The Public Health Impact of Ruchi S. Gupta, MD, MPH,a,​ ​b,​c,​d Christopher M. Warren, BA,​e Bridget M. Smith, PhD,​c,​f Jesse A. Blumenstock, BS,c​ JialingParent-Reported Jiang, BA,​c Matthew M. Davis, MD, MAPP,a,​ ​b,​c,​d, ​gChildhood Kari C. Nadeau, MD, PhDh Food Allergies in the United States BACKGROUND: abstract

Childhood food allergy (FA) is a life-threatening chronic condition that substantially impairs quality of life. This large, population-based survey estimates childhood FA prevalence and severity of all major allergenic foods. Detailed allergen- METHODS: specific information was also collected regarding FA management and health care use.

A survey was administered to US households between 2015 and 2016, obtaining ’ parent-proxy responses for 38408 children. Prevalence estimates were based on responses from NORC at the University of Chicago s nationally representative, probability-based AmeriSpeak Panel (51% completion rate), which were augmented by nonprobability-based responses via calibration weighting to increase precision. Prevalence was estimated via weighted proportions. Multiple logistic regression models were used to evaluate FA RESULTS: predictors. – Overall, estimated current FA prevalence was 7.6% (95% confidence interval: – 7.1% 8.1%) after excluding 4% of children whose parent-reported FA reaction history was inconsistent with immunoglobulin E mediated FA. The most prevalent allergens were ≥ peanut (2.2%), milk (1.9%), shellfish (1.3%), and tree nut (1.2%). Among food-allergic ≥ children, 42.3% reported 1 severe FA and 39.9% reported multiple FA. Furthermore, ≥ 19.0% reported 1 FA-related emergency department visit in the previous year and 42.0% reported 1 lifetime FA-related emergency department visit, whereas 40.7% had a current epinephrine autoinjector prescription. Prevalence rates were higher among African CONCLUSIONS: American children and children with atopic comorbidities.∼ FA is a major public health concern, affecting 8% of US children. However, >11% of children were perceived as food-allergic, suggesting that the perceived disease NIH burden may be greater than previously acknowledged.

Departments of aPediatrics, bMedicine, and gMedical Social Sciences and Preventive Medicine, and cInstitute WHAT’S KNOWN ON THIS SUBJECT: In 2011, food allergy d for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Mary (FA) was estimated to impact 8% of US children, of which Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children’s nearly 40% reported a history of a severe reaction. Among Hospital, Chicago, Illinois; eDepartment of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; fCenter for Innovation for Complex Chronic Healthcare, Edward J. Hines specific FAs, prevalence was highest for peanut, followed Jr Veterans Affairs Hospital, Hines, Illinois; and hSean N. Parker Center for Allergy and Asthma Research at by milk, shellfish, and tree nut. Stanford University School of Medicine, Stanford, California WHAT THIS STUDY ADDS: In this study, we provide updated Dr Gupta conceptualized and designed the study and oversaw data acquisition, analysis, and national FA prevalence estimates and characterization interpretation; Mr Warren participated in study design, was responsible for data analysis and of related health care use, including epinephrine interpretation, and drafted the manuscript; Dr Smith participated in study design and was prescription and emergency department visits. FA responsible for data analysis and interpretation; Mr Blumenstock participated in study design remains a substantial public health concern, with a and participated in data analysis and interpretation; Ms Jiang contributed to the study design, greater perceived disease burden than previously participated in the interpretation of data, and drafted the manuscript; Drs Davis and Nadeau anticipated. consulted on study design and contributed to interpretation of data; and all authors reviewed and/or revised the manuscript and approved the final manuscript as submitted and agree to be To cite: Gupta RS, Warren CM, Smith BM, et al. The Public accountable for all aspects of the work. Health Impact of Parent-Reported Childhood Food Allergies in the United States. Pediatrics. 2018;142(6):e20181235

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 6, December 2018:e20181235 ARTICLE Childhood food1,2​ allergy (FA) for many specific FAs. Furthermore, Parent-reported allergies with is a serious,​3 ‍ potentially life- by assessing rates of epinephrine reaction symptoms characteristic threatening condition known to autoinjector (EAI) possession and of oral allergy syndrome (OAS) substantially impair quality of life 4 use, as well as FA-related ED visits, or food intolerances were not among patients and their caregivers. the present survey provides the considered convincing and were Because food is integral to most most comprehensive assessment of categorized per the FA flowchart social interactions, children with FA pediatric FA severity and population- summarized in Fig 2, even if such may be at risk for a severe allergic level burden to date. allergies were physician diagnosed. reaction at any time. Childhood FA METHODS For instance, individual allergies to also imposes considerable financial peanut, shellfish, tree nut, fin fish, burden on affected families, with an wheat, soy, barley, rice, seed, spice, estimated annual economic impact A population-based survey was fruit, or vegetables were considered of $24.8 billion ($4184 per year per indicative of OAS instead of 5 – administered between October 2015 child). We concluded from a US convincing FA if their corresponding – and September 2016 to a sample of population based survey conducted US households. Informed consent reaction symptoms were limited to by our group in 2009 2010 the skin or oral mucosa and did not was obtained from all participants. ’ that childhood FA may be more The Northwestern University include hives. Convincing FAs for prevalent and severe6 than previously Institutional Review Board approved which parents reported a doctor s acknowledged. diagnosis were considered physician- Surveyall study Development activities. and Design confirmed FAs. For each convincing Since 2010, numerous review articles allergy, a severe reaction history was have suggested that the population- – indicated by the presence of multiple level burden of childhood FA is – The present parent-report stringent symptoms occurring growing and may be historically 7 11 survey extended our 2009 2010 within 2 or more of the following 4 high. ‍ For example, the authors of survey, which was developed by organ systems: skin or oral mucosa, a recent US study described a nearly pediatricians, pediatric allergists, and gastrointestinal, cardiovascular, 200% increase in food-induced survey methodologists with support and respiratory. If multiple allergies anaphylaxis-related emergency from an expertN panel. Expert panel were reported for a given child, department (ED) visits from 2005 12 review and key informant cognitive each reported allergy was evaluated to 2014 among 5 to 17-year-olds. interviews ( = 40) were conducted separately via the FA categorization With this growing epidemic and life- on the original survey by using – flowchart. For example, if a parent threatening nature of FAs, developing the approach15 described by Gupta reported their child had a nut allergy treatments and prevention strategies et al. While the core 2009 2010 with a reaction history limited to oral are critical. A recent study revealed survey was kept intact, additional symptoms indicative of OAS, as well that early introduction of peanut questions were added to the present as a shellfish allergy with a reaction products may prevent peanut 13 instrument to assess emerging history including throat tightening, allergy,​ and peanut immunotherapy research issues relating to the vomiting, and hives, the child would treatments are showing promise 14 etiology and management of FA. The be considered to have a single, severe in phase 3 trials. Understanding revised instrument was pretested on Studyshellfish Participants, allergy. Survey reported prevalence, types of FA, 345 pilot interviewees. Interviewee – Weighting, and Statistical Analysis associated symptoms and severity, data and feedback were reviewed diagnosis and management practices, and incorporated into the final 2015 and determinants of FA is critical ≥ Outcome2016 survey. Measures Eligible study participants included for clinicians, researchers, and adults ( 18 years old) able to policymakers in their efforts to complete the survey in English or address this important public health The primary outcome measure Spanish via Web or telephone who issue. – for the current study was the resided in a US household. As in With this study, we aim to describe prevalence of overall and food- the 2009 2010 survey, this study the public health impact of specific convincing childhood relied on a nationally representative childhood FA by studying a large, FA. Parent-reported FAs were household panel to support6 nationally representative sample considered convincing if the most population-level inference. Study of US households with children. We severe reaction reported to that participants were first recruited ’ collected parent proxy-report data food included at least 1 symptom from the NORC at the University on FA prevalence, symptomatology, on the stringent symptom list of Chicago s probability-based and health care use, both overall and developed by our expert panel (Fig 1). AmeriSpeak Panel, where a survey Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 GUPTA et al

