Ann Allergy Asthma Immunol xxx (2016) 1e6

Contents lists available at ScienceDirect

Mealtime behavior among parents and their young children with food
allergy
Linda Jones Herbert, PhD *, y; Priya Mehta, BA y; Hemant Sharma, MD, MHS *, y
* Division of Allergy and Immunology, Childrens National Health System, Washington, DC
y
The George Washington University, School of Medicine and Health Sciences, Washington, DC

A R T I C L E I N F O A B S T R A C T

Article history:
Received for publication August 4, 2016.
Received in revised form November 8, 2016.
Accepted for publication December 1, 2016.
Background: Food allergies are increasingly prevalent in the pediatric population. Balancing allergen
avoidance with the promotion of healthy eating behaviors can be challenging for families.
Objective: To characterize mealtime behaviors among parents of young children with food allergy.
Methods: Seventy-four parents of young children with food allergies (!7 years of age) completed measures
of mealtime behavior, perceptions of food allergy risk and severity, pediatric parenting stress, and food
allergyerelated quality of life. Mealtime behavior reports were compared with published data regarding
typically developing children, young children with type 1 diabetes, and children with diagnosed feeding
disorders (with or without related medical factors).
Results: Parents of young children with food allergies reported frequent mealtime concerns. Specically,
they reported signicantly more mealtime behavioral concerns than typically developing peers, comparable
mealtime behavioral concerns to young children with type 1 diabetes, and signicantly fewer mealtime
behavioral concerns than children with diagnosed feeding disorders. Parental mealtime concerns were
positively correlated with other parent perceptions of food allergy, such as risk of allergen exposure, illness-
related parenting stress, and food allergyerelated quality of life.
Conclusion: Young children with food allergy and their parents are more likely to exhibit mealtime
behavioral concerns than typically developing peers and their parents. Future research should investigate
the effect of food allergies and maladaptive mealtime behaviors on childrens nutrition to provide clinical
guidelines for parents who may benet from psychosocial and/or nutritional support.
! 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Introduction skills, and autonomy.10e12 Finding a balance between safe food al-
lergy management and engagement in normal developmental
Food allergies are increasingly prevalent in the pediatric popu-
tasks may be challenging.
lation, affecting an estimated 8% of children in the United States.1,2
A primary developmental task during early childhood is the
Food allergy diagnosis can be life-altering for the child and family; a
establishment of healthy eating habits. Mealtime behavioral con-
key component of treatment is allergen avoidance to prevent
cerns are very common in healthy, typically developing children.
potentially life-threatening allergic reactions.3e5 In early childhood,
Approximately 25% to 45% of parents of typically developing chil-
parents are often responsible for all aspects of food allergy man-
dren report concerns with their childs feeding and mealtime be-
agement because children may be too young to understand the
haviors, including disruptive child behaviors (eg, food refusal, food
complexities of allergen avoidance and lack the skills necessary to
selectivity, getting up from the table).13e16 Many parents report
implement food allergy management.6 Thus, food allergy man-
anxiety about their childs mealtime behaviors and use maladaptive
agement can be tedious, time-consuming, and stressful for paren-
techniques to encourage their child to eat.17 These behaviors may
ts.6e9 Further complicating food allergy management is that
have unintended consequences, such as more or less food intake or
parents are responsible for supporting their childs normal devel-
lack of a varied diet, which may then contribute to inadequate or
opmental needs, such as promoting healthy eating habits, social
excess weight gain and/or inappropriate nutritional intake.17
Furthermore, behavioral problems at mealtime may increase
Reprints: Linda Jones Herbert, PhD, Division of Allergy and Immunology, Childrens
parental stress and decrease quality of life.
National Health System, 111 Michigan Ave NW, Washington, DC 20010; E-mail:
lherbert@childrensnational.org. For families of children with chronic illnesses who require strict
Disclosures: Authors have nothing to disclose. diet management, such as type 1 diabetes, mealtime behavioral

