Food Allergy Among Children in the United States

ARTICLES Food Allergy Among Children in the United Sttes AUTHORS: Amy M. Brnum, MSPH nd Susn L. Lukcs, MSPH, DO Infnt, Child, nd Women s Helth Sttistics Brnch, Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention, Hyttsville, Mrylnd KEY WORDS food llergy, food hypersensitivity, surveys ABBREVIATIONS NHIS Ntionl Helth Interview Survey NHANES Ntionl Helth nd Nutrition Exmintion Survey NHAMCS Ntionl Hospitl Amultory Medicl Cre Survey NAMCS Ntionl Amultory Medicl Cre Survey NHDS Ntionl Hospitl Dischrge Survey ICD-9-CM Interntionl Clssifiction of Diseses, Ninth Revision, Clinicl Modifiction IgE immunogloulin E CI confidence intervl ED emergency deprtment The findings nd conclusions in this rticle re those of the uthors nd do not necessrily represent the views of the Ntionl Center for Helth Sttistics, Centers for Disese Control nd Prevention. www.peditrics.org/cgi/doi/10.1542/peds.2009-1210 doi:10.1542/peds.2009-1210 Accepted for puliction Jun 16, 2009 Address correspondence to Amy M. Brnum, MSPH, Ntionl Center for Helth Sttistics, 3311 Toledo Rd, Room 6113, Hyttsville, MD 20782-2003. E-mil: mrnum@cdc.gov PEDIATRICS (ISSN Numers: Print, 0031-4005; Online, 1098-4275). Copyright 2009 y the Americn Acdemy of Peditrics FINANCIAL DISCLOSURE: The uthors hve indicted they hve no finncil reltionships relevnt to this rticle to disclose. WHAT S KNOWN ON THIS SUBJECT: Food llergy wreness nd prevlence reportedly hve een incresing mong children in recent yers. WHAT THIS STUDY ADDS: This study is the first to mke ntionlly representtive trend estimtes of food llergy prevlence nd helth cre utiliztion in the United Sttes. In ddition, this study chrcterizes some food llergy chrcteristics ccording to rce/ethnicity, which few studies reported previously. strct OBJECTIVES: The gols were to estimte the prevlence of food llergy nd to descrie trends in food llergy prevlence nd helth cre use mong US children. METHODS: A cross-sectionl survey of dt on food llergy mong children 18 yers of ge, s reported in the 1997 2007 Ntionl Helth Interview Survey, 2005 2006 Ntionl Helth nd Nutrition Exmintion Survey, 1993 2006 Ntionl Hospitl Amultory Medicl Cre Survey nd Ntionl Amultory Medicl Cre Survey, nd 1998 2006 Ntionl Hospitl Dischrge Survey, ws performed. Reported food llergies, serum immunogloulin E ntiody levels for specific foods, multory cre visits, nd hospitliztions were ssessed. RESULTS: In 2007, 3.9% of US children 18 yers of ge hd reported food llergy. The prevlence of reported food llergy incresed 18% (z 3.4; P.01) from 1997 through 2007. In 2005 2006, serum immunogloulin E ntiodies to penut were detectle for n estimted 9% of US children. Amultory cre visits tripled etween 1993 nd 2006 (P.01). From 2003 through 2006, n estimted verge of 317 000 food llergy-relted, multory cre visits per yer (95% confidence intervl: 195 000 438 000 visits per yer) to emergency nd outptient deprtments nd physicin s offices were reported. Hospitliztions with ny recorded dignoses relted to food llergy lso incresed etween 1998 2000 nd 2004 2006, from n verge of 2600 dischrges per yer to 9500 dischrges per yer (z 3.4; P.01), possily ecuse of incresed use of food llergy V codes. CONCLUSION: Severl ntionl helth surveys indicte tht food llergy prevlence nd/or wreness hs incresed mong US children in recent yers. Peditrics 2009;124:1549 1555 PEDIATRICS Volume 124, Numer 6, Decemer 2009 1549

