A Survey of Canadian Dietitians on Identification of Infants at High Risk of Food Allergy and Frequency of Allergenic Food Consumption.

Purpose: To assess knowledge of Canadian dietitians on the topics of food allergy and food allergy prevention guidelines, including introduction of allergenic solids to infants at risk of food allergy.Methods: An online survey was distributed via email listservs targeting Canadian dietitians.Results: In total, 144 of 261 dietitians completed the survey (60.5%). Respondents recommend introduction of peanut (89.5%) and allergenic solids (91.2%) within the recommended age of 4-6 months for infants at high risk of food allergy, but only 26.2% recommend offering peanut three times per week once it has been introduced. In identifying what constitutes an infant at high risk of developing peanut allergy, dietitians expressed lower comfort levels and lower number of correct responses.Conclusions: Dietitians demonstrated they are up to date regarding the timing of introduction of allergenic solids, but not the frequency of consumption once introduced, for infants at high risk of food allergy. They also expressed low comfort level identifying risk factors for peanut allergy. There are opportunities for further education of dietitians, as well as potential to further utilize dietitian services for the benefit of patients with food allergy or who are at risk for food allergy.

Food-allergy-specific anxiety and distress in parents of children with food allergy: A systematic review.

BACKGROUND: Parenting a child with food allergy (FA) can lead to impaired quality of life and family functioning. Anxiety is a critical component of FA-associated distress and a potential target for therapeutic intervention. This systematic review aimed to clarify the concept of FA-specific anxiety (FAA) and its antecedents, consequences, and correlates and to determine the extent to which existing FA-specific outcome measures capture symptoms of parental distress and FAA. METHODS: MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for qualitative and quantitative studies examining distress or anxiety in parents of children with FA through August 2020. This review was registered with PROSPERO (CRD42020208316) and conducted in accordance with PRISMA guidelines. RESULTS: Ninety-eight studies were included in the final narrative synthesis. Most participants were mothers, and reporting of demographic data was limited. Parents identified anxiety as the most burdensome form of FA-specific emotional distress. Several allergy-related factors as well as medical and psychosocial interventions were associated with reduced parental anxiety and distress. However, affective, cognitive, and behavioral dimensions of FAA were only partially addressed by existing measures for general anxiety symptoms and FA-specific parental factors. CONCLUSIONS: FAA contributes to distress and functional impairment among parents of children with FA. Current FA-specific parent measures fail to adequately capture dimensions of FAA, suggesting that further work is needed to improve the assessment and monitoring of FAA and its impacts. Characterization of this construct represents an initial step in developing standardized methods for assessing and monitoring FAA in clinical populations.

Development of IMPAACT (Impairment Measure for Parental Food Allergy-Associated Anxiety and Coping Tool), a validated tool to screen for food allergy-associated parental anxiety.

BACKGROUND: Parents commonly experience anxiety owing to their children's food allergies (FAs). Although FA-specific anxiety screening tools for adult and pediatric patients exist, a tool for parents with children with food allergy is lacking. OBJECTIVE: To develop and validate a tool that measures parental anxiety related to their child's FA. METHODS: To construct the instrument, items were developed based on consultations with stakeholders and review of existing literature. The instrument was then pilot tested, and items were modified based on relevance, importance, item-total correlations, and fit with the instrument's overall factor structure. The modified instrument was validated through assessing internal validity (reliability), convergent and discriminant validity, concurrent validity, and practical usefulness at 2 time points (precoronavirus disease 2019 and current). RESULTS: The scale showed excellent reliability (Cronbach's α = 0.95). It had a 4-factor structure that was replicated at the 2 time points. The 4 subscales were moderately correlated (between r = 0.438 and 0.744). The scale showed excellent convergent and discriminatory validity, correlating moderately with State Trait Anxiety Inventory and Generalized Anxiety Disorder, and highly with Food Allergy Quality of Life-Parental Burden. It also showed excellent concurrent validity, differentiating among many external variables. Most importantly, it successfully differentiated parents in need of psychological support for problems related to their child's FA. CONCLUSION: The Impairment Measure for Parental Food Allergy-associated Anxiety and Coping Tool fills a gap in the existing literature as a validated screening tool for parental anxiety associated with a child's FA, employing a multi-factor structure addressing multiple dimensions of anxiety and its functional impacts. It has excellent internal and external validity and is well-suited for use in both research and clinical settings to quickly determine which parents of children with FA are in need of further psychological support.