completion rate of 51.2% was observed (7218 responses of 14095 invitees). Each child was assigned a ’ base, study-specific sampling weight equal to their responding parent s nonresponse-adjusted AmeriSpeak sampling weight. Parental weights were reconciled with external population totals associated with age, sex, education, race and/or ethnicity, housing tenure, telephone status, and census division via iterative proportional fitting to improve external validity. Child-specific weights were further adjusted to FIGURE 1 account for random selection of up to List of allergic reaction symptoms highlighting stringent symptoms indicative of convincing FA. All 3 children or households and raked symptoms lister are offered as answer choices in the survey. Symptoms in bold italics comprised to external pediatric population our expert panel’s stringent symptom list. A convincing FA required the patient report of at least 1 stringent symptom during a child’s most severe reaction to a given food. A severe reaction consisted totals. To increase precision of of a parent report of at least 2 stringent symptoms from 2 different body systems during a child’s estimates where data are scarce most severe reaction to a given food. (such as for the prevalence of rare allergies within specific age groups) data gleaned from population- weighted AmeriSpeak responses were augmented with calibration- weighted, nonprobability-based responses obtained through Survey Sampling International (SSI). Here, state-of-the-art estimation methods were used to minimize both the bias and variance of resulting estimates to a greater degree than independent analysis of either sample permits. The final, combined sample weight was derived by applying an optimal composition factor that minimizes mean square error associated with 16,17​ FA prevalence estimates. ‍ In total, surveys were completed by 51819 US households. Participants received $5 at survey completion. Weighted proportions were calculated to estimate prevalence. Covariate-adjusted weighted logistic regression models compared relative prevalence by sample characteristics. Robust SEs accounted for household- FIGURE 2 level clustering. Convincing, physician-confirmed, and severe childhood FA categorization flowchart. GI, gastrointestinal; RESULTS SPT, skin prick test; sIgE, allergen-specific immunoglobulin E.

