Psychosocial functioning in pediatric food allergies: A scoping review.

The psychosocial burden of food allergy (FA) can significantly affect the lives of pediatric patients and their families. A comprehensive understanding of the state of the literature on psychosocial functioning is imperative to identify gaps that may affect clinical care and future research. This review characterizes the current literature on psychosocial functioning in pediatric patients with FA and their caregivers, siblings, and families. A literature search of 5 databases (PubMed, Ovid MEDLINE, PsycINFO, Web of Science, and Embase) was conducted to identify original research articles and abstracts on psychosocial functioning of patients with FA who were aged 0 to 18 years and their caregivers, siblings, and families. A total of 257 studies met the inclusion criteria. The majority of studies examined child or caregiver psychosocial functioning, with child and caregiver quality of life examined most frequently. Most studies utilized quantitative and cross-sectional methods and inconsistently reported participant race and ethnicity. Existing research on psychosocial functioning in pediatric FA may not be generalizable to patients of color and families and siblings. Future research should diversify recruited samples regarding race, ethnicity, and country of origin; examine psychosocial functioning longitudinally; examine constructs beyond quality of life; and adopt a biopsychosocial approach by considering the interplay among psychosocial functioning, disease burden, and social contexts.

Allergic sensitization and objective measures of sleep in urban school-aged children with asthma.

BACKGROUND: Allergic sensitization is associated with increased child asthma morbidity and decreased pulmonary function. Nocturnal symptoms and/or awakenings typically are measured by self-report from diary data, whereas objective assessments of sleep in child asthma studies are lacking. OBJECTIVE: To investigate the association between increased allergic sensitization (number of positive allergy test results measured by skin prick test or specific immunoglobulin E) and sleep outcomes (sleep efficiency, sleep duration, and mean number of awakenings measured by actigraphy) in urban schoolchildren with persistent asthma. METHODS: One hundred ninety-six children with persistent asthma (7-9 years old) attending public school in 1 of 4 large urban school districts completed allergy testing during a study clinic visit. Forced expiratory volume in 1 second was monitored at home using a handheld spirometer. Sleep outcomes were measured with a wrist Actiwatch during a 1-month period in the fall and winter seasons. RESULTS: Number of positive allergy test results significantly predicted mean sleep efficiency (P = .02), such that children with more positive test results experienced less efficient sleep. Number of positive allergy test results significantly predicted mean number of night awakenings (P = .05), such that children with more positive allergy test results experienced more night awakenings. Variability in forced expiratory volume in 1 second was a significant moderator in the association between number of positive allergy test results and variability in sleep efficiency (P = .04). Racial and ethnic differences in allergic sensitization and sleep outcomes were found between African Americans and Latinos. CONCLUSION: More positive allergy test results were associated with poorer sleep outcomes measured objectively in this sample of urban children. Implications for environmental control interventions and asthma treatments in different racial and ethnic groups are discussed.

Asthma-related lung function, sleep quality, and sleep duration in urban children.

OBJECTIVES: Examine (1) the extent to which changes in objectively measured asthma-related lung function (forced expiratory volume in 1 second) within a sleep period are associated with sleep quality and sleep duration during that sleep period in a group of urban children with persistent asthma, (2) associations between morning and evening asthma-related lung function and sleep quality and duration on the adjacent night, and (3) whether these associations differ by ethnic group. DESIGN: Cross-sectional, multimethod approach. Children completed a clinic assessment of asthma and allergy status and used home-based objective measurements of asthma-related lung function and sleep. SETTING: Children and their caregivers participated in a clinic assessment at an asthma and allergy clinic and completed additional assessments at home. PARTICIPANTS: Two hundred and sixteen African American, Latino, and non-Latino white urban children, ages 7-9 years, and their primary caregivers. MEASUREMENTS: Participants took part in a clinic assessment of asthma and allergy status, completed interview-based questionnaires including a diary to track asthma symptoms and sleep patterns, and used actigraphy and home-based spirometry daily across a 4-week period to assess sleep and lung function. RESULTS AND CONCLUSIONS: Results from analyses using structural equation modeling revealed an association between worsening asthma-related lung function and poor sleep quality in the full sample, as well as better asthma-related lung function at night and more optimal sleep efficiency that night. Ethnic group differences emerged in the association with morning or nighttime lung function measurements and sleep quality. Urban minority children with asthma may be at heightened risk for poorer quality sleep. Timing of lung function worsening may be important when considering when and how to improve both asthma health outcomes and sleep quality within specific groups.

Sleep Hygiene and Sleep Outcomes in a Sample of Urban Children With and Without Asthma.

Objective: To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods: Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results: Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion: Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

Topical Review: Pediatric Food Allergies Among Diverse Children.

OBJECTIVE: To present a brief review of the literature regarding potential racial/ethnic disparities in pediatric food allergy (FA). METHODS: Topical review considering data regarding FA prevalence, asthma comorbidity, epinephrine access/use, and psychosocial impact (e.g., burden, quality of life). RESULTS: Methodological variation precludes firm conclusions regarding disparities in prevalence; however, some data suggest Black children may be at particular risk. The comorbidity of FA and asthma among urban populations may increase risk of negative outcomes. There are clear racial/ethnic and socioeconomic disparities in epinephrine access and use. Psychosocial measures are frequently validated on samples that are not racially or ethnically diverse. Studies investigating FA's psychosocial impact are often composed of mostly White, non-Hispanic participants (>85% of study sample). CONCLUSIONS: Further research is needed to clarify prevalence patterns by race/ethnicity, to investigate the sources of disparity in epinephrine use, and to evaluate the differential impact of FA on diverse children.

Good Sleep Health in Urban Children With Asthma: A Risk and Resilience Approach.

