Oral immunotherapy shows unclear impact on anxiety among children with peanut allergy
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Despite the potential for both allergic and nonallergic reactions, researchers did not find evidence for an association between levels of anxiety and oral immunotherapy treatment for peanut allergy in children, according to study results.
However, levels of anxiety increased with age regardless of OIT, Kelsey Kaman, MD, pediatric allergist and immunologist with Connecticut Asthma and Allergy, and colleagues wrote in the study, published in Annals of Allergy, Asthma & Immunology.
Baseline characteristics
The study comprised 114 patients (age < 7 years, n = 38; age 7 years, n = 76) on peanut OIT and 91 control patients (age < 7 years, n = 42; age 7 years, n = 49), all of whom had peanut allergy and a majority of whom were white and male.
Among patients on OIT, 74% of the younger cohort and 95% of the older cohort were on maintenance dosing, with the remaining patients in the build-up phase.
Among all patients in the younger cohort, 30% had asthma and more than 50% had eczema. A greater proportion of those in the OIT vs. control group had a history of anaphylaxis (21% vs. 7%).
Among all patients in the older cohort, more of those in the control group had asthma (63% vs. 42%; P = .02) and eczema (49% vs. 26%; P = .01), with comparable rates of prior anaphylaxis (22% vs. 26%) and diagnosed anxiety disorders (16% vs. 15%).
Approximately 56% of the caregivers in the control and OIT groups in the younger cohort said they had anxiety specifically related to their child’s allergy, as did 62% of the parents in the control group and 43% of those in the OIT group in the older cohort.
Anxiety scores
The researchers administered the Pediatric Anxiety Score (PAS) survey to the younger cohort, with scores more than one standard deviation above the mean indicating clinically significant anxiety. Mothers completed a majority of these (91%).
Overall, a comparable proportion of patients in the control and OIT groups had clinically significant anxiety scores (4.76% vs. 10.53%), with somewhat higher scores in the OIT group. After adjusting for age, these data indicated a small group difference (mean difference, 3.24; 95% CI, –2.46 to 8.94).
Mean PAS scores increased by 2.02 (95% CI, –0.09 to 4.13) for each year increase in age.
The older cohort completed the Screen for Childhood Anxiety Related Disorders (SCARED) survey, with scores of nine or higher indicating clinically significant generalized anxiety disorder. Mothers (50%) and the patients themselves (44%) completed a majority of these.
The control and OIT groups showed comparable rates of clinically significant anxiety (22.45% vs. 21.05%), with similar mean anxiety scores between groups.
Researchers observed higher mean SCARED scores among patients with vs. without asthma (mean difference, 4.42; 95% CI, 0.17-8.66) and among girls vs. boys (mean difference, 6.4; 95% CI, –0.09 to 4.13).
The researchers did not observe evidence indicating that OIT had any effect on separation anxiety, although patients aged 7 to 12 years had higher mean scores for separation anxiety than patients aged 12 years and older (mean difference, –2; 95% CI, –3.06 to –0.94) as did nonwhite patients (mean difference, 1.55; 95% CI, 0.001-3.1).
Separation anxiety also was impacted by the presence of asthma (mean difference, 1; 95% CI, –0.08 to 2.08) and eczema (mean difference, 1.38; 95% CI, 0.21-2.54).
The researchers also did not find enough evidence showing that OIT had an impact on social anxiety, although social anxiety was higher among nonwhite patients (mean difference, 1.9; 95% CI, 0.15-3.66) and patients with asthma (mean difference, 1.09; 95% CI, –0.16 to 2.34).
Conclusions
The researchers noted that anxiety may vary throughout childhood with increases around age 7 years, possibly due to cognitive development and to appreciation of the possibilities for serious allergic reactions.
Although female sex and the presence of asthma were potentially meaningful, the researchers wrote, they did not find sufficient evidence of an association between OIT and anxiety levels despite increases in anxiety with age.
These findings suggest that allergists should consider screening for anxiety and anxiety subtypes among those patients who are not white, girls and those who have asthma, potentially during discussions about OIT.
Perspective
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Kaman and colleagues sought to examine the relationship between peanut OIT treatment and anxiety among youth with food allergy. This study nicely follows Cushman and colleagues’ recent scoping review, which emphasized the importance of broadening our knowledge beyond quality-of-life measures to also include constructs such as anxiety.
To date, anxiety research in pediatric food allergy has largely focused on caregiver anxiety, yet understanding child anxiety is equally, if not more, important. Such an understanding is critical in the context of daily food allergy management, as well as when undergoing shared decision-making prior to treatment initiation.
In this study, there were no significant differences in anxiety scores between youth who were and were not undergoing OIT. These findings do not surprise me, as a doctoral candidate specializing in pediatric psychology.
Although OIT has been hypothesized to reduce anxiety, such effects may be specific to anxiety in the context of food allergies. In other words, should OIT contribute to reductions in pediatric anxiety, this may not be captured by general child anxiety measures.
For example, items on SCARED tap generalized anxiety, panic disorder, separation anxiety, social anxiety and school avoidance. Although this is a gold-standard measure of child anxiety, it does not reflect the unique psychosocial challenges of youth with food allergies.
It would be interesting to see if results were different if items were adapted to the context of food allergies. In this case, for instance, social anxiety may reflect a child’s fear of being judged for having different treats at a birthday party, telling peers or teachers about their food allergy or speaking with a manager or chef at a restaurant.
The recent development of the Child- and Parent-Rated Scales of Food Allergy Anxiety (SOFAA) provides an excellent step toward furthering our knowledge of food allergy anxiety. Whereas SOFAA primarily targets fear of having an allergic reaction, Kaman and colleagues articulate the importance of examining anxiety across domains. Thus, a logical next step may be expanding our conceptualization of food allergy-specific anxiety.
As Kaman and colleagues note, prospective longitudinal studies are needed to follow the trajectories of anxiety among youth who do and do not undergo OIT. Most of the OIT patients in this sample were on maintenance dosing. It would be interesting to examine anxiety throughout the build-up phase, as well as among those who do not drop out of treatment.
It would also be ideal to have both patient and caregiver reports of anxiety throughout the OIT process, as these data may inform shared decision-making among patients, caregivers and medical providers.
Furthermore, it is necessary that future studies of anxiety emphasize racial and ethnic diversity, especially given the increased prevalence and burden of food allergy among Black pediatric populations.
These results suggest that physicians should not expect OIT to render improvements in general child anxiety. Instead, elevated anxiety should be targeted through evidence-based psychological treatments such as cognitive behavioral therapy. As in the general population, female adolescent patients with food allergy may display elevated rates of anxiety.
Results also suggest that allergists should look out for anxiety among youth with comorbid asthma, complementing the existing literature on the heightened risk for anxiety disorders among patients with asthma. Given the bidirectional relationship between asthma and anxiety, this holds important implications for both physical health and psychological well-being.
References:
Cushman GK, et al. J Allergy Clin Immunol. 2022;doi:10.1016/j.jaci.2022.09.024.
Dahlsgaard KK, et al. Ann Allergy Asthma Immunol. 2022;doi:10.1016/j.anai.2022.09.021.
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