Application of the Eosinophilic Esophagitis Histology Scoring System Grade Scores in Patients at British Columbia Children's Hospital.

INTRODUCTION: Histologic diagnosis of eosinophilic esophagitis (EoE) involves peak eosinophil counts (PEC) being greater than 15 per high power field. The EoE Histology Scoring System (EoEHSS) was developed to comprehensively evaluate biopsies to better predict symptom and endoscopy response; we aimed to validate the EoEHSS in our provincial registry, where EoEHSS had not been employed. METHODS: We reviewed 186 esophageal biopsies from 16 patients at diagnosis and follow-up. Statistical analyses were conducted to quantify how grade scores correlate with active EoE status and PEC counts, and each feature's ability to predict active disease. RESULTS: Nearly all EoEHSS variables were associated with active EoE and high PEC, with basal zone hyperplasia, eosinophil abscesses, and surface epithelial alteration being most predictive in identifying active EoE. CONCLUSIONS: We validated and demonstrated each EoEHSS variable's strength in tracking traditional PEC counts, resulting in its adoption as a standard reporting element for our research registry.

How to Incorporate Oral Immunotherapy into Your Clinical Practice.

PURPOSE OF REVIEW: The purpose of this review is to discuss how to best incorporate oral immunotherapy into your clinical practice based on recent evidence and guidelines, and address controversies. RECENT FINDINGS: Oral immunotherapy is the food immunotherapy treatment with the most literature supporting its use. Recent data from both randomized clinical trials and real-world studies show OIT is especially safe and effective in preschoolers, while avoidance may be less safe than previously thought. OIT guidelines support its use outside of research. Oral immunotherapy can be safely and effectively incorporated into your clinical practice, with careful planning and consideration of scenarios where benefits outweigh risks. Baseline oral food challenges are necessary in clinical trials, but in clinical practice, these are best done when the history is unclear due to resource limitations. There is a role for both regular food and FDA-approved products. Future research should focus on optimizing safety and adherence in the real-world setting.

Current tools measuring anxiety in parents of food-allergic children are inadequate.

BACKGROUND: In the context of food allergy, excessive parental anxiety can be maladaptive and lead to unnecessary restriction of social activities. No validated tool exists to measure food allergy-associated anxiety (FAAA). This study sought to explore factors associated with parental FAAA, determine sensitivity and specificity of using generic state anxiety measure-State-Trait Anxiety Inventory (STAI) versus FAAA, and determine whether validated tools for generalized anxiety or food allergy-specific quality of life (QoL) could be used as surrogates for FAAA. METHODS: Canadian parents of food-allergic children completed an online survey. Without a validated tool for FAAA, a visual analogue scale was used to assess parent-reported FAAA. Multivariable linear regression was performed with FAAA as the outcome. Sensitivity and specificity analysis of state anxiety vs. FAAA, and factor analysis of state anxiety and QOL, was performed to determine whether these could be used as surrogates for FAAA. RESULTS: A total of 548 of 1244 parents (44.1%) completed the survey. Factors positively associated with FAAA included parental burden, risk perception, state anxiety, intolerance of uncertainty and perceived severity of child's food allergy; personal/family history of mental health was negatively associated. Sensitivity and specificity of state anxiety were 68.6% and 70.0%. Factor analysis revealed that state anxiety and QOL were correlated (r = 0.54, P < .001) but distinct constructs. CONCLUSION: Our study identified factors associated with FAAA, and determined that generic anxiety and QOL tools do not accurately categorize parents with self-reported high FAAA. Future research will develop a validated screening tool to help allergists identify anxious parents and provide psychosocial resources.

