ORIGINAL ARTICLE FOOD ALLERGY AND ANAPHYLAXIS Food avoidance in children with adverse food reactions: Influence of anxiety and clinical parameters Thuy-My Le 1 , Wieneke T. Zijlstra 2 , Eveline Y. van Opstal 1 , Mirjam J. Knol 3 , Monique P. L’Hoir 4 , Andr e C. Knulst 1 & Suzanne G. M. A. Pasmans 1,5 1 Department of Dermatology & Allergology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; 2 Department of Medical Psychology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; 3 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; 4 TNO Prevention and Health, Leiden, The Netherlands; 5 Pediatric Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands To cite this article: Le T-M, Zijlstra WT, van Opstal EY, Knol MJ, L’Hoir MP, Knulst AC, Pasmans SGMA. Food avoidance in children with adverse food reactions: influence of anxiety and clinical parameters. Pediatr Allergy Immunol 2013: 24: 650–655. Keywords children; food allergy; food avoidance; state anxiety; trait anxiety Correspondence Thuy-My Le, Department of Dermatology/ Allergology, University Medical Center Utrecht, G02.124, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands Tel.: +31 88 7557988 Fax: +31 88 7555404 E-mail: t.t.m.le-2@umcutrecht.nl T-M Le and WT Zijlstra equally contributed to the manuscript. Accepted for publication 10 July 2013 DOI:10.1111/pai.12114 Abstract Background: Many children in the general population avoid food because of self- reported adverse food reactions (AFR). Food avoidance can have negative consequences for well-being and nutritional status. This study aimed to investigate which factors are related to avoidance behavior in children (10–13 yr old) from the general population. Methods: Questionnaires for both mother and child were sent to participants from the Europrevall study: 164 children with self-reported AFR and 170 children without AFRs. Spielberger state anxiety and trait anxiety and clinical parameters, such as severity of the adverse reaction, specific IgE and doctor’s diagnosis, were compared between those who have (had) AFR and avoid food (i.e., avoiders) and those who have (had) AFR(s) and do not avoid food (anymore; i.e., non-avoiders). Results: In total, 59% of the children with AFRs avoided food, of whom 26% had positive specific immunoglobulin E (sIgE). Child’s state anxiety about an AFR was higher in avoiders than in non-avoiders, (p < 0.001), whereas child’s trait anxiety and maternal state anxiety and trait anxiety were comparable in both groups. Avoiders reported more often severe symptoms (i.e., generalized urticaria, respiratory or cardiovascular symptoms) than non-avoiders, (p = 0.03). Food avoidance was not associated with doctor’s diagnosis of food allergy or doctor’s advice to avoid food (p = 1.00). Conclusion: Food avoidance is related to child’s state anxiety about an adverse food reaction. Food avoidance seems to be independent of a doctor’s diagnosis of food allergy and advice on food avoidance. Food avoidance is currently the only way to treat patients with food allergy (FA) (1). In the UK, 16% and 19% of the 11- and 15-yr-old UK children from the general population avoid foods because of self-reported adverse food reactions (AFRs) (2). The prevalence of self-reported AFR is higher than the estimated prevalence of FA, respectively, 3–35% vs. 1–11% (2– 6). Continued avoidance of food has also been reported after negative double-blinded, placebo-controlled, food challenge (DBPCFC) and doctor’s advice to reintroduce food (7, 8). This indicates that food avoidance might be (partly) unnecessary in a considerable proportion of cases. It is important to base dietary advice on an accurate diagnosis, as food avoidance can have a negative impact on psycho-social well-being due to high levels of anxiety associ- ated with a potential accidental reaction (9–13). Furthermore, there is a risk of nutritional deficiencies (14, 15) In addition, there is a certain risk of developing FA in previously tolerant, but sensitized children (16, 17). The disadvantages of unnecessary food avoidance underline the importance of determining factors that influence avoidance behavior. Fear of the unknown, including fear of losing control and fear of causing harm, has been described as part of mothers’ experiences during DBPCFC and when reintroducing the food (18). To our knowledge, only one study has focused on different factors influencing food avoidance behavior after a negative provocation, showing that parents reported fear of an 650 Pediatric Allergy and Immunology 24 (2013) 650–655 ª 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Pediatric Allergy and Immunology