Food llergy mong children is serious helth issue tht cn e lifethretening. Reports indicte tht the prevlence of food llergy, prticulrly llergy to penuts, my e incresing mong children. 1 3 However, there re few dt sources ville tht cn e used to mke sttisticlly relile estimtes of food llergy mong ll children in the United Sttes, on ntionlly representtive sis. As result, descriptions of food llergy mong US children re lcking informtion out llergies in specific demogrphic groups (ie, ccording to ge, gender, or rce/ethnicity). Such informtion could revel disprities in food llergy mong sugroups of children. In ddition, there is limited knowledge out helth cre utiliztion for food llergy mong ffected children on ntionl sis. Therefore, the purpose of this nlysis ws to descrie trends in the prevlence of food llergy nd food llergy-relted helth cre use mong children in the United Sttes, y using ntionlly representtive survey dt. METHODS Dt Sources This nlysis used multiple US ntionl surveys collected or coordinted y the Ntionl Center for Helth Sttistics. Becuse the results presented were from secondry dt nlyses, Ntionl Center for Helth Sttistics institutionl review ord pprovl ws not required. Prevlence Dt Prevlence estimtes of food llergy mong children 0 to 17 yers of ge were from the Ntionl Helth Interview Survey (NHIS) for the yers 1997 2007. The NHIS, conducted continuously, is lrge-scle household interview survey of the civilin noninstitutionlized popultion in the United Sttes. The NHIS is sed on ntionlly representtive smple of households, uses multistge proility smpling design, nd serves s the min source of dt on vrious helth conditions in the US popultion. 4 This nlysis used dt from the smple child component (in which 1 child ws smpled from ech eligile household) of the NHIS, which hd finl response rte of 77% in 2007. Since 1997, question out food llergy ( During the pst 12 months, hs [child] hd ny kind of food or digestive llergy? ) hs een included in the NHIS; results were used to clculte prevlence estimtes. For children, this question is nswered y n dult proxy, most often the prent. In 1999, the question ws not sked for 2-yer-old prticipnts ecuse of skip pttern error. For comprison, prevlence estimtes for other llergic conditions sked out in the NHIS, including eczem/ skin llergy, respirtory llergy, nd hy fever, lso were clculted for ech yer from 1997 through 2007, on the sis of responses to questions with the sme formt s tht for food llergy. Prevlence estimtes from the NHIS were clculted s proportions of ll smpled children for ech individul yer. Period prevlence rtes for serum immunogloulin E (IgE) ntiodies to certin foods were derived from the llergy component of the 2005 2006 Ntionl Helth nd Nutrition Exmintion Survey (NHANES). 5 The response rte for the exmined smple ws 77%. Survey prticipnts 1 yer of ge who took prt in the exmintion portion of the NHANES were eligile for mesurement of serum IgE ntiodies to penut, egg, nd milk. IgE ntiodies to shrimp were mesured in exminees 6 yers of ge. The rnge of detectle serum IgE levels ws 0.35 to 1000 ku/l. Serum IgE levels were mesured y using the Phrmci Dignostics ImmunoCp 1000 system (Phrmci Dignostics, Klmzoo, MI). More informtion out this test nd lortory procedures cn e found elsewhere. 6 Amultory Cre Visits nd Hospitliztions Dt on food llergy-relted multory cre visits to hospitl fcilities nd physicin offices nd hospitliztions were derived from the Ntionl Amultory Medicl Cre Survey (NAMCS), the Ntionl Hospitl Amultory Medicl Cre Survey (NHAMCS), nd the Ntionl Hospitl Dischrge Survey (NHDS). Dt from the NAMCS nd NHAMCS were included for 1993 2006 nd dt from the NHDS for 1998 2006. The NAMCS is survey of visits to non federlly employed, office-sed physicins who re engged primrily in direct ptient cre. The NHAMCS is sed on ntionl smple of visits to emergency deprtments (EDs) nd outptient deprtments of noninstitutionl generl nd short-sty hospitls. Both the NAMCS nd the NHAMCS use multistge proility smpling. 7,8 In 2006, response rtes were 64% for the NAMCS, 73% for the NHAMCS outptient component, nd 89% for the NHAMCS ED component. The NHDS is conducted nnully nd is ntionlly representtive survey of hospitl dischrges from non federl, short-sty hospitls. In 2006, the NHDS response rte ws 92%. Smpling is sed on multistge pproch, nd dischrges re selected t rndom from smpled hospitls. 9 In 1993 2006, the NAMCS/NHAMCS collected up to 3 physicin dignoses, y using Interntionl Clssifiction of Diseses, Ninth Revision, Clinicl Modifiction (ICD-9-CM) codes, nd the NHDS collected up to 7 dignoses. Any listed, food llergy-relted dignoses from these surveys mong children 18 yers of ge were identified y using the ICD-9-CM codes shown in 1550 BRANUM nd LUKACS

