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Food hypersensitivity among schoolchildren: prevalence, Health Related Quality of Life and experiences of double-blind placebo-controlled food challenges. The Obstructive Lung Disease in Northern Sweden (OLIN) Studies, Thesis XVIII
Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. (Arcum)
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

The prevalence of reported food hypersensitivity among children has increased in Western countries. However, the prevalence varies largely due to differences in methods used in different studies. Double-blind placebo-controlled food challenge (DBPCFC) is the most reliable method to verify or exclude food hypersensitivity. The use of double-blind food challenges is increasing in clinical praxis, but since the method is time- and resource consuming it is rarely used in population-based cohort studies. There is a lack of knowledge on how adolescents and mothers experience participation in double-blind placebocontrolled food challenges and to what extent the food is reintroduced after a negative challenge. While several studies have described the impact of IgEmediated food allergy on Health-Related Quality of Life (HRQL), few studies have described HRQL among children with other food hypersensitivity phenotypes.

Aim

The aim of this thesis was to estimate the prevalence of reported food hypersensitivity, associated risk factors, and symptom expressions among schoolchildren. We also examined HRQL among children with total elimination of cow’s milk, hen’s egg, fish or wheat due to food hypersensitivity as a group compared with children with unrestricted diet, and after we categorised the children with eliminated foods into different phenotypes of FHS. Finally, adolescents’ and mothers’ experience of DBPCFC was examined as well if the food had been reintroduced.

Methods

Three studies were based on the Obstructive Lung Disease in Northern Sweden (OLIN) paediatric cohort II. The cohort was recruited in 2006 when all children in first and second grade (7-8 years) in three municipalities in Norrbotten were invited to a parental questionnaire study and 2,585 (96% of invited) participated. The questionnaire included questions about food hypersensitivity, asthma, rhinitis, eczema and possible risk factors. The children in two municipalities were also invited to skin prick testing with 10 airborne allergens, and 1,700 (90%) participated. Paper I is based on this initial survey of the cohort. Four years later, at age 11-12 years, the cohort was followed up using the same methods and with the same high participation rate. At the follow-up, 125 children (5% of the cohort) reported total elimination of cow’s milk, hen’s egg, fish or wheat due to food hypersensitivity. These children were invited to a clinical examination and to complete a generic (KIDSCREEN-52) and a diseasespecific HRQL questionnaire (FAQLQ-TF) (n=75). Based on the clinical examination the children were categorised into different phenotypes of food hypersensitivity: current food allergy, outgrown food allergy and lactose intolerance. In addition, a random sample of children with unrestricted diet from the same cohort, answered the generic questionnaire (n=209). Paper II is based on this HRQL study. Children categorised as having current food allergy were invited to a further evaluation including DBPCFC. Eighteen months after the challenges, these children were interviewed about their experiences during and after the challenge (n=17). Paper III is based on these interviews. Paper IV was based on interviews with mothers to children referred to a paediatric allergy specialist for evaluation of food allergy using DBPCFC (n=8). In the two interview studies results were analysed using qualitative content analysis.

