© Springer International Publishing AG 2017
Christina A. Di Bartolo and Maureen K. BraunPediatrician’s Guide to Discussing Research with Patients10.1007/978-3-319-49547-7_88. Food Allergies
(1)
The Child Study Center, NYU Langone Medical Center, New York, New York, USA
(2)
Department of Pediatrics, The Mount Sinai Hospital, New York, New York, USA
Keywords
Food avoidanceVigilanceFood sensitivitiesGrowth concernsSchool-wide peanut bansOverview
Food allergies among children are a prevalent issue in the United States. It is estimated that between 2 and 8% of children are affected [1]. Prevalence rates vary according to the food in question, the method of survey, region, and time period studied [2, 3]. The range in prevalence rates is just one example reflecting the field’s overall state. Research and clinical practice in food allergies are marked by ambiguity in definitions, variability of individual symptoms, lack of consensus as to testing thresholds for diagnostic clarity, and ambiguity as to preferred testing methods, all leading to a great deal of uncertainty in the field [4]. Even taking these uncertainties into account, data from the National Health Survey indicate that prevalence rates in the United States appear to be increasing [5].
The nine foods most commonly reported as producing allergic reactions in children are egg, fish (fin), milk, peanut, sesame, shellfish, soy, tree nuts, and wheat [6]. There are still no preventative treatments or permanent cures for food allergies [7]. Therefore, the commonly prescribed action is food avoidance and response to allergic reactions with appropriate treatment [7]. Complying with food avoidance and responding to accidental ingestion requires a number of activities, such as monitoring food intake, reading labels, monitoring for reactions, determining severity of reactions, and taking appropriate medication in response [8]. For younger children, parents largely assume these responsibilities [8, 9]. It is crucial that parents understand their children’s food allergies so that they may respond with the appropriate level of intervention.
The symptoms of food allergies can range from mild to life-threatening [7]. The range of possible symptoms may implicate the skin, gastrointestinal system, and/or respiratory system [7]. Mild symptoms include itchy mouth, a few hives or mild itching on skin, and mild nausea and discomfort [10]. Mild symptoms are typically treated using over-the-counter antihistamines [10]. Severe symptoms include shortness of breath, wheezing, repetitive cough, pale or blue skin, dizziness, confusion, faintness, weak pulse, tight or hoarse throat, trouble breathing or swallowing, and swollen tongue or lips [10]. A combination of more mild symptoms can be classified as a severe reaction when the symptoms affect different bodily systems [10]. For example, a child who presents with hives, itchy rashes, or swelling, along with gastrointestinal symptoms like vomiting, diarrhea, or cramps, would be said to be experiencing severe symptoms [10].
The primary life-threatening response to food allergies is anaphylaxis [7]. Anaphylaxis is characterized as a severe, life-threatening response to consuming an allergen that results in simultaneous impairment in more than one organ system [10]. Just as in more mild allergic reactions, the combination of symptoms that constitute anaphylaxis can vary by individual [11]. As such, there is no specific threshold for determining the severity of an anaphylactic reaction [11]. The indicated treatment for anaphylaxis is a dose of epinephrine, administered via injection in the outside thigh using an adrenaline auto-injector [10]. More severe reactions or anaphylaxis that presents in two waves may require more than one dose [12].
Parents become concerned about food allergies in various stages of their children’s development, such as in utero, during infancy, and throughout childhood, and concern can be seen as either preemptive or reactive. Mothers who are concerned about food allergies due to genetic load may ask questions or consider avoiding potentially allergenic foods even during pregnancy. The genetic influence of food allergies is challenging to study definitively due to individual variability in diagnosis [4]. However, there are indicators that allergies are at least partly determined by genetics. For example, children are seven times more likely to develop a peanut allergy if they have either a parent or a sibling with peanut allergy [13]. Monozygotic twin studies illuminate a strong genetic component, with children having a 64% increased risk of developing a food allergy if their identical twin has such an allergy [14]. These same mothers whose children can be classified as high-risk for developing food allergies may also be reluctant to eat highly allergenic foods during breastfeeding. Previously, mothers of high-risk infants were encouraged to avoid allergens while breastfeeding [15]. New evidence, however, which we will review, suggests that not only is maternal avoidance of allergens during breastfeeding not helpful, it may have deleterious effects on children’s development of immunities [4]. There were also similarly premature recommendations from the World Health Organization for parents to delay exposing high-risk children to allergens [4]. Another set of parents may not be preemptively concerned, but instead react to their children’s onset of allergies. Parental anxiety understandably increases when children have experienced anaphylaxis, as reported by young adults reflecting on memories of their parents’ overprotectiveness following such dramatic incidents [16].