ARTICLES TABLE 1 ICD-9-CM Codes Used to Identify Food Allergy Visits nd Hospitliztions Description ICD-9-CM Code Allergic rhinitis ttriutle to 477.1 food Allergic gstroenteritis nd 558.3 colitis Generl food llergy ccording to specific type of food Penuts V15.01 Milk products V15.02 Eggs V15.03 Sefood V15.04 Other foods V15.05 Contct dermtitis ttriutle 692.5 to food in contct with skin Dermtitis ttriutle to food 693.1 tken internlly Toxic effect of fish nd shellfish 988.0 Anphylctic shock ttriutle 995.6 to dverse food rection, specificlly for Unspecified food 995.60 Penuts 995.61 Crustcens 995.62 Fruits nd vegetles 995.63 Tree nuts nd seeds 995.64 Fish 995.65 Food dditives 995.66 Milk products 995.67 Eggs 995.68 Other specified food 995.69 Other dverse food rections, 995.7 not elsewhere clssified This dignosis ws used only in conjunction with n dditionl dignosis relted to llergy. Tle 1. ICD-9-CM code 988.0, for toxic effects of fish or shellfish eten, ws included if there ws ny other code on the sme record relted to llergy. For these surveys, the unit of nlysis is the visit (NAMCS/NHAMCS) or hospitl dischrge (NHDS) nd not the individul. Anlyses For ll of the surveys, SEs nd confidence intervls (CIs) for the pproprite unit of mesure were derived y using SAS 9 (SAS Institute, Cry, NC) nd SUDAAN (Reserch Tringle Institute, Reserch Tringle Prk, NC) to ccount for the complex smpling design, nd ll dt were weighted y using the designted smpling weights to reflect ntionl estimtes. Estimtes with 30 unweighted events per cell nd reltive SE (SE divided y its estimte) of 0.3 were considered relile nd re reported. Trend nlysis using ll dt points for given time period ws performed y using weighted, lestsqures regression to ccount for the vrinces derived from the complex smpling design. Differences etween demogrphic groups in the NHANES dt were tested y using the Ro- Scott F-djusted 2 test, s recommended in the NHANES nlytic guidelines. 10 After the initil nlysis, it ws determined tht there were not enough unweighted visits to llow seprte time trend estimtes for visits to EDs, hospitl outptient fcilities, nd physicin offices. Therefore, the dt from the NHAMCS nd NAMCS were comined for ssessment of time trends for food llergy-relted visits to ll multory emergency nd outptient hospitl fcilities nd physicin offices. RESULTS From 1997 through 2007, rtes of food llergy mong ll children incresed significntly (z 3.4; P.01) (Tle 2). By 2007, 3.9% of children 0 to 17 yers of ge reported hving hd food or digestive llergy in the previous 12 months. In ddition, rtes of reported skin llergy or eczem incresed significntly, wheres rtes of reported respirtory llergy showed no significnt trend nd rtes of reported hy fever decresed slightly (Tle 2). Trends in rtes of reported food llergy ccording to gender were similr over time (Tle 3). There lso were sttisticlly significnt, incresing trends in rtes of food llergy mong non-hispnic white, non- Hispnic lck, nd Hispnic children from 1997 through 2007 (Tle 3). Although Hispnic children hd significntly lower prevlence of reported food llergy in 2007, compred with non-hispnic white nd non-hispnic lck children, 11 they experienced the gretest increse in the prevlence of reported food llergy over the time period nlyzed. In 2005 2006, serum IgE ntiodies to penut were detectle in n estimted 9% of US children. Antiodies to egg, milk, nd shrimp were detectle in 7%, 12%, nd 5% of children, respectively (Tle 4). Becuse detectle levels of IgE lone were not relile indictor of true clinicl disese, 90th