http://dx.doi.org/10.1016/j.anai.2016.12.002
1081-1206/! 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
2 L.J. Herbert et al. / Ann Allergy Asthma Immunol xxx (2016) 1e6
concerns are even more common than among families of typically
developing children.18,19 These concerns may have consequences
for illness-specic physiologic and psychosocial outcomes.20 For
example, more frequent problematic child and parent mealtime
behavior was signicantly associated with poorer diabetes-related
quality of life in a sample of parents of young children with type
1 diabetes.21 Given the need to focus on eating and food con-
sumption similar to children with type 1 diabetes, children with
food allergy may also be at greater risk for mealtime behavioral
concerns than typically developing children. However, little is
known about mealtime behavioral concerns among children with
food allergy. Preliminary research indicates that food allergy pa-
tients may be overrepresented at feeding clinics compared with the
general population,22 and feeding concerns are common among
children diagnosed with cows milk allergy, food proteineinduced
gastrointestinal allergies, and eosinophilic gastrointestinal dis-
orders.23e25 However, no prior studies have examined mealtime
concerns among children with a broader array of food allergies;
therefore, it is unknown whether those concerns are increased
compared with typically developing children or associated with
increased parenting stress and/or poorer quality of life.
The aim of this study is to characterize mealtime concerns
among parents of young children with food allergy. To accomplish
this aim, we (1) describe mealtime behavioral concerns among a
sample of parents of young children with food allergy, (2) compare
the mealtime concerns of parents in our sample with published
data from 3 other samples (children with type 1 diabetes, children
with diagnosed feeding disorders, and typically developing chil-
dren), and (3) investigate the association of parents mealtime
concerns with parenting stress and food allergyerelated quality
of life.
Methods
Procedure
This study was approved by the Childrens National Health
Systems institutional review board. Participants were recruited
during a 16-month period (March 2014 to June 2015). Primary
caregivers of children 0 to 18 years old with at least one diagnosed
food allergy (hereafter referred to as parents) completed an online
clinical assessment of food allergyerelated psychosocial func-
tioning as part of routine clinical care. Practitioners identied their
patients who were diagnosed with food allergies at clinic ap-
pointments. Food allergies were diagnosed by allergists via one of
several methods: skin prick testing, IgE testing, oral food challenge,
or clinical history. Within a week of their childs food allergy clinic
appointment, parents received an e-mail asking them to complete a
set of questionnaires about their childs food allergy and their
psychosocial functioning. The e-mail also included a link to a
REDCap survey,26 an encrypted web-based application that is
designed to support data capture for research studies. After
completing questionnaires, parents reviewed an information page
that indicated their deidentied responses would be included in a
research database. Parents had the option to opt out of their in-
clusion in this database. Only research team members had access to
the deidentied data that were entered into the research database.
A waiver of documentation of consent was approved for this proj-
ect. Participants did not receive incentives. Approximately 34% of
all potential participants (N 303) completed the survey.
Participants
A total of 103 parents who received clinical care at an urban
Mid-Atlantic food allergy clinic in a pediatric medical center
completed the clinical assessment. Of these, 74 (72%) parents met
the inclusion criteria: child age between 9 months and 7 years
(to be consistent with the feeding measure guidelines), diagnosis of
at least one IgE-mediated food allergy by an allergist, access to the
internet, and English uency. No parents elected to opt out of
including their responses in the deidentied research database.
Measures
Demographic questionnaire
As part of the online survey, participants rst completed a de-
mographic and medical questionnaire developed by the study team
that assessed child age, sex, race, and ethnicity and parent age, sex,
and education level. Parents also reported diagnosis of peanut, tree
nut, cows milk, egg, soy, wheat, sh, and/or shellsh allergy.
Child mealtime behavior
Parents completed the Behavioral Pediatrics Feeding Assess-
ment Scale (BPFAS)15 to obtain parent report of childrens meal-
time behavior and parents strategies for managing these
behaviors. The BPFAS was developed for parents of children aged 9
months to 7 years. The measure includes 35 items regarding child
behaviors (25 items) and parents behaviors and emotions (10
items) associated with meals. For each behavior, parents report the
frequency on a 5-point Likert scale and indicate a dichotomous
endorsement (yes/no) of whether the behavior is a problem for
the parent. Six scores are derived from the BPFAS: child behavior
frequency, child problem, parent behavior frequency, parent
problem, total behavior frequency, and total problem. Higher
scores indicate more concerns. The BPFAS has acceptable validity
and reliability among typically developing populations.15 It has
also been successfully used in pediatric chronic illness pop-
ulations, such as those with type 1 diabetes, with satisfactory in-
ternal consistency.21,27 The Cronbach a values for this sample were
0.91 for the total behavior frequency scale and 0.93 for the total
problem scale.
Food allergy perceptions
Parents perceptions regarding their childs risk of allergen
exposure, food allergy severity, and food allergy worry were
assessed. Perceived risk of allergen exposure was rated on a 4-point
Likert scale (0 indicating no chance to 3 indicating high risk),
perceived food allergy severity was rated on a 100-point visual
analog scale, and food allergyerelated worry was rated on a 100-
point visual analog scale. Parents provided a rating for each indi-
vidual food allergy, and then composite variables were created as
the mean of the individual food allergy ratings.
Pediatric parenting stress
Stress regarding parenting a child with a medical illness was
assessed via the Pediatric Inventory for Parents (PIP).28 The PIP is a
42-item parent self-report measure. Parents rate the items fre-
quency in the last week (1 indicating never to 5 indicating very
often) and the level of difculty associated with it on a 5-point
Likert-type scale (1 indicating not at all to 5 indicating
extremely). Frequency and difculty ratings are summed for an
overall total frequency score and a total difculty score. Higher
scores indicate greater pediatric parenting stress. The PIP has been
used in diabetes samples and samples with other pediatric con-
ditions.28e30 The Cronbach a values for this sample were 0.92 for
the frequency scale and 0.95 for the difculty scale.
Food Allergy Quality of Lifeeparental burden
Parents food allergyerelated quality of life was assessed using
the Food Allergy Quality of LifeeParental Burden (FAQL-PB).31 The
FAQL-PB is a 17-item measure that assesses the effect of food al-
lergy on parents daily lives on a 7-point Likert scale (0 indicating
not limited or troubled to 6 indicating extremely limited/troubled).
A total score is derived by summing the items; higher scores
 L.J. Herbert et al. / Ann Allergy Asthma Immunol xxx (2016) 1e6 3