Parents of children with food allergy: A qualitative study describing needs and identifying solutions.

BACKGROUND: Parents experience a wide range of emotions, specifically stress and anxiety, when their child receives a diagnosis of a food allergy. Managing this health condition and coping with emotions require professional and peer support. Currently, there is a lack of resources and a lack of awareness of the resources that are required to help assist parents in managing their child's food allergy. OBJECTIVE: To describe parental experiences when caring for a child with food allergy and to review the resources parents need to manage living with a child with food allergy and more specifically how they would want these resources delivered. METHODS: A total of 7 semistructured focus groups were conducted in British Columbia, Canada. Parents were asked to describe their experiences with managing their child's food allergy and identify helpful resources. RESULTS: A total of 40 parents (33 females) participated in the focus groups. Participant demographics were collected. The following 3 main themes emerged: (1) anxiety (an emotional roller coaster); (2) a transformational journey (the waiting game, loss of normalcy, strained relationships and mistrust, and financial challenges); and (3) the need for resources (day to day management, ages and stages, mental health supports, and "the dream"). CONCLUSION: An in-person allied health care team is needed to provide an integrated, patient-centered approach for how families can live and manage food allergies. Credible information and resources, such as medically reviewed websites, support groups, and counseling services, with a goal of reducing child and parental anxiety, should be provided by health care professionals.

Poor Correlation of Oral Swabs with Esophageal Eosinophil Counts.

Eosinophilic esophagitis (EoE) is a chronic condition that requires repeated endoscopies/biopsies to track the disease and treatment response. This invasive procedure involves risk to the patient and has significant costs. We studied whether the detection of specific proteins (cytokines and eosinophil degranulation products) from oral swabs could serve as a minimally invasive test for EoE. Swabs of the oral cavity (buccal and oropharyngeal) were obtained prior to endoscopy/biopsies in patients with EoE, possible EoE, and non-EoE patients in addition to obtaining additional esophageal biopsy tissue. ELISAs measuring the levels of cytokines IL-5, IL-8, IL-13, and eosinophil degranulation products including major basic protein (MBP), eosinophil derived neurotoxin (EDN), and eosinophil peroxidase (EPO) were performed on the samples. Comparisons were made to peak esophageal eosinophil counts. Tolerability of the swabs was evaluated. 43 patients, 4-17 years old, participated in the study. Swabs were well tolerated and all showed measurable protein. 26 patients had EoE [14 active (> 15 eosinophils/high power field), 12 non-active], 17 patients did not have EoE. Results obtained from oral swabs showed poor correlation with those from esophageal tissue. Only measurement of eosinophil degranulation products EDN and EPO from esophageal tissues showed strong correlations with eosinophil counts. In this study, the levels of cytokines and eosinophil degranulation products detected from oral swabs did not correlate with esophageal eosinophilia, and their detection would be insufficient to displace endoscopy/biopsies.

Eczema in early childhood, sociodemographic factors and lifestyle habits are associated with food allergy: a nested case-control study.

BACKGROUND: Studies suggest an increase in food allergy prevalence over the last decade, but the contributing factors remain unknown. The aim of this study was to evaluate the association between the most common food allergies and atopic history, sociodemographic characteristics and lifestyle habits. METHODS: We conducted a case-control study nested within the SPAACE study (Surveying Prevalence of Food Allergy in All Canadian Environments) ­ a cross-Canada, random telephone survey. Cases consisted of individuals with probable food allergy (self-report of convincing symptoms and/or physician diagnosis) to milk, egg, peanut, tree nut, shellfish, fish, wheat, soy, or sesame. Controls consisted of nonallergic individuals, matched for age. Cases and controls were queried on personal and family history of atopy, sociodemographic characteristics and lifestyle habits. Multivariate logistic regression was used to evaluate the association between atopy, sociodemographic characteristics and lifestyle habits with probable food allergy. RESULTS: Between September 2010 and September 2011, 480 cases and 4,950 controls completed the questionnaire. For all 9 allergens, factors associated with a higher risk of probable allergy were as follows: (1) personal history of eczema (in the first 2 years of life), asthma or hay fever (odds ratio, OR 2.3, 95% CI 1.6-3.5; OR 2.8, 95% CI 2.2-3.6, and OR 2.3, 95% CI 1.8-3.0, respectively), (2) maternal, paternal or sibling's food allergy (OR 3.7, 95% CI 2.5-5.6; OR 3.0, 95% CI 1.8-5.1, and OR 3.1, 95% CI 2.2-4.2), (3) high household income (top 20%; OR 1.5, 95% CI 1.2-2.0). Males and older individuals were less likely to have food allergy (OR 0.7, 95% CI 0.6-0.9, and OR 0.99, 95% CI 0.99-1.00). Eczema in the first 2 years of life was the strongest risk factor for egg, peanut, tree nut and fish allergy. CONCLUSIONS: This is the largest population-based nested case-control study exploring factors associated with food allergies. Our results reveal that, in addition to previously reported factors, eczema in the first 2 years of life is consistently associated with food allergies.

