Black children face disparities in food allergy reaction severity
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Key takeaways:
- Black children reported greater ED use and less total lifetime epinephrine use than white children.
- Gaps in patient and caregiver understanding of food allergy may drive these disparities.
Black children had higher odds for severe food allergy reactions and ED usage as well as lower total lifetime epinephrine use than white children, according to a study in The Journal of Allergy and Clinical Immunology: In Practice.
Providing patients with resources to better manage their allergies, however, may improve these outcomes, Ruchi Gupta, MD, MPH, director, Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, and colleagues wrote.
The researchers examined data from 784 children (61.7% boys) from the prospective, multi-site Food Allergy Outcomes Related to White and African American Racial Differences or FORWARD study.
The cohort included 425 (54.2%) children who were non-Hispanic white, 282 (36%) who were non-Hispanic Black and 77 (9.8%) who were Hispanic/Latino. Overall, participants had an average of 3.3 (standard deviation [SD] 1.8) distinct food allergies.
Ages at first reaction included 1.4 years (SD 1.) overall, 1.1 years (SD 1.4) for white children, 1.7 years (SD 2.1) for Black children and (SD 1.) for Hispanic/Latino children (P < .001). Numbers of reactions included 3.6 for Black children, 3.2 for white children and 2.9 for Hispanic/Latino children (P = .009).
Percentages of children who reported severe reactions included 40.1% of the Black group, 40.3% of the Hispanic/Latino group and 34.1% of the white group, but the researchers did not consider these unadjusted differences to be significant.
Similarly, 30.1% of Black children, 26% of Hispanic/Latino children and 36% of white children reported epinephrine use, but the researchers did not consider these unadjusted differences to be significant either.
A mixed-effects ordinal logistic model, however, found 70% increased odds for a one-level increase in reaction severity among Black children, although age at first reaction, sex, age at enrollment and enrollment site did not have any significant effect on reaction severity, the researchers said.
After controlling for reaction severity and epinephrine use, Black children also had significantly higher odds for going to the ED, with an odds ratio of 2.8 (95% CI, 1.4-5.4), compared with white children. Odds for visiting the E were similar for Hispanic and Latino children compared with white children, with an odds ratio of 1.3 (95% CI, 0.4-4).
There was an association between epinephrine use and increases in odds for visiting the ED (OR = 7.9; 95% CI, 4.1-15) as well as a strong association between reaction severity and increases in odds for visiting the ED for a given reaction (OR = 11.6; 95% CI, 7.3-18.4), the researchers continued.
Compared with white children, total lifetime epinephrine use figures were 60% smaller for Black children (incidence rate ratio [IRR] = 0.4; 95% CI, 0.3-0.5) and 70% smaller for Hispanic/Latino children (IRR = 0.3; 95% CI, 0.2-0.5).
There also was an association between increases in maximum reaction severity and a 40% increase in incidence of total lifetime epinephrine use (IRR = 1.4; 95% CI, 1.2-1.6).
With each 1-year increase in the age at first reaction, incidence of lifetime epinephrine use decreased by approximately 20% (IRR = 0.8; 95% CI, 0.7-0.9). Increases in total lifetime epinephrine use were associated with ED use for a food allergy reaction as well (IRR = 2; 95% CI, 1.6-2.5).
Overall, the researchers concluded that Black children had higher odds for reaction severity and ED use in addition to less total lifetime epinephrine use due to food allergy compared with white children.
This greater likelihood for ED use and reduced likelihood for epinephrine use when Black children have severe reactions may be driven by gaps in understanding how to manage food allergies and their reactions, the researchers said.
For example, patients who exhibit less risky behaviors in buying and eating potential allergens minimize their risks for reactions, the researchers said. Also, caregivers with more food allergy knowledge may be better equipped to recognize and treat reactions without visiting the ED.
Socioeconomic disparities also may drive these disparities, the researchers continued, with differences in lifetime epinephrine use compounded by lack of access to autoinjectors.
Further, the researchers said, children who experience first reactions later in life may be more likely to have the tools that they need to avoid risks that may lead to reactions that require epinephrine.
The researchers encouraged pediatricians to consider these findings when treating patients with food allergy of all backgrounds. Also, they called for additional research into the mechanisms of how racial and socioeconomic factors influence outcomes, which may inform treatment as well as policy efforts to reduce these disparities.
Perspective
Back to TopThese findings are significant and align with broader trends in food allergy disparities. The fact that socioeconomic status and racial disparities impact food allergy management and outcomes highlights a crucial public health concern.
These disparities, particularly in the context of life-threatening allergic reactions, underscore the urgency of addressing equity in food allergy. The new findings in this study that Black children were more likely to have severe reactions and lower epinephrine autoinjector (EAI) use adds a critical dimension to our understanding of these disparities.
As the vice president of health equity and community engagement with Food Allergy Research & Education, I have observed that socioeconomic status and the conditions where people work, live and play can negatively impact health outcomes. The research backs these observations, particularly regarding access to education, resources EAI, and specialized care allergists/immunologists.
The higher ED visit rates in impoverished counties and the disparities in fatal anaphylactic reactions among non-Hispanic Black populations are in line with the challenges we face in community engagement and health education initiatives as well.
Like studies previously conducted by this research team, we have seen that improved food allergy knowledge can help with label reading, better allergen avoidance, and understanding and reacting to potential anaphylaxis. Income, as I see daily, also impacts parts of the food allergy community unequally. Cost is most certainly a factor in lower epinephrine use.
Doctors should strive to provide culturally competent care, tailoring their approach to their patients’ unique socioeconomic and cultural backgrounds. In the long term, better representation of food allergy is critical.
Increasing patient and caregiver education about the importance of epinephrine, how and when to use it, and how to access it affordably is also imperative. Community health workers can help provide clear communication, resources and information in multiple languages.
Additionally, there is an urgent need for policies that make lifesaving treatments epinephrine more affordable and accessible, especially in Black and lower-income communities.
Implementing widespread education programs about food allergies and anaphylaxis in schools and community centers, particularly in areas with higher rates of food allergies, is essential.
Reimbursing for vital resources for community health workers, nutrition education and healthy allergen-safe foods also are paramount.
Lastly, more significant research and funding on health disparities strategies in food allergy management can help mitigate the widening disparity gap.
Perspective
Back to Top
Unfortunately, I am not very surprised by the findings from the study that show socioeconomic and racial disparities in how food allergies are managed, but I was surprised there were reported differences in the severity of allergic reactions across racial groups.
The most important take-home point from this study is the importance of education. As physicians, we need to use every opportunity we have to educate patients about recognizing and treating allergic reactions.
It is compelling that the patients who reported the most severe allergic reactions and the most visits to the ED had the least use of epinephrine. In my experience, some patients do have difficulties in accessing epinephrine for home use. It is also important for physicians to follow up with patients to see if there are barriers in receiving epinephrine autoinjectors.
On a policy level, we should be working toward improving access to health care and medication for all patients, especially patients from resource-poor environments.
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