Feeding characteristics in young children with IgE‐mediated food allergies: A cross‐sectional observational study

Jennifer Kefford; Elizabeth C Ward; Rebecca L Packer; Merryn Netting; Shruti Swamy; Lara S Ford; Jeanne Marshall

doi:10.1111/pai.70508

. 2026 Oct 7;37(10):e70508. doi: 10.1111/pai.70508

Feeding characteristics in young children with IgE‐mediated food allergies: A cross‐sectional observational study

Jennifer Kefford ^1,^2,^✉, Elizabeth C Ward ^1,³, Rebecca L Packer ¹, Merryn Netting ^4,⁵, Shruti Swamy ^6,^7,^8,⁹, Lara S Ford ^6,¹⁰, Jeanne Marshall ^1,¹¹

PMCID: PMC13646849 PMID: 42844973

Abstract

Background

Research is limited regarding the intersection between Immunoglobulin‐E (IgE)‐mediated food allergies and paediatric feeding Disorder (PFD). The impact on caregivers managing a child with both conditions also remains poorly understood.

Objective

This study aimed to explore feeding characteristics in young children with IgE‐mediated food allergies to identify the proportion of children who may be at risk of PFD, and to examine associations between risk of PFD and caregiver‐reported stress and feeding‐related quality of life.

Methods

A cross‐sectional cohort (N = 107) of caregivers of children aged 0;6–4;11 years, with at least one diagnosed IgE‐mediated food allergy, was recruited from three paediatric allergy clinics. Validated caregiver‐reported questionnaires were used to assess feeding behaviours, caregiver stress and feeding‐related quality of life.

Results

Seventeen (16%) children were identified as being at risk of PFD based on the Behavioural Pediatric Feeding Assessment Scale‐Total Frequency Score (BPFAS‐TFS). Across the cohort, caregiver stress fell within the expected range. However, caregivers of children at risk of PFD reported significantly higher levels of stress on the Parental Stress Scale (PSS) (p < .001) and poorer feeding‐related quality of life on the Feeding Swallowing‐Impact Scale (FS‐IS) (p < .001).

Conclusion

Sixteen percent of children with IgE‐mediated food allergies screened as being at risk of PFD, suggesting that screening and assessment of PFD are valuable in this population. More frequent difficult mealtime behaviours were associated with increased caregiver stress and lower feeding‐related quality of life. Health services must recognise the compounded stressors of managing both food allergies and feeding behaviours/PFD to deliver holistic, family‐centred care.

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Keywords: caregiver burden, feeding and eating disorders, feeding behaviours, food allergy, food hypersensitivity

In young children with IgE‐mediated food allergy, 16% exhibited feeding behaviours associated with risk of paediatric feeding disorder. Caregivers reporting more frequent difficult feeding behaviours also experienced higher stress and poorer feeding‐related quality of life, highlighting the need for greater clinical awareness of feeding concerns in this population.

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Key message.

Caregivers of children with food allergies experience stress and anxiety during mealtimes and feeding. Caregivers of children with PFD also report higher levels of stress regarding feeding.

In this cohort of children with IgE‐mediated food allergies, 16% were reported to exhibit feeding behaviours associated with the risk of paediatric feeding disorder, supporting the consideration of referral for feeding assessment when concerns are identified. Caregivers of children with IgE‐mediated food allergies, who reported more frequent difficult feeding behaviours, also reported higher stress and lower feeding‐related quality of life. Therefore, enhanced clinical awareness of paediatric feeding disorder in the food allergy population is warranted to optimise care pathways for this group of children. To provide holistic care, health services must consider the cumulative burden for caregivers of managing both food allergies and paediatric feeding disorder.