percentile vlues of the detectle rnges of penut-, milk-, nd eggspecific serum IgE levels lso were ssessed (Tle 4). Non Hispnic lck children were twice s likely s non-hispnic white children to hve detectle levels of IgE ntiodies to penut nd were nerly twice s likely to hve detectle levels of IgE ntiodies to milk. In ddition, non-hispnic lck children were 4 times s likely s non-hispnic white children to hve detectle ntiodies to shellfish (Fig 1). Hispnic children were etween non-hispnic white nd non-hispnic lck children in the proportion with detectle levels of ny food-specific IgE ntiody. Unweighted smple sizes were too smll for investigtions of differences ccording to rce/ethnicity, ccording to 90th percentile vlues of serum IgE levels for ll foods. From the NAMCS nd NHAMCS dt, the verge numer of multory cre visits with food llergy-relted dignoses per yer nerly tripled from 1993 1997 through 2003 2006 (z 2.7; P 01) (Tle 5). Between 2003 nd 2006, n verge of 317 000 visits to multory cre fcilities per yer with food llergy-relted dignoses were reported. Using the NHDS dt, we demonstrted previously n increse in hospitliztions with ny dignosis of food llergy. 11 For the current nlysis, sensitivity nlysis of the NHDS dt ws conducted to determine whether the significnt increse PEDIATRICS Volume 124, Numer 6, Decemer 2009 1551

TABLE 2 Food, Skin, nd Respirtory Allergy nd Hy Fever Prevlence Estimtes Among Children 18 Yers of Age in the United Sttes in Selected Yers Condition Prevlence, No. of Cses (%, Estimte SE) 1997 1999 2001 2003 2005 2007 Food llergy 491 (3.3 0.2) 384 (3.2 0.2) 473 (3.5 0.2) 444 (3.6 0.2) 515 (4.0 0.2) 378 (3.9 0.3) Skin llergy/eczem c 1086 (7.9 0.3) 808 (7.0 0.3) 1105 (8.4 0.3) 1066 (9.1 0.3) 1222 (9.9 0.3) 856 (8.9 0.3) Respirtory llergy 1684 (12.0 0.3) 1313 (10.8 0.4) 1667 (12.6 0.4) 1386 (11.5 0.4) 1490 (11.7 0.4) 856 (9.6 0.4) Hy fever d 1485 (10.4 0.3) 1223 (10.3 0.3) 1319 (10.2 0.4) 1178 (9.7 0.3) 1309 (10.5 0.3) 931 (10.1 0.4) The dt source ws the NHIS. In 1999, the llergy questions were not sked for 2-yer-old sujects in the NHIS. P.01 for weighted, lest-squres, regression trend test. c P.0001 for weighted, lest-squres, regression trend test. d P.05 for weighted, lest-squres, regression trend test. TABLE 3 Food Allergy Prevlence Estimtes Among Children 18 Yers of Age in the United Sttes in Selected Yers, According to Gender nd Rce/ Ethnicity Prevlence, No. of Cses (%, Estimte SE) 1997 1999 2001 2003 2005 2007 Gender Mle 246 (3.2 0.2) 196 (3.3 0.3) 238 (3.4 0.3) 230 (3.6 0.3) 267 (3.9 0.3) 193 (3.8 0.3) Femle c 245 (3.4 0.3) 188 (3.0 0.3) 235 (3.7 0.3) 215 (3.5 0.3) 248 (4.0 0.3) 185 (4.1 0.4) Rce/ethnicity Non-Hispnic 294 (3.5 0.2) 249 (3.6 0.3) 284 (3.9 0.3) 265 (3.8 0.3) 277 (4.3 0.3) 184 (4.1 0.4) white c Non-Hispnic 78 (3.2 0.4) 59 (3.0 0.4) 73 (3.3 0.4) 67 (3.6 0.5) 86 (4.0 0.5) 74 (4.0 0.6) lck Hispnic d 95 (2.3 0.3) 63 (1.8 0.2) 94 (2.2 0.3) 88 (2.4 0.3) 128 (3.1 0.3) 88 (3.2 0.4) The dt source ws the NHIS. In 1999, the llergy questions were not sked for 2-yer-old sujects in the NHIS. P.01 for weighted, lest-squres, regression trend test. c P.05 for weighted, lest-squres, regression trend test. d P.0001 for weighted, lest-squres, regression trend test. TABLE 4 Numers, Proportions, nd 90th Percentile Vlues for Serum IgE Antiody Levels for Penut, Egg, Milk, nd Shellfish Among Children 1 to 17 Yers of Age in the United Sttes in 2005 2006 Food Unweighted No. Weighted No., Millions Proportion, Estimte SE, % 90th Percentile, Estimte (95% CI), ku/l Penut 339 6.5 9.3 0.8 11.1 (7.0 17.3) Egg 236 4.7 6.7 0.6 2.2 (1.4 3.1) Milk 461 8.5 12.2 0.9 2.0 (1.7 2.5) Shrimp 193 1.1 5.2 0.6 The dt source ws the NHANES. Shrimp IgE levels were mesured for children 6 yers of ge. Relile estimtes could not e mde ecuse of smll smple size. in hospitliztions for food llergy ws ttriutle to increses in dignoses more primrily relted to food llergy. Therefore, the