Cultural differences, racial inequities may create barriers to food allergen introduction
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Racial differences in when parents introduce their children to potential allergens may influence the development and manifestations of food allergies, according to a study in The Journal of Allergy and Clinical Immunology: In Practice.
Christopher M. Warren, PhD, assistant professor of preventive medicine and director of population health research at the Center for Food Allergy & Asthma Research, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues conducted the multisite Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD) cohort study, which included Black and white children aged 12 years and younger who had allergist-diagnosed IgE-mediated peanut, milk and egg allergies.
“We initiated the FORWARD cohort study after observing substantial racial/ethnic differences in food allergy prevalence and outcomes between non-Hispanic Black and white children in the U.S.,” Warren told Healio.
After a review of the literature and ongoing studies, Warren and colleagues realized there was a need to better understand the natural history of food allergy among patients from racial, ethnic and socioeconomic groups that are most affected.
“At the same time, evidence was growing that indicated that earlier dietary introduction of allergenic foods like peanut, egg and cow’s milk during the first year of life was associated with decreased risk for developing food allergies,” Warren said.
The researchers were then interested in seeing the extent to which there were differences in the reported introduction of these foods in their large sample of Black and white children with food allergy because they thought different infant feeding patterns could play a role in the racial and ethnic disparities in food allergy prevalence.
“At the same time, an influential clinical trial in the U.K., the EAT study, reported that white parents were more likely to adhere to early food allergen introduction protocols than non-white parents and that this may have contributed to the higher rates of food allergy observed among non-white children in their study, so we were interested in seeing to what extent their observations were generalizable to the U.S. context,” Warren said.
FORWARD findings
The FORWARD cohort included 234 Black and 398 white children (mean age, 6 years; standard deviation, 3.7 years). The most common allergy was peanut (65.3%), with similar occurrence by race (Black, 65.4% vs. white, 65.3%). However, Black children were introduced to peanut, milk and egg later than white children.
White children were more likely to have been introduced to peanut (OR = 2.6; 95% CI, 1.1-7.2) and milk (OR = 2.7; 95% CI, 1.1-6.7) at age 6 months or younger compared with Black children, after adjusting for participant demographics and food allergy characteristics.
Also, delayed introduction after age 11 months was less likely among white children for peanut (OR = 0.3; 95% CI, 0.1-0.5) and milk (OR = 0.2; 95% CI, 0.1-0.6) compared with Black children.
“This was suspected, but we were nevertheless surprised by the magnitude of the differences,” Warren said.
Overall, nearly 89% of Black children with peanut allergy were not introduced to peanuts by age 1 year or were never introduced to peanuts, compared with 67% of white children with peanut allergy.
The researchers did not find any statistical difference in early or delayed introduction to egg between the two groups.
“What is important to note in these data is that all children in the sample had food allergies, so clearly simply introducing allergenic solids at 6 months of age or less does not guarantee protection against allergy, although it is arguably the most important preventive approach that has been studied to date,” Warren said. “It is likely that the format, frequency and dose also play an important role, but much remains unknown in this realm.”
Study implications
Calling their study the first to explore racial differences in common feeding practices involving food allergens during infancy, the researchers said these differences may relate to the growing burden of food allergies among Black children.
However, they noted that it was unclear whether parents delayed introduction of allergens due to pediatric clinician recommendations, parental fears, cultural practices or high allergic sensitization to peanut. Also, the researchers acknowledged that differences in knowledge about the safety and effectiveness of early allergen introduction for prevention may vary among parents and caregivers.
According to the researchers, the study underscores the need to better characterize racial and cultural differences by examining barriers and facilitators in the early introduction of food allergens. This knowledge may then inform culturally specific strategies to educate families about the benefits of early introduction.
“It is crucial that clinicians educate themselves about the 2017 [National Institute of Allergy and Infectious Disease]-sponsored Addendum Guidelines for the Primary Prevention of Peanut Allergy and follow their recommendation to promote early introduction of peanut protein into the diet of high-risk infants in a timely, culturally sensitive manner,” Warren said.
Warren also noted that there is good evidence that delaying the introduction of any allergenic solid, not just peanut, is not advisable and that the early, regular introduction of allergenic solids is safe and likely to be an important way to reduce food allergy incidence at the population level.
“Given the public health burden of food allergies, it is crucial that clinicians stay abreast of the latest high-quality data regarding food allergy prevention and ensure it is translated rapidly and equitably to the most affected populations,” Warren said.
The researchers are working with a large and growing network of collaborators to better understand the optimal timing, frequency and dose of allergenic solids for effective food allergy prevention early in life and translate those findings into updated infant feeding guidelines.
“We are also committed to testing and disseminating interventions that aim to reduce disparities in the public health burden of food allergy at the population level,” Warren said.
Additionally, the researchers are expanding recruitment of their FORWARD cohort to include additional populations that are disproportionately affected by food allergies, including a large sample of Latinx patients with food allergy and their caregivers.
“Through our team’s combination of observational and interventional studies we hope to simultaneously inform public policy and clinical guidelines to directly improve food allergy outcomes and advance health equity at the population level,” Warren said.
Perspective
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Irene J. Mikhail, MD
Brewer and colleagues set out to see if there are racial differences in the rates of early introduction of allergenic foods. The recommendation to introduce allergenic foods early in life, especially for at-risk infants, was first introduced in 2015 after a landmark study showed that peanut introduction prior to 11 months was protective in preventing the development of peanut allergy.
In the current study, the authors identified higher rates of delayed peanut introduction (defined as peanut introduction after 11 months of age) among Black children with food allergy compared with white children with food allergy. They also found higher rates of milk and peanut introduction prior to 6 months of age among white children compared with Black children. These findings are particularly troubling considering the fact that Black children have higher rates of food allergy than white children.
Although this present study doesn’t attempt to examine causality, the findings beg the question if the feeding differences identified may be contributing to the higher rates of food allergy among Black children. Before attempting to answer questions about the relevance of these important observations, there are some facets to understand about the data. Most significantly, it is important to understand that a higher percentage of the Black cohort was born before 2008. Because guidelines for early introduction were only released in 2017, it is difficult to know if the differences found in this study would be replicated in a contemporary sample.
Despite this limitation, this study brings to light very important topics for further consideration. Do race-specific barriers exist in implementing the guideline of early introduction? Are there differences in cultural feeding practices that may be contributing to increased rates of food allergy?
The old adage “an ounce of prevention is better than a pound of cure” should be the rallying cry in food allergy research. It can be difficult to wrap our minds around the fact that we can decrease the burden of food allergy simply by feeding babies food early, as it is rare to have such profound impact from a relatively simple intervention. Understanding and addressing the barriers to early introduction in a culturally relevant manner, while identifying and addressing any racial inequities in the adoption of new guidelines, is essential moving forward.
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