Food Allergy Knowledge, Attitudes, and Beliefs of Primary Care Physicians
Ruchi S. Gupta, MD, MPHa,b, Elizabeth E. Springston, BAa, Jennifer S. Kim, MDc, Bridget Smith, PhDb,d, Jacqueline A. Pongracic, MDc, Xiaobin Wang, MD, MPH, ScDa, Jane Holl, MD, MPHb
a Smith Child Health Research Program
c Division of Allergy and Immunology, Children’s Memorial Hospital, Chicago, Illinois
b Institute for Healthcare Studies, Northwestern Feinberg School of Medicine; Chicago, Illinois
d Center for Management of Complex Chronic Care, Edward Hines Jr VA Hospital, Hines, Illinois
OBJECTIVE: To provide insight into food allergy knowledge and perceptions among pediatricians and family physicians in the United States.
METHODS: A national sample of pediatricians and family physicians was recruited between April and July 2008 to complete the validated, Web-based Chicago Food Allergy Research Survey for Primary Care Physicians. Findings were analyzed to provide composite/itemized knowledge scores, describe attitudes and beliefs, and examine the effects of participant characteristics on response. RESULTS: The sample included 407 primary care physicians; 99% of the respondents reported providing care for food-allergic patients. Participants answered 61% of knowledge-based items correctly. Strengths and weaknesses were identified in each content domain evaluated by the survey. For example, 80% of physicians surveyed knew that the flu vaccine is unsafe for egg-allergic children, 90% recognized that the number of food-allergic children is increasing in the United States, and 80% were aware that there is no cure for food allergy. However, only 24% knew that oral food challenges may be used in the diagnosis of food allergy, 12% correctly rejected that chronic nasal problems are not symptom of food allergy, and 23% recognized that yogurts/cheeses from milk are unsafe for children with immunoglobulin E–mediated milk allergies. Fewer than 30% of the participants felt comfortable interpreting laboratory tests to diagnose food allergy or felt adequately prepared by their medical training to care for food-allergic children. CONCLUSIONS: Knowledge of food allergy among primary care physicians was fair. Opportunities for improvement exist, as acknowledged by participants’ own perceptions of their clinical abilities in the management of food allergy.
Key Words: food allergy • pediatricians • family physicians • anaphylaxis • diagnosis • treatment • knowledgeAbbreviations: CFARS-PHYS—Chicago Food Allergy Research Survey for Primary Care Physicians
Food allergy is a growing concern in the United States, affecting an estimated 4% to 6% of children.1,2 For these children, the standard of care is limited to avoidance of allergenic foods and prompt response after accidental ingestion.3 Management is further complicated by the unpredictable nature of the disease. Case studies have shown that food allergy may be fatal at a time and place that cannot be predicted and may occur despite perceived allergen avoidance, self-treatment, and medical attention.4 Although such anaphylactic occurrences are rare, food-induced anaphylaxis is the most common type of anaphylaxis in children5 and is responsible for an estimated 150 deaths annually in the United States.6
Given the uncertainty of predicting future risk for food-allergic children, prevention is of utmost importance. Accordingly, the primary care physician plays a critical role in the protection of food-allergic children. Pediatricians and family physicians are often the first and sometimes the only line of defense against childhood food allergy. They are frequently relied on by families for an initial diagnosis of food allergy, instruction in the management of food allergy, and evaluation of the allergy over time. At the very least, the primary care physician is expected to recognize the signs of food allergy to make an appropriate referral to an allergist.
Few data exist detailing food allergy knowledge and perceptions among primary care physicians. However, it has been suggested that uncertainty among families regarding their child’s food allergy is compounded by divergent medical opinions.7 Differing diagnostic approaches8,9 and perceived clinical manifestations of food allergy10 among providers have been documented. In addition, knowledge gaps regarding the identification and treatment of food-induced anaphylaxis have been reported.11,12 To date, research regarding knowledge and perceptions of food allergy among physicians has tended to focus on a specific aspect of the disease (eg, food-induced anaphylaxis) or has included primary care physicians only as a small subset of the total study sample. A comprehensive evaluation of food allergy knowledge, attitudes, and beliefs among pediatricians and family physicians in the United States is needed.
