Gender, Asthma, Race May Be Linked to Anxiety in Children With Food Allergy

In the group of children aged 7 to 18 years old with peanut allergy, patients with asthma, girls, and non-White patients had higher anxiety scores.

Although there is no clear link between undergoing oral immunotherapy (OIT) for peanut allergy and anxiety in children, it appears possible that children with peanut allergy who are older, female, non-White, and/or have asthma may be more likely to experience anxiety. These were among study findings published in Annals of Allergy, Asthma & Immunology.

Researchers sought to explore the relationship between undergoing OIT and clinical anxiety in children with peanut allergy. Toward that end, the researchers conducted a prospective cross-sectional cohort study in 2021 comparing anxiety between children undergoing OIT for peanut allergy and children with peanut allergy not undergoing OIT (the control group).  

For this community-based study, children in the OIT cohort were from the New England Food Allergy Treatment Center in West Hartford, CT, and children who did not undergo OIT were enrolled from the Connecticut Asthma and Allergy Center in West Hartford. All patients undergoing OIT were volunteers and typically achieved maintenance of 500-600 mg peanut protein daily dose around 6 months. Patients were advised to continue treatment daily at home and were followed annually. Patients with prior history of OIT therapy with discontinuation were excluded.

The study involved a younger cohort (<7 years of age; n=80) and an older cohort (≥7 and less than 19 years of age; n=125). Data was collected through electronic survey questionnaires, filled out by children and/or parents, with age-appropriate anxiety scales. The younger cohort received the Pediatric Anxiety Score, a 29-question Likert scale instrument intended to be completed by the parent(s). The older cohort received the Screen for Childhood Anxiety Related Disorders, a 41-question Likert scale instrument. Anxiety levels between patients on OIT and not on OIT were compared using generalized linear regressions.

Patients and families not completing the survey in entirety were excluded from analysis. Among the 241 OIT patients initially contacted, 114 (n=38 <7 years; n=76 ≥7 years) patients were eligible for analysis. Among the 742 control patients contacted, 91 (n=42 <7 years; n=49 ≥7 years) were eligible for analysis.

White, non-Hispanic boys were predominant in both cohorts. Average was 4 years of age in the younger cohort and 12 years of age in the older cohort. Patients in the younger cohort were comparable to their control group with respect to sex, race, ethnicity, and socioeconomic status. Patients in the older cohort were well matched with patients in the control group. In the younger cohort 74% of patients on OIT were on maintenance dosing and 26% on build-up. In the older cohort, 95% of patients on OIT were on maintenance dosing and 5% on build-up.

Although our study was not able to identify a relationship between OIT and anxiety scores, it did show interesting signals for anxiety being associated with race, age, and comorbid asthma in food-allergic patients.

The younger cohort included 30% of patients with asthma and over 50% with eczema, with comparable levels in the OIT and control groups. In the older cohort, a greater proportion of patients in the control group vs OIT group had asthma (63% vs 42%) and eczema (49% vs 26%).

Among the younger cohort, the OIT group reported family history of anxiety disorder 42% of the time vs 29% of the time in the control group. Approximately 56% of all parents in this cohort reported anxiety specifically related to their child’s food allergy.

Among the older cohort, there was no meaningful difference in the OIT vs control group with respect to reported family history of anxiety disorder (22% vs 18%) or patient- reported diagnosed anxiety disorder (15% vs 16%). When parents completed surveys (which occurred for 55% of cohort members), 43% in the OIT group and 62% in the control group said they experienced anxiety specifically related to their child’s food allergy.

Researchers found a low prevalence of diagnosable anxiety across patients on OIT and controls in the younger cohort. They noted a higher prevalence of anxiety in the older cohort but no clinically meaningful difference between anxiety scores of patients on OIT and those in the control group.

Patients with asthma vs without asthma in the older cohort were more likely to have higher mean anxiety scores (P =.04) as did girls vs boys in the older cohort (P =.004). Researchers noted subanalysis of the older cohort (7-12 years of age vs >12 years of age) revealed that in the younger subgroup, non-White race (P =.04) and eczema (P =.02) were meaningful predictors of higher separation anxiety scores. Additional subanalysis of the older cohort suggested non-White race was a meaningful predictor of higher social anxiety scores (P <.02).

Study limitations include underpowered sample sizes, limited racial diversity, lacking pre- and post-OIT measurements of anxiety, unaccounted-for variation in how long patients on OIT had received this therapy, all of OIT treatment in a single-center, possible participation bias, and surveys completed by parents may not accurately reflect the child’s anxiety level.

“Although our study was not able to identify a relationship between OIT and anxiety scores, it did show interesting signals for anxiety being associated with race, age, and comorbid asthma in food-allergic patients,” said study authors. “The clinical implications of these findings suggest that allergists should particularly consider screening food-allergic children for anxiety and anxiety-subtypes among patients who are non-white, female, and/or have asthma,” said the researchers.

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kaman K, Dhodapkar M, Shabanova V, McCollum S, Factor J, Leeds S. Validated anxiety assessments among pediatric peanut-allergic patients on oral immunotherapy. Ann Allergy Asthma Immunol. Published online February 2, 2023. doi:10.1016/j.anai.2023.01.028