indicate greater parental burden. This measure has been well (SD) child mealtime problem score of 3.57 (4.69) (range, 0e18), a
validated.31,32 The Cronbach a for this sample was 0.94. mean (SD) parent mealtime concerns score of 19.32 (5.28)
(range, 11e36), and a mean (SD) parent mealtime problem score
Statistical Analysis of 1.54 (2.16) (range, 0e9). Parents reported a mean (SD) total
frequency score of 70.93 (16.67) (range, 41e127) and a mean
All statistical analyses were based on the 74 participants who
(SD) total problem score of 5.11 (6.51) (range, 0e27) (Table 2).
completed the online survey and were conducted using SPSS sta-
The BPFAS scores were signicantly positively correlated with
tistical software, 23rd edition (SPSS Inc, Chicago, Illinois). Pre-
each other (P < .001 for all) but were not related to number of
liminary descriptive statistics were generated for demographic and
food allergies, child age, parent age, or parent educational level
medical characteristics, the BPFAS, food allergy perceptions ratings,
(P > .05).
the PIP, and the FAQL-PB. Independent-samples t tests were con-
ducted comparing the mean BPFAS scores of this sample to pub-
Parenting Stress and Food AllergyeRelated Quality of Life
lished BPFAS data from typically developing and clinical
samples.15,21,33 Finally, Pearson Product Moment and Spearman r Parents reported a mean (SD) total frequency score on the PIP of
correlational analyses and a univariate regression analysis were 78.98 (21.11) (range, 46e140) and a mean (SD) total difculty score
conducted regarding the associations among demographic and of 68.18 (22.16) (range, 42e144) (Table 2). The BPFAS scores were
medical characteristics, BPFAS scores, food allergy perceptions, PIP signicantly positively correlated with PIP frequency and difculty
scores, and FAQL-PB scores. scores (P < .05 for all). Parents who reported greater mealtime
concerns also reported greater parenting stress related to parenting
Results a child with a medical illness. On the FAQL-PB, parents reported a
Participant Characteristics mean (SD) score of 1.76 (1.18) (range, 0e5). The FAQL-PB scores
were signicantly positively correlated with the BPFAS scores;
Table 1 lists the characteristics of the study participants. Chil- parents who reported greater mealtime concerns reported poorer
dren had a mean (SD) age of 3.57 (1.91) years. Most children were food allergyerelated quality of life. Finally, the BPFAS scores were
male (62%) and diagnosed with peanut (76%), tree nut (55%), or signicantly positively correlated with parents perceptions of their
direct egg (53%) allergies; 69% were diagnosed with more than one childs risk of allergen exposure; parents who reported greater
food allergy. Parents had a mean (SD) age of 36.32 (4.95) years. mealtime concerns also perceived a greater risk of allergen expo-
Most parents were female (92%) and white (44%) or African sure (P < .05 for all) (Table 3).
American (29%). Approximately half of parents had a graduate or A univariate regression analysis was conducted to assess the
professional degree (54%). relative contributions of parenting stress, food allergyerelated
In general, our sample reects the sex breakdown of our clinic quality of life, and perceived risk of allergen exposure on parents
population (62% vs 60% male). Our sample represents a slightly perceptions of mealtime behavioral concerns. The overall model
more white group of parents than our clinic population, which is was signicant (F3,67 13.50, P < .001). All 3 variables made a
25% white, 41% African American, 5% Asian American, 12% His- signicant contribution to mealtime behavioral concerns, with
panics, and 17% other race/ethnicity. parenting stress having the greatest impact (PIP: b .33, P < .001;
FAQL-PB: b .26, P < .001; risk of allergen exposure: b .20,
Mealtime Behavior P < .001).
On the BPFAS, parents reported a mean (SD) child mealtime
concerns frequency score of 51.61 (12.32) (range, 28e93), a mean Comparisons With Other Samples
Parents of children with food allergies reported signicantly
more mealtime problems than parents of typically developing
Table 1
Demographic and Food Allergy Characteristics of the 74 Study Participantsa children.33 Parents of children with food allergy reported more