Parent-reported data were collected for 41341 children; 2933 children were excluded because of Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 6, December 2018 3 TABLE 1 Demographic Distribution of Current Childhood FA Versus All Children Variable Population-Weighted Frequency % (95% CI) incomplete data on FA outcomes. All Children Children With FA P Sociodemographic characteristics of the omitted children did not Race and/or ethnicity significantly differ from the final Asian American, non-Hispanic 3.2 (2.8–3.8) 2.8 (2.2–3.5) .20 African American, non-Hispanic 13.2 (12.3–14.2) 15.4 (13.1–18.1) .06 analytic sample of 38408 children. * * * Demographic Characteristics White, non-Hispanic 52.8 (51.2–54.4) 48.3 (45.0–51.7) <.01 Hispanic 24.1 (22.5–25.7) 26.5 (23.2–30.0) .14 Multiracial or other 6.6 (6.1–7.3) 7.1 (5.7–8.7) .56 Sex Half (51.1%) of the population- Female 48.9 (47.8–50.0) 48.2 (45.0–51.5) .68 weighted sample was male. Race Male 51.1 (50.0–52.2) 51.8 (48.6–55.0) and/or ethnicity was mutually Age, y exclusive, with 52.8% white, non- 0 5.3 (4.8–5.9)* 1.9 (1.5–2.5)* <.001* 1 4.9 (4.4 5.3) 5.6 (4.3 7.3) .28 Hispanic; 24.1% Hispanic, 13.2% – – 2 5.7 (5.3–6.3) 7.5 (5.4–10.4) .09 African American, non-Hispanic; and 3–5 16.2 (15.5–17.0) 17.8 (15.3–20.5) .22 3.2% Asian American, non-Hispanic 6–10 27.9 (26.9–28.8) 29.1 (26.5–31.9) .34 (Table 1). Rates of physician-P 11–13 16.6 (15.9–17.4) 16.5 (14.3–18.9) .88 diagnosed atopic conditions were 14–17 23.4 (22.4–24.4) 21.6 (19.3–24.2) .17 Household income, $ significantly higher ( < .05) <25 000 16.1 (14.9–17.3) 15.4 (13.0–18.1) .55 among children with convincing FA 25 000–49 999 22.2 (20.9–23.5) 23.2 (20.6–26.1) .43 Prevalencecompared with other children. 50 000–99 999 31.1 (29.8–32.5) 31.5 (28.6–34.5) .82 100 000–149 999 19.2 (18–20.5) 20.4 (17.4–23.7) .40 >150 000 11.4 (10.3–12.6) 9.6 (7.6–11.9) .12 Geographic region The estimated prevalence of – West 24.4 (22.9–25.9) 22.4 (19.7–25.4) .17 childhood FA was 7.6% (95% Midwest 20.6 (19.5–21.7) 19.1 (16.8–21.7) .23 confidence interval [CI]: 7.1 8.1) South 38.4 (36.9–40.0) 39.9 (36.6–43.2) .37 Northeast 16.1 (15.0 17.2) 17.7 (15.1 20.7) .21 (Table 2), with 40% of children – – Physician-diagnosed comorbid with FA reporting multiple FAs. conditions Peanut (2.2%) and milk (1.9%) Asthma 12.2 (11.4–13.0)* 32.6 (29.5–35.9)* <.001* allergies were the most common Atopic dermatitis and/or 5.9 (5.3–6.5)* 14.9 (12.5–17.7)* <.001* food-specific FAs. When treated as eczema Eosinophilic esophagitis 0.2 (0.1 0.2)* 0.7 (0.4 1.1)* <.001* single allergens, shellfish (1.3%), and – – Allergic rhinitis 12.8 (12.0–13.6)* 30.4 (27.6–33.4)* <.001* tree nut (1.2%) were the next most Insect sting allergy 2.2 (1.9–2.6)* 6.4 (5.3–7.8)* <.001* common allergens, followed by egg Latex allergy 1.0 (0.8–1.3)* 6.6 (4.8–9.0)* <.001* (0.9%) and fin fish (0.6%). Among Medication allergy 4.2 (3.7–4.7)* 10.1 (8.2–12.3)* <.001* * * * specific shellfish allergies, shrimp Urticaria and/or chronic hives 0.5 (0.4–0.6) 1.9 (1.4–2.6) <.001 Other chronic condition 3.2 (2.8 3.7)* 7.2 (5.9 8.9)* <.001* (1.0%) was most prevalent followed – – * by crab (0.6%), mollusks (0.6%), and Two-sided P < .05 lobster (0.6%). Among specific tree nuts, rates of almond (0.7%), cashew (0.7%), walnut (0.6%), pecan (0.6%), reaction symptoms indicative of peanut (73.0%), tree nut (70.4%), and hazelnut (0.6%) allergies were a severe FA (Table 3). Severe FA and sesame (64.8%) allergy. similar. Sesame allergy prevalence Associations was estimated at 0.2%. An estimated was more common among children 61.1% of children with convincing FA with allergy to peanut (59.2%), tree nut (56.1%), and shellfish (48.7%). had at least 1 physician-confirmed Adjusted odds of convincing FA are Among children with convincing FA. Overall, 11.4% of children's presented in Table 4. Significant FA, 42.0% had been treated in caregivers reported a current FA differences in convincing FA the ED for a food allergic reaction before stringent symptom criteria prevalence were observed by race were used to filter out those lacking at some point in their life, with and/or ethnicity, with non-Hispanic a convincing history of IgE-mediated 19.0% treated in the ED within the African American children at SeverityFA. past year. However, only 40.7% of significantly elevated risk relative to – children with convincing FA reported non-Hispanic white children (odds a current prescription for an EAI. ratio [OR] = 1.4 [95% CI: 1.1 1.7]). Among children with convincing The highest rates of EAI prescription In adjusted models, children who had FA, 42.3% were estimated to have were observed for children with ever received a physician-diagnosis Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 GUPTA et al 1.2 – 3.7 2.1 – 4.2 3.6 – 8.0 4.5 – 8.6 3.9 – 7.8 6.3 – 7.9 1.1 – 2.0 4.8 – 9.1 3.5 – 7.2 0.2 – 0.8 1.6 – 2.7 0.9 – 1.4 0.5 – 2.7 0.7 – 1.2 0.5 – 0.9 0.3 – 0.6 