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J Food Allergy
J Food Allergy
Journal of Food Allergy
2689-0267
2689-0275
OceanSide Publications, Inc. Providence, RIUSA

JFA020-23
10.2500/jfa.2024.6.240001
Short Communication
The public health burden of parent-reported food allergy-related missed school days among US children
Sansweet Samantha R. M.P.H. 1
Dyer Ashley A. M.P.H., D.A.C.M. 1
Hultquist Haley W. B.A. 1
Gupta Ruchi S. M.D., M.P.H. 1 2
Warren Christopher M. Ph.D. 3
From the 1Center for Food Allergy and Asthma Research, Feinberg School of Medicine, Northwestern University, Chicago, IL;
2Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL; and
3Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
Address correspondence to Christopher M. Warren, Ph.D., Center for Food Allergy and Asthma Research, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr., no. 680, Chicago, IL 60611 E-mail address: Christopher.warren@northwestern.edu
1 7 2024
7 2024
6 1 4751
Copyright © 2024, The Author(s). Published by OceanSide Publications, Inc., U.S.A.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This article is distributed under the terms of the Creative Commons Attribution License-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits reproduction and redistribution in any medium or format according to the license terms, provided the work is not used for commercial purposes and provided the original authors and source are properly credited and a link is provided to the Creative Commons license. For commercial permissions, visit https://oceansidepubl.com/permission-to-use-content/

Background:

Food allergy (FA) is a common chronic condition among U.S. children. Children with FA and their families often report greater psychosocial burden, which is adversely impacted by the inability to participate in daily activities. Regularly attending school remains central to supporting the well-being of children with FAs and related academic success.

Objective:

The objective was to estimate the frequency of FA-related school absences, determine predictors, and understand how report of such absences is associated with FA-related psychosocial burden.

Methods:

A survey was administered to a nationally representative sample of U.S. households in 2015–2016, obtaining parent-proxy responses for 38,408 children. Prevalence estimates were based on responses from NORC’s AmeriSpeak Panel (51% completion rate), which were augmented by nonprobability-based responses via calibration weighting to increase precision. Prevalence was estimated via weighted proportions. Multiple logistic regression models evaluated factors associated with FA-related missed school days.

Results:

Thirty-seven percent of children with FA who attended school in the past 12 months reportedly had one or more FA-related absence, with 13% missing 1–2 days (95% confidence interval [CI], 11.41–15.49 days), 17% missing 3–7 days (95% CI, 6.82–10.91 days), and 4% missing 8–14 days (95% CI, 3.13–6.20 days). Hispanic children were more likely to report missed school days in the past 12 months compared with white, non-Hispanic children with FA (odds ratio [OR] 1.62 [95% CI, 1.16–2.26]). Children with multiple FAs (OR 1.35 [95% CI, 1.03–1.76]), history of epinephrine use (OR 2.22 [95% CI, 1.70–2.90]), and anaphylaxis (OR 1.64 [95% CI, 1.26–2.14]) in the past 12 months, and those with a current epinephrine prescription (OR 1.05 [95% CI, 0.075–1.47]) have greater odds of reported FA-related school absence. Report of one or more FA-related absences was also associated with greater FA-related psychosocial burden (OR 1.72 [95% CI, 1.46–2.01]).

Conclusion:

Parent report of children missing school for reasons related to FA is remarkably common and associated with greater FA-related psychosocial burden.

food allergy
anaphylaxis
school absenteeism
missed school
anxiety
bullying
mental health
psychosocial burden
quality of life
public health
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pmcMore than 40% of children in the United States have at least one chronic illness,1 with asthma as one of the most prevalent,2 that currently affects an estimated 6% of U.S. children and that is a prominent contributor to school absenteeism.3 The relationship between chronic illness and missed school days is apparent because 7.9 million school days were missed among those with asthma as of 2018.4 Analysis of research suggests that school absenteeism is associated with negative immediate and long-term impacts on overall health and well-being.5 For example, one study explored the impacts of school absenteeism and found that, regardless of the reason, children who missed school frequently were at a greater risk for social and behavioral problems, lower academic achievement and reading proficiency, and a higher likelihood of low income and poor health in adulthood.6

In recent years, food allergies (FA) have come to impact a large and growing population, which leads to adverse impacts on physical and psychosocial health as well as substantial economic burden and health-care utilization.7 Moreover, children with FAs frequently have other chronic comorbidities, including asthma, which impacts an estimated one in three children with FA.8 As with asthma, FA has the potential to cause school absenteeism through physical impacts (e.g., allergic reactions due to allergen ingestion and associated health-care utilization) and mental health–related impacts on both children with FA and their caregivers.9,10 With the accompanying potential for an allergic reaction, FA comes with additional stressors, such as fear and anxiety over the risk of anaphylaxis, and feelings of isolation and loneliness stemming from feeling different than their peers.11 Analysis of previous work into the psychosocial burden of FA suggests that the most notable impacts stem from concerns with regard to meal preparation and social activities, such as going to restaurants, parties, sleepovers, and school. The caregiver cannot always be present when his or her child is around food; therefore, some caregivers opt to avoid or limit some of the child’s social encounters, including school-related activities, in an effort to promote the child’s safety.12 However, social limitation and isolation can have detrimental psychosocial impacts on both the child and caregiver.

