In the largest, most comprehensive, nationwide study to examine the prevalence of allergies from early childhood to old age, scientists from the National Institutes of Health (NIH) report that allergy prevalence is the same across different regions of the United States, except in children 5 years old and younger.
“Before this study, if you would have asked 10 allergy specialists if allergy prevalence varied depending on where people live, all 10 of them would have said yes, because allergen exposures tend to be more common in certain regions of the US,” said Darryl Zeldin, MD, scientific director of the National Institute of Environmental Health Sciences (NIEHS), part of NIH. “This study suggests that people prone to developing allergies are going to develop an allergy to whatever is in their environment. It’s what people become allergic to that differs.”
The research appeared online in February in the Journal of Allergy and Clinical Immunology and is the result of analyses performed on blood serum data compiled from approximately 10,000 Americans in the National Health and Nutrition Examination Survey (NHANES) 2005-2006.
Although the study found that the overall prevalence of allergies did not differ between regions, researchers discovered that one group of participants did exhibit a regional response to allergens. Among children aged 1 to 5 years old, those from the southern US displayed a higher prevalence of allergies than their peers living in other US regions. These southern states included Texas, Oklahoma, Louisiana, Arkansas, Tennessee, Kentucky, Mississippi, Alabama, Georgia, West Virginia, Virginia, North Carolina, South Carolina, and Florida.
“The higher allergy prevalence among the youngest children in southern states seemed to be attributable to dust mites and cockroaches,” explained Paivi Salo, PhD, an epidemiologist in Zeldin’s research group and lead author on the paper. “As children get older, both indoor and outdoor allergies become more common, and the difference in the overall prevalence of allergies fades away.”
The NHANES 2005-2006 not only tested a greater number of allergens across a wider age range than prior NHANES studies, but also provided quantitative information on the extent of allergic sensitization. The survey analyzed serum for nine different antibodies in children aged 1 to 5 years, and nineteen different antibodies in subjects 6 years and older. Previous NHANES studies used skin prick tests to test for allergies.
The scientists determined risk factors that made a person more likely to be allergic. The study found that in the 6 years and older group, males, non-Hispanic blacks, and those who avoided pets had an increased chance of having allergen-specific IgE antibodies, the common hallmark of allergies.
Socioeconomic status (SES) did not predict allergies, but people in higher SES groups were more commonly allergic to dogs and cats, whereas those in lower SES groups were more commonly allergic to shrimp and cockroaches.
By generating a more complete picture of US allergen sensitivity, the team uncovered regional differences in the prevalence of specific types of allergies. Sensitization to indoor allergens was more prevalent in the South, while sensitivity to outdoor allergens was more common in the West. Food allergies among those 6 years and older were also highest in the South.
The researchers anticipate using more NHANES 2005-2006 data to examine questions allergists have been asking for decades. For example, using dust samples obtained from subjects’ homes, the group plans to examine the link between allergen exposure and disease outcomes in a large representative sample of the US population.
NIEHS supports research to understand the effects of the environment on human health. For more information on environmental health topics, visit www.niehs.nih.gov.
Minority children have higher rates of food allergy than their white counterparts, yet they’re less likely to receive the treatment they need to manage their condition and avoid potentially life-threatening allergic reactions. Nurses can play a key role in serving up interventions that will help take food allergy disparities off the menu.
“Food allergy doesn’t discriminate,” proclaims a poster from the national nonprofit organization FARE (Food Allergy Research and Education). But even though allergies to foods such as peanuts, milk, fish, eggs, wheat, soy, shellfish, and tree nuts affect some 15 million Americans of all ages, races, and ethnicities, a growing body of scientific evidence shows that food allergy does affect some populations disproportionately—and children of color are at particularly high risk.
According to a recent study published in the Journal of Allergy and Clinical Immunology, minority children and children from low-income families are more likely to have undiagnosed and untreated food allergies than their majority and/or more affluent peers.1
“What’s interesting about food allergy is that we tend to see it more in mid- to high-income Caucasian kids,” says the study’s lead author, Ruchi Gupta, MD, MPH, associate professor of pediatrics at Northwestern University’s Feinberg School of Medicine in Chicago. “So one big question I had was: Is food allergy really less prevalent in minority and low-income kids or are we just not diagnosing it in them?”
Other recent studies reveal similarly troubling findings:
Black and Asian children have significantly higher odds of having a food allergy than Caucasian youngsters.2
Between 1997 and 2007, Hispanic children had the greatest increase in parent-reported food allergies, compared with kids from other ethnic groups.3
Black children are twice as likely as white children to have peanut and milk allergies and four times as likely to be allergic to shellfish. Unlike some other food allergies, which children tend to outgrow, shellfish and peanut allergies are more likely to continue into adulthood, creating a lifelong risk.3-4
FARE calls food allergy “a growing public health concern” that currently affects one in 13 children and adolescents in the United States. Symptoms of an allergic reaction to food may include itching, coughing, sneezing, swelling of the mouth and throat, vomiting, stomach cramps, skin rash, diarrhea, trouble breathing, and loss of consciousness. The severity of reactions can range from mild to life-threatening. In its most dangerous form, a food allergy attack can result in anaphylaxis, a rapid-onset whole-body reaction that can be fatal if the child is not immediately treated with the drug epinephrine.