Results

At age 7-8 years, the prevalence of reported food hypersensitivity was 21%. Food hypersensitivity to milk, egg, fish, wheat or soy was reported by 10.9% and hypersensitivity to fruits or nuts by 14.6%. The most common essential food to trigger symptoms was milk, reported by 9%. The most frequently reported food induced symptoms, were oral symptoms mainly caused by fruits, followed by gastrointestinal symptoms mainly caused by milk. The risk factor pattern was different for food hypersensitivity to milk compared to hypersensitivity to other foods. No significant difference in distribution in generic or disease-specific HRQL was found among children with reported total elimination of milk, egg, fish and/or wheat due to FHS compared to children with unrestricted diet. However, a trend indicated that the disease-specific HRQL was most impaired among children with current food allergy compared to children with outgrown food allergy and lactose intolerance. The proportion of poor HRQL defined as ≥75 percentile was significantly higher among children with current food allergy than the other phenotypes. A DBPCFC was an opportunity for the adolescents and the mothers to overcome the fear of reactions to food that had been eliminated for a long time. After the challenge, when the food was partially or fully reintroduced, socializing became easier and both adolescents and mothers experienced more freedom regarding food intake. A negative challenge was not consistently associated with reintroduction of the food. Reasons for reintroduction failure were fear of allergic reactions, that the adolescent did not like the taste of the food, or that living with an elimination diet was considered as normal. Conclusion In this population-based study, one in five of children at age 7-8 years reported food hypersensitivity to any food. The generic HRQL was similar among children with and without food hypersensitivity. However, poor disease-specific HRQL was more common among children with current food allergy compared to children with other FHS phenotypes. If the tested food was reintroduced after a DBPCFC, both adolescents and mothers described a changed life with less fear, and that life had become easier regarding meal preparations and social events. As reintroduction failure was present despite a negative food challenge, follow-ups and evaluations of food reintroduction should be performed independent of the outcome of a food challenge.

Abstract [sv]

Bakgrund

Andelen barn med rapporterad födoämnesöverkänslighet har ökat. Prevalensen varierar mycket beroende på var studien genomförts och vilka metoder som använts. Dubbel-blinda placebo-kontrollerade födoämnesprovokationer (DBPCFC) är den mest tillförlitliga metoden för att utesluta eller verifiera födoämnesöverkänslighet. I klinisk praxis används DBPCFC alltmer, men eftersom metoden är resurskrävande används den sällan i populationsbaserade studier. Det saknas kunskap om mödrars och tonåringars egna upplevelser av att delta i DBPCFC och i vilken utsträckning livsmedlet återintroduceras efter en negativ provokation. Studier har beskrivit IgE-medierad födoämnesallergi och dess påverkan på hälsorelaterad livskvalitet men det saknas studier om livskvalitet bland barn med andra fenotyper av födoämnesöverkänslighet.

Syfte

Syfte med avhandlingen var att undersöka rapporterad förekomst av födoämnesöverkänslighet, riskfaktorer och symtomyttringar bland skolbarn. Vi har även studerat hälsorelaterad livskvalitet bland barn som helt eliminerat baslivsmedel, som hel grupp jämfört med barn utan eliminerad föda, samt efter att barnen kategoriserats i olika fenotyper av födoämnesöverkänslighet. Ett ytterligare syfte var att beskriva ungdomars och mödrars upplevelser, konsekvenser av DBPCFC samt i vilken omfattning livsmedlet återintroducerades.

Metod

Tre studier baseras på en barnkohort som rekryterades 2006 inom OLIN studierna (Obstruktiv Lungsjukdom i Norrbotten). Kohorten innefattade alla barn i årskurs 1 och 2 (7-8 år) i Luleå, Kiruna och Piteå där 2585 (96 % av de inbjudna) deltog i en föräldrabesvarad enkät. Enkäten innehöll frågor om födoämnesöverkänslighet, astma, rinit, eksem och möjliga riskfaktorer. Barn från Kiruna och Luleå inbjöds även till pricktest med 10 luftburna allergen och 1700 (90 %) deltog. Artikel I baseras på denna initiala enkätstudie. Fyra år senare följdes kohorten upp med samma metoder och höga deltagande. Totalt 125 barn (5 % av kohorten) uppgav total elimination av mjölk, ägg, fisk och/eller vete på grund av födoämnesöverkänslighet. Dessa barn inbjöds till en klinisk undersökning och 94 barn deltog. Sjuttiofem (80 %) av dessa barn besvarade hälsorelaterade livskvalitetsfrågor innefattande det generiska mätinstrumentet KIDSCREEN-52 samt det sjukdomsspecifika frågeformuläret FAQLQ-TF. Frågeformuläret KIDSCREEN-52 skickades även till ett slumpurval av barn utan eliminationskost från samma kohort, och 209 barn (65 %) deltog. Artikel II baseras på denna hälsorelaterade livskvalitetsstudie. Baserat på den kliniska undersökningen kategoriserades barnen med eliminerad kost i olika fenotyper av födoämnesöverkänslighet: pågående födoämnesallergi, utläkt födoämnesallergi och laktosintolerans. De barn som bedömdes ha pågående födoämnesallergi inbjöds till DBPCFC. Arton månader efter provokationen intervjuades deltagarna om sina upplevelser av provokationen och i vilken omfattning livsmedlet återintroducerades. Artikel III baseras på dessa intervjuer. Den fjärde studien baseras på intervjuer av mödrar vars barn remitterats till en pediatrisk barnallergolog för utredning av misstänkt födoämnesallergi med DBPCFC. Intervjuerna har analyserats med kvalitativ innehållsanalys.