1. INTRODUCTION

Food allergies are immune reactions that occur when a person touches or ingests an allergen. ¹ Immunoglobulin E (IgE)–mediated food allergies represent the most prevalent subtype of food allergy and are characterised by rapid onset of symptoms following allergen exposure, with the potential to lead to anaphylaxis. ² The primary management is avoidance of the food allergen/s themselves. ¹ , ³ In the developed world, the prevalence of IgE‐mediated food allergy in preschool children is reported to be around 8%. ³ , ⁴ For young children in Australia, the prevalence of IgE‐mediated food allergies peaks at 10% around 12 months of age, with egg and peanut being the most common food allergens. ⁵

Paediatric feeding disorder (PFD) is a diagnostic term applied when a child presents with impaired oral intake that is not considered age‐appropriate, and which may be associated with medical, nutritional, feeding skill and/or psychosocial dysfunction. ⁶ To meet diagnostic criteria for PFD, a child must demonstrate impaired oral intake and dysfunction in one or more of the medical, nutritional, feeding skill, or psychosocial domains. ⁶ Emerging research has begun to investigate whether food allergy may represent one potential underlying aetiology of PFD, ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ and several potential drivers have been proposed. Given the early onset of food allergy in many children, the introduction of complementary foods and the progression of typical feeding development may be disrupted, ¹² with some children further self‐restricting their already medically restricted diet. ¹ , ¹³

In many children, the process of identifying food allergy has been known to be delayed for a range of reasons. This may be due to difficulty with recognising symptoms, ¹⁴ , ¹⁵ limited food‐allergy knowledge and confidence in primary care, ¹⁶ , ¹⁷ delays in referral pathways, ¹⁸ , ¹⁹ and limited access to allergy specialists. ¹⁹ , ²⁰ A delayed diagnosis can lead to continued exposure to food allergens and resulting symptoms, causing some children to develop a negative association between eating and pain or discomfort. ⁷ , ¹⁰ If there are concerns regarding the child's weight or nutrition, for example, or if behaviour is particularly challenging, caregivers can fall into a pattern of offering only food the child is likely to accept, ⁷ , ¹⁰ potentially creating a vicious cycle that further perpetuates feeding and behavioural challenges. Even though the majority of children do outgrow their food allergies, it has been observed that these difficult feeding behaviours established in early childhood can persist beyond this resolution. ²¹

Currently, despite these theoretical underpinnings, there is only limited research focussing on the intersection between PFD and IgE‐mediated food allergies. Most studies including children with IgE‐mediated food allergies have reported on feeding outcomes for children with single food allergies, ⁹ , ²² did not distinguish between children with IgE and non‐IgE‐mediated food allergies, ⁸ , ²¹ , ²³ or included children with significant medical complexities, making it difficult to determine clearly aetiology for PFD. ²¹ , ²⁴ , ²⁵ A recent scoping review of feeding characteristics of children with food allergies identified the need for further systematic research regarding this intersection, particularly for children with IgE‐mediated food allergies. ¹¹

Caregivers of children with food allergies report increased levels of stress in themselves. ²⁶ , ²⁷ , ²⁸ Much of this stress has been linked to the demands of anaphylaxis management including use of adrenaline/epinephrine injectors, ²⁷ , ²⁹ as well as the everyday challenges of feeding a child with food allergies, especially the challenge of ensuring strict allergen avoidance while still offering a developmentally appropriate, balanced diet. ¹³ , ²⁶ , ³⁰ It is well understood, however, that PFD also contributes significantly to caregiver stress and can have a negative impact on the caregiver‐child relationship. ³¹ , ³² , ³³ For caregivers managing both food allergies and potentially PFD, it is postulated that the burden of mealtimes may be associated with heightened stress as they navigate the cognitive and emotional demands of strict allergen avoidance alongside the challenging feeding behaviours of the child.