frequent child mealtime concerns than parents of typically devel-
Characteristic Finding
oping children (t581 3.90, P < .0001) and were more likely to
Child age, mean (SD) [range], y 3.57 (1.91) [0.82e7.93]
Female children 28 (38.40)
Food allergies Table 2
Peanut 56 (75.70) Descriptive Statistics Regarding Mealtime Behavior, Parenting Stress, and Food
Tree nuts 41 (55.40) AllergyeRelated Parental Quality of Life
Direct egg 39 (53.40)
Baked egg 15 (23.10) Variable No. of Mean (SD) Range
Direct cows milk 21 (28.40) participants
Baked cows milk 12 (17.40)
Soy 9 (12.20) Behavioral Pediatric Feeding
Wheat 8 (10.80) Assessment Scale
Fish 11 (14.90) Child frequency 74 51.61 (12.32) 28.00e93.00
Shellsh 9 (12.30) Child problem 74 3.57 (4.69) 0.00e18.00
Diagnosed with >1 food allergy 51 (68.90) Parent frequency 74 19.32 (5.28) 11.00e36.00
Parent age, mean (SD) [range], y 36.32 (4.95) [23.92e50.93] Parent problem 74 1.54 (2.16) 0.00e9.00
Female parents 68 (91.90) Total frequency 74 70.93 (16.67) 41.00e127.00
Parent race/ethnicity Total problem 74 5.11 (6.51) 0.00e27.00
White 31 (44.30) Pediatric Inventory for Parents
African American 20 (28.60) Total frequency 71 78.98 (21.11) 46.00e140.00
Asian American 8 (11.40) Total difculty 71 68.18 (22.16) 42.00e144.00
Hispanic 4 (5.80) Food Allergy Quality of 74 1.76 (1.18) 0.00e5.50
Other 11 (15.70) LifeeParental Burden total score
Parent educational level of graduate or 39 (54.20) Mean perceived risk of allergen 74 1.24 (0.49) 0.09e2.60
professional degree exposure
a
Mean perceived food allergy severity 67 52.36 (24.02) 4.00e100.00
Data are presented as number (percentage) of participants unless otherwise Mean food allergy worry 72 63.35 (24.48) 10.00e100.00
indicated.
4 L.J. Herbert et al. / Ann Allergy Asthma Immunol xxx (2016) 1e6
Table 3
Correlations Among Parents Mealtime Concerns and Food Allergy Perceptions
BPFAS Perceived risk of allergen exposure Perceived food allergy severity
Child frequency .25a .20
Child problem .19 .13
Parent frequency .40b .13
Parent problem .28a .15
Total frequency .31b .19
Total problem .23a .14
Abbreviations: BPFAS, Behavioral Pediatric Feeding Assessment Scale; FAQL-PB, Food Allergy Quality of LifeeParental Burden; PIP, Pediatric Inventory for Parents.
a
P < .05.
b
P < .001.
c
P < .01.
report these behaviors as a problem than parents of typically
developing children (t581 3.36, P < .001). Similarly, parents of
children with food allergy reported more frequent parent mealtime
concerns than parents of typically developing children (t581 3.50,
P < .001) and were more likely to report that these concerns were a
problem than parents of typically developing children (t581 3.83,
P < .001) (Table 4).
When compared with parents of children with type 1 diabetes,
parents of children with food allergy reported more frequent child
mealtime concerns (t206 3.06, P < .01), but parents concerns in
other areas were comparable between the 2 samples (P > .05).
Finally, when compared with parents of children with diagnosed
feeding disorders with or without related medical factors, parents
of children with food allergy consistently reported fewer mealtime
concerns (P < .001) for all. See Table 4 for additional details. Of note,
the food allergy sample was younger than the type 1 diabetes
sample (mean, 3.57 vs 5.33 years).
Discussion
This is the rst study to examine the effect of mealtime con-
cerns among a diverse sample of children with food allergy. Par-
ents of children with food allergies reported signicantly more
mealtime problems than typically developing children. Several
factors may explain why mealtime concerns are more common
among parents of children with food allergies. Allergic reactions
may contribute to child and/or parental fear about trying new
foods and anxiety about eating previously introduced foods that
are similar to the allergen.34e36 Indeed, food avoidance among
children with food allergy has a stronger association with anxiety
regarding allergic reactions than medical recommendations
regarding elimination diets.37 Very young children who are unable
to communicate about their anxiety and physical symptoms may
cry, have tantrums, or refuse to eat, so parents may hesitate to
feed children certain foods or alter mealtime patterns because
