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.

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.

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) differ across socioeconomic strata and provides guidance for practicing clinicians about how to improve equity in research participation, health care delivery, and patient outcomes through a deeper understanding of the socioeconomic determinants of FA. DATA SOURCES: Epidemiologic and biomedical literature published before April 2022. RESULTS: Socioeconomic status (SES) is a complex concept that encompasses not only economic resources (eg, income, wealth) but also a person's social, economic, and political power and standing, each of which can affect 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 used 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 with those identifying as non-Hispanic White. CONCLUSION: Reports of FA management and outcomes highlight inequities among specific low SES populations in the United States. Clinicians can and should act to reduce inequities by engaging more diverse populations in clinical research, equitably implementing FA risk screening and prevention, thoughtfully using emerging technologies to ameliorate disparities based on SES in health care delivery and outcomes, and advocating for social change.

Implementation of the Addendum Guidelines for Peanut Allergy Prevention by US allergists, a survey conducted by the NIAID, in collaboration with the AAAAI.

BACKGROUND: In 2017, the Addendum Guidelines for the Prevention of Peanut Allergy were published with recommendations on early introduction of peanut-containing foods based on infants' clinical history. OBJECTIVE: We sought to conduct a nationwide US survey to assess Guidelines implementation among allergists and immunologists who manage infants for food allergy. METHODS: Survey invitations were delivered to 3281 nonretired, US members of the American Academy of Asthma, Allergy & Immunology, board certified in allergy and immunology. The survey assessed awareness and implementation of the Guidelines and barriers to implementation. Descriptive statistics were generated. RESULTS: Twenty-nine percent (946 of 3281) of surveyed allergists/immunologists responded, and 87.1% (825 of 946) of responders met eligibility criteria. Among eligible responders, 97.1% were aware of the Guidelines. Of these, 64.5% reported full implementation of the Guidelines as published, 34.4% reported partial implementation, and 1.1% reported using none of the Guidelines. Barriers to Guidelines use included parental (47.6%) and self (21.8%) concerns about allergic reactions, lack of referrals (33.6%), parents uninterested in early feeding (28.2%), and lack of clinic time (20.9%). The 2 most common deviations from the Guidelines were considering additional factors not specified in the Guidelines such as family history (50.2%) and conducting skin prick testing in non-high-risk children (43.9%). Of respondents using the Guidelines, 45.7% indicated they needed more education or training. CONCLUSIONS: Essentially all allergists/immunologists who responded to the survey reported full or partial Guidelines implementation. Parental concerns and lack of referrals are major identifiable barriers. Improved Guidelines messaging to parents and referring physicians is warranted.

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.

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.

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).

Understanding the burden of food allergy among urban and rural school children from north India.

Background: There is paucity of reliable epidemiological data regarding the burden of food allergy in most developing countries, including India. Objective: To provide current estimates of the prevalence and distribution of food allergy among urban and rural school children aged 6-14 years in Delhi and the National Capital Region (NCR) of Khekra in India. Methods: A cross-sectional study was conducted from January 2022 to February 2023 to enroll school children, 6-14 years, from select urban and rural schools in Delhi and NCR. A questionnaire consisting of questions focused on household environment, early life factors, and pediatric food allergy characteristics was administered by a trained medical researcher to collect parent-proxy data. Univariate statistics were used to describe frequencies, percentages, and 95% confidence intervals for survey items. Results: The estimated prevalence of parent-reported food allergy was 0.8% (95% CI: 0.4-1.5; urban: 0.4%, 95% CI: 0.1-1.1; rural: 1.7%, 95% CI: 0.7-3.5). Fruits such as mango (0.3%, 95% CI: 0.1-0.9), strawberry (0.1%, 95% CI: 0.0-0.7), orange (0.1%, 95% CI: 0.0-0.7), and custard apple (0.1%, 95% CI: 0.0-0.7) were reported only by urban children, while rural children reported yogurt (0.6%, 95% CI: 0.1-1.8) and wheat (0.3%, 95% CI: 0.0-1.3). Both groups reported brinjal (also known as eggplant) and banana, 0.1% (95% CI: 0.0-0.7) of urban and 0.3% (95% CI: 0.0-1.3) of rural, respectively. Overall, commonly reported clinical symptoms were diarrhea and/or vomiting (100%, 95% CI: 76.2-100), abdominal pain (88.9%, 95% CI: 58.6-98.8), and rash/itchy skin (66.7%, 95% CI: 34.8-89.6). Among children with parent reported food allergy, 66.7% (95% CI: 34.8-89.6) of food allergies were physician diagnosed, of which 33.3% were diagnosed via history alone (95% CI:7.7-71.4) while 66.7% (95% CI: 28.6-92.3) were confirmed via skin prick test and/or blood test. Conclusion: The overall prevalence of food allergy is very low in Delhi and Khekra, India. Future work should focus on elucidating the complex interplay of early-life, environmental, genetic, and lifestyle factors to understand the reasons for India's low food allergy burden and improve epidemiological clues to prevention for the nations with higher disease burden.

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.

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.