Resultat

Vid 7-8 år var prevalensen av rapporterad födoämnesöverkänslighet 21 %. Överkänslighet mot basföda (mjölk, ägg, fisk, vete eller soja) rapporterades av 10.9% och 14.6% uppgav att de reagerade på frukt eller nötter. Klåda i munnen var det vanligaste rapporterade födoämnesutlösta symtomet som huvudsakligen orsakades av frukt. Det näst vanligaste symtomet var mag- och tarmbesvär, huvudsakligen orsakat av mjölk. Riskfaktormönstret för födoämnesöverkänslighet mot mjölk skiljde sig från överkänslighet mot andra födoämnen. Vi fann ingen statistiskt signifikant skillnad i generisk eller sjukdomsspecifik hälsorelaterad livskvalitet mellan barn som helt eliminerat mjölk, ägg, fisk eller vete på grund av födoämnesöverkänslighet jämfört med barn utan eliminerad kost. En trend indikerade att barn med pågående födoämnesallergi hade sämre sjukdomsspecifik hälsorelaterad livskvalitet jämfört med barn med utläkt födoämnesallergi eller laktosintolerans. Dålig livskvalitet, definierat som den ≥75e percentilen i det sjukdomsspecifika frågeformuläret, var vanligast hos barn med pågående födoämnesallergi. Deltagande i DBPCFC var en möjlighet för tonåringar och mödrar att övervinna rädslan för födoämnesorsakade symtom. I de fall då det testade livsmedlet helt eller delvis återintroducerades efter provokationen, upplevde både tonåringarna och mödrarna att det sociala umgänget blev lättare och att de inte längre behövde ha samma kontroll över födoämnesintaget. Ett negativt provokationsutfall resulterade inte alltid i att det testade livsmedlet återintroducerades i kosten. Orsaker till att inte återintroducera födoämnet var rädsla för allergiska reaktioner, att livsmedlet inte smakade gott och att det upplevdes som normalt att leva ett liv utan det eliminerade livsmedlet.

Slutsats

Vart femte barn rapporterade någon form av födoämnesöverkänslighet i denna populationsbaserade studie. Det var ingen signifikant skillnad i generisk livskvalitet mellan barn med och utan födoämnesöverkänslighet men barn med pågående födoämnesallergi tenderade att ha sämre sjukdomsspecifik livskvalitet jämfört med barn med utläkt födoämnesallergi och laktosintolerans. De deltagare som återintroducerade det testade livsmedlet efter provokationstestet upplevde att livet var mindre begränsat jämfört med innan provokationen. Alla återintroducerade inte det testade livsmedlet trots en negativ provokation, vilket styrker vikten av uppföljning och utvärdering av födoämnesprovokationer.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 90+4 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1881
Keyword [en]
Epidemiology, food-induced symptoms, food-reintroduction, interview
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-132223ISBN: 978-91-7601-665-7 (print)OAI: oai:DiVA.org:umu-132223DiVA: diva2:1078954
Public defence
2017-04-07, Triple Helix, Samverkanshuset, Umeå Universitet, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2017-03-17 Created: 2017-03-07 Last updated: 2017-05-08Bibliographically approved
List of papers
1. Food hypersensitivity is common in Swedish schoolchildren, especially oral reactions to fruit and gastrointestinal reactions to milk
Open this publication in new window or tab >>Food hypersensitivity is common in Swedish schoolchildren, especially oral reactions to fruit and gastrointestinal reactions to milk
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2014 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 12, 1290-1296 p.Article in journal (Refereed) Published
Abstract [en]