they are uncertain if child behavior is due to an allergic reaction or
general food pickiness.34 Further complicating feeding is that
elimination diets may affect overall growth and nutrition; parents
may be concerned about meeting nutritional guidelines; feel
pressured to ensure that their child eats an appropriate amount of
protein, carbohydrates, and vitamins; and engage in maladaptive
mealtime behaviors.34,38e40 Avoiding allergens may also lead to a
monotonous diet,41 which may adversely affect mealtime
behaviors.
Parents of children with food allergies reported signicantly
fewer mealtime behavioral problems than children with diag-
nosed feeding concerns. Compared with another pediatric chronic
illness that affects diet, type 1 diabetes, parents of children with
food allergy reported signicantly more frequent child mealtime
concerns but similar perceptions regarding whether these child
behaviors were a problem and similar perceptions regarding
parent mealtime concerns. Although ingestion of an allergen may
Food allergy worry PIP- frequency PIP- difculty FAQL-PB
.03 .48b .33c .42b
.13 .44b .26a .39c
.15 .53b .43b .49b
.18 .48b .38c .37c
.07 .53b .38c .47b
.15 .47b .31c .40b
result in acutely severe and life-threatening anaphylaxis, mealtime
behavioral concerns may be most related to the fact that a strict
diet is required of both children with type 1 diabetes and food
allergy.
Finally, mealtime concerns were strongly related to other
parent perceptions of food allergy, such as risk of allergen
exposure, food allergyerelated quality of life, and illness-
related parenting stress. These ndings indicate that the par-
ents who are mostly likely to experience mealtime concerns are
parents who report general psychosocial functioning concerns
as well. This is consistent with ndings that increased
worry regarding food allergy correlates with decreased quality
of life.
Strengths, Limitations, and Future Directions
This study is the rst to assess mealtime behaviors among
children with food allergy compared with typically developing
children and examine the association of mealtime behaviors with
quality of life. Results were based on large sample sizes, and the
food allergy sample was racially diverse. Limitations to this study
include the cross-sectional design, reliance on internet-based
questionnaires, and the restricted age group of the children with
food allergies (as necessitated by the validated mealtime behavior
measure). It is uncertain whether the ndings are generalizable to
older age groups, but they are nonetheless important because early
childhood is developmentally when parents have primary re-
sponsibility for mealtime behaviors. Parents were the sole source of
information, and parental perceptions may not necessarily align
with those of children. Finally, there were no data on whether
children were also diagnosed with eosinophilic esophagitis, a
condition that may have a more severe effect on mealtime behav-
iors than IgE-mediated food allergy.
Future research should replicate these ndings among a longi-
tudinal sample that has access to in-person or telephone partici-
pation and should include more objective measures of feeding
concerns (ie, observational studies). Additional details regarding
food allergy and general medical history may further elucidate the
way that food allergies may affect nutritional concerns and meal-
time behavior (ie, epinephrine autoinjector prescription, allergic
reaction history, length of food allergy diagnosis, history of feeding
difculties, growth difculties, and/or appointments with a regis-
tered dietician). It will be advantageous to also examine how par-
ents mealtime behavioral concerns affect childrens intake (ie,
examine food records). Finally, there is little information about
older childrens feeding concerns and patterns, so inclusion of older
children in future studies is warranted. As the body of literature
regarding feeding concerns among children with food allergy in-
creases, it will be possible to develop clinical guidelines regarding
the assessment of feeding concerns among patients with food al-
lergy and advocate for appropriate referral to psychologists and
registered dieticians who may be able to provide intervention.
 L.J. Herbert et al. / Ann Allergy Asthma Immunol xxx (2016) 1e6 5