No known studies have explicitly explored the nature and relationship between IgE‐mediated food allergy and PFD. However, it is important to note that Avoidant/Restrictive Food Intake Disorder (ARFID) is also a diagnosis that results in impaired oral intake, and considerable overlap has been acknowledged in the literature regarding PFD and ARFID, with international consensus in early stages. ³⁴ ARFID criteria include nutritional limitations alongside psychosocial limitations, but there is no suggested dysfunction in the medical or feeding skills domain, ³⁵ which differentiates it from PFD to a degree. Given the considerable overlap between these conditions, however, it is worth acknowledging that research in the feeding disorder space regarding the interaction between food allergies and feeding problems may represent either PFD or ARFID or both disorders. This study collected information from the caregivers of children aged between 0;6 and 4;11 years with IgE‐mediated food allergies and aimed to explore (a) the feeding characteristics of young children in this population; and (b) examine associations between risk of PFD and both caregiver‐reported stress and feeding‐related quality of life. It was hypothesised that feeding behaviours consistent with PFD would be common in children with IgE‐mediated food allergies, and that heightened caregiver stress and reduced feeding‐related quality of life would be associated with greater risk of PFD.

2. METHODS

The study involved a cross‐sectional cohort design. Ethics approval for this study was granted by the Northern Sydney Local Health District Ethics Committee (2022/ETH03126) and was ratified by The University of Queensland (2021/HE000240). All participants provided written informed consent. The study is reported using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. ³⁶

2.1. Setting

Participants were recruited from February 2023 to July 2024 across 3 sites: The Children's Hospital Westmead, Sydney Children's Hospital and Royal North Shore Hospital. All facilities are located in Sydney, New South Wales, Australia. The state of New South Wales has the largest population in Australia of 8.66 million people. The Children's Hospital at Westmead and Sydney Children's Hospital are specialist quaternary children's hospitals, and Royal North Shore Hospital is a tertiary hospital providing both adult and paediatric services. Participants were recruited from paediatric allergy clinics at each of these facilities.

2.2. Participants

Participants were the caregivers of children 0;6–4;11 years, who had been medically diagnosed with one or more IgE‐mediated food allergies and who attended an appointment at one of the allergy services within the data collection period. Posters showing information regarding the study's purpose, inclusion criteria and instructions on how to access the data collection tools were displayed in each clinic. Medical and nursing staff were briefed on the study and brought the posters to the attention of appropriate caregivers. The first author (J.K.) attended all three sites regularly during the data collection period to answer questions and support participants in completing the tools if required, and a research assistant was engaged at The Children's Hospital at Westmead to support recruitment at that site. Eligibility was checked either in person at the time of data collection or during data analysis. Children with any other co‐morbidities that may have affected feeding development (e.g., autism or non‐IgE‐mediated food allergies) were excluded. Potential participants were required to have sufficient English to complete the online assessment tools.

Eligible children were recruited across the following age groups: infants (6–18 months); toddlers (19–36 months); and preschoolers (37–59 months). The age groups were selected to reflect clinically relevant developmental stages in line with changes in feeding skill development, eating behaviour, communication development, and the diagnosis and progression of food allergy development and resolution. A target convenience sample of approximately 10–15 children across each age group at each site was set, with a total target sample size of 90–135 children.

2.3. Data collection

Data collection occurred online via REDCap ³⁷ (Research Electronic Data Capture), hosted at Northern Sydney Local Health District and involved completion of a demographic questionnaire and then three validated assessment tools. Once caregivers had provided consent to participate in the study, they were provided a QR code to be scanned on their own smart device to gain access to the data collection tools. All data were entered anonymously. Caregivers could complete the tools whilst waiting in the allergy clinic or could provide consent for email links to be sent for later completion. There were no incentives for participation.

2.3.1. Demographic questionnaire

A purpose‐built 23‐item demographic questionnaire was used to collect information on the child's food allergy diagnoses, family history of food allergies/atopy, history of anaphylaxis and any clinical support the family may have accessed (see File S1). The questionnaire also asked the caregivers to rate their concern regarding feeding using a single binary response question: ‘Have you ever had any concerns regarding your child's behaviour at mealtimes?’

