Food hypersensitivity among schoolchildren

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Food hypersensitivity among schoolchildren prevalence, Health Related Quality of Life and experiences of double-blind placebo-controlled food challenges.

1 Food hypersensitivity among schoolchildren prevalence, Health Related Quality of Life and experiences of double-blind placebo-controlled food challenges. OLIN PhD Thesis XVIII Åsa Strinnholm, PhD ¹/ Allergikonsulent Supervisors : Eva Rönmark¹, Linnea Hedman¹ and Viveca Lindh² ¹ Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, The OLIN Unit, Umeå University, Sweden ²Department of Nursing, Umeå University, Sweden.

2 Background Prevalence of reported food hypersensitivity? Most studies are hospital based and only include children with IgE mediated food allergy. Different phenotypes of food hypersensitivity with different degree of severity. Impaired HRQL? Few studies have examined experiences of food challenges

3 Overvall aim To investigate prevalence, symptoms expressions and risk factors for food hypersentivity among schoolchildren. To compare HRQL among children with and without food hypersensitivity To investigate experiences of double-blind placebo-controlled food challenge among adolescents and mothers.

4 7-8 years Paper I. OLIN paediatric cohort II, study start Questionnaire survey in 3 areas n=2,585 (96% of invited) Skin prick test in 2 areas n=1,700 (90% of invited) Study design years Follow-up study in Questionnaire survey in 3 areas n=2,612 (n=96% of invited) Skin prick test in 2 areas n=1,657 (86% of invited) Complete avoidance of milk, egg, fish or wheat due to FHS n=125 (5% in the cohort) Invited to HRQL study n=320 Children in the same population with unrestricted diet. Clinical examination n=94 (75% of invited) Paper II. Answered KIDSCREEN-52 N=75 (80% of invited) Paper II. Answered KIDSCREEN-52 N= 209 (65% of invited) Answered FAQLQ-TF n=74 (79% of invited)

5 n=25 invited to DBPCFC n=18 (72% of invited) participated, totally 20 DBPCFCs Study design Interviews 18 months after DBPCFC n=17 (94%) Paper III Paper IV. Interviews with mothers after their children participated in DBPCFC. n=8

6 Paper I. Methods: Study area 2006: Cohort recruitment All children in grade 1 and 2 (7-8 years) in Kiruna, Luleå and Piteå Participation: Parental questionnaire n=2,585 (96%) Skin prick test (airborne allergens) 1,700 children (90%) Kiruna and Luleå The Obstructive Lung Disease in Northern Sweden Studies

7 Prevalence (%) of food hypersensitivity (FHS) to different foods among children and among girls and boys, respectively, at the age of 7-8 years by sex. All Boys Girls diff by sex % (n) % (n) % (n) p-value Essential foods Milk 9.0 (232) 7.0 (94) 11.0 (138) <0.001 Egg 1.4 (36) 1.2 (16) 1.6 (20) Fish 1.2 (32) 1.3 (18) 1.1 (14) Wheat 1.0 (26) 1.1 (15) 0.9 (11) Soy 0.6 (15) 0.6 (8) 0.6 (7) Any essential foods 10.9 (283) 9.1 (122) 12.9 (161) Any essential foods, milk excluded 3.5 (90) 3.6 (48) 3.4 (42) Fruits and nuts Kiwi 8.0 (208) 6.2 (83) 10.0 (125) <0.001 Orange 4.5 (117) 3.3 (44) 5.8 (73) Apple 3.9 (100) 4.1 (55) 3.6 (45) Raw carrots 1.4 (36) 1.7 (23) 1.0 (13) Banana 0.7 (18) 0.7 (9) 0.7 (9) Tree nuts 3.6 (93) 4.1 (55) 3.0 (38) Peanuts 3.2 (84) 3.7 (50) 2.7 (34) Almonds 2.0 (51) 2.3 (31) 1.6 (20) Any fruits or nuts 14.6 (377) 12.7 (169) 16.6 (208) Any of the above foods (Any FHS) 21.3 (551) 18.1 (242) 24.7 (309) <0.001

8 Prevalence (%) of triggering foods among children with different clinical symptoms. 47.2% 10.3% 45.7% 35.2%

9 Prevalence (%) of food hypersensitivity (FHS) to different foods in relation to allergic sensitization, asthma, rhinitis, eczema and living conditions. Any FHS p-value FHS milk p-value Any positive SPT No 18.0 < Yes Positive SPT pollen No 19.1 < Yes Positive SPT animal No 18.5 < Yes Asthma No 20.1 < Yes Rhinitis No 18.8 < Yes No associations were found between any of the FHS and breastfeeding < 3 months, parental smoking or having older siblings Eczema No 17.6 < <0.001 Yes Allergic heredity No 13.7 < <0.001 Yes Current living House Apartment Both Area Piteå Kiruna Luleå

10 Risk factors for food hypersensitivity, analysed by multiple logistic regression analysis, and expressed as odds ratios with 95% confidence intervall. FHS essential foods milk excluded FHS fruits and nuts FHS milk OR with 95% CI OR with 95% CI OR with 95% CI Female sex Female sex Female sex Allergic heredity Allergic heredity Allergic heredity Any positive SPT Any positive SPT Any positive SPT Asthma Asthma Asthma Rhinitis Rhinitis Rhinitis Eczema Eczema Eczema IStrinnholm Å, Winberg A, West C, Hedman L, Rönmark E. Food hypersensitivity is common in Swedish schoolchildren, especially oral reactions to fruit and gastrointestinal reactions to milk. Acta Paediatr 2014; 103(12):

11 Paper II Methods: The cohort was followed up 2010 with the same methods. The children were now at age years. Five percent (n=125) reported total elimination of milk, egg, fish and/or wheat due to food hypersensitivity, and 94 (75%)of these children participated in a clinical examination: Structured interview Spec IgE Transglutaminase IgA antibodies

12 Children with total elimination of milk, egg, fish or wheat n= 75 (80% of invited) Generic and disease specific HRQL questionnaires Control group n=209 (65% of invited) Generic HRQL questionnaire Current food allergy n= 23 Outgrown food allergy n=16 Lactose Intolerance n=33 Non-definable cases (n=3)

Median score Median scores in KIDSCREEN-52 domains, among children with and without food hypersensitivity. A higher score indicate better HRQL.

