Managing Anxiety Related to Anaphylaxis in Childhood: A Systematic Review

Table 1

Key findings and recommendations of included studies.

Study	Method	Key findings	Recommendations
Akeson et al., 2007 [15]	Qualitative study of anaphylactic adolescents and their parents.	Adolescents perceived anaphylaxis as “no big deal” and could not remember a reaction; parents reported anxiety about “handing over” management of anaphylaxis to adolescents.	Tailored information for transition from parental to self-management needed; regular reviews and reinforcement about avoidance and emergency management needed; offer peer support via workshops.
Avery et al., 2003 [9]	Peanut allergic and diabetic children compared on a quality of life questionnaire.	Peanut allergic children reported lower quality of life and higher anxiety; epinephrine injectors and eating in familiar places seemed to reduce anxiety.	Anxiety may promote better adherence to allergen avoidance; epinephrine injectors may ease excessive anxiety.
Cummings et al., 2010 [10]	Nut allergic children and mothers completed questionnaires on anxiety and quality of life.	Children had lower quality of life relative to norms; mothers and children were less anxious when prescribed epinephrine injectors, regardless of their adherence to precautions.	Prescribe epinephrine injectors to reduce anxiety; provide additional education/advice to improve adherence and reduce risk taking.
DunnGalvin et al., 2009 [27]	Comparison of parents of food allergic children who enrolled child in immunotherapy study with those who did not.	Parents who enrolled their children reported higher anxiety, but similar quality of life.	Study samples may be biased towards anxious parents; avoid taking advantage of anxious parents’ vulnerability when recruiting for studies.
DunnGalvin et al., 2008 [28]	Evaluation of quality of life questionnaire for parents of food allergic children.	The Food Allergy QoL-Parent Form shows excellent reliability and validity.	Consider using this questionnaire to assess health-related quality of life in parents of food allergic children.
Eigenmann et al., 2006 [25]	Survey of food allergic patients after a negative food challenge.	25% of patients continued to avoid the food, fearing persistence of allergy.	Reassess food consumption in patients with negative food challenge; repeat challenge if avoidance continues.
Friedman et al., 1994 [4]	Case series of 10 patients with recurrent unexplained flushing.	Several were originally diagnosed as anaphylactic, but eventually found to have somatization disorders.	Recognition of this presentation is needed to avoid unwarranted examinations and procedures.
Hawkes et al., 2010 [29]	Retrospective review of cases admitted to hospital for MMR immunization in Ireland.	Children often admitted due to history of egg allergy, even though risk of anaphylactic reaction is very low in this population.	Advise routine community vaccination for children with egg allergy; educate physicians about their low anaphylaxis risk.
Herbert and Dahlquist, 2008 [11]	Comparison of food allergic and nonallergic adolescents/young adults on self-report measures.	Perceived autonomy, anxiety, depression, and parental behavior did not differ between groups; those with anaphylaxis reported more worry and parental overprotection than those with less severe allergies.	Recognize that anaphylactic individuals and their parents are at particular risk for psychological distress; further study is needed.
Hu et al., 2008 [16]	Survey and qualitative interviews with parents of food allergic children.	Parents found consumer organizations good sources of practical information and support, but some nonspecific advice and contact with other anxious parents were unhelpful.	Clinicians should guide parents as to what aspects of consumer organizations are most helpful.
Khetsuriani et al., 2010 [5]	Review of adverse events in a measles-rubella vaccination campaign in Georgia.	79 severe adverse events; 37 of these had symptoms of syncope or anxiety attack, and all but one of these was initially diagnosed anaphylactic.	Risk communication strategies for care providers and the public are needed during public vaccination campaigns.
King et al., 2009 [14]	Quality of life reports from children with peanut allergy, parents, and siblings.	Mothers reported poorer quality of life and higher anxiety than fathers; separation anxiety greater in children with peanut allergy than their siblings.	Be aware that child’s allergy management may fall to mothers, increasing their personal and family stress; foster allergy self-care for children to reduce anxiety.