dt were restricted to the first 3 dignoses with 1 dignosis relted to food llergy. An incresing trend in hospitliztions ws still pprent (dt not shown). A more indepth exmintion of the types of food llergy dignoses ws undertken to determine whether ny specific dignosis ws responsile for the increse in hospitliztions over time. This nlysis reveled tht growing numer of dignoses were ttriutle to generl food llergy nd specific food llergy (ICD-9-CM codes V150.1 V150.5) coded secondry to other nonllergy indictions for hospitliztion. Therefore, the dt were renlyzed fter exclusion of the V codes for food llergy. After this exclusion, the incresing trend in hospitliztions with dignoses relted to food llergy ws not sttisticlly significnt (Fig 2). DISCUSSION This nlysis of dt from ntionlly representtive helth nd helth cre surveys provides evidence of incresed food llergy mong US children nd/or food llergy wreness y helth cre professionls nd prents. In the pst decde, the prevlence of reported food llergy nd food llergyrelted dignoses in helth cre settings hs incresed. The results of this nlysis lso revel potentil rcil disprities in food llergy prevlence mong children. It is importnt to note tht the NHIS dt re sed on prentl or proxy reports of food llergy rther thn clinicl dignoses, which could potentilly result in 1552 BRANUM nd LUKACS

ARTICLES Percent 20 16 12 8 4 0 non-hispnic white non-hispnic lck Hispnic Penut Egg Milk Shrimp IgE ntiodies FIGURE 1 Proportions of children 18 yers of ge with detectle levels of IgE ntiodies to specific foods in the United Sttes in 2005 2006, ccording to rce/ethnicity. The dt were from NHANES. P.01; P.0001; c P.0001. TABLE 5 Averge Numers of Visits per Yer to EDs, Hospitl Outptient Deprtments, nd Physicin Offices With Any Dignosis of Food Allergy Among Children 18 Yers of Age in the United Sttes in 1993 2006 Yer Weighted Estimte (95% CI), Visits per Yer 1993 1997 116 000 (61 000 171 000) 1998 2002 247 000 (126 000 368 000) 2003 2006 317 000 (196 000 438 000) Dt sources were the NHAMCS nd NAMCS. Test for trend, P.01. Numer of nnul dischrges 12,000 10,000 8,000 6,000 4,000 2,000 0 inflted estimtes ecuse it hs een demonstrted tht perceived food llergy is often misunderstood nd overestimted, compred with cliniclly dignosed food llergy. 12 14 It is importnt to note tht prents re not given guidnce in the NHIS on wht constitutes digestive llergy nd prentl interprettions of the question might include conditions such s lctose intolernce or celic disese, which re not true food llergic conditions. However, we noted similr proportion of children with food llergy in the NHIS, compred with estimtes of food llergy in the US popultion tht re sed on smller, less-representtive smples with more-stringent definitions of food llergy. 2 In ddition, nother ntionl survey, the Ntionl Survey of Children s Helth conducted in 2003 2004, sked out food llergy on the sis of prent reports ut sked whether prents hd een told y doctor or helth cre professionl tht their child hd food llergy. The Ntionl Survey of Children s Helth Dischrges with food llergy V-codes Dischrges with no food llergy V-codes 1998-2000 2001-2003 2004-2006 FIGURE 2 Averge numers of hospitl dischrges per yer with ny dignosis of food llergy, with nd without food llergy-specific V codes, mong children 18 yers of ge in the United Sttes in 1998 2006. The dt were from the NHDS. * V codes for food llergy were introduced in 2000; therefore, no visits from 1998 2000 used food llergy V codes. 1 Overll trend sttisticlly significnt (z 6.72; P.0001); 2 trend mong dischrges with no food llergy V codes not sttisticlly significnt. 