Despite the growing number of U.S. children affected by FA and the possibility that it may be an important contributor to school absenteeism, remarkably little remains known about rates of school absenteeism among children with FA. Consequently, the present study aims to better understand the relationship between parent-reported pediatric FA and school absenteeism by estimating the frequency and determinants of FA-related missed school days in a large, nationally representative sample of U.S. children with FA as well as by estimating associations between parent-reported FA-related school absenteeism and established disease-specific indicators of FA-related psychosocial burden.

METHODS

To achieve these aims, we analyzed parent-reported responses for 38,408 U.S. children, collected via a U.S. population–based survey administered in 2015–2016, 3,432 of whom met convincing symptom-report criteria for probable immunoglobulin E–mediated FA. As comprehensively described in previous work, population-weighted estimates were derived from survey responses collected through NORC at the University of Chicago’s nationally representative, probability-based AmeriSpeak (NORC at the University of Chicago, IL) Panel (51% completion rate), which were systematically augmented by nonprobability-based responses via calibration weighting to increase precision. The public health impact of parent-reported childhood food allergies in the United States.8 Annual pediatric population–based estimates of the frequency of parent report of one or more FA-related missed school days were estimated via complex survey-weighted frequencies. Multiple logistic regression models evaluated clinical, demographic, and psychosocial factors associated with FA-related missed school days, including composite measures calculated from a validated instrument for assessment of FA-related psychosocial burden, the Food Allergy Independent Measure-Parent Form.13

RESULTS

On analysis of these national survey responses, among the estimated 7.6% (95% CI, 7.1–8.1%) of children whose current, parent-reported FA met symptom-report criteria for immunoglobulin E–mediated FA, the reported racial/ethnic distribution was as follows: 48.3% non-Hispanic white, 26.5% Hispanic, 15.4% non-Hispanic black, 2.8% non-Hispanic Asian, 7.1% non-Hispanic other/multi-racial (Table 1).8 We found that 37% of children with FA who attended school in the past 12 months reported one or more FA-related absences and 13% reported missing 1–2 days (95% CI, 11.41 – 15.49 days), 17% reported missing 3–7 days (95% CI, 6.82 – 10.91 days), and 4% reported missing 8–14 days (95% CI, 3.13 – 6.20 days) (Fig. 1).

Figure 1. Distribution of food allergy–related missed school days among a large, nationally representative sample of children with food allergy.

When the probability of reporting one or more reported FA-related missed school days in the past 12 months was modeled (compared with no FA-related missed school days), adjusting for child age, household income, and two indicators of a history of severe reactions (reported reaction symptomatology that approximates anaphylaxis due to multiorgan system involvement and reported use of an epinephrine autoinjector to treat a FA reaction), we found that Hispanic children with FA had significantly increased odds (odds ratio [OR] 1.62 [95% CI, 1.16 – 2.26]) of reporting any missed school days in the past 12 months compared with non-Hispanic white children with FA.

Our findings revealed additional factors associated with the greater probability of reporting FA-related school absenteeism. By adjusting for participants’ race/ethnicity, age, sex, and household income, children with multiple FAs (OR 1.35 [95% CI, 1.03–1.76]), a history of epinephrine use (OR 2.22 [95% CI, 1.70–2.90]), and anaphylactic symptomatology (OR 1.64 [95% CI, 1.26–2.14]) were associated with greater odds of reporting one or more FA-related missed school days, whereas report of a current epinephrine autoinjector prescription was not (OR 1.05 [95% CI, 0.75–1.47]). Parent report of a FA-related emergency department visit during the past 12 months was also strongly associated with report of at least one FA-related school absence (OR 4.11 [95% CI, 2.84–5.94]). Parent report of at least one FA-related absence was also associated with greater FA-related psychosocial burden (OR 1.72 [95% CI, 1.46–2.01]) (Fig. 2) Table 2.

Figure 2. Predicted probability of a child missing one or more school days due to food allergy across levels of Food Allergy Independent Measure–Parent Form score.