2.3.2. Behavioural Pediatric Feeding Assessment Scale (BPFAS)

The Behavioural Pediatric Feeding Assessment Scale (BPFAS) ³⁸ is a valid and reliable, widely used caregiver‐reported measure of behavioural and skill‐based feeding difficulties in children from 9 months to 8 years of age. It contains 25 questions regarding the child's mealtime behaviours and 10 questions regarding caregiver feelings and behaviours around mealtimes with their child.

Caregivers rate each item for the frequency that it occurs on a 5‐point Likert scale (Never‐Always experienced). This data is used to calculate the BPFAS‐Total Frequency Score (BPFAS‐TFS), where higher scores indicate more pronounced difficult feeding behaviours. A BPFAS‐TFS of >84 is suggestive of a child at risk of clinically significant feeding problems, ³⁸ and this score was used in the current study to identify children at risk of PFD. In addition, caregivers are also asked to consider all test items and provide a binary rating as to whether that particular behaviour is/is not a problem. These scores are then used to calculate the BPFAS‐Total Problem Score (BPFAS‐TPS), with a cut score of >9 considered clinically significant. Normative data are available in the original article by Crist, Napier‐Phillips ³⁸ as well as other studies, ³⁹ including Australian normative data, ⁴⁰ and this tool has been used in other studies of children with food allergies. ⁸ , ⁴¹ In this study, the BFPAS is used as a proxy screening tool to indicate risk of PFD. The tool provides a cut score that suggests a child has problematic feeding behaviour frequency, and multiple studies have used the BPFAS to this end. ⁴¹ , ⁴² , ⁴³

2.3.3. Parental Stress Scale (PSS)

The Parental Stress Scale (PSS) ⁴⁴ is a caregiver‐reported tool that measures individual differences in the level of stress that can be associated with raising children. It is made up of 18 questions and uses a 5‐point Likert scale investigating the challenges involved in routine caregiving tasks, stressors relating to a child's behaviour, development and health, and the societal pressures and personal attributes related to caregiving.

Higher scores on the PSS indicate higher caregiver‐reported stress, with a mean of 37.1 considered indicative of typical expected caregiver stress. ⁴⁴ This tool has demonstrated validity and reliability, ⁴⁴ with psychometric data available for caregivers of children with chronic medical conditions, including food allergies. ⁴⁵

2.3.4. Feeding Swallowing Impact Scale (FS‐IS)

The Feeding Swallowing Impact Scale (FS‐IS) ⁴⁶ is a valid and reliable caregiver‐reported tool that measures the impact of children's feeding and swallowing problems on the feeding‐related quality of life of their caregivers. It contains 18 questions across three subscales. Caregivers use a 5‐point Likert scale to answer questions regarding the time demands with daily activities; regarding any worries or concerns about their child's wellbeing; and any challenges surrounding the specific feeding and swallowing needs their child may have. ⁴⁶ Scores are calculated for each subscale and in total; the higher the score, the greater the caregiver impact. A recent UK study has provided normative data for the FS‐IS from a sample of 904 children from one to seven years of age. ⁴⁷

2.4. Statistical methods

Data were analyzed using descriptive statistics run via the Statistical Package for the Social Sciences (SPSS, version 29). Normality for all continuous variables was tested using the Kolmogorov–Smirnov test. Analyses to compare differences in proportions were conducted using chi‐square tests. Differences between two groups were measured using independent t‐tests (or Mann–Whitney‐ U tests for non‐parametric data), and differences between three groups were measured using one way analysis of variance (ANOVA) (or Kruskal–Wallis tests for non‐parametric data). Correlation analyses were run to explore relationships between continuous variables regarding feeding behaviours, caregiver stress and feeding‐related quality of life. Significance was set at <0.05.

