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.