Food-Allergic Adolescents at Risk for Anaphylaxis: A Randomized Controlled Study of Supervised Injection to Improve Comfort with Epinephrine Self-Injection.

BACKGROUND: Epinephrine self-injection is a key element in the management of food allergy, yet many adolescents report that they may not be able to use the autoinjector when needed. We hypothesized that supervised self-injection with an empty syringe would increase adolescents' comfort with self-injection. OBJECTIVE: The objective of this study was to examine the effect of supervised self-injection on self- and parent-reported comfort and anxiety during and after clinic visits in a food allergy center. METHODS: Sixty adolescent/parent pairs were randomized to self-injection versus control (education only). The predefined primary outcome was a self-reported comfort level with the injection before versus after the intervention on a Likert scale with scores of 1 (Not at all comfortable) to 10 (Extremely comfortable). The primary outcome was evaluated via within-group and between-group analyses. Secondary outcomes included adolescent and parent reports before versus after the injection, and changes in quality of life (QoL) and anxiety a month later. RESULTS: Self-injection was associated with a significant immediate increase in comfort levels (primary outcome; within-group comparison: mean scores: 6.93 preintervention vs 8.37 postintervention, P < .01; between-group ANOVA: 8.37 vs 6.69, P < .01) and with significant improvements in all other predefined (secondary) measures. On follow-up, QoL improved in 52% of intervention patients as compared with 25% of controls; similar differences were observed for anxiety. Those differences were not statistically significant. CONCLUSIONS: A self-injection (with an empty syringe) procedure in a clinic setting improves adolescents' and parents' comfort level with self-injecting. It may translate into substantial clinical benefits should self-injection be needed.

Mental Health Screening Outcomes in a Pediatric Specialty Care Setting.

OBJECTIVE: To evaluate whether a psychosocial screening program that included free and flexible access to mental health (MH) consultation resulted in increased rate of consultations. STUDY DESIGN: This is a post hoc review of a clinical screening program in a pediatric food allergy clinic in New York City. Screening was limited to 2 days per week, providing an opportunity to compare screened and nonscreened cohorts. Previous results from more than 1000 other families were analyzed to create the 1-page screening questionnaire. Participants were children with allergies and their parents who sought care at the clinic between March and September 2013. Parents were screened for distress and quality of life burden related to their child's allergy, and children were screened for anxiety, bullying, and quality of life. The predefined primary outcome was the percentage of families who received the free MH consultation after screening vs no-screening days in the allergy clinic. RESULTS: The 3143 encounters during the study period included 1171 on screening days and 1972 on no-screening days. Most (86%) eligible families completed the screen. Almost one-half (44%) met the initial screening thresholds. A total of 71 families (6.1% of screening days encounters) were referred to a MH consultation after a secondary review, but only 11 (1% of screening days encounters) scheduled a MH appointment. Eighteen families from the no-screening days came to a MH evaluation (1% of no-screening days encounters). CONCLUSION: Screening did not lead to enhanced MH follow-up. Resources may be better used on ensuring the availability of MH care rather than on screening in pediatric specialty clinics.

Allocation of food allergy responsibilities and its correlates for children and adolescents.

This study examined the degree to which children and adolescents with food allergy accept responsibility for their own care, and the extent to which greater self-management is associated with past history of a life-threatening allergic reaction or anxiety. For children (n = 190), caregiver and patient report of self-management was consistent, but agreement was poor for adolescent dyads (n = 59). History of a life-threatening allergic reaction was associated with greater self-management for children only, while among adolescents, it was associated with greater anxiety. Given that shifting to self-management may be challenging, discussion and preparation about this process is warranted.

The importance of mental health monitoring during transfer to adult care settings as examined among paediatric transplant recipients.

AIM: Although the transfer out of paediatrics is established as a dangerous time for transplant recipients, the reasons for this are not well understood. One possible explanation is that in general, young adulthood is a period of vulnerability to psychological distress, which could impact self-management. The purpose of the present study was to investigate whether psychological distress is associated with medication non-adherence after transfer. METHODS: Twenty paediatric liver transplant recipients (mean age = 22.42, standard deviation (SD) = 1.64) have been followed prospectively at our site for a year after they transferred from paediatrics. At their last visit in paediatrics, they completed the Symptom Checklist-90, a measure of psychological distress. Additionally, patients' medication adherence was tracked 1 year after transfer, using a validated measure, SDs of tacrolimus blood levels. RESULTS: Psychological distress and medication non-adherence after transfer were significantly correlated, r = 0.50, P = 0.04. Furthermore, there was a significant interaction between adherence status and changes in mental health after transfer. CONCLUSION: Psychological distress may be one factor behind deteriorating medical outcomes when transplant recipients transfer out of paediatric settings. It is important to consider mental health screening as a part of the transition process. Further research is needed to determine if identified patients may require services in addition to transitional interventions.

Utilizing physician screening questions for detecting anxiety among food-allergic pediatric patients.

OBJECTIVE: To explore the utility of clinician screening for anxiety in pediatric food-allergic patients. STUDY DESIGN: In Phase I, 39 patients completed an anxiety questionnaire while their allergists completed a companion questionnaire estimating their patient's responses. Allergists then attended an educational workshop to improve their anxiety detection. In Phase II, following the workshop, questionnaires were completed by an additional 39 patients and their allergists. RESULTS: The percentage of clinician questionnaires with a "do not know" response decreased from 70% to 5% after the workshop. Correlation between allergists' and children's responses remained nonsignificant (r = .314, P = .321) before the workshop and after (r = .303, P = .068) and only 25% of patients who reported elevated anxiety were identified. Additionally, clinicians expressed poor acceptability of the screening. CONCLUSIONS: After the workshop, clinicians did not more accurately detect anxiety and found the process intrusive. Alternative methods for uncovering anxiety among high-risk patients are needed.

Child and parental reports of bullying in a consecutive sample of children with food allergy.

OBJECTIVE: The social vulnerability that is associated with food allergy (FA) might predispose children with FA to bullying and harassment. This study sought to quantify the extent, methods, and correlates of bullying in a cohort of food-allergic children. METHODS: Patient and parent (83.6% mothers) pairs were consecutively recruited during allergy clinic visits to independently answer questionnaires. Bullying due to FA or for any cause, quality of life (QoL), and distress in both the child and parent were evaluated via questionnaires. RESULTS: Of 251 families who completed the surveys, 45.4% of the children and 36.3% of their parents indicated that the child had been bullied or harassed for any reason, and 31.5% of the children and 24.7% of the parents reported bullying specifically due to FA, frequently including threats with foods, primarily by classmates. Bullying was significantly associated with decreased QoL and increased distress in parents and children, independent of the reported severity of the allergy. A greater frequency of bullying was related to poorer QoL. Parents knew about the child-reported bullying in only 52.1% of the cases. Parental knowledge of bullying was associated with better QoL and less distress in the bullied children. CONCLUSIONS: Bullying is common in food-allergic children. It is associated with lower QoL and distress in children and their parents. Half of the bullying cases remain unknown to parents. When parents are aware of the bullying, the child's QoL is better. It is important to proactively identify and address cases in this population.