Lebovidge et al., 2006 [12]	Development and evaluation of a questionnaire regarding parental response to children’s food allergies.	Factor analysis revealed anxiety/distress, psychosocial impact of allergy, parental coping/competence, and family support factors. Greatest anxiety if child had many allergies or had anaphylaxis.	This measure may be a useful screening tool to identify parents of allergic children who are most vulnerable to anxiety and high psychosocial impact of child’s allergy.
Lyons and Forde, 2004 [17]	Comparison of adolescents/young adults with/without food allergy on self-report questionnaire.	Allergy had less impact on allergic individuals’ lives than others thought; allergic youth with high health competence reported greatest anxiety; few subjects knew the meaning of the term “anaphylaxis.”	Health education is needed in this population; increased vigilance among health competent individuals may increase anxiety or anxious individuals may self-diagnose food allergy; more research is needed.
Mandell et al., 2005 [2]	Qualitative interviews of parents of anaphylactic children.	Repeated cycles of adaptation to episodic anxiety-provoking (i.e., anaphylaxis-related) events challenge families to regain a sense of control.	Recognize patterns of family adaptation to anaphylaxis; help families maintain an optimal balance between protective and debilitating anxiety.
Oude et al., 2002 [23]	Randomized controlled trial of patients receiving either immunotherapy or epinephrine injector for yellow jacket allergy.	Quality of life reported as improved in immunotherapy group but not in epinephrine injector group.	Provide venom immunotherapy to improve quality of life and decrease anxiety in this population.
Powers, 2004 [6]	Single case report of reaction to jellyfish sting reported as anaphylaxis.	Individual had asthmatic attack due to anxiety induced by the jellyfish sting.	Emergency workers should treat presenting symptoms rather than assuming that anaphylaxis has occurred.
Primeau et al., 2000 [18]	Comparison of quality of life and family relations in parents of children with peanut allergy versus rheumatological disease.	Parents of peanut allergic children reported that children had more disruption in daily life and the condition had more impact on the family.	Accurate diagnosis of peanut allergy, support for families, and offering more peanut-free products would help these children and families.
Roberts-Thompson et al., 1985 [13]	Retrospective review of 98 cases of bee sting anaphylaxis.	Most reactions occurred in children; considerable anxiety present in some subjects.	Provide venom immunotherapy to alleviate anxiety.
Sampson et al., 2006 [19]	Internet questionnaire for 174 food allergic adolescents and young adults.	High-risk behavior associated with less “concern,” and with social situations involving peers.	Education of food allergic teens and also of their peers is needed to reduce risk of anaphylaxis.
Sicherer et al., 2001 [20]	Comparison of 253 parents of food allergic children versus established norms on psychosocial function questionnaire.	Low health perception of child, high emotional impact on parent, high limitation of family activities reported, especially if child had multiple food allergies.	Be aware of these psychological effects on child and family; provide family support and education; raise public awareness of the issue; advocate for food labeling.
Somers, 2011 [21]	Case report of 11-year old with peanut allergy.	Subject had very restricted diet due to fear of anaphylaxis, affecting weight gain; tense family interactions around meals.	Offer nutritional guidance; use 24-hour food recall; offer behavioral guidelines for parents; get child involved in food preparation to increase confidence.
Vargas et al., 2011 [22]	Qualitative study of parents of food allergic children.	Parents wanted (1) concise information on symptoms, cross-contamination of foods, label reading, epinephrine injectors, and advocacy; (2) education of professionals and community.	Parents of newly diagnosed children could benefit from a food allergy management curriculum; clear, concise materials would likely reduce anxiety.
Zijlstra et al., 2010 [24]	Parental anxiety measured before and after allergic children underwent food challenges.	Parental state anxiety decreased with food challenge regardless of result; parental trait anxiety was unchanged.	Food challenges may help alleviate parental anxiety about their children’s allergies.