1 2 c estimted tht 3.6% of US children hd some food or digestive llergy on the sis of this question, which ws the sme s tht from the 2003 NHIS. 15 Therefore, it does not seem tht relince on prentl determintion of perceived food llergy oversttes reported prevlence estimtes for food llergy. As expected, food sensitiztion mesured on the sis of serum foodspecific IgE levels ws greter thn the self-reports from the NHIS. Although serum IgE mesurements cnnot e used lone to determine the prevlence of food-specific llergies or to predict rections to certin foods, they cn give n indiction of incresed topy nd risk for llergic rections to food. The dt from NHANES might reflect children who demonstrted rections to food previously nd outgrew them or those who hve current food llergy nd my or my not ever hve rection to food. Reported food llergy is incresing mong children of ll ges, mong oys nd girls, nd mong children of different rces/ethnicities. Although the trend ws significnt for non-hispnic white, non-hispnic lck, nd Hispnic children, food llergy incresed most mong Hispnic children, lthough non- Hispnic lck children generlly hd the lrgest proportions of detectle serum IgE ntiodies to specific foods. This might demonstrte disprities in wreness nd reporting mong different demogrphic groups. Non Hispnic white children hd significntly smller proportions of serum IgE ntiodies to penut, milk, nd shellfish, compred with non-hispnic lck nd Hispnic children, ut hd the highest reported prevlence of food llergy in the NHIS. Therefore, the incresing prevlence of food llergy in prent reports might indicte incresing recognition of food llergy mong groups tht previously regrded symptoms s those of non PEDIATRICS Volume 124, Numer 6, Decemer 2009 1553

food llergy. Alterntively, rcil differences etween food-specific IgE levels nd self-reported food llergies might e ttriutle to differences in dietry hits or other fctors tht differ mong these rcil/ethnic groups. The increses in food llergy-relted multory cre visits nd hospitliztions lso lend support to incresing wreness nd use of food llergy-relted dignostic codes in the helth cre setting, in ddition to supporting possile increses in rtes of children seeking helth cre services ecuse of food llergy. The results found in the current study corroorte other reports of incresing hospitl stys for food llergy. 16,17 The pprent increse in food llergy-relted hospitliztions seems to e ttriutle in lrge prt to the incresing use of generl V codes for food llergy in conjunction with other resons for hospitliztions. The V codes were dopted in 2000, nd incresing cceptnce nd wreness of the codes might help explin the increse in food llergyrelted hospitliztions etween the 1998 2000 nd 2001 2003 time periods nd possily the lrge increse through 2004 2006. It is plusile tht the increse in generl food llergy dignoses reflects incresed food llergy prevlence tht is eing recorded when ptients come to the hospitl for other resons or incresed wreness y physicins nd other medicl personnel regrding the use of V codes to designte ptients with food llergy who re stying in the hospitl. Although there hve een no other estimtes of food llergy-relted visits in the United Sttes from dt comprle to the NHAMCS nd NHDS in scope, estimtes from the Ntionl Electronic Injury Surveillnce System, ntionl system used to identify dverse events presenting in EDs resulting from consumer product use, were similr to those mde in this nlysis. Ross et l 18 estimted tht 20 821 food llergyrelted visits to EDs occurred in 2-month period, on the sis of medicl chrt review. Of those visits, pproximtely one fourth were mong children 5 yers of ge, which yields n estimte of food llergy-relted visits to EDs mong preschool-ged children of 5200 in 2-month period. The NHAMCS dt for the sme period (1999 2000) yield n estimte for children of ll ges of 6600 visits to EDs nd outptient clinics comined in 2-month period. Although they re not completely comprle, these estimtes re similr enough to lend strength to the reporting of food llergy visits in the NHAMCS. However, it is importnt to note tht there is evidence for underreporting of food llergy with the use of ICD- 9-CM codes lone. 18 20 