We will review common parental concerns specific to food allergies pertaining to Quality of Life and child growth. Misconceptions about food allergies and methods to mitigate their effects abound. This chapter will review common misconceptions that cause parents to expend energy in likely unfruitful endeavors, or worse, may worsen their children’s allergies or place them at higher risk of serious adverse events. Finally, research about food allergies is still inconclusive in a number of areas. We will outline current findings in food allergy prevention and treatment research.
Common Parental Concerns
General
Clinicians frequently encounter parents who are concerned about food allergies. Compared to other health concerns, a 2012 survey of 1,119 parents indicated that allergies (including food allergies) captured the concerns of the highest percentage of parents [17]. Allergies were a significant concern for 69% of parents, with 38% of these reporting it as a medium problem and another 31% reporting it as large [17]. When examined according to child age group, the issues common to all ages were mental health, healthy nutrition, healthy growth and development, and safety [17]. A quick review of these concerns reveals that all of these are implicated in a food allergy [17]. This section will review findings in parental concerns regarding Quality of Life and child growth.
Quality of Life
Robust research shows that food allergies directly affect Quality of Life [18, 19]. When related to health, Quality of Life typically refers to the effects of an illness and the treatment of the illness on the patient [20]. Patient perception of the impact of the illness on his or her life also affects Quality of Life [20]. With regard to food allergies, we can include the impact of efforts to prevent an allergic response within this definition. Mild allergic responses are bothersome, and severe reactions are frightening and life-threatening [7]. In addition to the temporary incidents associated with allergic reactions, quality of life in between such incidents is affected by the vigilance required by parents and children [20]. Parents of young children, for whom accidental ingestion is common, show considerable vigilance [20]. At the same time, research shows that having a child with a food allergy has a detrimental effect of on family quality of life [21].
In their vigilance, parents engage in many behaviors to prevent or reduce their children’s ingestion of the offending food. Behaviors include reading labels, paying attention to methods of food preparation, providing alternative food options outside the home (e.g., at school, during play dates, on trips), educating key adults in their children’s life who also assume some responsibility for feeding (e.g., teachers, grandparents, parents of child’s friends), and making needed preparations for emergency responses [9]. Given that children must eat multiple times a day, it is not surprising that among one sample of 221 parents, most reported thinking about their children’s food allergy on a daily basis [9].
Well-documented food allergy anxiety is clearly helpful for initiating and maintaining the vigilance needed to implement avoidance successfully [22]. In the same sample of 221 parents of children with food allergies, more than half reported frequently feeling fearful for their children’s safety [9]. Parents of children who suffered anaphylaxis or who have allergies to more than one food reported higher levels of fear than other parents of food allergic children [9]. Very high levels of anxiety are associated with initial diagnosis, prior to the establishment of familiarity with symptom prevention and management [22]. Fortunately, parents’ fear tends to decrease as their children’s age increases [9]. Similarly, there is not current evidence of clinically meaningful differences in anxiety among teenagers with food allergies compared to their nonallergic peers [23].
Extra counseling is recommended in cases where parents’ or children’s levels of anxiety do not remit [22]. Among a sample of Italian families with a food allergic child, four categories of problems that led families to seek additional counseling for living with food allergies were: (1) social/emotional functioning, (2) managing the allergy, (3) eating, and (4) behavior [22]. Of those who sought additional counseling, 36% were referred by clinicians such as allergists, pediatricians, or dieticians [22]. That fully one-third of families obtained help after referrals emphasizes the need for primary care physicians to make referrals when they perceive a family struggling with any of those four issues.