0.6 – 1.0 0.5 – 0.9 0.5 – 1.3 0.3 – 0.5 0.0 – 0.2 0.4 – 0.8 0.3 – 0.7 0.4 – 0.7 0.4 – 0.9 0.2 – 0.5 0.0 – 0.1 0.3 – 0.6 0.9 – 1.4 0.1 – 0.3 0.1 – 0.3 5.1 – 12.1 8.3 – 14.4 6.5 – 12.2 5.1 – 10.7 5.4 – 10.0 7.9 – 17.5 6.6 – 12.1 10.4 – 17.0 12.6 – 20.1 16.7 – 26.8 12.4 – 19.4 23.8 – 36.1 14 – 17 y 2.1 3.0 5.4 13.3 7.9 6.2 5.5 16.0 7.1 1.5 11.0 6.6 0.4 8.9 7.5 7.4 5.0 21.3 2.1 1.1 1.2 11.9 9.0 15.6 0.9 0.6 0.4 0.8 0.6 0.8 0.4 0.1 0.5 0.5 0.5 0.6 0.4 0.0 0.4 1.1 29.5 0.2 0.1 0.9 – 3.5 2.1 – 6.1 3.9 – 9.6 6.5 – 8.8 1.2 – 1.9 0.3 – 1.7 1.6 – 3.2 0.9 – 1.5 0.2 – 2.5 1.2 – 2.1 0.4 – 0.8 0.5 – 1.0 0.5 – 0.9 0.5 – 0.9 0.5 – 0.9 0.5 – 1.2 0.0 – 0.2 0.5 – 1.0 0.7 – 1.4 0.7 – 1.3 0.4 – 0.8 0.5 – 1.1 0.0 – 0.1 0.3 – 0.7 0.8 – 1.6 0.2 – 0.5 0.1 – 0.3 5.0 – 10.0 6.5 – 12.6 6.6 – 15.5 6.5 – 12.2 9.0 – 17.8 6.6 – 12.5 6.6 – 13.0 8.7 – 16.8 6.8 – 14.5 5.9 – 12.0 5.8 – 11.3 16.3 – 27.4 10.8 – 20.2 16.0 – 25.2 11.8 – 20.0 23.1 – 39.1 11 – 13 y 1.8 3.6 6.2 7.1 9.1 9.0 9.1 9.3 7.5 1.5 8.5 0.8 8.1 2.3 1.2 0.7 1.6 0.6 0.7 0.7 0.7 0.6 0.8 0.1 0.7 1.0 0.9 0.5 0.8 0.1 0.5 1.1 0.3 0.1 21.3 10.2 14.9 12.8 12.2 10.0 20.2 15.4 30.5 2.0 – 5.5 4.3 – 9.6 7.2 – 8.9 1.1 – 1.9 0.1 – 0.7 2.2 – 3.1 0.9 – 1.5 0.2 – 2.2 1.1 – 1.7 0.4 – 1.0 0.7 – 1.3 0.5 – 1.0 0.6 – 1.0 0.5 – 1.0 0.5 – 1.0 0.0 – 0.2 0.6 – 1.0 0.6 – 1.3 0.6 – 1.0 0.4 – 0.9 0.5 – 0.9 0.0 – 0.1 0.3 – 0.8 1.5 – 2.5 0.3 – 0.8 0.2 – 0.4 4.0 – 10.2 5.3 – 11.4 9.3 – 16.0 6.0 – 12.7 7.6 – 12.8 6.8 – 12.9 7.4 – 12.8 5.9 – 12.2 7.5 – 15.3 5.5 – 11.6 7.2 – 12.5 6.0 – 11.2 14.3 – 21.6 19.5 – 30.0 14.6 – 22.9 10.9 – 18.4 28.2 – 37.8 6 – 10 y 3.3 6.5 6.4 7.8 8.7 9.9 9.4 9.8 8.0 1.5 8.5 0.3 8.1 9.5 8.3 2.6 1.1 0.7 1.4 0.6 1.0 0.7 0.8 0.7 0.7 0.1 0.8 0.9 0.8 0.6 0.0 0.7 0.5 1.9 0.5 0.3 17.6 12.3 24.4 10.8 18.4 14.3 32.8 – 21.5 1.5 – 5.0 4.3 – 9.8 7.1 – 9.8 0.7 – 1.7 0.2 – 5.1 2.8 – 7.3 1.7 – 2.6 0.5 – 1.4 0.2 – 1.1 1.0 – 1.8 0.3 – 1.1 0.4 – 1.0 0.4 – 1.4 0.5 – 1.0 0.3 – 1.2 0.4 – 1.1 0.0 – 0.1 0.4 – 0.8 0.8 – 1.9 0.4 – 0.9 0.2 – 1.1 0.0 – 0.4 0.2 – 0.6 0.2 – 1.5 2.1 – 3.8 0.2 – 1.6 0.1 – 0.4 2.6 – 17.0 2.4 – 16.8 4.6 – 11.1 2.9 – 13.0 4.6 – 15.7 5.6 – 11.6 4.4 – 12.6 8.4 – 19.6 3.6 – 13.3 3.1 – 12.8 5.1 – 10.5 6.4 – 16.1 11.6 25.9 – 42.2 10.1 – 21.7 20.0 – 31.1 3 – 5 y 2.7 6.9 6.6 7.2 6.2 6.5 8.3 1.1 8.6 8.1 7.5 4.6 2.1 0.9 0.4 7.0 6.4 7.4 1.3 0.5 0.6 0.7 0.7 0.6 0.6 0.0 0.5 1.3 0.6 0.5 0.4 0.5 2.8 0.6 0.2 15.9 33.6 13.0 15.0 10.2 25.1 – 2.2 – 2.7 0.6 0.4 1.6 – 3.6 0.3 – 1.6 0.5 – 2.2 0.1 – 1.5 0.2 – 1.8 0.0 – 0.3 0.3 – 2.0 0.2 – 1.6 0.2 – 1.8 0.0 – 1.3 0.2 – 1.9 0.8 – 2.4 0.4 – 2.0 0.2 – 1.6 0.2 – 1.8 0.4 – 2.2 2.2 – 8.3 0.4 – 1.9 0.0 – 1.2 0.4 – 11.1 3.8 – 18.5 4.3 – 21.4 5.3 – 21.3 2.0 – 17.0 2.2 – 15.4 2.4 – 17.8 5.8 – 21.5 7.2 – 13.7 7.7 – 24.4 3.3 – 18.9 2.2 – 17.4 2.1 – 17.1 3.0 – 16.1 0.3 – 12.4 2.3 – 15.2 1.1 – 14.5 3.7 – 19.0 26.6 – 62.1 15.2 – 37.1 2 y 2.3 8.6 9.9 6.1 1.1 6.0 1.1 6.8 2.4 0.7 8.2 6.4 6.2 0.0 N/A7.1 1.0 1.1 1.9 0.4 6.1 4.2 8.6 0.6 0.1 0.8 0.6 0.6 0.2 0.7 1.4 0.9 0.6 0.6 1.0 0.0 N/A 0.1 4.3 0.9 0.2 11.5 10.0 14.1 43.5 10.9 24.5 4.7 – 0.8 0.6 – 4.0 2.3 – 8.4 2.8 – 8.9 1.5 – 3.0 0.1 – 0.5 2.5 – 8.6 2.4 – 8.1 2.2 – 8.5 0.0 – 2.4 1.5 – 5.7 0.4 – 1.1 0.1 – 2.2 0.2 – 0.6 0.9 – 5.0 1.7 – 6.9 1.1 – 2.1 – 7.6 0.1 – 0.3 0.1 – 0.4 0.2 – 0.7 0.1 – 0.4 0.2 – 0.7 0.0 – 0.2 0.2 – 0.7 1.0 – 4.1 0.2 – 0.7 0.2 – 1.3 0.2 – 0.7 0.2 – 1.3 0.0 – 0.2 2.1 – 5.2 0.5 – 3.9 0.3 0.2 – 1.1 1.8 – 12.5 6.6 – 35.8 2.5 – 14.0 6.7 – 11.4 2.8 – 13.9 4.8 – 13.1 12.0 – 39.1 25.4 – 52.0 16.8 – 34.5 1 y 4.9 1.6 6.0 5.1 2.2 8.8 0.3 6.4 4.6 4.4 4.4 3.0 0.7 0.3 2.2 3.5 2.2 4.0 0.1 0.2 0.4 0.2 0.4 2.0 0.4 0.6 0.4 0.5 3.3 1.5 0.4 8.0 0.4 16.6 22.8 37.8 24.6 0.3 – 0.9 2.1 – 3.7 0.0 – 0.2 0.8 – 7.5 0.4 – 6.5 0.7 – 7.2 0.4 – 5.4 0.1 – 0.6 0.1 – 0.4 0.0 – 0.3 0.0 – 0.4 0.1 – 0.5 0.0 – 0.4 0.0 – 0.2 0.2 – 0.7 0.0 – 0.5 0.0 – 0.2 0.0 – 0.2 0.2 – 1.1 0.9 – 2.3 0.2 – 0.8 0.1 – 0.5 0.1 – 0.3 1.8 – 10.9 8.5 – 26.4 1.3 – 11.0 6.0 – 32.3 3.0 – 16.0 7.6 – 23.0 1.9 – 15.5 0.6 – 14.5 2.1 – 15.1 1.4 – 14.6 0.6 – 15.6 4.0 – 18.9 39.7 – 65.8 12.1 – 31.6 <1 y 4.6 3.9 0.0 N/A7.1 4.5 0.6 2.8 0.0 2.6 5.6 1.6 2.3 0.0 N/A1.6 0.3 0.2 0.2 0.0 N/A 0.5 3.0 5.8 4.7 3.3 0.1 0.1 0.2 0.1 0.0 0.0 N/A 0.0 0.0 N/A 0.4 0.4 0.1 0.1 0.1 0.4 0.01.5 N/A 0.0 0.4 0.2 9.0 0.1 15.4 14.9 13.5 53.0 20.2 – 3.6 – 8.3 – 9.9 – 8.6 – 9.4 – 19.2 – 8.9 – 9.4 – 8.1 – 0.9 – 28.8 – 14.5 – 1.4 – 9.0 – 9.9 – 32.0 – 10.2 – 10.3 – 14.4 – 10.1 2.1 4.7 7.0 5.0 6.6 2.0 – 2.5 7.1 – 8.1 0.8 – 1.1 5.7 6.3 5.5 0.2 1.1 – 1.4 0.5 – 0.7 0.5 6.0 6.8 0.5 – 0.8 0.5 – 0.8 0.6 – 0.8 0.5 – 0.8 0.5 – 0.7 0.0 – 0.1 0.5 – 0.7 0.7 – 1.1 0.6 – 0.8 0.4 – 0.9 0.4 – 0.6 0.4 – 0.7 0.0 – 0.1 1.7 – 2.3 0.4 – 0.6 1.1 – 1.5 0.2 – 0.3 7.5 6.7 9.8 7.3 14.8 22.2 10.9 13.9 – 17.9 26.3 All Children % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI 2.7 6.2 8.3 6.6 8.7 7.9 2.2 7.6 1.0 8.3 7.1 7.7 8.6 6.7 0.5 1.2 0.6 0.8 7.4 8.2 0.6 0.6 0.7 0.6 0.6 0.9 0.7 0.6 0.5 1.9 0.5 0.2 16.9 25.4 12.6 11.9 15.8 29.0  Prevalence of Most Common FAs by Age

