Jonathan S. Tam
Neema Izadi
Joyce E. Yu- 1Division of Clinical Immunology and Allergy, Children’s Hospital of Los Angeles, Los Angeles, CA, United States
- 2Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, United States
Editorial on the Research Topic
Patient focused developments in food allergy
Food allergy is one of the most common chronic conditions of childhood and affects up to 10% of children (1). Perhaps because of its increase in prevalence over the past 30 years, it is not surprising that there has been a significant growth in academic research and awareness from the general public. Without a doubt, great strides have been made in not only understanding the immunology of food allergy but also in potential therapeutic options for patients. While at this time there is only one FDA approved therapeutic for peanut allergy, a number of immunotherapeutic approaches are currently under investigation—including different routes of immunotherapy (oral, sublingual and epicutaneous), immunotherapy with modified recombinant proteins, and use of biologics (with and without immunotherapy) (2).
However, despite these advances, the general experience for the vast majority of patients has not changed. Fundamentally, real change in understanding of food allergy, treatments and diagnostics have had little impact on clinical practice. Moreover, despite the best intentions, efforts directed at affecting change have historically not always led to the best results.
Prevention of food allergy has long been a target in the effort to stem the rising tide of food allergy. Over 20 years ago, a guideline by the American Academy of Pediatrics (published in 2000) recommended the use of hydrolyzed formulas and delayed introduction of allergenic foods including peanut until the age of 3 years. The guidelines were based on expert opinion at the time and on studies from the preceding 2 decades which seemed to support the recommendation. However, the prevalence of food allergies continued to increase and in 2008 the guidelines changed to remove those specific recommendations. The guidelines would completely change again following the publication of the results of the Learning Early About Peanut (LEAP) trial (3). Feeding guidelines across the globe changed dramatically promptly encouraging the early introduction of allergenic foods, particularly in high-risk infants (4). While the full impact of the change to early introduction is still being evaluated, recent results highlight two important lessons on the implementation of promising research—generalizability and unintended consequences. A report from Australia (5) looking at 2 population-based cross-sectional samples used to evaluate the prevalence of peanut allergy before and after introduction of Australia's new infant feeding guidelines revealed minimal effect on peanut allergy prevalence; thus, underscoring the potential difficulty in translating research to a population.
In terms of unintended consequences, the quest to reduce immediate food allergic reaction to peanuts may have unintentionally increased a different type of food allergy—food protein induced enterocolitis syndrome (FPIES). Shortly after the establishment of the new guidelines, a series of three cases of FPIES to peanut were reported (6). Subsequently, a retrospective analysis identified 14 cases of peanut FPIES from 2019 to 2021 in stark contrast to a previous review of 160 patients with FPIES in the same institution from 2001 to 2011, with no reported cases of peanut FPIES (7).
Even efforts which may seem innocuous or generally benign can have strange consequences. In the United States, the Food Allergy Safety, Treatment, Education and Research (or FASTER) Act was signed into law in 2021 and as a result sesame was added to the list of major food allergens requiring mandatory labeling. The law was clearly designed to protect those patients affected with sesame allergy. However, in an epic twist, some food companies have chosen to add small amounts of sesame flour (8) to products that were previously sesame-free to reduce their own liability (instead of conducting the cleaning required to ensure the foods are without sesame). So instead of making products safer for patients with sesame allergy, it may have had the opposite effect.
This is all to say, progress is hard even with the best intentions. As with Newton's third law, every action has an equal and opposite reaction. So while we push forward toward the ultimate goal of a cure, we cannot lose sight for whom we fight. Our efforts must value the patient's experience and be wary of unintended consequences—in the risk, burden, expense and psychosocial effect they may have on our patients.
Author contributions
JT: Conceptualization, Writing – original draft, Writing – review & editing. NI: Conceptualization, Writing – review & editing. JY: Conceptualization, Writing – review & editing.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
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References
1. Peters RL, Krawiec M, Koplin JJ, Santos AF. Update on food allergy. Pediatr Allergy Immunol. (2021) 32(4):647–57. doi: 10.1111/pai.13443
2. Fowler J, Lieberman J. Update on clinical research for food allergy treatment. Front Allergy. (2023) 4:1154541.37520143
3. Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. (2015) 372(9):803–13. doi: 10.1056/NEJMoa1414850
4. Vale SL, Lobb M, Netting MJ, Murray K, Clifford R, Campbell DE, et al. A systematic review of infant feeding food allergy prevention guidelines—can we AGREE? World Allergy Organ J. (2021) 14(6):100550. doi: 10.1016/j.waojou.2021.100550
5. Soriano VX, Peters RL, Moreno-Betancur M, Ponsonby A-L, Gell G, Odoi A, et al. Association between earlier Introduction of peanut and prevalence of peanut allergy in infants in Australia. JAMA. (2022) 328(1):48–56. doi: 10.1001/jama.2022.9224
6. Robbins KA, Ackerman OR, Carter CA, Uygungil B, Sprunger A, Sharma HP. Food protein-induced enterocolitis syndrome to peanut with early introduction: a clinical dilemma. J Allergy Clin Immunol Pract. (2018) 6(2):664–6. doi: 10.1016/j.jaip.2017.06.038
Keywords: food allergy, patient, consequence, shared decision making, prevention
Citation: Tam JS, Izadi N and Yu JE (2023) Editorial: Patient focused developments in food allergy. Front. Allergy 4:1287078. doi: 10.3389/falgy.2023.1287078
Received: 1 September 2023; Accepted: 12 September 2023;
Published: 26 September 2023.
Edited and Reviwed by: Ronald van Ree, Amsterdam University Medical Center, Netherlands
© 2023 Tam, Izadi and Yu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jonathan S. Tam Jstam@chla.usc.edu