AIM: This study examined the prevalence, symptom expression and risk factors for food hypersensitivity among Swedish schoolchildren.

METHODS: Parents of 2585 (96% of invited) children aged 7-8 years completed a questionnaire regarding food hypersensitivity and allergic diseases. A random sample of 1700 children (90% of invited) also participated in skin prick testing with ten airborne allergens.

RESULTS: The overall prevalence of reported food hypersensitivity to milk, egg, fish, wheat, soya, fruits and, or, nuts was 21%, with symptoms caused by milk (9%) being the most common. The most frequently reported symptoms were oral symptoms (47.4%), mainly caused by fruit, and gastrointestinal symptoms (45.7%), mainly caused by milk. Factors associated with any food hypersensitivity were female sex, allergic heredity and a positive skin prick test. Eczema was consistently associated with symptoms caused by milk, egg, fish, wheat, soya, fruits and nuts. Rhinitis was associated to the same foods, except milk.

CONCLUSION: Reported food hypersensitivity was common among Swedish schoolchildren. The most frequent symptom expressions were oral symptoms triggered by fruits and gastrointestinal symptoms triggered by milk. The high prevalence of reported symptoms should be validated by clinical examinations to provide a diagnosis.

Keyword
child, epidemiology, food hypersensitivity, prevalence, risk factors
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-96002 (URN)10.1111/apa.12772 (DOI)000345503600026 ()25109310 (PubMedID)2-s2.0-84906637371 (Scopus ID)
Available from: 2014-11-11 Created: 2014-11-11 Last updated: 2017-05-09Bibliographically approved
2. Health Related Quality of Life among schoolchildren aged 12-13 years in relation to food hypersensitivity phenotypes: a population-based study
Open this publication in new window or tab >>Health Related Quality of Life among schoolchildren aged 12-13 years in relation to food hypersensitivity phenotypes: a population-based study
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background:

While Health Related Quality of Life has been investigated among children with IgE-mediated food allergy, less is known about quality of life among children with other types of hypersensitivity to food. The aim of this study was to investigate Health Related Quality of Life (HRQL) in children with and without food hypersensitivity. Further, we compared HRQL between children with different phenotypes of food hypersensitivity.  

Methods:

In a large population-based cohort of schoolchildren in Northern Sweden, the parents of 2,612 (96% of invited) completed a questionnaire. All 125 (5%) children who reported complete elimination of milk, egg, fish or wheat due to food hypersensitivity were invited to a clinical examination and 94 children participated. Of these, 75 children also completed a generic (KIDSCREEN -52) and a disease-specific HRQL questionnaire (FAQLQ-TF). Thereafter, these children were categorised into the different phenotypes: current food allergy, outgrown food allergy, and lactose intolerance. Additionally, 209 children with unrestricted diets answered the generic questionnaire.

Results:

The median score of all KIDSCREEN -52 domains were above the population norm of 50 both in children with and without food hypersensitivity. No significant differences in distribution in generic or disease-specific HRQL were found between children with or without food hypersensitivity. There were no significant differences in HRQL between children with different phenotypes of food hypersensitivity. However, children with current food allergy tended to have the lowest HRQL. Further, poor HRQL defined as ≥75th percentile for the disease specific score was significantly more common in the current food allergy phenotype in the domain Emotional impact and the total FAQLQ, compared to the other phenotypes.