This nlysis is suject to other limittions, in ddition to those discussed ove. The NHIS provides no informtion on llergies to specific foods; therefore, the prevlence nd trend of llergies to penuts, milk, nd shellfish cnnot e determined with this ntionl dt source. As stted previously, the IgE dt from NHANES do not indicte the severity of food llergy, nd the other components of NHANES do not contin dditionl questions on food llergy. To cpture food prevlence on ntionl level, survey idelly would contin oth clinicl nd self-reported mesures of food llergy, which neither NHIS nor NHANES currently do. Therefore, the IgE dt re limited in their ility to chrcterize children who my e t risk for dverse rections to food. In ddition, the NAMCS, NHAMCS, nd NHDS dt re limited to ICD-9-CM codes nd there is no wy to vlidte these results. Nevertheless, there re mny dvntges in using these dt to estimte trends in food llergy prevlence nd hospitl visits. The NHIS, NAMCS, NHAMCS, nd NHDS ll generte ntionlly representtive dt tht re collected in consistent mnner ech yer. This is impertive for continued trcking of future trends in food llergy prevlence nd helth cre utiliztion. The NHIS lso provides lrge smple size for explortion of differences in food llergy ccording to rce/ethnicity nd gender, which previous reports of food llergy hve not een le to descrie. CONCLUSIONS Dt from ntionlly representtive helth nd helth cre surveys indicte increses in reported food llergy estimtes mong US children. However, it cnnot e determined how much of the increses in estimtes re truly ttriutle to increses in clinicl disese nd how much re ttriutle to incresed wreness y physicins, other helth cre providers, nd prents. However, the consistent increses cross surveys nd mong children in ll ge, 11 gender, nd rce/ ethnicity groups provide evidence tht the increses re not limited to certin setting, reporting mechnism, or demogrphic group. ACKNOWLEDGMENTS We thnk Dr Lester Curtin of the Ntionl Center for Helth Sttistics nd Dr Michel Pistiner of Children s Hospitl Boston for their suggestions nd ssistnce with sttisticl nd content issues. 1554 BRANUM nd LUKACS

ARTICLES REFERENCES 1. Sicherer SH, Smpson HA. Penut llergy: emerging concepts nd pproches for n pprent epidemic. J Allergy Clin Immunol. 2007;120(3):491 503 2. Sicherer SH, Muñoz-Furlong A, Smpson HA. Prevlence of penut nd tree nut llergy in the United Sttes determined y mens of rndom digit dil telephone survey: 5-yer follow-up study. J Allergy Clin Immunol. 2003;112(6):1203 1207 3. Grundy J, Mtthews S, Btemn B, Den T, Arshd SH. Rising prevlence of llergy to penut in children: dt from 2 sequentil cohorts. J Allergy Clin Immunol. 2002; 110(5):784 789 4. Ntionl Center for Helth Sttistics. Dt File Documenttion, Ntionl Helth Interview Survey, 2007 [mchine redle dt file nd documenttion]. Hyttsville, MD: Ntionl Center for Helth Sttistics; 2008 5. Centers for Disese Control nd Prevention. NHANES 2005 2006 Documenttion, Codeook, nd Frequencies, Lortory Component: Allergen Specific IgE(s) nd Totl IgE in Serum. Atlnt, GA: Centers for Disese Control nd Prevention; 2008. Aville t: www.cdc.gov/nchs/dt/ nhnes/nhnes 05 06/l ige d.pdf. Accessed April 10, 2009 6. Centers for Disese Control nd Prevention. NHANES 2005 2006 Lortory Procedure Mnul for Serum IgE. Atlnt, GA: Centers for Disese Control nd Prevention; 2006. Aville t: www.cdc.gov/nchs/dt/ nhnes/nhnes 05 06/ l ige d met specific ige totl ige.pdf. Accessed April 10, 2009 7. Centers for Disese Control nd Prevention. NHAMCS scope nd study design. Aville t: www.cdc.gov/nchs/out/ mjor/hcd/smphm.htm. Accessed Octoer 20, 2009 8. Centers for Disese Control nd Prevention. NAMCS scope nd study design. Aville t: www.cdc.gov/nchs/hcd/ smpnm.htm. Accessed Octoer 20, 2009 9. Centers for Disese Control nd Prevention. NHDS scope nd design. Aville t: www.cdc.gov/nchs/nhds/out_nhds.htm. Accessed Octoer 20, 2009 10. Centers for Disese Control nd Prevention. Continuous NHANES we tutoril: descriptive sttistics. Aville t: www.cdc.gov/nchs/tutorils/nhnes/ NHANESAnlyses/DescriptiveSttistics/ descriptive sttistics intro.htm. Accessed April 10, 2009 11. Brnum AM, Lukcs SL. Food Allergy Among US Children: Trends in Prevlence nd Hospitliztions. Hyttsville, MD: Ntionl Center for Helth Sttistics; 2008. NCHS dt rief 10 12. Vierk KA, Koehler KM, Fein SB, Street DA. Prevlence of self-reported food llergy in Americn dults nd use of food lels. J Allergy Clin Immunol. 