3. RESULTS

3.1. Demographics

A total of 191 caregivers of children with food allergies opened the survey. Of these, 84 were excluded as they opened but did not commence the survey (n = 46), did not complete the primary data collection tool (BPFAS) (n = 13), or failed to meet eligibility criteria due to comorbidities or age of their child (n = 25). Of the final 107 children included in this study, 47 (43.9%) were recruited from the Children's Hospital at Westmead, 49 (45.8%) from Sydney Children's Hospital (n = 49, 45.8%), and 11 (10.3%) from Royal North Shore Hospital. The children were predominantly male, with >1 food allergy and just over half presented with confirmed history of anaphylaxis (Table 1). Egg, dairy, tree nuts and peanuts were the most common food allergies (Table 2). Most children came from an atopic family and had at least 1 sibling, but only 10% of siblings also had a food allergy. One child with a complete BPFAS was <9 months of age.

TABLE 1.

Participant demographics for total cohort and subgroups by age.

Variable		Total cohort n = 107	Sub analyses by age
Variable		Total cohort n = 107	Infants (6–18 months) n = 32	Toddlers (19–36 months) n = 38	Preschool (37–59 months) n = 37	Statistic	p
Gender	Male	57 (53.3%)	19 (59.4%)	21 (55.3%)	17 (45.9%)	χ ² = 0.443	.801
	Female	42 (39.3%)	12 (37.5%)	15 (39.5%)	15 (40.5%)	χ ² = 0.443	.801
	Unspecified	8 (7.5%)	1 (3.1%)	2 (5.2%)	5 (13.6%)	–	–
Age (mean, SD)	–	30.0 (±15.3)	12.3 (±3.5)	27.5 (±5.1)	47.9 (±6.1)	–	–
Food allergy profile	1 food allergy	43 (40.2%)	22 (68.7%)	9 (23.7%)	12 (32.4%)	χ ² = 16.09	<.001
Food allergy profile	>1 food allergy	64 (59.8%)	10 (31.3%)	29 (76.3%)	25 (67.6%)	χ ² = 16.09	<.001
Confirmed anaphylaxis	No	49 (45.8%)	22 (68.7%)	18 (47.3%)	9 (24.3%)	χ ² = 13.70	.001
Confirmed anaphylaxis	Yes	58 (54.2%)	10 (31.1%)	20 (52.6%)	28 (75.7%)	χ ² = 13.70	.001
Atopic family	No	11 (10.3%)	3 (9.4%)	3 (7.8%)	5 (13.5%)	Unable to calculate ^a
Atopic family	Yes	96 (89.7%)	29 (90.6%)	35 (92.1%)	32 (86.5%)	Unable to calculate ^a
Siblings	No	49 (45.8%)	21 (65.6%)	20 (52.6%)	8 (21.6%)	χ ² = 14.50	<.001
Siblings	Yes	58 (54.2%)	11 (34.3%)	18 (47.3%)	29 (78.4%)	χ ² = 14.50	<.001
Sibling food allergy	No	97 (90.7%)	30 (93.7%)	36 (94.7%)	31 (83.8%)	Unable to calculate ^a
Sibling food allergy	Yes	10 (9.3%)	2 (6.2%)	2 (5.3%)	6 (16.2%)	Unable to calculate ^a

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^{^a}

Chi‐square test not able to be performed due to at least one cell being below the expected count.

TABLE 2.

Specific food allergies for total cohort and subgroups by age.