Conclusions:  

In this population-based study, 12-13 year old children reported good HRQL regardless of having food hypersensitivity or not. However, the children with the current phenotype reported lower HRQL than the other phenotypes. 

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-132250 (URN)
Available from: 2017-03-08 Created: 2017-03-08 Last updated: 2017-05-10
3. Reintroduction failure is common among adolescents after double-blind placebo-controlled food challenges
Open this publication in new window or tab >>Reintroduction failure is common among adolescents after double-blind placebo-controlled food challenges
Show others...
2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 2, 282-287 p.Article in journal (Refereed) Epub ahead of print
Abstract [en]

AIM: There has been a lack of research on adolescents' who undergo double-blind placebo-controlled food challenges. The aim of this study was to investigate food allergic adolescents' experiences and consequences of double-blind placebo-controlled food challenges.

METHODS: This qualitative, descriptive interview study included 17 adolescents aged 14-15 years with total elimination of cows' milk, hens' eggs or cod due to food allergies. The participants, who were initially identified from a large population-based cohort study, were interviewed 18 months after completing their challenges.

RESULTS: The double-blind placebo-controlled food challenge proved to be a complex experience for the adolescents, involving fear of potential reactions and the hope that the food could be reintroduced. Experiences during the challenge were described in three themes: facing fears in a secure environment, being hesitant but curious about unknown tastes and waiting for unknown food reactions. Experiences after the challenge were desribed in two themes: gaining control and freedom and continuing old habits. A negative challenge was not consistently associated with the reintroduction of the challenged food.

CONCLUSION: This study highlighted the importance of considering the adolescents' expectations and experiences of the challenge and the reintroduction process to ensure desirable changes in their dietary habits. Follow ups should be performed regardless of the outcome of challenges. This article is protected by copyright. All rights reserved.

Keyword
adolescents, double-blind placebo-controlled food challenges, food allergy, qualitative study, reintroduction
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-128114 (URN)10.1111/apa.13673 (DOI)000397337100017 ()27859574 (PubMedID)
Available from: 2016-11-23 Created: 2016-11-23 Last updated: 2017-05-10Bibliographically approved
4. Experiences of Double-Blind, Placebo-Controlled Food Challenge (DBPCFC): a qualitative analysis of mothers' experiences
Open this publication in new window or tab >>Experiences of Double-Blind, Placebo-Controlled Food Challenge (DBPCFC): a qualitative analysis of mothers' experiences
2010 (English)In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 14, no 2, 179-188 p.Article in journal (Refereed) Published
Abstract [en]

Fear and anxiety are recurring problems for parents of food-allergic children. However, no study has described parents' experiences of introducing food to their children after double-blind provocation. Therefore the aim of this study was to investigate mothers' experiences during their child's negative Double-Blind, Placebo-Controlled Food Challenge (DBPCFC) and the following reintroduction of food. Eight mothers were interviewed and a qualitative content analysis displayed two themes and six subthemes. The first theme, 'living with fear of the unknown', included the subthemes of 'fear of losing control', 'having faith even though fear prevails', 'reintroducing despite fear' and 'fear of causing harm'. In the second theme, the mothers described the challenging process of 're-evaluating earlier experiences' through the sub-themes of 'daring to take new challenges'and 'refraining from new challenges'. Our study indicates that the maternal perspective - not only the professional perspective - needs to be taken into account if mothers are to succeed in the challenging process of reintroducing foods.

Place, publisher, year, edition, pages
London: Published for the Association of British Paediatric Nurses by Greycoat Pub., 2010
Keyword
Double-Blind, Placebo-Controlled Food Challenge, experience, food allergy, narratives, parents
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-32870 (URN)10.1177/1367493509359227 (DOI)000281503600006 ()20212057 (PubMedID)
Available from: 2010-03-30 Created: 2010-03-30 Last updated: 2017-05-10Bibliographically approved

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