Eating, sleeping disorders associated with early childhood anaphylaxis
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Key takeaways:
- Mean time to diagnosis with a psychological disorder after food-induced anaphylaxis was 6.5 years.
- Feeding difficulties and loss of appetite appeared increased in patients with anaphylaxis.
Children who experienced food-induced anaphylaxis before age 3 years had greater odds for developing eating and sleeping disorders that could persist into adulthood, according to a study published in Pediatric Allergy and Immunology.
Allergists should therefore consider psychological workups for these children, Shay Nemet, MD, allergy and clinical immunology unit, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, and colleagues wrote.
The population-based, retrospective study examined data from a matched pediatric cohort of 545 children (39.6% girls) with food-induced anaphylaxis (FIA) and 4,514 (39% girls) controls treated by the Clalit health care organization between 2001 and 2021.
The researchers stratified data based on age, including 476 (87.3%) of those with FIA and 3,955 (87.6%) of controls aged younger than 3 years.
Mean follow-up times included 10.9 ± 5.4 years for the full cohort, 10.9 ± 5.4 years for the FIA group and 10.6 ± 5.5 years for the control group, with 54,910 patient-years of follow-up time in total.
Mean time to a diagnosis of a psychological disorder was 6.5 ± 5.3 years with a maximum of 17.8 years for the patients who were diagnosed with FIA before age 3 years.
Based on univariable analyses, there was a significant association (P < .001) between FIA and any psychological disorder for both age groups overall as well as for sleeping disorders (P < .001) and eating disorders (P = .035) specifically, the researchers said.
FIA before age 3 years also was associated with sleeping and eating disorders, but FIA after age 3 years was not, the researchers continued. Major food allergens among children with FIA before age 3 years included cow’s milk (54.2%), eggs (12.6%) and peanuts (4.2%).
There were no significant associations between anxiety, depression, post-traumatic stress disorder and other psychological disorders and FIA, the researchers added.
One (0.21%) child in the group with FIA before age 3 years and seven (0.18%) children in the control group developed anorexia nervosa, but the researchers did not consider this to be a significant difference.
Similarly, six (1.26%) children in the group with FIA before age 3 years and 17 (0.43%) children in the control group reported feeding difficulties. Fifteen (3.15%) in the group with FIA before age 3 years and 93 (2.35%) in the control group reported loss of appetite.
The researchers included the ICD-10 code for avoidant/restrictive food intake disorder as well, but they did not find any patients reporting it in their records.
Associations persisted with FIA in multivariable Cox regression models, including:
- any psychological disorder: adjusted HR = 1.515; 95% CI, 1.224-1.875;
- sleeping disorders: aHR = 2.01; 95% CI, 1.39-2.909; and
- eating disorders: aHR = 1.412; 95% CI, 1-1.995.
Kaplan-Meier curves indicated increased cumulative risks for developing any psychological disorders as well as sleeping and eating disorders over the follow-up time for children with FIA before age 3 years as well.
Strict and excessive food avoidance may drive the increased risk for eating disorders among children with FIA, the researchers suggested. Perhaps because of dietary restrictions, the researchers continued, these children experienced more loss of appetite and feeding difficulties, but there was no significant increase in anorexia nervosa.
The researchers cautioned, however, that their study may be underpowered to detect differences due to its small numbers in the composite outcome of eating disorders.
Further, the researchers said that primary caregivers may contribute to the development of psychological disorders in children with FIA as well.
Despite these significant associations, the researchers cautioned, these findings do not indicate a clear causative relationship. Large prospective studies should evaluate these issues, they continued.
Still, physicians should be aware of these associations, the researchers said, with greater attention on accurately diagnosing children with FIA and initiating psychological interventions.
Perspective
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Nemet and colleagues conducted a thoughtfully designed study to examine the potentially long-lasting psychological effects of early life food allergy. The literature on psychosocial functioning in pediatric food allergy has largely focused on anxiety and health-related quality of life, and I was pleased to see an expanded focus on psychological disorders more broadly.
It is encouraging to see that, at the population level, youth with food allergy were not at increased risk for many psychological disorders, including anxiety and depressive disorders. That being said, it is important to keep in mind that this study was conducted in Israel beginning in 2001 focused on disorders as opposed to subthreshold or condition-specific symptoms, and did not necessarily follow youth through adolescence, a period in which internalizing disorders are especially likely to develop.
I was particularly struck by the relationship between early life food allergy and subsequent eating disorder diagnosis. Food allergy management inherently requires a significant focus on food preparation and planning, along with diligent awareness (ie, reading food labels, only eating certain brands) and restriction (ie, certain food groups being “off limits,” dining out at only select establishments).
It is easy to imagine how youth with food allergy could be at increased risk for disordered eating, although this area has yet to receive much attention. In contrast, this relationship is well established in other diet-related pediatric medical conditions.
For example, a systematic review found that children and adolescents with diet-related chronic illness (type 1 diabetes, cystic fibrosis, celiac disease, gastrointestinal disorders and inflammatory bowel diseases) were more likely to meet criteria for disordered eating and eating disorders. Onset of diet-related chronic illness tended to precede the onset of disordered eating and eating disorders, and these relationships were especially salient in girls.
Growing food allergy research has shed light on avoidant/restrictive food intake disorder, which was not included in the current study due to lack of incidence. It is critical that future research comprehensively assess the development of disordered eating and eating disorders in youth with food allergy. The results of this study suggest that sleep should also be investigated further, although the mechanisms of this association are less intuitive. I am hopeful that Nemet and colleagues will continue both lines of this important research going forward.
Clinically, allergists can specifically ask patients about their eating and sleeping habits, in addition to more general mental health screening. Multidisciplinary care is ideal, as psychologists can develop and implement optimal screening, prevention and intervention efforts.
Reference s :
Conviser JH, et al. Int J Eat Disord. 2018;doi:10.1002/eat.22831.
Cushman GK, et al. J Allergy Clin Immunol. 2022;doi:10.1016/j.jaci.2022.09.024.
Patrawala MM, et al. J Allergy Clin Immunol Pract. 2021;doi:10.1016/j.jaip.2021.07.052.
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