By Jessica B. Edwards George, Ph.D., and Elizabeth L. McQuaid, Ph.D.
Food allergies affect from 2% to 8% of children in the United States, and by most reports, food allergies are on the rise, particularly amongst infants and young children. By one estimate, between 1997 and 2002, the incidence of food allergies increased 18% among U.S. children. Peanut allergies are believed to have doubled in that time period. (Increasingly, schools are implementing peanut-free policies, or at the very least placing children with peanut allergies at separate lunch tables).
November 2010 Vol. 26, No. 11
This article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.
There is no cure or means to prevent food allergies, thus effective management (including food avoidance and the management of epinephrine) are key for all affected families. While reducing morbidity and mortality are at the top of the list of priorities, understanding the quality-of-life and psychosocial impact on allergic children, their families, and the community becomes increasingly important.
A food allergy is an abnormal immunologic response to food proteins that can produce acute, life-threatening reactions, and/or chronic disease. (A food allergy is distinct from a food "intolerance" [such as lactose intolerance], which does not engage the body's immune system and is therefore not life threatening.) Unfortunately, the food allergy diagnosis is almost always made when a child first has a reaction, which can be quite harrowing for the family. After an individual has a reaction, a "skin prick" test and blood work serve as supporting evidence. Food allergies have been documented in response to approximately 200 different foods, but eggs, fish, milk, peanuts, shellfish, soy, tree nuts, and wheat account for about 90% of reactions.
Symptoms of a food allergy vary greatly, ranging from mild gastrointestinal, respiratory, and/or skin symptoms (i.e., rash or hives) to life-threatening anaphylaxis, in which breathing or blood circulation is impaired. More than 150 people die annually from anaphylaxis and it accounts for 50,000 emergency room visits each year. Fatal food allergic reactions are most common among adolescents and young adults and occur most frequently outside of the home environment, such as in restaurants or school. For many children, food allergies disappear or elicit less severe symptoms by the age of 3 years, but for some children food allergies persist into adulthood.
Claire, a 5-year-old girl with a peanut allergy, is entering kindergarten. Claire's allergy to peanuts was discovered at age 2 when she had a near fatal reaction to peanut butter after eating a peanut butter and jelly sandwich for the first time while with her grandmother. In this case, Claire was rushed to the emergency room. Since then Claire reportedly has experienced hives and difficulty breathing when in the proximity of peanuts. At age 3, after being kissed on the cheek by her friend at the library Claire had a reaction, only to discover that her friend had recently ingested a peanut containing food.
Claire's parents have become well versed in managing Claire's severe food allergy and are vigilant in assisting Claire in avoiding peanuts. They ensure that her injectable epinephrine kit (i.e., EpiPen; www.epipen.com) is close by at all times. Despite this vigilance, at age 4 Claire was exposed to peanut oil while eating fried food at a trusted restaurant. Claire's parents recognized some of the signs of anaphylactic shock, but delayed using the injectable epinephrine and instead tried a dose of antihistamine first. They reported after the incident that they "weren't sure that this was it" and did not want to "hurt her" if this was not a reaction.
As Claire gets ready to enter kindergarten her parents are feeling very uneasy about placing the management of her food allergy into the hands of other adults. Recently, Claire has begun refusing to attend birthday parties and family functions, saying that she is afraid she might be exposed to peanuts. On the other hand, bringing her own food to social gathering makes her "feel different." Significantly, Claire has begun to refuse to separate from her parents.
The impact of pediatric food allergies and their management on quality of life and daily activities has been an area of active research in recent years. In a study by Bollinger et al. (2006) food allergies were found to have a significant effect on the activities of the affected families, including meal preparation, social activities, stress levels, and school attendance. In fact, 10% of this sample chose to homeschool their child, related to concerns about food allergies. In addition, the younger the child, as well as the more food allergies a child had, the greater the impact on the child's and their family's activities.
In our case example, Claire and her family had stopped participating in special events and felt uneasy about transitioning Claire's care to the school environment. Overprotection of the food-allergic child is common, with parents accompanying their children to social situations beyond the age at which nonallergic children are accompanied, sometimes extending into young adulthood. Thus, parents, siblings, and extended family members have been found to be negatively impacted by food allergy in their family members.
Although the management of a food allergy can pose a burden on families, few global differences in psychological symptoms have been found between food allergic children and those without food allergies. In one online study of young adults with food allergy, no general psychosocial concerns were found, although the young adults who reported a history of anaphylaxis appeared to worry more than the norm. While most studies suggest that the global psychological adjustment in the areas of depression and anxiety in children with food allergies tends to be no different than norms, some studies have found elevated separation anxiety and anxious coping, such as in our case illustration.
Witnessing your child experience an anaphylactic episode (or constantly anticipating that it may happen) can produce anxiety in parents. Parents of food allergic children commonly report anxiety about accidental exposures to allergenic foods. While some level of anxiety may be protective in mobilizing families to manage food allergies, persistent anxiety may serve to significantly limit family activities or even exaggerate actual risk. Not surprisingly, qualitative research has indicated that mothers tend to have primary responsibility for food allergy management. Maternal anxiety has been found to be related to child distress and mothers have been found to fare significantly worse than fathers on measures of food allergy adjustment. The psychosocial well-being of mothers of children with food allergies appears to warrant further attention.
At this time, evidence-based interventions to improve pediatric food allergy management and alleviate the psychological burden are limited. While results from psychosocial research to date allow us to hypothesize what interventions may or may not be helpful or necessary, randomized control trials of food allergy interventions are required.
Jessica B. Edwards George, Ph.D., is a licensed psychologist at Rhode Island Hospital/Hasbro Children's Hospital in the Divisions of Child and Family Psychiatry and Pediatric Gastroenterology, Nutrition, and Liver Diseases, and The Food Allergy and Feeding Programs.
Elizabeth L. McQuaid, Ph.D., is an Associate Professor (Research) in the Department of Psychiatry and Human Behavior at Alpert Medical School, and Director of the Brown Clinical Psychology Training Consortium.
The Food Allergy and Anaphylaxis Network (FAAN): www.foodallergy.org
Allergy Support.org: http://allergysupport.org
Kids with Food Allergies: www.kidswithfoodallergies.org
Food Allergy Initiative: www.faiusa.org/?page=support_groups (includes list of support groups in many states)
Bollinger ME, et al.: Ann Allergy Asthma Immunolo 2006; 96:415-421.
Cummings AJ, et al.: Allergy 2010; 65:933-945.