Models of health promotion have hypothesized that increased knowledge regarding food allergies would lead to increased sense of self-efficacy, the sense that people are able to achieve a specific outcome through their own behaviors [24, 25]. However, the research does not support this theory. Research instead indicates that the more knowledge parents have about food allergy, the lower their quality of life [18]. For example, one study of nearly 300 parents of food allergic children from the Netherlands found that while they had less knowledge about allergies than their American counterparts, they were also more optimistic about their children’s condition [8]. To explain the finding, study authors proposed that as parents learn about their children’s illness and the possible symptoms, their anxiety about potential outcomes and their frustration about their ability to keep their children safe increase [8]. Increased negative emotions such as anxiety and frustration could easily affect quality of life.
Another study examined differences between maternal and paternal quality of life in relation to their sense of competence and knowledge about food allergies [24]. As fathers spend more time with their children than in previous generations, they also take on increasing responsibility for management of their children’s chronic health conditions [26]. Despite fathers’ increased involvement, it appears the primary burden for education, competence, and management of allergies still falls on mothers [24]. Mothers reported statistically higher levels of competence in dealing with their children’s food allergies than fathers and at the same time reported a lower quality of life [24]. In this case, the proposed mechanism explaining the results is that mothers’ higher involvement in the daily management of their children’s allergies simultaneously improves their personal competence in this area and decreases their quality of life [24]. Put another way, parental empowerment was not associated with increases in quality of life [24]. Study authors suggest that parents with greater knowledge of food allergies are more aware that most fatal reactions occur outside of the home, where parental competence cannot mitigate risk [24].
Knowledge may be more positively linked to quality of life when the knowledge is delivered at clinically relevant times and in formats that parents find useful [27–30]. Parents who accessed information subsequent to their children’s diagnosis felt higher competence than they did at the time of diagnosis [9]. Many parents already seek out the information they feel they need to help their food allergic children, with most parents in one sample reporting that they frequently seek out information about allergies [9]. When properly educated, parents improve their skills in food avoidance, identifying reactions, and administering emergency treatment [31, 32]. A randomized controlled trial of distributing a parent handbook found that parent satisfaction with information is attainable [33]. Among 87 parents who received a handbook (most of whom reported spending one to 2 h reading it) significantly improved their knowledge and confidence ratings from baseline to post, in contrast with the control group, who reported no such improvement in confidence [33].
Growth
Most food allergies appear in the first 2 years of life, coinciding with a critical growth period in child development [34]. When children avoid foods due to allergy, their intake of macronutrients, such as protein, carbohydrates, and fat is affected [35]. These children are also at risk of not receiving the micronutrients needed for appropriate growth, such as vitamins, minerals, and trace elements [35]. Children with allergies to foods common to a healthy diet, such as milk, eggs, or wheat, are most at risk of retarded growth [35]. Children with more than one allergy have diets that are further restricted, impacting the ability of their parents to provide them with a sufficiently nutrient-dense diet. Fortunately, most children are allergic to no more than two food allergens [36, 37]. Regardless, macro- and micronutrients found in allergy-producing foods must be supplemented elsewhere in diets of food allergic children [35].
Case studies have found that parental misconceptions or misunderstandings about their children’s adverse reactions to food, if not properly checked with a physician’s expertise, can lead to severe elimination diets [38–40]. These diets have resulted in instances of vitamin and mineral inadequacies [38], kwashiorkor [39], and failure to thrive [40]. Most of the research on growth in children with food allergies focuses on cow’s milk [41]. One longitudinal study found that children who developed an allergy to cow’s milk experienced a slowing in their growth after their diagnosis, and their height and weight had not normalized by 2 years of age [42]. Other studies found that children with milk allergy had a lower height-to-age ratio than their unaffected peers [43, 44]. One study, while small (197 children, 98 of whom had at least one food allergy), assessed food allergies more broadly (i.e., not just milk) [41]. This study found that while 16% of children with one allergy were in the twenty-fifth percentile of height-for-age, 35% of children with more than one food allergy fell into the lowest quartile [41]. While height-for-age was normally distributed across children with food allergies, more children with food allergies were in the lowest quartile than children without [41]. Accordingly, the NIAID Food Allergy Guidelines recommends food counseling for all parents of children with food allergies to facilitate appropriate substitutions to compensate for removal of key foods from children’s diets [10]. An annual nutritional assessment for children with food allergies has also been recommended to assess whether their growth is on track and that they are consuming adequate nutrients [41].
