Food Allergy among Irish Children: An Exploration of the Risk and Impact of Accidental Allergic Reactions

Abstract

Introduction

Food allergy (FA) now impacts almost 1 in 20 Irish children. These children are at risk of allergic reactions and anaphylaxis. Food is an integral part of all social activities, and thus children with FA are at risk of exclusion or over supervision at these events. The burden of FA among Irish children has not previously been defined. Parents and food allergic children attending our service are educated in how to minimise risk and avoid accidental reactions; we promote safe, age appropriate, social interaction and eating practices. However, there is a paucity of evidence based educational interventions to support newly diagnosed parents.

The aims of this project on Irish food allergic children are (i) to establish the social practices and eating out habits of these children (ii) to report their incidence of accidental allergic reactions and (iii) design an educational tool using this information and assess its impact.

Methods

This thesis is comprised of 2 studies:

Chapters 1-4

A prospective observational study “ReAACt” (Recording Accidental Allergic Reactions in Children) was established, enrolling food allergic Irish children aged 2 to 16 years with confirmed FA. Data was collected between November 2018 and May 2020 from two tertiary allergy sites- Children’s Health Ireland at Crumlin and Tallaght with a catchment area of Leinster and surrounding counties. At enrolment, information on social activities and eating out habits was collected by questionnaire both retrospectively and also prospectively at 3 monthly contacts. Participants were contacted at 3 monthly intervals for 1yr to prospectively report accidental allergic reactions (AARs) to food.

(Chapter 5)

We built on the results of ReACCT by using data collected to design an educational booklet. Subsequently, a prospective RCT enrolling parents of newly diagnosed nut allergy was established with this booklet as the intervention. Participants completed 4 questionnaires both before and after the intervention.

Results

(Chapter 1-4)

531 children were enrolled, and allergic reaction data was reported on 498. These children are attending age-appropriate social activities; (e.g. 5-12 yr olds: 302 (97%) go to birthday parties and 272 (85%) to friend’s houses). Overall, 523 (98 %) were visiting food establishments. Among those who did not participate in social activities, significantly more had a previous history of anaphylaxis (RR 1.44, 95% CI 0.97 to 2.14; p=0.06).

We report a high annual incidence of allergic reactions as 0.44 (95% CI 0.38-0.50); 155(31.1%) reported at least one reaction in the year. Overall 31 (14%) of the reactions were graded as anaphylaxis; only 12 of 31 (39%) received intramuscular adrenaline. In 77 (35%) reactions, the allergen was unidentified. Schools were unprepared to manage FA with only half having a FA policy and less than two thirds of children had an emergency plan there, however those that did had a significantly lower risk of a reaction (RR 0.2, 95% CI 0.09-0.47, P=0.0002).

Chapter 5 Within the subsequent RCT with a separate patient cohort, there were 20 participants in the intervention group and 15 in the control group. We found a significant improvement in quality-of-life scores, anxiety score as well as an improvement in self-efficacy scores in parents who had received the educational tool booklet intervention.

Conclusion

Irish children with FA are “living with allergy” ; they attend age-appropriate social activities and visit food establishments. The annual incidence of reactions is 0.44 (95% CI, 0.39 to 0.48) is high, however most were mild, non-anaphylaxis reactions (n= 189, 86%). Only 21/31 (39%) of anaphylaxis cases were administered intramuscular adrenaline. Nearly half of reactions were caused by unintentional administration by parents. This highlights the difficulty in relying on avoidance to manage FA as well as highlighting the ongoing need for education on avoidance strategies. A low cost, low intensity educational intervention in the form of a booklet was effective at improving quality of life and anxiety in parents of newly diagnosed children with nut allergy, a tool which can be rolled out with immediately in our clinic.