Table 1 Sample demographics

Variable	Children with Food Allergy, % (95% confidence interval)	
Race and/or ethnicity		
 Asian American, non-Hispanic	2.8 (2.2–3.5)	
 African American, non-Hispanic	15.4 (13.1–18.1)	
 White, non-Hispanic	48.3 (45.0–51.7)	
 Hispanic	26.5 (23.2–30.0)	
 Multiracial or other	7.1 (5.7–8.7)	
Sex		
 Girls	48.2 (45.0–51.5)	
 Boys	51.8 (48.6–55.0)	
Age		
 0 year	1.9 (1.5–2.5)	
 1 year	5.6 (4.3–7.3)	
 2 years	7.5 (5.4–10.4)	
 3–5 years	17.8 (15.3–20.5)	
 6–10 years	29.1 (26.5–31.9)	
 11–13 years	16.5 (14.3–18.9)	
 14–17 years	21.6 (19.3–24.2)	
Household income		
 <$25,000	15.4 (13.0–18.1)	
 $25,000–$49,999	23.2 (20.6–26.1)	
 $50,000–$99,999	31.5 (28.6–34.5)	
 $100,000–$149,999	20.4 (17.4–23.7)	
 >$150,000	9.6 (7.6–11.9)	
Geographic region		
 West	22.4 (19.7–25.4)	
 Midwest	19.1 (16.8–21.7)	
 South	39.9 (36.6–43.2)	
 Northeast	17.7 (15.1–20.7)	
Physician-diagnosed comorbid  conditions		
 Asthma	32.6 (29.5–35.9)	
 Atopic dermatitis and/or eczema	14.9 (12.5–17.7)	
 Eosinophilic esophagitis	0.7 (0.4–1.1)	
 Allergic rhinitis	30.4 (27.6–33.4)	
 Insect sting allergy	6.4 (5.3–7.8)	
 Latex allergy	6.6 (4.8–9.0)	
 Medication allergy	10.1 (8.2–12.3)	
 Urticaria and/or chronic hives	1.9 (1.4–2.6)	
 Other chronic condition	7.2 (5.9–8.9)	

Table 2 Sociodemographic and clinical predictors of missing one or more school days due to FA modeled via three increasingly adjusted logistic regression models

	Model 1	Model 2	Model 3	
Variable	OR	95% CI	OR	95% CI	OR	95% CI	
Race/ethnicity (vs white, non-Hispanic)							
 Black, non-Hispanic	1.14	0.81–1.60	1.03	0.68–1.57	1.01	0.66–1.52	
 Asian, non-Hispanic	1.24	0.77–2.00	1.32	0.76–2.27	1.30	0.72–2.32	
 Hispanic	1.62	1.16–2.26	1.21	0.87–1.69	1.24	0.88–1.76	
 Multiple/other	0.65	0.43–0.97	0.65	0.39–1.08	0.61	0.36–1.02	
Age (vs 0–5 years)							
 6–10 years	0.98	0.73–1.31	0.94	0.63–1.40	1.00	0.65–1.54	
 11–13 years	1.10	0.73–1.65	0.72	0.47–1.09	0.84	0.53–1.32	
 14–17 years	0.78	0.55–1.10	0.62	0.41–0.93	0.71	0.46–1.11	
Sex (vs boys)							
 Girls	1.02	0.79–1.31	1.07	0.82–1.40	1.07	0.81–1.43	
Annual household income (vs <$25,000)							
 $25,000-$49,999	1.23	0.77–1.97	1.01	0.62–1.65	1.09	0.65–1.83	
 $50,000-$99,999	1.06	0.72–1.56	1.11	0.69–1.78	1.14	0.70–1.86	
 $100,000-$149,999	1.15	0.77–1.74	1.11	0.66–1.85	1.25	0.73–2.14	
 >$150,000	1.13	0.61–2.09	0.78	0.41–1.49	0.89	0.46–1.71	
Severe FA reaction history	1.64	1.26–2.14	1.50	1.12–2.00	1.52	1.13–2.05	
Previous use of EAI to treat FA reaction (vs not)	2.22	1.70–2.90	2.02	1.43–2.90	1.77	1.24–2.53	
Physician-diagnosed asthma (vs not)	1.68	1.30–2.17	1.69	1.28–2.23	1.59	1.20–2.11	
Current epinephrine Rx (vs not)			1.05	0.75–1.47	1.04	0.74–1.46	
Multiple FAs (vs single FA)			1.35	1.03–1.76	1.18	0.90–1.56	
Hx of ≥1 FA-related ED visit (vs not)					4.11	2.84–5.94	
FA = Food allergy; OR = odds ratio; CI = confidence interval; EAI = Epinephrine auto-injector; Rx = prescription; Hx = history; ED = emergency department.

