Food Allergy Education and Management in Early Learning and Childcare Centres: A Scoping Review on Current Practices and Gaps.

Anaphylaxis has occurred in preschools/schools yet there are no consistent food allergy (FA) management practices in early learning and childcare centres (ELCC) across jurisdictions. Presently, there are no reviews that have synthesized FA-related knowledge and management practices within ELCC. We aimed to perform a scoping review of FA management in ELCC, and report on perceived gaps or barriers. A PRISMA-ScR-guided search was conducted for North American, European and Australian articles in English/French in the OVID-MedLine, Scopus, and PsycInfo databases. Two independent reviewers screened the titles/abstracts of 2010 articles and full-text screened 77 articles; 15 of which were specifically related to ELCC. If the two reviewers could not agree to the relevance of a given study, a third reviewer provided guidance. This third reviewer also screened French articles. Thematic and descriptive reports of the studies were presented. We reported solely on pre-Coronavirus Disease pandemic ELCC studies. We included ten articles in this review, which provide evidence that ELCC staff have variable baseline knowledge, comprehension, experience, and practices in place to manage FA. ELCC staff also have limited FA-related training and experience regarding administration of epinephrine auto-injectors (EAI). Emergency Anaphylaxis Plans (EAP) were described in four studies. One study reported the parental influence on the site's food purchasing and FA management. Three studies provided educational interventions, which demonstrated increased and sustained FA-related knowledge and confidence post-intervention. Participants deemed the training beneficial and desired annual training and more FA resources to be available. Across jurisdictions, ELCC staff have provided care and administered EAI in emergencies, but training remained variable. Communication and care planning amongst ELCC staff, and parents, is crucial. Annual education, available EAI and EAPs are tools necessary for effectively managing emergencies.

Temporal examination of adult food insecurity amongst Canadian families managing food allergy.

BACKGROUND: Pediatric food allergy is associated with excess familial food costs compared to families without allergy. Since the start of the COVID-19 pandemic, food prices have increased substantially. OBJECTIVE: To understand the temporal pattern of food insecurity amongst Canadian families with food allergy from the year prior to the pandemic, through May 2022. METHODS: Using data collected electronically from families reporting food allergy using a validated food security questionnaire, we estimated food insecurity, including categories of food insecurity (marginal, moderate, secure) in the year prior to the pandemic (2019; Wave 1), and the first (2020; Wave 2) and second years of the pandemic (2022; Wave 3). RESULTS: Participants in all waves were commonly in 2 + adult, 2 child households. Less than half of participants (Waves 1-3: 45.7%, 31.0%, and 22.9%, respectively) reported household incomes below the median Canadian. Common allergies were milk, eggs, peanuts and tree nuts. In Wave 1, 22.9% of families reported food insecurity; corresponding numbers at Waves 2 and 3 were 30.6% and 74.4%, respectively, representing an overall increase of 225.6%, including notable increases in severe food insecurity. CONCLUSION: Canadian families with pediatric food allergy report higher rates of food insecurity compared to the general Canadian population, especially during the pandemic.

Changes in food-related costs during the COVID-19 pandemic among families managing food allergy.

Background: The COVID-19 pandemic has affected the supply, cost, and demand for certain foods, but it is not clear how these changes have affected food-allergic households. Objective: To describe the changes in food-related costs that have followed COVID-19, as reported by higher- and lower-income households with a food-allergic member. Methods: Between May 1-June 30, 2020, Canadian households, with at least one food-allergic member, completed an online survey on food shopping and preparation habits before and during the COVID-19 pandemic. The sample was divided into binary groups, either higher or lower than the sample median income. Data were analyzed using descriptive statistics and multiple regression. Results: The sample was comprised of 102 participants (i.e., 51/ income group). The three most common food allergies amongst both groups were peanuts, tree nuts and milk. Since the start of the pandemic, both groups reported greater monthly direct grocery costs, although costs amongst the higher-income group were twice as high as the lower-income group ($212.86 vs. $98.89, respectively). Indirect food preparation costs were similarly elevated. Higher-income households with food procurement difficulties reported increased indirect shopping costs following the outbreak of COVID-19, whereas those without such difficulties reported decreased costs. Lower-income households with allergies to milk, wheat, or eggs (i.e., staple allergy) experienced a larger change in indirect food preparation costs following the outbreak of COVID-19 relative to those with other food allergies ($244.58 vs. -$20.28, respectively; p = 0.03). Conclusion: Both higher and lower income households with food allergy reported greater direct food costs and indirect food preparation costs following the COVID-19. Households with staple allergy and those with difficulties finding their typical food items were particularly affected.

Food Allergy Education and Management in Schools: A Scoping Review on Current Practices and Gaps.