Safety and Effectiveness of Bypassing Oral Immunotherapy Buildup With an Initial Phase of Sublingual Immunotherapy for Higher-Risk Food Allergy.

BACKGROUND: Because of its favorable safety, sublingual immunotherapy (SLIT) for food allergy has been proposed as an alternative treatment for those in whom oral immunotherapy (OIT) is of higher risk-older children, adolescents, adults, and those with a history of severe reactions. Although safe, SLIT has been shown to be less effective than OIT. OBJECTIVE: To describe the safety of multifood SLIT in pediatric patients aged 4 to 18 years and the effectiveness of bypassing OIT buildup with an initial phase of SLIT. METHODS: Patients aged 4 to 18 years were offered (multi)food SLIT. Patients built up to 2 mg protein SLIT maintenance over the course of 3 to 5 visits under nurse supervision. After 1 to 2 years of daily SLIT maintenance, patients were offered a low-dose oral food challenge (OFC) (cumulative dose, 300 mg protein) with the goal of bypassing OIT buildup. RESULTS: Between summer 2020 and winter 2023, 188 patients were enrolled in SLIT (median age, 11 years). Four patients (2.10%) received epinephrine during buildup and went to the emergency department, but none experienced grade 4 (severe) reaction. A subset of 20 patients had 50 low-dose OFCs to 300 mg protein and 35 (70%) OFCs were successful, thereby bypassing OIT buildup. CONCLUSIONS: In combination with very favorable safety of SLIT, with no life-threatening reactions and few reactions requiring epinephrine, we propose that an initial phase of SLIT to bypass supervised OIT buildup be considered for children in whom OIT is considered to be of higher risk.

Bypassing the build-up phase for oral immunotherapy in shrimp-allergic children.

Background: Oral immunotherapy is an effective treatment for food allergies; however, its use in clinical practice is limited by resources and lack of standardized protocols for foods other than peanut. Previous studies have suggested that shrimp has a higher threshold for reaction than other allergenic foods, suggesting it may be safe to directly administer maintenance doses of immunotherapy. Methods: Children aged 3-17 years who had 1) skin prick test ≥3 mm and/or specific IgE level ≥0.35 kU/L and convincing objective IgE-mediated reaction to shrimp, or 2) no ingestion history and specific IgE level ≥5 kU/L, underwent a low-dose oral food challenge to 300 mg shrimp protein, with the goal of continuing daily ingestion of the 300 mg maintenance dose as oral immunotherapy. Results: Between January 2020 and April 2023, 17 children completed the low-dose oral food challenge. Nine (53%) tolerated this amount with no reaction, and 8 (47%) had a mild reaction (isolated oral pruritis or redness on chin). Sixteen (94%) continued maintenance low-dose oral immunotherapy eating 300 mg shrimp protein daily. None of the patients developed anaphylaxis related to the immunotherapy. Conclusion: Our case series suggests that some shrimp allergic patients being considered for oral immunotherapy should be offered a low-dose oral food challenge, to potentially bypass the build-up phase of immunotherapy.