The impact of food allergy and bullying

ambitious goal not only in children and young adults but also in the aging population. PAUL A. GREENBERGER, MD Division of Allergy-Immunology Department of Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois p-greenberger@northwestern.edu REFERENCES 1. Centers for Disease Control and Prevention. FastStats: asthma. http:// www.cdc.gov/nchs/fastats/asthma.htm. Accessed August 20, 2010. 2. Lemanske RF Jr, Busse WW. The US Food and Drug Administration and long-acting ␤2-agonists: the importance of striking the right balance between risks versus benefits of therapy? J Allergy Clin Immunol. 2010;126:449 – 452. 3. Kramer JM. Balancing the benefits and risks of inhaled long-acting ␤-agonists: the influence of values. N Engl J Med. 2009;360:1592–1595. 4. von Mutius E, Drazen JM. Choosing asthma step-up care. N Engl J Med. 2010;362:1042–1043. 5. Greenberger PA. Personalized medicine for patients with asthma. J Allergy Clin Immunol. 2010;125:305–306. 6. Peters SP, Jones CA, Haselkorn T, et al. Real world evaluation of asthma control and treatment (REACT): findings from a national web-based survey. J Allergy Clin Immunol. 2007;119:1454 –1461. 7. Brusselle G, Michils A, Louis R, et al. “Real-life” effectiveness of omalizumab in patients with severe persistent allergic asthma: the PERSIST study. Repir Med. 2009;103:1633–1642. 8. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma–summary report 2007. J Allergy Clin Immunol. 2007;120: S94 –S138. 9. DeFrances CJ, Lucas CA, Buie VC, et al. 2006 National Hospital Discharge Survey. National Health Statistics Reports. http:// www.cdc.gov/nchs/data/nhsr/nhsr005.pdf. Accessed August 20, 2010. 10. Korn S, Schumann C, Kropf C, et al. Effectiveness of omalizumab in patients 50 years and older with severe persistent allergic asthma. Ann Allergy Asthma Immunol. 2010;105:313–319. 11. Bousquet J, Rabe K, Humbert M, et al. Predicting and evaluating response to omalizumab in patients with severe allergic asthma. Respir Med. 2007;101:1483–1492. 12. Bousquet J, Wenzel S, Holgate S, et al. Predicting response to omalizumab, an anti-IgE antibody, in patients with allergic asthma. Chest. 2004;125:1378 –1386. 13. Casale TB, Stokes JR. Immunomodulators for allergic respiratory disorders. J Allergy Clin Immunol. 2008;121:288 –296. 14. Holgate S, Smith N, Massanari M, et al. Effects of omalizumab on markers of inflammation in patients with allergic asthma. Allergy. 2009; 64:1728 –1736. 15. Corren J, Shapiro G, Reimann J, et al. Allergen skin tests and free IgE levels during reduction and cessation of omalizumab therapy. J Allergy Clin Immunol. 2008;121:506 –511. 16. Fahy JV, Fleming HE, Wong HH, et al. The effect of an anti-IgE monoclonal antibody on the early- and late-phase responses to allergen inhalation in asthmatic subjects. Am J Respir Crit Care Med. 1997;155:1828 –1834. 17. Hanf G, Noga O, O’Connor A, et al. Omalizumab inhibits allergen challenge-induced nasal response. Eur Respir J. 2004;23:414 – 418. 18. Ong YE, Menzies-Gow A, Barkans J, et al. Anti-IgE (omalizumab) inhibits late-phase reactions and inflammatory cells after repeat skin allergen challenge. J Allergy Clin Immunol. 2005;116:558 –564. 19. Djukanovic R, Wilson SJ, Kraft M, et al. Effects of treatment with anti-immunoglobulin E antibody omalizumab on airway inflammation in allergic asthma. Am J Respir Crit Care Med. 2004;170:583–593. 20. Beck LA, Marcotte GV, MacGlashan D Jr, et al. Omalizumab-induced reductions in mast cell Fc␧RI expression and function. J Allergy Clin Immunol. 2004;114:527–530. 21. Prussin C, Griffith DT, Boesel KM, et al. Omalizumab treatment downregulates dendritic cell Fc␧RI expression. J Allergy Clin Immunol. 2003;112:1147–1154. 22. Klunker S, Saggar LR, Seyfert-Margolis V, et al. Combination treatment with omalizumab and rush immunotherapy for ragweed-induced allergic rhinitis: inhibition of IgE-facilitated allergen binding. J Allergy Clin Immunol. 2007;120:688 – 695. Guest editorial The impact of food allergy and bullying Food allergy is a common childhood illness, affecting approximately 3.9% of the US population.1 To add to the psychological stress of the potential morbidity2 and even mortality associated with this illness, in this issue of the Annals, Lieberman et al3 highlight the fact that 24% of children who participated in a questionnaire survey reported having been teased, harassed, or bullied as a result of their food allergy. Furthermore, 57% of those who reported harassment described acts of physical provocation, such as being touched by the food allergen or having it waved at them or put into their food. Even more disconcerting Disclosures: Authors have nothing to disclose. © 2010 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.anai.2010.10.003 410 was the fact that teachers or school staff were reported as the perpetrators of the harassment in 21% of cases. This article is informative and thought provoking to the allergist caring for food-allergic children. Furthermore, it should prompt new research that extends beyond the limitations of this sentinel work. These limitations include the fact that the surveys were completed by a subset of food-allergic families attending a Food Allergy & Anaphylaxis Network meeting and may not be representative of the larger population of food-allergic children. Most questionnaires were completed not by the allergy sufferers but by parents or caregivers of the food-allergic children. New research should encompass a more diverse patient population and include reports from parents, children, and, perhaps, other observers to confirm or correct the startling statistics presented in this article. ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY The problem of bullying lies in the perceived imbalance of power that can be the result of age, strength, or size, with the more powerful child attacking the physically or psychologically vulnerable victim.4 Bullying can be direct or indirect and can be perpetrated through physical, verbal, or other means.4 Although the results of the study by Lieberman et al3 seem to suggest an unusually high rate of bullying of children with food allergies, bullying in general is alarmingly common. In a large-scale report5 on the occurrence of bullying among 6th to 10th graders across the United States, 17% reported being bullied “sometimes” or more frequently. A direct comparison of these national data with the results of the study by Lieberman et al3 is not possible because the latter study inquired about food allergy– related bullying only. However, future studies may include an assessment of food-related and non–food-related bullying, with a comparison of the incidence of the latter between food-allergic and nonallergic children. It is unlikely that a child will present to the allergist with the complaint of being bullied. It is, thus, our job to identify children who are possibly being bullied, to assess potential psychiatric sequela, and to advocate bullying prevention programs at school when necessary. Although no classic phenotype of a bullied child exists, good students and children who are obese or physically disabled are more likely to be bullied.6 This study adds concern that food allergy sufferers may need to be included in the list. What then should we, as allergists, look for as a sign of a child being bullied? Indicators of concern include recent poor school performance and frequent absences, psychosomatic or behavioral problems, and initiation of tobacco, drug, or alcohol use.7 A particularly troubling finding from the study by Lieberman et al3 is that school faculty members were the perpetrators of bullying in more than 20% of cases. Although surprising, one cannot help but wonder if this is a reaction from school staff to parental pressure to conform to demands that the school environment be adapted to the food-allergic child’s needs. A solution specifically for the problem of the bullying of food-allergic children by peers and adults has not been introduced, likely owing to a general lack of awareness of the problem, thus reinforcing the need for further research. VOLUME 105, DECEMBER, 2010 In the meantime, in an attempt to move forward regarding this issue, we suggest that the following steps be considered: (1) better education regarding food allergies would help adults and children appreciate the special challenges faced by the food-allergic child and, perhaps, help counter the perception that such atopic problems are not serious; (2) school personnel should be informed about the possibility of food allergy–related bullying to increase awareness and prompt counter measures; and (3) parents of food-allergic children may need help recognizing that adopting an adversarial approach to requesting food-safe areas may generate resentment. In the end, careful education and tactful solicitation of support is a better approach than is assertion of entitlement. JOHN OPPENHEIMER, MD* BRUCE BENDER, PHD† * Department of Medicine New Jersey Medical School Newark, New Jersey † Division of Pediatric Behavioral Health National Jewish Health Denver, Colorado REFERENCES 1. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. 2009;124:1549 –1555. 2. Sicherer SH, Noone SA, Muñoz-Furlong A. The impact of childhood food allergy on quality of life. Ann Allergy Asthma Immunol. 2001;87:461– 464. 3. Lieberman JA, Weiss C, Furlong TJ, Sicherer M, Sicherer SH. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2010;105:282–286. 4. Lyznicki JM, McCafree MA, Robinowitz CB. Childhood bullying: implications for physicians. Am Fam Physician. 2004;70:1723–1728. 5. Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285:2094 – 2100. 6. Espelage DL, Swearer SM. Research on school bullying and victimization: what have we learned and where do we go from here. School Psychol Rev. 2003;12:365–383. 7. Vreeman R, Carroll A. A systematic review of school-based interventions to prevent bullying. Arch Pediatr Adolesc Med. 2007;161: 78 – 88. 411