ree nut Sesame Soy Walnut Wheat Almond Pecan Shellfish Mollusk Fin fish Hazelnut Cashew Pistachio Other tree nut Milk Shrimp Other shellfish Egg Lobster Crab T Peanut

Peanut Any FA Shrimp

Tree nut Tree Lobster

Walnut Crab Almond Mollusk Hazelnut 0.6 Other shellfish 0.1 Pecan Egg Cashew Fin fish Pistachio 0.5 Wheat Other tree nutMilk 0.0 Soy Shellfish 1.3

Sesame

Prevalence of specific allergies among children with FA Prevalence of specific allergies TABLE 2 N/A, not applicable.

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 6, December 2018 5 – of asthma (OR = 3.2 [95% CI: – 4.2 – 38.8

8.4 – 48.2 2.7 3.8]), atopic dermatitis and/or (95% CI) 17.6 – 39.2 16.1 – 22.3 25.0 – 48.9 19.1 – 27.2 28.6 – 51.7 19.3 – 30.3 13.3 – 30.3 16.2 – 33.1 22.3 – 50.5 20.8 – 34.8 22.2 – 46.0 17.5 – 35.8 17.7 – 32.8 18.2 – 32.0 15.4 – 31.8 18.1 – 36.5 17.1 – 29.4 18.9 – 33.9 18.6 – 41.3 19.1 – 39.5 eczema (OR = 1.9 [95% CI: 1.4 2.4]), – allergic rhinitis (OR = 2.3 [95% CI: – in the Past y 1.9 2.7]), insect sting allergy (OR = – 2.5 [95% CI: 1.8 3.4]), medication 27.1 19.0 14.2 36.1 22.9 39.5 24.4 20.5 23.6 35.1 27.2 33.0 25.6 24.5 24.4 22.6 22.6 26.3 22.7 25.7 28.6 28.2 – allergy (OR = 1.9 [95% CI: 1.4 2.4]), One or More FA-Related ED Visits urticaria (OR = 2.9 [95% CI: 1.4 6.0]), – or latex allergy (OR = 7.9 [95% CI: 5.5 11.3]) had increased odds of convincing FA. 54.1 – 72.5 38.8 – 45.4 20.9 – 69.8 46.6 – 65.8 44.9 – 55.9 59.0 – 78.8 43.1 – 55.6 31.2 – 57.1 43.7 – 60.7 38.6 – 67.8 51.2 – 66.2 44.3 – 70.9 43.7 – 63.7 44.7 – 61.8 44.1 – 59.8 43.9 – 62.6 15.6 – 68.2 39.2 – 55.1 48.1 – 61.4 46.8 – 61.2 53.1 – 70.9 51.7 – 70.0 Among children with 1 or more Visits convincing FAs, having multiple FAs, a current epinephrine prescription, 63.8 42.0 43.9 56.4 50.4 69.8 49.4 43.7 52.3 53.5 58.9 58.2 53.9 53.4 52.0 53.4 38.7 47.1 54.9 54.1 62.4 61.2 One or More Lifetime ED a history of 1 or more lifetime FA-related ED visits, a severe reaction history, and comorbid allergic rhinitis were each associated with 31.8 – 51.9 37.6 – 43.9 22.2 – 72.1 40.6 – 61.5 68.0 – 77.5 36.6 – 58.6 64.0 – 76.1 24.5 – 47.1 68.6 – 83.1 27.8 – 55.4 70.2 – 83.1 50.3 – 77.0 61.6 – 81.7 67.7 – 82.7 70.0 – 83.2 72.5 – 87.6 56.6 – 94.6 21.1 – 31.3 39.2 – 52.4 39.2 – 53.4 34.0 – 53.4 36.8 – 56.3 the presence of 1 or more physician- confirmed FAs. Having multiple FAs,

Prescription a current epinephrine prescription, 41.5 40.7 51.1 73.0 47.5 70.4 35.0 76.6 40.9 77.3 64.8 72.8 77.3 81.2 25.9 45.7 46.2 43.5 46.4

Current Epinephrine a history of 1 or more lifetime FA-related ED visits, or comorbid asthma were also significantly associated with increased odds of a

– 94.2 severe allergic reaction history. 86.4 36.9 – 43.1 68.7 – 81.7 49.1 – 60.3 73.8 – 90.6 84.6 – 93.0 53.0 – 77.8 89.4 – 96.8 62.5 – 84.0 94.5 – 98.1 69.2 – 94.7 81.9 – 98.7 91.8 – 97.9 95.5 – 99.2 35.5 – 51.0 67.0 – 78.1 67.5 – 79.7 92.2 – 98.1 82.9 – 95.4 In Table 5, we present factors associated with having a current

Multiple FAs epinephrine prescription, reporting Proportion of Children With Each Specific FA Who Have 91.0 39.9 75.8 54.8 83.9 89.5 66.6 94.1 74.7 96.7 86.4 95.0 95.8 98.0 43.1 72.9 74.1 96.1 90.9 100.0 N/A 46.2 100.0 N/A 76.0 100.0 N/A 82.7 1 or more lifetime FA-related ED visit and reporting 1 or more FA-related ED visit within the past year. Children who had 1 or more lifetime ED visits or severe FA had significantly elevated 38.6 – 60.2 57.6 – 64.5 31.5 – 84.6 63.9 – 79.3 77.0 – 84.4 41.6 – 64.5 66.2 – 78.6 40.6 – 68.5 52.7 – 70.0 28.6 – 54.1 65.0 – 79.2 41.6 – 68.6 49.7 – 70.2 57.7 – 74.0 62.6 – 77.0 56.6 – 73.7 44.3 – 89.3 44.2 – 60.0 52.3 – 65.8 49.3 – 64.1 34.3 – 53.2 37.6 – 56.9 odds of having a current epinephrine prescription, as did children with That Food peanut or pistachio allergy, whereas 61.1 61.3 72.2 80.9 53.2 72.9 54.9 61.7 40.7 72.7 55.5 60.4 66.4 70.3 65.7 72.1 52.1 59.3 56.9 43.5 47.1 49.4 children allergic to milk had significantly reduced odds. Children with multiple or more severe FAs, milk or fin fish allergies, or comorbid asthma, insect allergy, or urticaria had 39.1 – 45.4 12.5 – 54.7 21.5 – 36.0 53.6 – 64.6 37.8 – 60.3 50.1 – 61.9 23.5 – 52.3 28.5 – 45.6 24.7 – 50.8 43.0 – 58.1 17.5 – 39.7 36.1 – 56.4 31.0 – 47.3 34.8 – 50.2 28.9 – 47.1 34.8 – 85.8 20.4 – 31.0 41.9 – 55.5 43.8 – 58.4 31.9 – 53.1 31.1 – 51.0 32.7 – 55.5 significantly greater odds of 1 or more lifetime FA-related ED visits. DISCUSSION gy-Specific Prevalence of FA-Related Outcomes % 95% CI % 95% CI % 95% CI % 95% CI % (95% CI) % 42.3 28.1 59.2 49.0 56.1 36.7 36.6 36.8 50.6 27.2 46.1 38.9 42.3 37.6 25.3 48.7 51.1 42.1 40.6 43.8 Severe FA to That Food Physician-Diagnosed FA to