DISCUSSION

Analysis of these data suggests that many children in the United States miss school for reasons believed by their parents to be FA related and that children who miss more school for such reasons also have greater FA-related psychosocial burden. These findings of substantial numbers of reportedly FA-related school absences aligns with previous work reporting that “the presence of a FA has been found to affect school performance, with allergic children having a greater number of school absences.”12 However, identifying the principal driver(s) of the positive association observed between FA-related school absences and psychosocial burden remains challenging owing to the cross-sectionality of these data, and the fact that there are many factors perceived by parents as “FA related,” which may contribute to missed school. These include fear and anxiety of having an allergic reaction in a context in which management is perceived to be suboptimal, concerns about the child’s feelings of isolation and difference, and experiencing FA reactions that result in school absence or removal from school. Notably, fears and worries can be attributed to the child as well as the caregiver’s feeling of lack of control over his or her child’s safety and his or her environment. Caregivers may find it difficult to trust that their child will be safe in the care of another individual, particularly in light of data11 that FA-related bullying victimization is common among school-age children. However, removal of the child from a daycare or school environment may lead to increased direct (e.g., childcare) or other indirect costs (e.g., missed wages), along with the corresponding psychosocial stress.14

This brings into question the possibility that having more than one FA creates more opportunities for the accidental ingestion of allergens. These varied factors indicate that accidental ingestions both in and out of the school environment may also result in missed school days. Thus, there may be FA-related emergency health-care utilization, FA-related sick days, and FA-related fear and anxiety with regard to the safety of the child (among children with FA and their caregivers), each of which may contribute to these absences. This is supported by the fact that, when added as an additional predictor to the above model, children with at least one reported FA-related emergency department visit were at greatly increased odds of FA-related missed school days.

A recently published analysis from this same population-based prevalence survey reported that multi-FAs is associated with greater FA-related disease burden and psychosocial impact.15 When examining predictors of FA-related missed school days in this dataset, reported allergy to multiple foods did significantly increase the odds of reporting at least one FA-related missed school day. Whether this observed increased risk is attributable to a greater opportunity for allergen ingestion and concomitant allergic reactions and/or greater parental willingness to withdraw the caregivers’ child from school for reasons relating to their child’s FA, whether medically indicated or not, remains unknown.

We also found that Hispanic children with FA had significantly increased odds (OR 1.62 [95% CI, 1.16 – 2.26]) of reporting any missed school days in the past 12 months compared with non-Hispanic white children with FA. Existing research has found that children of racial and ethnic minority backgrounds generally miss more school than white children,6,16 potentially due to many factors, including exposure to violence, poverty, chronic illness, and unreliable and/or unsafe transportation.6,16 Racial and ethnic differences in asthma prevalence and severity are also well established,17 and children with FA and physician-diagnosed asthma in our sample were significantly more likely to miss school due to FA, even after adjusting for a variety of demographic and clinical covariates. This may be due to residual confounding by FA severity, mistaken attribution of asthma symptoms to a food trigger or other phenomena. In any event, it highlights children with atopic disease–related school absenteeism and a corresponding need for targeted approaches to minimize associated adverse impacts.

There are strengths and limitations to this research. The nationally representative sampling frame used, and the resulting large, diverse, nationally generalizable pediatric sample permits insights into the population-level distribution of the constructs measured by this study. However, a key limitation is that we do not actually know the true cause of the reported FA-related missed school days, including the relative influences of parent versus child-level factors. We lack first-hand explanations from participants with regard to the specific contributors to FA-related psychosocial burden and the extent to which they contribute to missed school days. Note also that these survey data provide a snapshot of the constructs of interest at a specific moment in time (2016) and that updated data are needed to better understand current dynamics. Future research should consider augmenting the parent report with a child self report to better contextualize their experiences and understand the determinants of the many missed school days reported by parents of U.S. children with FA.

CONCLUSION

FA seems to be an important determinant of school absenteeism for U.S. children. Achieving a better understanding of the U.S. population-level distribution and determinants of FA-related absences can inform development of more effective policies and clinical supports for reducing FA-related absenteeism. In addition, school is an environment where children spend much of their waking hours, thus it is important to ensure it is socioemotionally and physically safe so that the myriad benefits of school attendance can be manifest.

R.S. Gupta reports receiving research support from the National Institutes of Health (R21 ID AI135705, R01 ID AI130348, U01 ID AI138907), Food Allergy Research and Education, Melchiorre Family Foundation, Sunshine Charitable Foundation; The Walder Foundation, UnitedHealth Group, Thermo Fisher Scientific, and Genentech; serves as a medical consultant/advisor for Genentech, Novartis, Aimmune LLC, Allergenis LLC, and Food Allergy Research and Education; and reports having an ownership interest in Yobee Care, Inc. C.M. Warren reports research support from the National Institutes of Health, Food Allergy Research and Education, and the Sunshine Charitable Foundation. The remaining authors have no conflicts of interest to declare pertaining to this article

The funding source was the National Institute of Allergy and Infectious Diseases (R21AI135702).
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