Common Misconceptions
Food sensitivities are the same as food allergies
A number of different adverse reactions to food can occur, which are classified differently according to symptom presentation and—when known—underlying causal mechanism [45]. Confusion can occur when parents are not aware of the symptomatic differences between food allergies and other food reactions, when similar symptoms present for different underlying reasons, and when they misattribute their children’s symptoms as caused by consumption of a food. Allergies are specific to an immunologic process by which the body misidentifies proteins found in food as foreign and reacts with initiation of an immunologic response [45]. Adverse reactions to foods not caused by this immunologic response to proteins include lactose intolerance, celiac disease, and reactions that are toxic, metabolic, infectious, or pharmacologic [45]. One commonly cited misconception is that lactose intolerance is the same as a dairy allergy. In the case of lactose intolerance, the body does not produce a sufficient amount of the enzyme needed to break down sugars within milk [45]. Symptoms of lactose intolerance result from the excess gas that is produced as a result, such as cramps, bloating, flatulence, and diarrhea [45]. This is in contrast to a milk allergy, in which the protein in milk is perceived as a direct threat to the body due to insufficient barriers in the gut that, when functioning correctly, cause antigens found in food to be admitted safely in the body [45]. Symptoms of a milk allergy include systems other than the digestive tract (as in lactose intolerance), such as skin and respiratory reactions [7].
Some portion of parental confusion about their children’s diagnostic status may stem from incomplete or incorrect diagnoses made in doctors’ offices. One survey of 2,355 parents of children with reported food allergies found that approximately 32% of children did not obtain a diagnostic test (skin test, blood test, or oral challenge) [6]. In this sample, only one of every five reported allergy diagnoses were supported with collateral results of an oral challenge [6]. Children with the most severe reactions were more likely to receive a diagnosis from a physician [6]. Children with peanut, milk, and tree nut allergies were the most likely to have received a diagnosis from their physician [6]. Shellfish diagnoses were significantly less likely to be diagnosed or assessed with blood or skin testing [6].
The study authors hypothesized a few mechanisms by which parents might report their children have food allergies without diagnosis from a physician, as occurred in one third of their sample [6]. They propose that once parents suspect a food allergy, they may begin to eliminate that food from their children’s diets without consulting their physician [6]. Even once parents seek medical support, diagnosis of food allergies is difficult due to the wide range of symptoms, differential symptom presentation based on individual characteristics (of the child and the food), and the changing reaction severity over repeated exposures [6]. The level of diagnostic testing indicated depends on the symptom presentation, family history, and age of child [7]. Some allergic reactions are life-threatening, and the average time between referral to allergist and visit to allergist is 4 months [7]. Accordingly, primary care physicians who suspect food allergy based on reports of severe reactions should refer an allergist immediately and prescribe epinephrine, antihistamines, and counsel parents about food management for the interim [7].
Parents who observe their children experiencing reactions to foods should simply remove that food from their children’s diet, as there is no cure for food allergies, anyway
Similar to the above misconception wherein parents attempt to diagnose a food allergy without medical expertise, parents who initiate treatment for their children’s perceived food allergies without consulting their physician are similarly placing their children at risk. While there is still no established definitive mode for food allergy testing, physicians can clarify further for parents the level of caution they should take in response to an observed reaction. For example, if children show an allergic response to one food, a comprehensive skin prick battery should still not be performed in absence of clinical history for other food allergies [7, 45]. While some parents may want a battery performed, skin prick testing produces many false positives [7, 45]. Skin prick tests can be further misleading to parents because the magnitude of response during testing (i.e., size of skin reaction to the prick) is not associated with severity of response [46]. In fact, the size of the skin reaction is connected to the likelihood that the food indeed caused the reaction [46]. Blood tests can provide further diagnostic clarity, but primary care physicians have varying levels of confidence in interpreting laboratory results [7]. Oral food challenge—the most labor-intensive method for assessing food allergy—should be performed by only an allergist due to the potential for severe reactions during the test [7]. Oral food challenge consists of the child consuming the suspected allergen in gradually increasing amounts under close supervision from a professional equipped to respond to possible severe reactions [47].