Based on population-weighted estimates obtained from this  Overall and Aller nationally representative, parent- reported sample, an estimated 7.6% of ∼ Any FA Other shellfishEgg 29.4 Peanut Fin fish Tree nut Tree Wheat Walnut Soy Almond Sesame Hazelnut Pecan Cashew Pistachio Other tree nutMilk 64.2 Shellfish Shrimp Lobster Crab Mollusk N/A, not applicable. TABLE 3 US children have an FA, corresponding to 5.6 million children. Moreover, an estimated 42.3% of children with Downloaded from www.aappublications.org/news by guest on September 24, 2021 6 GUPTA et al TABLE 4 Multivariate Predictors of FA Characteristics Convincing FA Versus Physician-Confirmed FA Severe FA Versus Mild- Multiple FA Versus No FA Versus Convincing FA to-Moderate FA Single FA OR 95% CI OR 95% CI OR 95% CI OR 95% CI Race and/or ethnicity (versus white, non-Hispanic) Asian American, non-Hispanic 1.0 0.8–1.4 0.7 0.4–1.3 1.0 0.6–1.8 1.9* 1.1–3.3* African American, non-Hispanic 1.4 1.1–1.7 1.2 0.8–1.9 0.9 0.5–1.4 2.0* 1.3–2.8* Hispanic 1.2 0.9–1.4 1.0 0.7–1.4 0.9 0.7–1.3 0.9 0.7–1.3 Multiracial and/or other 1.1 0.8–1.3 1.1 0.7–1.8 1.0 0.7–1.4 1.0 0.7–1.6 Sex Female versus male 1.0 0.9–1.2 1.0 0.7–1.2 0.6* 0.5–0.8* 1.1 0.9–1.4 Age in y (versus 0–1 y) 1 2.8* 1.9–4.2* 1.3 0.6–2.8 1.1 0.5–2.3 0.6 0.3–1.3 2 3.3* 2.0–5.3* 0.8 0.3–1.7 0.8 0.4–1.6 0.5 0.2–1.2 3–5 2.4* 1.7–3.3* 0.9 0.4–1.8 1.2 0.6–2.2 0.8 0.4–1.7 6–10 1.9* 1.4–2.6* 1.5 0.8–2.9 0.9 0.5–1.6 0.5 0.2–1.1 11–13 1.6* 1.1–2.2* 1.4 0.7–2.6 1.2 0.6–2.2 0.6 0.3–1.3 14–17 1.6* 1.1–2.2* 1.1 0.6–2.1 1.4 0.7–2.5 0.5 0.2–1.0 Household income (versus <$25 000/y) $25 000–$49 999 1.2 0.9–1.6 1.0 0.6–1.7 0.7 0.4–1.1 1.0 0.6–1.5 $50 000–$99 999 1.2 1.0–1.5 1.4 0.9–2.2 0.7 0.5–1.1 1.1 0.7–1.6 $100 000–$149 999 1.3 1.0–1.7 1.3 0.8–2.2 0.3* 0.2–0.5* 1.0 0.7–1.6 >$150 000 1.0 0.7–1.5 1.3 0.7–2.6 0.7 0.4–1.2 1.3 0.7–2.2 Geographic location (versus Midwest) West 1.0 0.8–1.2 0.8 0.6–1.3 1.1 0.7–1.6 1.0 0.7–1.5 South 1.0 0.8–1.2 1.0 0.7–1.4 1.0 0.7–1.5 0.8 0.6–1.2 Northeast 1.1 0.9–1.4 0.7 0.4–1.1 0.8 0.5–1.3 1.2 0.8–1.9 One or more physician-confirmed FA ———— 1.6* 1.1–2.1* 1.5* 1.2–2.0* Multiple FA versus 1 FA —— 1.5* 1.1–2.0* 2.4* 1.8–3.1* —— Current epinephrine prescription —— 5.1* 3.8–6.9* 2.6* 1.9–3.4* 1.1 0.8–1.5 One or more lifetime ED visit —— 1.9* 1.4–2.5* 1.8* 1.4–2.3* 1.6* 1.3–2.1* One or more severe FA —— 1.6* 1.2–2.1* —— 2.4* 1.8–3.1* Physician-diagnosed comorbidities (versus absence of that condition) Asthma 3.2* 2.7–3.8* 1.2 0.9–1.6 1.6* 1.2–2.1* 1.4* 1.1–1.8* Atopic dermatitis and/or eczema 1.9* 1.4–2.4* 1.5 1.0–2.3 0.8 0.6–1.2 1.2 0.8–1.7 Eosinophilic esophagitis 2.5 0.8–7.5 1.7 0.7–4.2 0.6 0.2–2.4 2.7* 1.1–6.7* Allergic rhinitis 2.3* 1.9–2.7* 1.7* 1.3–2.3* 1.1 0.9–1.5 1.5* 1.1–1.9* Insect sting allergy 2.5* 1.8–3.4* 1.3 0.7–2.6 1.0 0.7–1.6 1.7* 1.0–2.9* Latex allergy 7.9* 5.5–11.3* 1.5 0.9–2.5 1.1 0.7–1.7 1.2 0.8–1.9 Medication allergy 1.9* 1.4–2.4* 1.0 0.6–1.6 0.9 0.6–1.4 0.9 0.6–1.4 Urticaria and/or chronic hives 2.9* 1.4–6.0* 0.8 0.3–2.2 1.5 0.7–3.2 2.0* 1.0–3.9* Other chronic condition 2.3* 1.6–3.3* 1.5 0.9–2.5 1.6* 1.1–2.5* 0.9 0.6–1.4 —, not applicable. * Two-sided P < .05

an FA have a history of at least 1 current survey indicates that peanut tree nut allergy prevalence rates, ∼ severe food allergic reaction, and remains the most common FA in the however, did not significantly differ. 39.9% have multiple FAs. At least United States (affecting 1.6 million These findings contrast with previous 1 lifetime FA-related visit to the children), followed by milk (1.4 studies in which researchers ED was reported by an estimated million), shellfish (1 million), tree reported walnut and cashew allergies 42.0% of children with FA, with nut (0.9 million), egg (0.6 million), fin to be substantially more prevalent–

19.0% of children reporting at least fish (0.4 million), wheat (0.4 million), than other tree nut allergies, 20 22 1 FA-related ED visit in the last year. soy (0.4 million), and sesame (0.15 including pecan and almond. ‍ Furthermore, these data indicate that million). Among shellfish allergies, Moreover, sesame was the ninth only 40.7% of food-allergic children shrimp allergy was most common, most common allergen in our study, in the United States have a current followed by crab, mollusk, and with a prevalence of 0.2%. This is prescription for an EAI. lobster. These findings are consistent consistent with previous studies in with past research suggesting which researchers reported sesame