Conclusions

t Score

3.06b

0.80

0.74

1.38
Parents of young children with food allergy report more

Type 1 diabetes (n 134)

behavioral mealtime concerns than parents of typically developing

206

206

206

206
children and comparable concerns with parents of children with

df
other pediatric illnesses, such as type 1 diabetes. Mealtime con-
cerns were related to parents other perceptions about the childs

18.78 (4.92)
46.84 (9.8)

4.11 (4.66)

1.97 (2.14)
Mean (SD)
food allergy and may be an appropriate area for intervention.
Future research should investigate feeding concerns over time
and how food allergies and maladaptive mealtime behaviors affect
nutrition. These data may help clinicians better serve patients with
food allergy by identifying which families may need psychosocial
or nutritional support in addition to medical guidance. In particular,
Medical conditions requiring devices (n 154)

parents would likely benet from additional assistance in choosing

t Score

9.40a

7.21a

a
9.39

6.66

nutritionally appropriate hypoallergenic formulas, vitamin and

mineral supplements, and other food alternatives to ensure chil-
dren on avoidance diets receive a balanced, healthy diet.
BPFAS Comparisons Among Parents of Children With Food Allergy, Type 1 Diabetes, Feeding Disorders, Medical Conditions Requiring Feeding Devices, and Healthy Children

226

226

226

226

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eproblem

54:1081e1086.
P ! .001.
P < .01.
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