Social well-being among children with vs without food allergy before and during coronavirus disease 2019.

Prepandemic studies note high rates of bullying among children with food allergy, specifically because of their condition, often on school grounds such as on the playground or in the classroom. In addition, we have recently reported that, among mothers of children with food allergy, 44% reported symptoms indicative of clinical anxiety. Whereas anxiety has increased in children and their families, children who experience bullying at school—such as those with food allergy—may have indirectly experienced a reprieve as a result of pandemic-related physical distancing and public health restrictions. This is the first study to analyze the outcomes of distanced learning and bullying of children with food allergy.

This analysis makes use of data from 2 cohorts on the costs of food allergy, collected in the year before the coronavirus disease 2019 pandemic and 2 months during the pandemic (May 1-June 30, 2020) when schools were largely closed to in-person learning. Both cohorts completed similar questionnaires based on the EcoQ questionnaire. Each cohort consisted of cases and controls without food allergy. In the prepandemic cohort, cases were recruited from a tertiary pediatric allergy clinic during food allergy-related follow-up visits, controls were recruited via convenience and snowball sampling, and caregivers completed a paper version of the questionnaire. This cohort included participants from the Province of Manitoba, Canada, only. The pandemic cohort was recruited via convenience sampling through e-mail and social media advertisements. Cases were defined as the oldest child (aged 0-18 years) in the family, and who were reported to have 1+ food allergy. Controls were also defined as the oldest child in the family (as this provided best-scenario age matching with the cases), but who did not have reports of food allergy. The pandemic cohort completed an online version of the caregiver-completed questionnaire, with participants recruited from across Canada. Data were described using n/N, %, and mean ± SD and compared using χ2 tests, with statistical significance set at P less than .05, using Stata version 15.1 (College Station, Texas). Families reporting monthly .household income in excess of $30,000 (ie, half the annual median household income in Canada) were excluded from the calculations of income to prevent skewing of the data (prepandemic cohort: 2 cases, 2 controls; pandemic cohort, 2 cases, 3 controls). This study was approved by the University of Manitoba Health Research Ethics Board (H2018:319 [HS22066]).

The prepandemic cohort included 65 cases (55.1%) and 53 controls (44.9%), with corresponding numbers of 62 (60.8%) and 40 (39.2%) from the pandemic cohort (Table 1 ). Gender distribution was comparable between the cohorts, although slightly more boys than girls were cases in the pandemic cohort (72.1% vs 27.9%). The prepandemic cohort was approximately 2 years younger than the pandemic cohort [(prepandemic: cases—mean 6.9 [median 6.0] years, controls—mean 7.4 [median 6.0] years); (pandemic: cases—mean 9.2 [median 10.0] years, controls—mean 8.7 [median 7.0] years)]. Monthly household income was comparable between the cohorts, and children were typically part of a 4-person (2 adults, 2 children) household. Among the cases, the 3 most common food allergies were, among the prepandemic cohort, as follows: peanut and/or tree nut (81.5%), egg (29.2%), and fish (21.5%); and, among the pandemic cohort: peanut/tree nut (51.6%), milk (32.3%), and egg (27.4%).

Table 1

Demographic Characteristics of the 2 Cohorts

Characteristic	Prepandemic cohort				Pandemic cohort
	Food allergy (N = 65)		No food allergy (N = 53)		Food allergy (N = 62)		No food allergy (N = 40)
	n	%	n	%	n	%	n	%
Sex
Boy	33	50.8	30	56.6	44	72.1	16	40.0
Girl	32	49.2	23	43.4	17	27.9	24	60.0
Single-parent family	3	4.6	2	3.8	5	8.1	4	10.0
	Mean ± SD		Mean ± SD		Mean ± SD		Mean ± SD
Age (y)	6.9 ± 4.9		7.4 ± 4.8		9.2 ± 5.1		8.7 ± 5.1
Monthly household incomea	6265 ± 2964		6591 ± 4755		8568 ± 9916		7433 ± 8693
Family size	3.8 ± 0.9		4.1 ± 1.1		3.8 ± 0.7		3.8 ± 0.9
Followed by a physician for food allergy	65	100	—	—	60	96.8	—	—
Types of food allergyb
Milk	10	15.4	—	—	20	32.3	—	—
Egg	19	29.2	—	—	17	27.4	—	—
PN, TN, or both	53	81.5	—	—	32	51.6	—	—
Fish	14	21.5	—	—	11	17.7	—	—
Shellfish	8	12.3	—	—	5	8.1	—	—
Soy	4	6.2	—	—	7	11.3	—	—
Wheat	4	6.2	—	—	4	6.5	—	—
Sesame	6	9.2	—	—	8	12.9	—	—
Sulfites	0	0.0	—	—	1	1.6	—	—
Other	2	3.1	—	—	12	19.4	—	—
	%		%			%		%
Social well-being
Anxiety	19.0		29.4			67.2		59.5
Isolation	31.0		19.6			51.7		48.7
Bullying	31.0		20.0			6.9		16.2

