DISCUSSION
This study, one of the few to assess QoL in children with
TNA12,13, differs from previous studies by including
parental anxiety in two domains: state and trait anxiety. While our
findings are consistent with previous research in showing the
detrimental impact of negative experiences on QoL12,
they also offer new insights in three key areas. First, our study
suggests that assessing QoL from the father’s perspective may yield
better results. Second, it highlights the potential impact of parental
state anxiety on reported QoL. Third, it suggests that local traits such
as certain nut allergies may also contribute to the reported QoL.
Limited data are available concerning FARQL in children under 12 years
old. When comparing the total scores of our group with those from
previous studies employing the same scales, our FARQL scores appear on
the negative spectrum (0-3 years: 3.15±1.28; 4-6 years: 3.76±1.42; 7-12
years: 3.73±1.19) of the previous reports14. In
accordance with the validation study of Turkish version of FAQLQ-PF and
a recently conducted one in another region of the country, our scores
still remain on the negative side9,15. However, our
study’s findings align with those from Dunn-Galvin’s
sample8,16, which included scores from Irish and
American children, as well as Limpitikul’s sample of Thai
children17, indicating consistency across these
diverse populations.18 This discrepancy might be
attributed to tree nut allergies inducing persistent and severe
reactions, as well as the particularities of the study group.
Research on parental anxiety and mental health in the context of
children’s FAs has been subject of extensive research with mixed
results19-24. Some studies have found that mothers of
children with FAs experience negative effects on their mental
well-being, reporting higher levels of stress and anxiety than mothers
of children without food allergies. Other studies have found no
significant differences in anxiety or depression levels between parents
of children with and without FAs25. Parents play a
crucial role in shaping a child’s emotional development and
well-being.26 Children often learn by observing and
imitating their parents’ behaviors. This phenomenon is often referred to
as ”emotional contagion” or ”emotional mirroring.” Young children are
particularly susceptible to this because they are still developing their
emotional regulation skills and rely heavily on their caregivers for
emotional guidance and support.
To our knowledge, only two previous studies have explored the connection
between FARQL in children and parental anxiety
levels27. DunGalvin’s study reported a significant
link between parental general anxiety levels and Russian
children/adolescents’ FARQL by using Generalized Anxiety Disorder 7
(GAD-7) questionnaire. The other study on this subject, Acaster’s study,
used Hospital Anxiety and Depression Scale (HADS) and reported parental
anxiety significantly predicted higher levels of burden for the peanut
allergic child. While one could argue that our study reaffirms the
connection between parental anxiety and QoL, our findings offer a
nuanced perspective that focuses specifically on the state domain of
anxiety. Although we showed a significant correlation between state and
trait domains of anxiety, the difference in predictive capacity related
to state anxiety contributes to a deeper understanding of how to enhance
the accuracy of QoL assessment within the context of FAs. The STAI, HADS
and GAD-7, though both designed to measure aspects of anxiety, serve
different purposes and focus on different dimensions of this emotional
state. The STAI is designed to assess both state anxiety, which reflects
an individual’s immediate emotional state, and trait anxiety, which
gauges their enduring predisposition to anxiety. It provides a more
comprehensive assessment of anxiety levels overall. In contrast, the
GAD-7 is specifically designed to identify and assess symptoms of
generalized anxiety disorder, making it a more specialized tool for
clinical diagnosis and screening. HADS is often used for quick screening
of anxiety and depression in medical settings without distinguishing
between transient emotional states and enduring traits. Given these
differences in assessment tools, as well as the specific characteristics
of the populations and study groups, it is plausible that the observed
disparities in results are a consequence of these differences.
We showed that assessing QoL from the father’s perspective may yield
better results. Whether parental anxiety differs between mothers and
fathers is a multifaceted question that has been explored by various
researchers26,28, yielding mixed results. Some studies
suggest that mothers are more prone to experiencing anxiety compared to
fathers, particularly concerning aspects like their children’s health
and safety.29 The fear of losing a child is a profound
and universal concern among parents, particularly mothers, rooted in the
deep emotional bond and attachment formed with their child. In the
context of food allergies, it is crucial to recognize that parental
fears may be further exacerbated due to self/non-self negative
experiences, healthcare messages emphasizing the persistent/severe
nature of these allergies, and the necessity to carry an AAI for life.
Mothers and fathers may experience distinct types of anxiety at various
stages in their children’s lives. For example, a mother might be more
inclined to feel anxious about her child’s health if the child has a
chronic illness, while a father could be more prone to anxiety regarding
the child’s social development if the child is shy or
introverted.29
We demonstrated that the presence of hazelnut allergy exerts a negative
impact on FARQL, implying that local factors may also play a role in the
reported QoL. In this context, it is not surprising that hazelnut takes
center stage among other tree nuts in our study, given that Turkey leads
the world in hazelnut production and ranks third in per capita
consumption.30 Furthermore, in contrast to peanuts in
the Western world, hazelnut stands as the primary cause of IgE-mediated
food allergies and anaphylaxis.3,31,32 The widespread
production and consumption of hazelnuts could be indicative of a
heightened perception of the risk of unintentional exposure among
parents.
Nevertheless, it is important to acknowledge the limitations of our
study. These limitations encompass the absence of a prospective aspect
to document the evolving impact of state anxiety on FARQLQ-PF scores
over time, as well as the relatively modest sample size of the patient
group, which could introduce the possibility of type 2 errors for other
predictors. Nevertheless, our study boasts several strengths, including
being the sole study exclusively dedicated to TNA in the pediatric
population. It represents a pioneering effort in the Eastern
Mediterranean region and stands as the first and only study to explore
various domains of anxiety within this context.
In conclusion, the QoL of children with TNA, as perceived by their
parents, is influenced by a variety of factors. Among these factors,
some are universal, such as adverse life experiences; some are
influenced by local context, such as culinary culture; some are
situational, such as state anxiety; and some are parent-specific, such
as gender. Comprehending and addressing these multifaceted factors is
crucial for the accuracy of FARQL assessment in children.