Why the Disparities?
If food allergies are more common in racial and ethnic minority children, why do these kids have a lower chance of being diagnosed? Is it simply because there’s a need for more awareness about these allergies in communities of color? Or are the usual socioeconomic suspects that so often contribute to health disparities—such as cultural and linguistic barriers, limited financial resources, and unequal access to quality medical care—also a factor?
“It could be a little of both,” says Gupta, who is also a pediatrician at Ann & Robert H. Lurie Children’s Hospital of Chicago. “If the family doesn’t have access to a primary care provider, they may take it into their own hands and just try to make sure their child avoids the food. But there are also many parents who just don’t discuss their child’s food allergy with their clinician, because they’re unaware that there is any kind of treatment or plan that would help the child.”
Cynthia Samuel, RN, MS, PhD-C, a school nurse at Grove Street Elementary School in Irvington, New Jersey, believes one of the biggest culprits is “just not being educated about food allergies—not knowing what signs to look for and what to do should symptoms occur. In some instances, the family may think the child will outgrow the allergy, so they don’t do anything until it becomes more complex to treat or so severe that they have no other option but to take the child to the emergency room.”
Still, another reason for the underdiagnosis is that health care professionals don’t always know what to look for either, says Karen Rance, DNP, RN, CPNP, AE-C, a pediatric nurse practitioner at Allergy, Asthma, & Clinical Immunology Associates in Indianapolis. “Overall, there’s room for improvement in helping health care providers recognize the symptoms of food allergy,” she explains. “There are so many moving parts with that diagnosis that often the symptoms can be very subtle.”
What Nurses Can Do
Nurses—including pediatric nurses, allergy nurses, school nurses, camp nurses, public health nurses, and nurse practitioners—can make a tremendous difference in helping to level the playing field for minority children with food allergies. Because nurses are the professionals who are most often responsible for health teaching, says Gupta, they can play a crucial part in educating patients, families, caregivers, and even entire communities about everything from understanding the risks to handling anaphylaxis emergencies.
“It’s critical that parents and kids get educated about things like how to choose safe foods and how to read food [ingredient] labels in stores,” she emphasizes. “Nurses also need to make sure families know that food allergy is serious and that it will have a major impact on their lives.”
But before they can teach others, nurses must become knowledgeable about this health issue themselves. “We need to encourage nurses and nurse practitioners, especially those who care for children at high risk for food allergies, to seek [those] educational opportunities,” says Rance. Fortunately, there’s no shortage of information available to bring you up to speed, from NIH clinical guidelines and professional association websites (see “Resources” sidebar) to books like The Health Professional’s Guide to Food Allergies and Intolerances, published by the Academy of Nutrition and Dietetics.
Kids and families must also learn how to administer the epinephrine that could potentially save the child’s life if he or she were to have a severe reaction, Gupta continues. “Nurses should all know how to use an epinephrine auto-injector, and they should have a practice device available to teach with,” she says. “You can show [parents] a video demonstration, but that’s not going to help in an emergency situation. Unless they have practiced holding the auto-injector, popping the top off, and sticking [the needle] in, they’re not going to feel comfortable trying to inject their child.”
For community education, nurses can tap into national outreach programs such as Food Allergy Awareness Week (sponsored by FARE) and Anaphylaxis Community Experts (ACEs). The award-winning ACEs program, developed by Allergy & Asthma Network Mothers of Asthmatics in partnership with the American College of Allergy, Asthma & Immunology, sends teams of health professionals into communities to increase awareness of anaphylaxis and conduct free seminars on treating and preventing anaphylaxis episodes.
At South Bay Allergy & Asthma Associates in Torrance, California, staff nurses Ruena Mantes, BSN, RN, PHN, Lisa Lin, BSN, RN, and Anna Chocholek, BSN, RN, PHN, are actively involved in their local ACE team. They host workshops for parents, schools, employees of area businesses, and other community groups about how to recognize and respond to food allergy emergencies. This past summer, the nurses visited a nearby preschool where they trained 20 teachers to use epinephrine auto-injectors.
The School Nurse’s Role
In its most recent position statement on allergy and anaphylaxis management in the school setting, the National Association of School Nurses states that “the registered professional school nurse [must be] the leader in a comprehensive approach [that] includes planning and coordination of care, educating staff, providing a safe environment, and ensuring prompt emergency response should exposure to a life-threatening allergen occur.”
Gupta couldn’t agree more. “School nurses are going to become more and more critical in caring for children with food allergies,” she says. “The students are in school all day and food is a part of everything they do. Between breakfast, lunch, snacks, holiday treats, etc., there’s a ton of exposure to foods at school.”