The relative prevalence of specific that crustacea elicit more18, allergic19​ allergy prevalence of 0.1% to 0.2%20,23,​ 24​ in parent-reported FAs observed in the reactions than mollusks. ‍ Specific the United States and Canada. ‍ ‍ Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 6, December 2018 7 TABLE 5 Multivariate Predictors of Epinephrine Prescription, Lifetime ED Visits, and Last Year ED Visits Current Epinephrine Lifetime ED Visits Last Year ED Visits Prescription OR 95% CI OR 95% CI OR 95% CI Race and/or ethnicity (versus white, non-Hispanic) Asian American, non-Hispanic 1.3 0.7–2.5 0.9 0.6–1.6 1.0 0.5–2.0 African American, non-Hispanic 0.8 0.5–1.2 1.3 0.9–1.8 1.4 0.8–2.3 Hispanic 0.8 0.6–1.2 1.5* 1.1–2.1* 1.1 0.7–1.6 Multiracial and/or other 0.9 0.6–1.5 0.9 0.5–1.6 1.4 0.8–2.7 Sex Female versus male 1.1 0.9–1.5 0.9 0.7–1.2 1.0 0.7–1.3 Age in y (versus 0–1 y) 1 0.9 0.4–2.0 1.2 0.5–2.9 0.9 0.4–2.1 2 0.7 0.3–1.6 3.4* 1.3–9.0* 2.0 0.7–5.6 3–5 1.3 0.7–2.6 1.8 0.9–3.5 0.8 0.4–1.6 6–10 1.0 0.5–1.9 2.8* 1.4–5.4* 0.7 0.3–1.4 11–13 1.0 0.5–2.0 1.8 0.9–3.5 0.4* 0.2–0.8* 14–17 0.8 0.4–1.6 2.1* 1.1–4.1* 0.5* 0.2–0.9* Household income (versus <$25 000/y) $25 000–$49 999 0.7 0.5–1.1 0.9 0.6–1.4 0.4* 0.3–0.7* $50 000–$99 999 1.1 0.8–1.7 1.0 0.7–1.5 0.6* 0.4–1.0* $100 000–$149 999 1.2 0.8–1.9 0.9 0.5–1.5 0.6 0.3–1.1 >$150 000 1.3 0.7–2.3 0.6* 0.3–1.0* 0.4* 0.2–0.7* Geographic location (versus Midwest) West 0.9 0.7–1.4 1.3 0.9–1.9 1.8* 1.1–2.9* South 1.1 0.8–1.5 0.8 0.6–1.2 0.9 0.6–1.4 Northeast 1.8* 1.1–2.7* 0.9 0.6–1.3 1.2 0.7–2.0 One or more physician-diagnosed FA 4.3* 3.2–5.8* 1.8* 1.3–2.4* 1.4 0.9–2.0 Multiple FA versus 1 FA 0.8 0.6–1.2 1.5* 1.1–2.0* 1.5* 1.0–2.1* Has epinephrine — — 1.5* 1.2–2.0* 1.4 1.0–2.0 One or more lifetime ED visit 1.6* 1.2–2.0* — — — — One or more severe FA 2.1* 1.6–2.7* 1.9* 1.4–2.4* 1.0 0.8–1.4 Specific FAs (versus absence of that allergy) Peanut 3.9* 2.9–5.2* 0.9 0.7–1.3 1.0 0.8–1.4 Tree nut 1.6 0.9–2.9 0.5* 0.3–0.9* 1.2 0.7–2.2 Almond 1.0 0.5–1.8 1.6 1.0–2.7 1.0 0.5–1.7 Walnut 1.4 0.7–2.7 0.9 0.5–1.5 0.7 0.4–1.2 Cashew 1.3 0.7–2.5 1.1 0.6–1.9 1.2 0.7–2.2 Hazelnut 0.7 0.3–1.4 1.2 0.7–2.2 1.2 0.7–2.3 Pistachio 2.5* 1.3–5.0* 0.9 0.5–1.7 0.6 0.3–1.2 Pecan 0.8 0.4–1.5 1.0 0.5–1.8 1.0 0.5–2.0 Other tree nut 1.3 0.3–6.8 0.6 0.1–2.8 0.9 0.1–8.9 Sesame 1.4 0.6–3.2 1.3 0.7–2.3 1.5 0.8–2.9 Milk 0.5* 0.3–0.6* 1.6* 1.1–2.3* 1.7* 1.1–2.6* Egg 1.3 0.8–2.1 1.2 0.8–1.8 1.7* 1.0–2.6* Finfish 0.8 0.4–1.4 2.2* 1.3–3.6* 2.2* 1.3–3.7* Shellfish 1.1 0.4–3.4 1.2 0.6–2.3 0.5 0.3–1.1 Shrimp 1.4 0.5–4.1 0.7 0.4–1.3 2.0 1.0–4.0 Lobster 0.7 0.3–1.6 0.9 0.5–1.6 0.5 0.3–1.1 Crab 1.7 0.6–4.9 1.5 0.8–2.9 2.1 1.0–4.4 Mollusk 0.4 0.2–1.0 1.4 0.8–2.4 1.2 0.6–2.3 Other shellfish 0.9 0.2–3.9 0.3* 0.1–1.0* 0.4 0.1–2.0 Soy 0.7 0.4–1.1 1.2 0.7–2.0 1.6 0.9–2.8 Wheat 0.7 0.4–1.2 0.8 0.4–1.6 0.7 0.4–1.2 Physician-diagnosed comorbidities (versus absence of that condition) Asthma 1.2 0.9–1.6 2.1* 1.6–2.7* 1.8* 1.3–2.5* Atopic dermatitis and/or eczema 1.4 1.0–2.0 0.6* 0.4–0.9* 0.8 0.5–1.2 Eosinophilic esophagitis 3.1 1.0–10.0 2.5 0.8–7.3 3.6* 1.1–11.1* Allergic rhinitis 0.9 0.7–1.2 0.9 0.7–1.2 0.8 0.6–1.1 Insect sting allergy 1.6 0.9–2.8 1.6* 1.0–2.4* 0.8 0.5–1.2 Latex allergy 2.6* 1.5–4.6* 0.9 0.5–1.6 1.2 0.8–2.0 Medication allergy 1.8* 1.2–2.7* 1.0 0.7–1.6 0.7 0.5–1.1 Urticaria and/or chronic hives 0.6 0.2–2.0 2.5* 1.2–5.5* 2.5* 1.1–6.0*

Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 GUPTA et al TABLE 5 Continued Current Epinephrine Lifetime ED Visits Last Year ED Visits Prescription OR 95% CI OR 95% CI OR 95% CI Other chronic condition 1.6* 1.0–2.6* 0.8 0.5–1.3 0.4* 0.2–0.8* —, not applicable. * Two-sided P < .05