Currently, no synthesis of in-school policies, practices and teachers and school staff's food allergy-related knowledge exists. We aimed to conduct a scoping review on in-school food allergy management, and perceived gaps or barriers in these systems. We conducted a PRISMA-ScR-guided search for eligible English or French language articles from North America, Europe, or Australia published in OVID-MedLine, Scopus, and PsycINFO databases. Two reviewers screened 2010 articles' titles/abstracts, with 77 full-text screened. Reviewers differed by language. Results were reported descriptively and thematically. We included 12 studies. Among teachers and school staff, food allergy experiences, training, and knowledge varied widely. Food allergy experience was reported in 10/12 studies (83.4%); 20.0-88.0% had received previous training (4/10 studies; 40.0%) and 43.0-72.2% never had training (2/10 studies; 20.0%). In-school policies including epinephrine auto-injector (EAI) and emergency anaphylaxis plans (EAP) were described in 5/12 studies (41.7%). Educational interventions (8/12 studies; 66.7%) increased participants' knowledge, attitudes, beliefs, and confidence to manage food allergy and anaphylaxis vs. baseline. Teachers and school staff have more food allergy-related experiences than training and knowledge to manage emergencies. Mandatory, standardized training including EAI use and evaluation, and the provision of available EAI and EAPs may increase school staff emergency preparedness.

Peanut, soy, and emerging legume allergy in Canada.

Background: Individuals with 1 legume allergy may be cosensitized to other legumes and thus may potentially have other legume allergies as well. Although the use of emerging legumes (eg, pea, lentils, chickpeas) in commercial food production is increasingly common, the literature has largely focused on peanut and soy, both of which are priority allergens in Canada. Objective: We aimed to describe the distribution of priority and emerging legume allergies in Canada, with consideration for patient age. Methods: Cross-sectional survey data collected between 2019 and 2021 from families who follow food allergy-related social media platforms were queried for demographics, as well as for food allergy (including by type and number of foods and by age [0-5 vs ≥6 years]). Data were described and then analyzed by using logistic regression and adjusted for sex, age at diagnosis, and number of food allergies. Results: Of the 115 participating children, the majority (64.6%) were boys. Nearly all of the children (109 of 115 [94.8%]) had peanut allergy, whereas soy and emerging legume allergies were reported by 15.7% and 13.0% of the children, respectively. Of these 115 children, 85 had mono-peanut allergy, 6 had mono-soy allergy, none had emerging legume allergy in the absence of peanut or soy, 12 had peanut and emerging legume allergy, 9 had peanut and soy allergy, and 3 had peanut, soy, and emerging legume allergy. Compared with children aged 0 to 5 years, children aged 6 years or older were significantly less likely to have peanut plus soy or emerging legume allergy (odds ratio = 0.22 [95% CI = 0.05-0.94]; P = .04). Conclusion: Of the children with peanut allergy, a considerable number also had peanut allergy and soy allergy and/or another legume allergy. Younger children have higher odds of multiple legume allergy.

The perceived impact of pediatric food allergy on mental health care needs and supports: A pilot study.

Background: Evidence suggests a mental health impact of food allergy on affected children and their families; however, little is known about health care professionals' understanding of these impacts and the resources available to patients and their families. Objective: Our aim was to conduct a pilot study examining health care professionals' perceptions of the psychosocial and financial burden of food allergy to identify gaps in education and resources and thus better support families with food allergy moving forward. Methods: Between February 20 and November 19, 2020, we conducted audiorecorded interviews (n = 6) and profession-specific focus groups (n = 2 [representing 7 individuals]). The participants included pediatric allergists, allergy nurse educators, and clinical dietitians who were directly involved in pediatric food allergy care. The interviews were recorded and transcribed verbatim. Thematic analysis was subsequently applied to identify the main themes. Results: Our study consisted of an interdisciplinary group of Manitoban health care providers (N = 13) who were directly involved with pediatric food allergy care. We identified 3 main themes from these interviews: anxiety among families with food allergy, which is a common comorbidity; limited resources available within current public infrastructure; and empowerment through education. These themes describe issues surrounding access to information and resources and how this can affect anxiety and parenting styles among families with food allergy. Conclusions: Health care professionals perceive that many families experience anxiety as a result of their child's food allergy. They further advocate that access to information and suitability of public resources be considered when planning for related programs.

Peanut Can Be Used as a Reference Allergen for Hazard Characterization in Food Allergen Risk Management: A Rapid Evidence Assessment and Meta-Analysis.

Regional and national legislation mandates the disclosure of "priority" allergens when present as an ingredient in foods, but this does not extend to the unintended presence of allergens due to shared production facilities. This has resulted in a proliferation of precautionary allergen ("may contain") labels (PAL) that are frequently ignored by food-allergic consumers. Attempts have been made to improve allergen risk management to better inform the use of PAL, but a lack of consensus has led to variety of regulatory approaches and nonuniformity in the use of PAL by food businesses. One potential solution would be to establish internationally agreed "reference doses," below which no PAL would be needed. However, if reference doses are to be used to inform the need for PAL, then it is essential to characterize the hazard associated with these low-level exposures. For peanut, there are now published data relating to over 3000 double-blind, placebo-controlled challenges in allergic individuals, but a similar level of evidence is lacking for other priority allergens. We present the results of a rapid evidence assessment and meta-analysis for the risk of anaphylaxis to a low-level allergen exposure for priority allergens. On the basis of this analysis, we propose that peanut can and should be considered an exemplar allergen for the hazard characterization at a low-level allergen exposure.

Harmonizing allergy care-integrated care pathways and multidisciplinary approaches.

There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.

Allergy education and training for physicians.

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.