Samuel points out that in economically disadvantaged communities of color, school nurses can play a unique role in closing the gap of food allergy disparities by serving as an entry point into the health care system. “Many of these families don’t have the time, money, or transportation resources to easily reach doctors,” she explains. “By having the school nurse there, at least the student and the family have someone they can turn to who understands them and is familiar with their cultural background.”
If a student with an undiagnosed food allergy suddenly has an allergic reaction at school, “the school nurse can bring the family in and use that as a teachable moment for initiating a health care plan for that child,” Samuel says. “And in the case of a severe reaction, the school nurse may be able to administer emergency epinephrine or at least call an ambulance to get the child to an emergency room.”
Providing referrals for allergy testing is another way school nurses can make it easier for minority students to get the diagnosis and treatment they need. “I had a case involving a student who would eat lunch at school and get a stomachache every day,” says Beverly Horne, RN, BSN, MPH, a lead school nurse for Chicago Public Schools’ South Cluster magnet schools. “I was able to contact the girl’s mother to find out if this was also happening at home. I referred the student to a pediatrician who did the workup on her and found that she was having [allergy] problems with some of the foods that were being served at school.”
In addition, school nurses can take the lead in helping their institutions develop food allergy policies and action plans.
“One of the things I did at my school was that I color-coded the lunch cards for all of the kids with food allergies,” says Samuel. “A green smiley face indicates an allergy to milk and dairy products; a yellow smiley face means ‘allergic to peanuts,’ and so on. When the student gives his or her card to the lunch aides, they know right away that this is what this child is allergic to. I also faxed this information to the food service company that supplies our school. We implemented this safety measure in 2011 and it’s had an extremely high success rate.”
Food Allergy Advocacy
One of the most empowering contributions nurses and nurse practitioners can make to the fight against food allergy disparities is helping minority and low-income families find resources and support systems. For instance, families who live in impoverished, food desert communities may have difficulty locating and affording allergen-free or low-allergen foods, which are often expensive.
“We just did a study on the economics of food allergy,” reports Gupta, who is the author of the book The Food Allergy Experience (www.foodallergyexperience.com), a guide for families, caregivers, and teachers of food-allergic kids. “It found that ‘special foods for your child’ was one of the biggest out-of-pocket costs for these families.”
Nurses can bridge this gap by letting families know that financial assistance options are available. “For those parents who are on a limited income and yet their child presents with a challenging and complex food allergy diagnosis, [I] will refer them to the children’s hospital in our area, which has a nutrition department,” says Rance. “The parents’ Medicaid insurance will pay for a nutrition consult.”
She also informs her patients who have access to the federally funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)—which serves low-income mothers and children up to age five who are at nutritional risk—that WIC will cover the cost of certain specialty foods, such as soy-based milk and amino acid-based infant formulas for children who are allergic to milk products.
Nurses can also be advocates by urging their federal, state, and local lawmakers to support legislation that could provide greater protection for all children with food allergies. One example is the federal School Access to Emergency Epinephrine Act (S. 1884/H.R. 3627), which was introduced into Congress in late 2011. If passed, this legislation would give states incentives to adopt laws allowing schools to maintain a supply of stock epinephrine auto-injectors that could be administered to any student in the event of an anaphylaxis emergency. For more information, visit www.foodallergy.org/page/school-access-to-emergency-epinephrine-act1.
In underfunded school districts that have cut back on staff to reduce costs, nurses must work together to make the case that hiring a full-time nurse at every school is not a luxury but a lifesaving necessity, says Samuel.
“If a district has only one or two school nurses, those nurses need to come together and get on the same page,” she stresses. “They have to pool their documentation so they can say, ‘On a given day, I see this many kids with food allergy problems,’ or ‘I had four occurrences this month in which students had an allergic reaction or went into anaphylactic shock.’ [Then they can] pull all this data together and come up with a report [that summarizes the need]. You really have to present the evidence, because that’s what’s going to support the potential hiring of another school nurse. If people don’t recognize food allergy as a problem or a challenge, it’s not going to be treated as such.”
Gupta RS, Springston EE, Smith B, Pongracic J, Holl JL, Warrier MR. Parent report of physician diagnosis in pediatric food allergy. J Allergy Clin Immunol. 2013 Jan;131(1):150-6.
Gupta RS, Springston EE, Warrier MR, et al. The Prevalence, Severity, and Distribution of Childhood Food Allergy in the United States. Pediatrics. 2011;128(1):e9-e17.
Liu AH, Jaramillo R, Sicherer SH, et al. National Prevalence and Risk Factors for Food Allergy and Relationship to Asthma: Results from the National Health and Nutrition Examination Survey 2005-2006. J Allergy Clin Immunol. 2010 Oct;126(4):798-806.e14.
Food Allergy & Anaphylaxis Network. Food Allergy Facts and Statistics for the U.S. http://www.foodallergy.org/page/facts-and-stats. Accessed October 29, 2012.
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