Because the prevalence and before exclusion of nonconvincing of children with milk allergy. All severity of sesame allergy appears symptoms) was 11.4%. This allergens can cause severe, potentially comparable to allergens for which discrepancy underscores the life-threatening reactions, so all FA labeling is currently mandated, importance of improving patient patients require counseling on proper these findings suggest that including access to physicians trained in the anaphylaxis management. Low EAI sesame under allergen labeling accurate diagnosis of FA to prevent prescription29 rates have been reported laws in the United States may be placing families under the social, previously. Additionally, previous warranted, as is already the case emotional, and economic burden research suggests that even with in Canada, the European11 Union, of unnecessarily avoiding foods to a current prescription, families of Australia, and Israel. which they are not truly allergic. children with FAs frequently fail to Reactions to food may actually be fill and refill EAI prescriptions as Although the current 7.6% FA 30,31​ intolerances or OAS, which are recommended. ‍ The low rate of prevalence estimate is similar to difficult for parents to decipher on epinephrine prescriptions observed the 8.0% estimate published by their own. Additionally, positive in our study suggests that efforts to our group in 2011, it is important test results without a reaction improve physician evaluation and/or to note that the current study “ ” history may mislabel children as diagnosis of an FA and appropriate used more stringent criteria to having an FA when they may be prescription of EAIs may be warranted. define convincing allergies, thus able to tolerate the food. Indeed, 6 precluding direct comparison of As in our 2011 prevalence study just over two-thirds of children the estimates. The updated criteria and previous analysis of NHANES with convincing FA in our study had 32 (most notably the exclusion of data non-Hispanic African American received a physician diagnosis of FA. children reporting only nonsystemic, children were more likely to have an Among convincing allergies, peanut oropharyngeal reaction symptoms FA than non-Hispanic white children. had the highest rates of physician and those whose symptoms were African American children were also diagnosis (81%), whereas soy had limited to the gastrointestinal system, more likely to have multiple FAs than the lowest rates (41%). As evident even in cases of physician-diagnosed children of other racial and/or ethnic in Fig 3, the proportion of children FA) reflect recent advances in groups with FA. These findings suggest experiencing severe reactions as understanding of the key differential that the racial disparities observed in well as the proportion parent- diagnoses of OAS and specific food other atopic conditions (eg, asthma) 25 reported FAs that were classified as 32,33​ intolerances, respectively. If we may also exist in the context of FAs. ‍ convincing or physician-confirmed applied 2011 criteria for a convincing It is noteworthy that this observed also varied substantially by allergen. FA to the present data, estimated difference in FA prevalence between Additionally, these data suggest that current FA prevalence would be non-Hispanic African American and >40% of children with FAs in the higher. However, even if identical white children persisted even after United States have been treated in criteria were used at both waves, accounting for atopic comorbidities the ED for their FA, with just under temporal trends in FA prevalence and other covariates, including 20% reporting an FA-related ED are almost certainly influenced by household income. Consequently, visit within the past year. These growing FA awareness and diagnosis additional research is necessary to 26 data are consistent with recent among both patients and clinicians. better understand the etiology of reports suggesting that ED admission Such increased awareness may these racial differences, particularly rates for anaphylaxis are rising, contribute to higher observed rates 12,27,​ 28​ in the context of FA. particularly among children. ‍ ‍ of both convincing and physician- Finally, peanut allergy prevalence diagnosed allergy. ∼ Approximately 40% of children in our study was 2.2%, slightly Although these findings suggest with an FA in the current study higher than the 2.0% estimated ∼ that 8% of US children have an reported current EAI prescriptions, by our group in 2011, the 2.0% 34 FA, the estimated prevalence of ranging from 70% of children with estimated by Bunyavanich et al current FA (parent-reported rate peanut and tree nut allergies to 26% in 2014 among a northeastern US Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 6, December 2018 9 FIGURE 3 Comparing rates of parent-reported versus convincing versus physician-confirmed FAs.

’ cohort,20 and higher than Sicherer for FA diagnosis, such methods issue resulting in relatively high et al s national estimate of 1.4% were not employed in the current rates of severe allergic reactions and in 2008. Although our data suggest study because of their expense, ED use. Previous findings of racial that the burden of childhood peanut impracticality, and concerns about differences in FA prevalence were allergy has increased over the past nonparticipation20 bias. As in past also supported here with elevated decade, the authors of a recent study work to strengthen the rigor of rates identified among non-Hispanic demonstrated that introducing our parent-reported questionnaire, African American children. Overall, peanut-containing foods alongside stringent criteria were established these findings provide critical typical complementary foods between in collaboration with an expert panel epidemiologic information that 4 and 11 months can achieve relative to exclude FAs where corresponding improves understanding of the public – reductions13 in peanut allergy risk of symptom report was not consistent health impact of childhood FA. up to 80% among high-risk infants. with immunoglobulin E mediated ACKNOWLEDGMENTS – Consequently, the National Institute FA. Nevertheless, by relying “ of Allergy and Infectious Diseases exclusively on parent-report and sponsored 2017 Addendum not directly observing symptoms ” We thank Michael Dennis, PhD, and Guidelines for the Prevention of immediately after allergenic food Nada Ganesh, PhD, of NORC at the Peanut Allergy were released, which protein consumption, misestimation University of Chicago; Ozge Nur guide clinicians in promoting early of true FA prevalence and Aktas, MD, Lauren Kao, MA, and the peanut introduction for primary symptomatology remains possible. “ 35 ” members of our expert panel. peanut allergy prevention. Therefore, However, it is important to recognize ABBREVIATIONS if the Prevention of Peanut Allergy the use of survey-based approaches guidelines are broadly implemented, given their ability to capture patients the age-specific peanut allergy with FAs who may not receive formal CI: confidence interval prevalence estimates reported in this evaluations or diagnoses. EAI: epinephrine autoinjector study may provide important baseline ED: emergency department CONCLUSIONS reference points for future work. FA: food allergy OAS: oral allergy syndrome Although double-blinded placebo- “ ” OR: odds ratio controlled oral food challenges These data suggest that childhood SSI: Survey Sampling International remain the current gold standard FA is a significant public health Downloaded from www.aappublications.org/news by guest on September 24, 2021 10 GUPTA et al DOI: https://​doi.​org/​10.​1542/​peds.​2018-​1235 Accepted for publication Sep 18, 2018 Address correspondence to Ruchi S. Gupta, MD, MPH, Center for Community Health, Northwestern Feinberg School of Medicine, 750 N Lake Shore Dr, Suite 680, Chicago, IL 60611. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded by the National Institute of Allergy and Infectious Disease (R21AI135702 [Principal Investigator: Dr Gupta]), Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Aimmune Therapeutics, and Denise and Dave Bunning. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 12 GUPTA et al The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States Ruchi S. Gupta, Christopher M. Warren, Bridget M. Smith, Jesse A. Blumenstock, Jialing Jiang, Matthew M. Davis and Kari C. Nadeau Pediatrics 2018;142; DOI: 10.1542/peds.2018-1235 originally published online November 19, 2018;

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States Ruchi S. Gupta, Christopher M. Warren, Bridget M. Smith, Jesse A. Blumenstock, Jialing Jiang, Matthew M. Davis and Kari C. Nadeau Pediatrics 2018;142; DOI: 10.1542/peds.2018-1235 originally published online November 19, 2018;

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