13 Median score Median scores in KIDSCREEN-52 domains, among children with and without food hypersensitivity. A higher score indicate better HRQL. Differences between groups was analysed by Mann Whitney U test 60 p= p=0.878 p=0.653 p=0.567 p=0.146 p=0.219 p=0.531 p=0.964 p=0.892 p= Cases Controls

14 Median score Median scores in FAQLQ domains, by food hypersensitivity phenotypes. A higher score indicate a poorer HRQL. Differences between groups was analysed by Kruskal-Wallis test. 4,50 4,00 p= ,50 3,00 2,50 2,00 1,50 1,00 0,50 0,00 Allergen Avoidance and Dietary restrictions Risk of Accidental exposure Emotional Impact Total FAQLQ score Current food allergy (n=23) Outgrown allergy (n=16) Lactose intolerance (n=32)

15 Prevalence (%) of poor HRQL Prevalence (%) of poor HRQL ( 75 percentile) in FAQLQ-TF domains by food hypersensitivity phenotypes. Differences between groups was analysed by Linear by linear association (Mantel Haenszel). 60,0 50,0 40,0 p= ,0 20,0 10,0 0,0 Allergen Avoidance and Dietary restrictions Risk of Accidental exposure Emotional Impact Total FAQLQ score Current food allergy (n=23) Outgrown allergy (n=16) Lactose intolerance (n=32) Strinnholm Å, Hedman L, Winberg A, Jansson S-A, Lindh V, Rönmark E. Health Related Quality of Life among schoolchildren aged years, in relation to food hypersensitivity phenotypes: a population-based cohort study. Clin Transl Allergy 2017 Jul 3;7:20 doi: /s

16 Paper III Method: n=25 invited to DBPCFC n=18 ( 72% of invited) participated, totally 20 DBPCFCs Milk, egg or cod Interviews 18 months after DBPCFC n=17 (94%) Paper III

Participants in the interview study, challenge outcome and achived reintroduction Study participants n=17 19 DBPCFC Not invited n=1 Negative DBPCFC n=11 Positive DBPCFC n=8

17 Participants in the interview study, challenge outcome and achived reintroduction Study participants n=17 19 DBPCFC Not invited n=1 Negative DBPCFC n=11 Positive DBPCFC n=8 Reintroduction failure n=6 Reintroduced n=5 Anafylaxis n=3 Mild reactions n=5 2 milk 4 cod 3 milk 2 egg 3 egg Reintroduced partially n=4 (3 milk, 1 egg) Did not reintroduced 1 cod

18 I had to sit there and eat what I not allowed to eat I know that they had everything needed. It is so disgusting, to drink milk, I m not used to it A reward, missing lessons.. or it was boring but I have great patience Domains Experiences during the DBPCFC Themes Challenging fears in a secure environment Being hesitant but also curious about unknown tastes Waiting for unknown food reactions Experiences after the DBPCFC Gaining control and freedom Continuing old habits I know I can eat fish, but I dont. I believe that I imagine that I can t eat it since I have been without it for 14 years, so I don t eat it Overwelming: It was a huge relief, it was really nice It is sad, but that s the way it is Strinnholm Å, Winberg A, Hedman L, Rönmark E, Lindh V Reintroduction failure is common among adolescents after double-blind placebo-controlled food challenges. Acta Paediatr. 2017;106(2):

19 Paper IV Method Invited n=10 mothers to children who had performed DBPCFC. With a negative outcome. Reintroduced the food in the childs diet Reintroduced completely n=6 Reintroduced partially n=2 Reintroduction failure Excluded n=2 Interviews n=8

20 If I had reintroduced milk (after the challenge) I would t have trusted my feelings We were having panncakes. I could see with my own eyes that he was feeling well and I understood that it s probably my own fears or feelings that stop me mixing poison into the childs food To have someone else take responsibility I didn t know what was administerad during the challenge, and that was a relief Theme Fear of the unknown Re-evaluating earlier experiences Subtheme Fear of losing control Having faith even though fear prevails Reintroducting despite fear Fear if causing harm Daring to take new challenges Refraining from new challenges New knowledge. No longer having to be the food police If he drinks too much milk, he will have an upset stomach, butthat s manageable Partially reintroduction Difficult to reintroduce a normal diet It s the way our lives are Strinnholm Å, Brulin C, Lindh. Experiences of Double-Blind, Placebo- Controlled Food Challenges (DBPCFC): a qualitative analysis of mothers experiences. J Child Health Care 2010; 14 (2):

21 Conclusions The reported prevalence of any FHS was 21%. Symptoms caused by milk was most common, 9%. The prevalence of poor disease-specific HRQL was higher among children with current food allergy compared to children with other phenotypes of FHS. A negative outcome was not always associated with reintroduction of the challenged food. Reasons for reintroduction failure were fear of food reactions, not liking the taste of the challenged food and being used to an elimination diet.

22 Tack för att ni lyssnade! det som är mjölk för en, kan vara gift för den andre Fritt översatt från ett citat av Titus Lucretius Cato

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