OBJECTIVES: To identify children demonstrating "good" sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with "good" versus "poor" sleep health; and to examine protective effects of family-based health behaviors on sleep health. METHODS: Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7-9 years, and their primary caregivers. RESULTS: 32 percent of children had "good" sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group. CONCLUSIONS: This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.

Asthma, allergic rhinitis, and sleep problems in urban children.

OBJECTIVES: In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background. METHODS: Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods. RESULTS: Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children. CONCLUSIONS: Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Underdiagnosed and Undertreated Allergic Rhinitis in Urban School-Aged Children with Asthma.

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

Allergic rhinitis quality of life in urban children with asthma.

BACKGROUND: Urban children with asthma and allergic rhinitis (AR) are at risk for experiencing worse AR-related quality of life (QOL). Although AR may be underdiagnosed and undertreated in urban minority children, research has not considered which illness-related indicators (eg, AR control) may contribute to AR QOL in this population. OBJECTIVE: To examine associations among AR control, asthma control, allergy symptoms, asthma symptoms, and AR QOL in a sample of 195 urban caregivers and their children with asthma (7-9 years of age) from African American, Latino, and non-Latino white backgrounds. Racial and ethnic differences in AR QOL were also examined. METHODS: Families resided in 1 of 4 cities selected as recruitment sources because of their high concentrations of ethnic minority and non-Latino white, urban families. Caregivers and children completed a series of interview-based and clinician-based assessments across one academic year and 4-week periods to track daily asthma and nasal symptoms. RESULTS: Better AR control was associated with higher AR QOL (ß = -.32, P < .01) and all QOL subscales. AR control predicted AR QOL over and above asthma control (ß = -.28, P < .01). Controlling for AR control, non-Latino white children reported better QOL related to practical problems than both Latino and African American children (P < .05). CONCLUSION: Findings suggest that strategies to enhance AR control in urban children with asthma may assist in improving AR QOL. Non-Latino white children may experience less impairment of their AR QOL because of practical problems (eg, blow nose) than African American or Latino children with asthma.

Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research.

Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.

The home environment and family asthma management among ethnically diverse urban youth with asthma.

Although the pediatric psychology literature underscores the importance of illness-related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to (a) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino White (NLW), and African American urban children with asthma; and (b) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management. Urban, low-income children (N = 131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multimodal assessment, including an in-home observation and semistructured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g., Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness-specific aspects of the home environment when addressing families' asthma management strategies.

Sleep and allergic disease: a summary of the literature and future directions for research.

Atopic diseases, such as asthma and allergic rhinitis, are common conditions that can influence sleep and subsequent daytime functioning. Children and patients with allergic conditions from ethnic minority groups might be particularly vulnerable to poor sleep and compromised daytime functioning because of the prevalence of these illnesses in these groups and the high level of morbidity. Research over the past 10 years has shed light on the pathophysiologic mechanisms (eg, inflammatory mediators) involved in many atopic diseases that can underlie sleep disruptions as a consequence of the presence of nocturnal symptoms. Associations between nocturnal symptoms and sleep and poorer quality of life as a result of missed sleep have been demonstrated across studies. Patients with severe illness and poor control appear to bear the most burden in terms of sleep impairment. Sleep-disordered breathing is also more common in patients with allergic diseases. Upper and lower airway resistance can increase the risk for sleep-disordered breathing events. In patients with allergic rhinitis, nasal congestion is a risk factor for apnea and snoring. Finally, consistent and appropriate use of medications can minimize nocturnal asthma or allergic symptoms that might disrupt sleep. Despite these advances, there is much room for improvement in this area. A summary of the sleep and allergic disease literature is reviewed, with methodological, conceptual, and clinical suggestions presented for future research.

Medication adherence among Latino and non-Latino white children with asthma.

OBJECTIVE: Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico. METHODS: Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7-16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence. RESULTS: Medication adherence differed by ethnic group (F(2, 271) = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45). CONCLUSIONS: Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.

Factors associated with disparities in emergency department use among Latino children with asthma.

BACKGROUND: Significant disparities in emergency department (ED) rates exist for Latinos; however, few studies have investigated the factors that may account for these disparities. OBJECTIVES: To examine individual/family and health system factors among Latino and non-Latino white (NLW) children with asthma to explain disparities in ED rates. METHODS: The study was carried out in Puerto Rico (PR) and Rhode Island (RI) with the same design: a cross-sectional, observational approach with repeated measurements of selected variables. RESULTS: The sample was composed of 804 children ages 7 to 15 years, with 405 from PR and 399 from RI. Latino children from both sites had significantly higher rates of ED use as compared with NLWs from RI. Regression analyses showed site, asthma control, parental reported severity of asthma and public insurance to be significantly associated with ED use. CONCLUSION: Latino ethnicity and public insurance were among the most important factors related to frequent ED use. Revisions of the policies driving public insurance to assure better access to specialists, preventive education, and evidence-based treatment are needed. The results also suggest the need for the development of interventions in the ED that are geared toward educating families on how best to use emergency services.

Immigration and acculturation-related factors and asthma morbidity in Latino children.

OBJECTIVE: This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. METHODS: Latino children with asthma (n = 232), ages 7-16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. RESULTS: The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. CONCLUSION: Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.

Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?

RATIONALE: Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non-Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process. OBJECTIVES: To determine (1) if differences exist between Latino and non-Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes. METHODS: Five hundred and twelve children, aged 7-16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use. MEASUREMENTS AND MAIN RESULTS: Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non-Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity. CONCLUSIONS: Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non-Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.

Cultural-related, contextual, and asthma-specific risks associated with asthma morbidity in urban children.

The objective of this study was to examine associations between specific dimensions of the multi-dimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7-15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.