Given the growing burden of childhood food allergy among children and the significant role of the primary care physician in its diagnosis and treatment, we developed and administered the Chicago Food Allergy Research Survey for Pediatricians and Primary Care Physicians (CFARS-PHYS). The goal of this survey was to characterize food allergy knowledge, attitudes, and beliefs among primary care physicians and family physicians in the United States.
To our knowledge, this study is the first to provide a comprehensive review of food allergy knowledge and perceptions among primary care physicians in the United States. It should be noted that 99% of participants reported providing care for food-allergic patients. Respondents’ knowledge of food allergy was fair, with strengths and weaknesses identified in each content domain. Of particular interest, participants correctly answered a number of items pertaining to triggers/environmental risks, susceptibility/prevalence, and treatment/utilization of health care. However, significant knowledge gaps were also identified in areas relating to triggers/environmental risks, as well as on several items regarding the definition/ diagnosis and symptoms/severity of food allergy. Perceptions regarding food allergy were generally well distributed, although respondents consistently expressed concern regarding their ability to care for affected children.
Pediatricians and family physicians acknowledged that an increasing number of children are affected by food allergy. They also identified children 5 years old as the group most commonly affected by food allergy. To this end, a report recently released from the Centers for Disease Control and Prevention highlighted the growing commonality of perceived childhood food allergy and digestive disorders as well as an increase in the number of children discharged from the hospital with a diagnosis of food allergy or a related disorder.17 Epidemiological data indicate that food allergy is most common in the first 3 years of life and is less frequently observed in the years that follow.2
There was some confusion among participants regarding signs and symptoms suggestive of an underlying food allergy. Although the majority of respondents recognized hives and eczema as food allergy symptoms, many participants also associated chronic nasal problems with childhood food allergy. Symptoms of a food allergy reaction commonly involve localized hives and worsening eczema,18 with moderate-to-severe atopic dermatitis a frequent comorbid condition of food allergy.19 Although there is currently no evidence to suggest that chronic nasal congestion is a sign of food allergy, acute rhinitis may be a symptom of a food-induced allergic reaction.18 This distinction may cause confusion, explaining the frequency with which participants incorrectly selected chronic nasal problems as a sign of food allergy.
Previous research has suggested that varied approaches to the diagnosis of food allergy exist among primary care physicians.8 When making a diagnosis of food allergy, participants in our study tended to prefer food-specific immunoglobulin E levels and, to a lesser extent, skin-prick testing. Few respondents reported using oral food challenges as a diagnostic tool. Consistent with these findings, a study that included a small sample of nonallergists revealed that this group favored food-specific immunoglobulin E levels to diagnose food allergy more frequently than percutaneous skin testing.9 Nonallergists in this study were also much less likely than allergists to use oral food challenges to confirm a food allergy diagnosis.9
The majority of respondents correctly identified peanut, milk, and egg as the top 3 food allergens in children.2 However, shellfish was also frequently selected, which, although the most common allergen among US adults, is less likely to be a food allergen in children.20 In addition, most participants were unaware of the relative frequency with which children outgrow common food allergies. Respondents were expected to recognize that >75% of milk-allergic children and <25% of peanut-allergic children develop tolerance. These ranges are well documented in the literature. At the upper limit, it has been reported that 79% to 87% of milk-allergic children will outgrow their allergy.21,22 Conversely, peanut-allergic children tend to carry their allergy into adulthood; at most, tolerance has been shown to occur in 22% of cases.23
Providers were aware of many triggers of food-induced reactions. They aptly identified certain medications as containing allergenic food ingredients and knew that the influenza vaccine may be unsafe for children with an egg allergy. Because the influenza virus is grown in chick embryos, the vaccine may contain measurable amounts of egg protein. Therefore, the American Academy of Pediatrics does not generally recommend the influenza vaccine for children with a history of egg-induced anaphylaxis.23
Most participants recognized that no cure exists for food allergy and also acknowledged the importance of timely administration of epinephrine to prevent fatal anaphylaxis. However, the majority of participants believed that anaphylaxis posed the greatest threat to young children rather than teenagers. Although food-induced anaphylaxis can occur at any age, epidemiological studies have shown that adolescents, particularly those with peanut and treenut allergies, are disproportionately affected.25