Without a formal diagnosis, parents take the chance that they will eliminate foods from their children’s diets that are not true allergic offenders [6]. Removing the incorrect food is problematic for three reasons. First, because removing common foods diminishes quality of life, unnecessary elimination should be avoided [6]. Second, removing the incorrect food fails to identify the true cause of the child’s adverse reaction to the food [6]. If the observed reaction was due to a food allergy, the child remains at risk for ingestion of the true offender [6]. Third, parents who choose to manage their children’s allergies via elimination without consulting with a physician may miss crucial information about food allergies, such as that previous reaction history does not accurately predict severity of future reactions [6]. Instead, parents who confer with pediatricians about a suspected allergy before attempting elimination receive counseling and education about label reading and emergency response. Education about label reading is recommended because food manufacturers commonly utilize several allergy-producing foods in one product, increasing the risk of accidental ingestion [41]. After consulting with a physician, parents can also obtain life-saving injectable epinephrine in case of accidental ingestion if their child’s allergy warrants [6].
Young children are most at risk for suffering severe reactions to food allergies
Certainly quality of life and accidental ingestion are legitimate concerns for parents of young children with food allergies. However, the quality of life concerns regarding food avoidance and accidental ingestion that affect young children also present in adolescents [23]. An elevated number of psychiatric symptoms were observed in food allergic adolescents (ages 10–15) compared to nonallergic peers [23]. The observed increase in symptoms was not clinically meaningful—on average, food allergic adolescents displayed one additional psychiatric symptom [23]. Study authors proposed the possibility that these additional symptoms did not reflect true psychiatric concerns, but rather were thoughts or behaviors associated with the tasks needed to avoid certain foods [23]. For example, preoccupying thoughts about food that may indicate an eating disorder in a nonallergic adolescent reflect appropriate thought patterns needed to sufficiently avoid the offending foods in allergic teens [23].
While adolescents’ quality of life appears to be influenced in a way similar to that of young children, differences emerge between children and adolescents in the realm of anaphylaxis [48, 49]. Fatal allergic reactions disproportionately affect adolescents [48, 49]. Adolescents engage in risk-taking behaviors when managing their food allergies, such as not carrying their AAIs, consuming foods they know themselves to be allergic to, or eating foods with a “may contain” label [11]. Adolescent risk-taking behavior is commonly misunderstood as a lack of appreciation for the risks of their actions. Consequently, interventions for teenagers often focus on providing information about allergies [50]. These narrow interventions must be limited, because knowledge alone does not address the psychosocial concerns teenagers face when managing their food allergies.
Adolescents present unique psychosocial profiles that make adherence to safety protocols challenging [22]. By around age 8 years old, children begin demonstrating awareness that their allergies set them apart from their peers [51]. Allergic teenagers report feeling misunderstood and insecure [52]. Many teens also report being teased or bullied by peers as a consequence of their food allergies [11, 51, 53–55]. Many adolescents come to understand having an allergy as a way of life [51, 52]. The constant vigilance needed to remain safe is a source of frustration for many teens [22]. Concurrently, the developmental stage of adolescence promotes increasing independence and autonomy from parents. Food allergic teens are attempting to separate and individuate from their parents, which requires assuming increasing responsibility for managing their condition. This transfer of responsibility occurs in the context of anxiety from parents and sometimes the teens themselves [22]. Subsequently, the emphasis on simply informing teenagers about the risks of food allergies oversimplifies adolescents’ reasons for not engaging in strategies to stay safe from their food allergy [11]. The simplistic understanding neglects to view the teenager as a whole person with other factors to consider in decision-making than just their food allergy [11].
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