Abbreviations: PN, peanut; TN, tree nut.

Restricted to households with a monthly income of $60,000 or less.

Not mutually exclusive.

Within each cohort, cases and controls had similar frequencies of parent-reported anxiety and/or depression, bullying, and isolation. At baseline, anxiety was comparable and not statistically different between the cases and controls (19.0% vs 29.4%, respectively; P < .20). With consideration to the prepandemic vs pandemic cohorts, anxiety was more common among both cases (19.0% vs 67.2%; P < .001) and controls (29.4% vs 59.5%; P < .005) during the pandemic; bullying decreased among the cases (31.0% vs 6.9%; P < .008), but not controls (20.0% vs 16.2% P = .66); and social isolation did not change significantly among the cases (31.0% vs 51.7%; P = .07), but it did increase among the controls (19.6% vs 48.7%; P < .005).

We demonstrated that the rates of childhood anxiety doubled from the year before the pandemic to the early months of the pandemic, a finding that aligns with reports from previous pandemics. Whereas children with food allergy had considerably lower rates of bullying during the pandemic, this remained unchanged among those without food allergy. This observation suggests that children with food allergy tend to be bullied on school grounds, whereas children without food allergies are bullied outside the school environment. Given that the mean ages of all cohorts were between 7 and 9 years old, it is likely that most participants have similar access to technology. However, if this is not the case, children with more access to online resources such as chat rooms or social media will be subjected to increased cyberbullying, likely unrelated to food allergy. As ages increase, increased access and comfort with technology are presumable, and cyberbullying is likely to increase as well. That being said, our findings underscore an urgent need to address food allergy-related bullying, which abruptly and considerably decreased when the pandemic started. As noted by Brown et al, racialized children with food allergy may experience different kinds of bullying, specifically nonfood-allergy–related. This study does not provide race-specific data on rates of bullying, which is a limitation of the study. However, previous reporting indicates that it is also of great importance for school staff to pay close attention to racialized students being bullied at school.

Unlike children without food allergy, children with food allergy did not report differences in isolation before vs during the pandemic. As many social events such as school and extracurriculars have been paused amidst the pandemic, it is likely that this has caused feelings of missing out. One hypothesis as to why children without food allergies would experience this considerably more than children with food allergies is that the latter feel less pressure at virtual social events, where they feel less food-related pressure.

Owing to the coronavirus disease 2019 pandemic, this study was limited to online sampling, with a reliance on internet and technology to obtain data. Unfortunately, the study was not accessible to participants without internet in their homes, limiting the sample to a specific demographic of people with access to internet. Future research should be done to include families without access to internet. In addition, further research could be done to focus on students who obtain school-supplied or government-subsidized lunches, as this provides another avenue for bullying at school.

Given that these findings provide evidence to suggest that food-allergy–related bullying takes place on school grounds, it is suggested that a zero-tolerance policy for the bullying of students with food allergy be introduced and enforced while children are on school property, more specifically where food is involved, such as in the lunchroom. Furthermore, given the finding that anxiety increased in both groups of children during the pandemic, caution should be taken with return to school to ensure that children feel safe on school grounds. As schools slowly reopen, and as we slowly move toward a postpandemic world, the time to act is now.