Difficulty also arose when participants were asked specific questions regarding the treatment of anaphylaxis. Although respondents knew the recommended injection site for epinephrine, only half were able to identify the correct dosage based on a child’s weight. Likewise, only half chose the correct concentration and route of administration for epinephrine in the event of food-induced anaphylaxis. This finding is consistent with other studies of anaphylactic care among primary care physicians. A previous study revealed that only 56% of pediatricians were able to identify and address anaphylactic reactions in children.11 Similarly, survey (including pediatricians and internists) reported that half of the respondents selected the incorrect concentration of epinephrine and route of administration for food-induced anaphylaxis.12
There was no clear consensus among the participants in our study regarding the need for nut-free classrooms. Previous research has indicated that 68% of parents with nonfood-allergic children oppose such policies,15 whereas our preliminary, unpublished data suggested that parents with food-allergic children tended to support nut-free classrooms (49% supported, 28% opposed, and 23% were neutral). Several private and public schools in the United States have banned peanuts, although the viability and efficacy of such policies remain a point of contention. It is worth noting, however, that 18% of preschool- and school-aged children with food allergy have been reported to experience at least 1 reaction over a 2-year period while at school, with peanut the most common cause among school-aged children.25
Participants in our study acknowledged limitations in their knowledge of food allergy. Few felt comfortable interpreting laboratory test results to diagnose food allergy or felt adequately prepared by their medical training to care for food-allergic children. Most pediatric and family medicine training programs do not offer formal training in food allergy, although experience likely varies by program. With the recent increase in childhood food allergy and the threat posed by food-induced anaphylaxis, it is important for generalists to be educated about the diagnosis and treatment of this condition. It is encouraging that medical residents who select an allergy rotation have been shown to be more comfortable with common allergic disorders and were more likely to refer patients to allergists.26
Several resources exist to assist physicians in the diagnosis and management of food allergy. A food allergy practice parameter, outlining risk factors, diagnostic techniques, and treatment plans, was developed and published in 2006 by the American Academy of Allergy Asthma & Immunology and the American College of Allergy, Asthma, and Immunology.27 A practice parameter for the diagnosis and management of anaphylaxis was also published in 2005.3 Additional review articles in both the New England Journal of Medicine and Pediatrics are useful tools for an overview of food allergy management and provide decision trees that can be used as a quick reference when evaluating a child with suspected food allergy.18,28 Finally, educational resources have been specifically developed and validated to meet the needs of the primary care physician.29 However, efforts are needed to encourage the dissemination and use of these materials to better prepare generalists to address the needs of their food-allergic patients. Familiarity with current resources is a first step toward improving physicians’ confidence and clinical ability when dealing with childhood food allergy.
This study has several limitations. Although more than 400 participants completed our survey, only those able to complete the survey in English, those with access to the Internet, and those listed in the commercial vendor’s sampling database or in attendance at the annual meeting of the Pediatric Academic Society were recruited. In addition, there is some selection bias inherent in the recruitment process; those with an interest in food allergy may have been more inclined to complete the survey. Intuitively, one might expect this to result in higher knowledge scores among participants in our study; even so, significant knowledge gaps were identified. Although Web-based surveys have been shown to be valid and reliable means of data collection, potential difficulties have been highlighted, such as multiple entries for a given individual and poor sample representation that result from limited Internet access.30–32 Responses were carefully monitored to avoid duplicate entries, and the survey was deployed in a controlled and secure online environment with particular attention paid to the demographic characteristics of respondents.
Knowledge of food allergy among primary care physicians was fair. Opportunities for improvement exist as acknowledged by the respondents’ own perceptions of their clinical abilities in the management of food allergy. Given the recent increase in childhood food allergy, the threat posed by food-induced anaphylaxis, and the frequency with which the primary care physician encounters these patients, it is imperative that efforts be made to better equip generalists in the provision of care for food-allergic children.
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13. Eigenmann PA, Sicherer SH, Borkowski TA, Cohen BA, Sampson HA. Prevalence of IgE-mediated food allergy among children with atopic dermatitis. Pediatrics. 1998;101 (3). Available at: www.pediatrics.org/cgi/content/full/101/3/e8
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