2007;119(6): 1504 1510 13. Altmn DR, Chirmonte LT. Pulic perception of food llergy. J Allergy Clin Immunol. 1996;97(6):1247 1251 14. Gupt RS, Kim JS, Brnthn JA, Amsden LB, Tumml LS, Holl JL. Food llergy knowledge, ttitudes nd eliefs: focus groups of prents, physicins, nd the generl pulic. BMC Peditrics. 2008;8:36 15. The Child nd Adolescent Helth Mesurement Inititive. Ntionl Survey of Children s Helth. DtResourceCenter.On-linedtquerysystem ccessile t: http://nschdt.org/dtquery/ SurveyAres.spx. Accessed April 10, 2009 16. Gupt R, Sheikh A, Strchn D, Anderson HR. Incresing hospitl dmissions for systemic llergic disorders in Englnd: nlysis of ntionl dmissions dt. BMJ. 2003; 327(7424):1142 1143 17. Sheikh A, Alves B. Hospitl dmissions for cute nphylxis: time trend study. BMJ. 2000;320(7247):1441 18. Ross MP, Ferguson M, Street D, Klontz K, Schroeder T, Lucciolo S. Anlysis of foodllergic nd nphylctic events in the Ntionl Electronic Injury Surveillnce System. J Allergy Clin Immunol. 2008;121(1): 166 171 19. Clrk S, Bock SA, Get TJ, Brenner BE, Cydulk RK, Cmrgo CA. Multicenter study of emergency deprtment visits for food llergies. J Allergy Clin Immunol. 2004;113(2): 347 352 20. Clrk S, Get TJ, Kmrthi GS, Cmrgo CA. ICD-9-CM coding of emergency deprtment visits for food nd insect sting llergy. Ann Epidemiol. 2006;16(9):696 700 PEDIATRICS Volume 124, Numer 6, Decemer 2009 1555

Food Allergy Among Children in the United Sttes Amy M. Brnum nd Susn L. Lukcs Peditrics 2009;124;1549; originlly pulished online Novemer 16, 2009; DOI: 10.1542/peds.2009-1210 Updted Informtion & Services References Cittions Suspecilty Collections Permissions & Licensing Reprints including high resolution figures, cn e found t: /content/124/6/1549.full This rticle cites 11 rticles, 2 of which cn e ccessed free t: /content/124/6/1549.full.html#ref-list-1 This rticle hs een cited y 20 HighWire-hosted rticles: /content/124/6/1549.full.html#relted-urls This rticle, long with others on similr topics, ppers in the following collection(s): Nutrition /cgi/collection/nutrition_su Allergy/Immunology /cgi/collection/llergy:immunology_su Informtion out reproducing this rticle in prts (figures, tles) or in its entirety cn e found online t: /site/misc/permissions.xhtml Informtion out ordering reprints cn e found online: /site/misc/reprints.xhtml PEDIATRICS is the officil journl of the Americn Acdemy of Peditrics. A monthly puliction, it hs een pulished continuously since 1948. PEDIATRICS is owned, pulished, nd trdemrked y the Americn Acdemy of Peditrics, 141 Northwest Point Boulevrd, Elk Grove Villge, Illinois, 60007. Copyright 2009 y the Americn Acdemy of Peditrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Food Allergy Among Children in the United Sttes Amy M. Brnum nd Susn L. Lukcs Peditrics 2009;124;1549; originlly pulished online Novemer 16, 2009; DOI: 10.1542/peds.2009-1210 The online version of this rticle, long with updted informtion nd services, is locted on the World Wide We t: /content/124/6/1549.full PEDIATRICS is the officil journl of the Americn Acdemy of Peditrics. A monthly puliction, it hs een pulished continuously since 1948. PEDIATRICS is owned, pulished, nd trdemrked y the Americn Acdemy of Peditrics, 141 Northwest Point Boulevrd, Elk Grove Villge, Illinois, 60007. Copyright 2009 y the Americn Acdemy of Peditrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.