immunotherapy. Still, data on the frequency and context of food-related allergic reactions remain sparse.

OBJECTIVE

To identify the frequency and context of food-related allergic reactions among children and adults.

METHODS

We analyzed surveys from the Patient Registry established by Food Allergy Research and Education. Multivariable logistic regression evaluated characteristics associated with having frequent food-related allergic reactions as well as intentional food-related allergic reactions.

RESULTS

Over one-third of 4075 (37.7%) respondents reported having more than 1 food-related allergic reaction per year, and 12.8% reported having 1 reaction per year. Of the 3054 respondents who completed the most recent reaction survey, 9.9% of food allergen exposures were classified as intentional, 82.1% as unintentional, and 4.8% as medically related. Among children with intentional exposures, the most common reason was that the child had never had a serious reaction (50.0%), and among adults, it was the decision to take the risk anyway (47.8%). Cross-contamination was the most commonly cited reason for unintentional exposure (children: 24.1%; adults: 32.2%).

CONCLUSION

Among patients in a national food allergy registry, reports of food-related allergic reactions were common, and a non-negligible number of intentional reactions were reported. Our findings indicate the need for research on reactions in and out of the emergency department as well as intentional risk-taking behavior.

The economic impact of childhood food allergy in the United States

IMPORTANCE

Describing the economic impact of childhood food allergy in the United States is important to guide public health policies.

OBJECTIVE

To determine the economic impact of childhood food allergy in the United States and caregivers' willingness to pay for food allergy treatment.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional survey was conducted from November 28, 2011, through January 26, 2012. A representative sample of 1643 US caregivers of a child with a current food allergy were recruited for participation.

MAIN OUTCOMES AND MEASURES

Caregivers of children with food allergies were asked to quantify the direct medical, out-of-pocket, lost labor productivity, and related opportunity costs. As an alternative valuation approach, caregivers were asked their willingness to pay for an effective food allergy treatment.

RESULTS

The overall economic cost of food allergy was estimated at $24.8 (95% CI, $20.6-$29.4) billion annually ($4184 per year per child). Direct medical costs were $4.3 (95% CI, $2.8-$6.3) billion annually, including clinician visits, emergency department visits, and hospitalizations. Costs borne by the family totaled $20.5 billion annually, including lost labor productivity, out-of-pocket, and opportunity costs. Lost labor productivity costs totaled $0.77 (95% CI, $0.53-$1.0) billion annually, accounting for caregiver time off work for medical visits. Out-of-pocket costs were $5.5 (95% CI, $4.7-$6.4) billion annually, with 31% stemming from the cost of special foods. Opportunity costs totaled $14.2 (95% CI, $10.5-$18.4) billion annually, relating to a caregiver needing to leave or change jobs. Caregivers reported a willingness to pay of $20.8 billion annually ($3504 per year per child) for food allergy treatment.

CONCLUSIONS AND RELEVANCE

Childhood food allergy results in significant direct medical costs for the US health care system and even larger costs for families with a food-allergic child.