Clinician's Corner: Approaching Excessive Anxiety and Anaphylaxis Phobia in Food Allergic Children

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Children's Doctor

Katherine Dahlsgaard, PhD, ABPP, Megan O. Lewis, MSN, CRNP Contributed by Katherine Dahlsgaard, PhD, ABPP, Megan O. Lewis, MSN, CRNP Sarah is an 11-year-old girl with milk and egg allergy who you have seen for years. In the past, she was a joyful child; however, this year she had an episode of anaphylaxis requiring an ED visit after cross-contamination in a muffin. At the visit, you notice she is reluctant to talk about the experience and has lost weight. She is newly unwilling to attend sleepovers or birthday parties, “because she doesn’t want to go.” You suspect she has increased anxiety after her allergic reaction. What is the next best step for her?

Anxiety is adaptive and protective in children with food allergies. Learning to avoid specific allergens, reading labels, and managing safety social situations—like dining out—are all additional responsibilities families with food allergies must navigate. However, that anxiety can become excessive, which can prove debilitating to child and family functioning. Excessive anxiety in the context of food allergies is identified by medically unnecessary avoidance that is persistent (typically months, not weeks) and pervasive across multiple contexts.

The first line treatment for anxiety disorders is cognitive-behavioral therapy (CBT) with a focus on exposure. Exposure is the systematic, gradual introduction of the individual to safe situations they have nonetheless been avoiding. Via exposure, individuals have a corrective learning experience and improve the accuracy of their risk assessment, which lowers anxiety and improves confidence and skills.

CHOP clinicians have observed increasing incidents of excessive anxiety in food allergic families. To address this, they created a unique clinic—with cross-disciplinary engagement—devoted exclusively to evidence-based assessment of child anxiety disorders that occur in the context of food allergies. The FAB (Food Allergy Bravery) Clinic is co-directed by the authors, a CBT psychologist and nurse practitioner, and Section Chief of Allergy, Jonathan Spergel, MD, PhD. Group sessions with multiple families take place with both the psychologist and allergy provider present.

The focus is on structured, gradual, and repeated "Bravery Challenges" (exposures) designed to help overly anxious kids test out whether their fearful predictions about being unsafe in the mere presence of their allergen are true or untrue. All Bravery Challenges are designed to help children learn by doing what is truly safe, with those lessons designed to be directly transferable to real-world situations. For instance, a child who learns in the FAB Clinic that smelling peanut butter does not cause an allergic reaction will, with repeated practice, become much more comfortable and confident when eating at the school lunch table with their friends.

Identification of children and families engaging in unnecessary avoidance is critical to prevention of excessive anxiety. Specific, helpful questions when seeing families with food allergies include: “Even if food is brought from home, does your child refuse to go to parties due to fears of cross-contamination?” and “Do they avoid new foods, even if you tell them they are safe to eat?”

Prompt identification and intervention can also improve the child and family’s overall quality of life. Ideally, we can prevent anxiety disorders from forming, and the FAB Clinic has offered parent education nights to provide general information on food allergy safety and anxiety prevention. Families that need additional support are referred to the FAB Clinic for treatment. To continue to provide FAB services, in light of current events, we have switched all groups to telemedicine and have had continued success with families.

Reference and Suggested Reading

New issue of food allergy: Phobia of anaphylaxis in pediatric patients. Journal of Allergy and Clinical Immunology Web site. Accessed September 9, 2020.

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