Allergen		Total cohort n = 107	Sub analysis by age
Allergen		Total cohort n = 107	Infants (6–18 months) n = 32	Toddlers (19–36 months) n = 38	Preschool (37–59 months) n = 37	Chi‐square Statistic	p‐value
Egg	No	49 (45.8%)	15	13	21	3.86	.145
Egg	Yes	58 (54.2%)	17	25	16	3.86	.145
Dairy	No	62 (57.9%)	21	15	26	8.40	.015
Dairy	Yes	45 (42.1%)	11	23	11	8.40	.015
Tree nuts	No	75 (70.1%)	27	26	22	5.16	.076
Tree nuts	Yes	32 (29.9%)	5	12	15	5.16	.076
Peanut	No	77 (72%)	28	28	21	8.13	.017
Peanut	Yes	30 (28%)	4	10	16	8.13	.017
Sesame	No	93 (86.9%)	31	31	31	Unable to be calculated ^a
Sesame	Yes	14 (13.1%)	1	7	6	Unable to be calculated ^a
Nuts	No	101 (94.4%)	31	35	35	Unable to be calculated ^a
Nuts	Yes	6 (5.6%)	1	3	2	Unable to be calculated ^a
Fish	No	102 (95.3%)	30	37	35	Unable to be calculated ^a
Fish	Yes	5 (4.7%)	2	1	2	Unable to be calculated ^a
Wheat	No	103 (96.3%)	30	36	37	Unable to be calculated ^a
Wheat	Yes	4 (3.7%)	2	2	0	Unable to be calculated ^a
Soy	No	103 (96.3%)	29	38	36	Unable to be calculated ^a
Soy	Yes	4 (3.7%)	3	0	1	Unable to be calculated ^a
Shellfish	No	104 (97.2%)	32	37	35	Unable to be calculated ^a
Shellfish	Yes	3 (2.8%)	0	1	2	Unable to be calculated ^a

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^{^a}

Chi‐square test not able to be performed due to at least one cell being below the expected count.

Tables 1 and 2 present comparisons of these variables across the infant, toddler and preschool age‐groups. Across these age groups, children were significantly more likely to present with more than one food allergy and history of anaphylaxis in the older age‐groups (i.e., toddler, preschool) than in the infant age group. There was a significant difference in specific food allergy presentation for dairy and peanut allergy, where cow's milk allergy was significantly overrepresented in the toddler age group compared to the other age groups, and peanut allergy was more common in pre‐school children (p = .017).

3.2. Feeding behaviour

In response to the question ‘Have you ever had any concerns regarding your child's behaviour at mealtimes or during eating?’, 29 (27.1%) caregivers reported concerns (Table 3). This proportion was almost double that demonstrated by the BPFAS, which identified that 17 participants (15.9%) scored above the normative cut‐score of 84 for the BPFAS‐TFS, and 15 participants (14.0%) scored above the normative cut‐score of 9 for the BPFAS‐TPS.

TABLE 3.

Assessment results for total cohort and subgroups by age.

Variable	Total cohort n = 107	Mean (±SD)	Sub analyses by age
Variable	Total cohort n = 107		Infants (6–18 months) n = 32	Toddlers (19–36 months) n = 38	Preschool (37–59 months) n = 37	Statistic	p‐value
Caregiver concern about feeding	Yes = 29 (27.1%)		4	13	12	χ ² = 4.957	.084
Caregiver concern about feeding	No = 78 (72.9%)		28	25	25	χ ² = 4.957	.084
BPFAS total frequency score (n = 107)		71.7 (±14.2) Range = 47–115	67.8 (±13.0)	71.7 (±14.5)	75.1 (±14.5)	F = 2.319	.103
BPFAS TFS ≤84	90 (84.1%)		29	32	29	χ ² = 1.926	.382
BFPAS TFS >84	17 (15.9%)		3	6	8	χ ² = 1.926	.382
BPFAS total problem score (n = 107)		4.1 (±5.9) Range = 0–24	2.1 (±4.4)	4.8 (±6.6)	5.1 (±6.1)	H = 7.467	.024
BPFAS TPS ≤9	92 (86%)		30	31	31	Unable to calculate ^a
BFPAS TPS >9	15 (14%)		2	7	6	Unable to calculate ^a
Feeding‐Swallowing Impact Scale (n = 92)		30.5 (±17.3) Range = 0–108	30.7 (±18.9)	28.5 (±12.4)	32.5 (±20.3)	H = 0.559	.756
Daily activities		9.6 (±5.6)	9.2 (±6.1)	9.2 (±4.6)	10.3 (±6.4)	H = 0.851	.653
Worry		12.1 (±7.2)	12.0 (±7.6)	11.8 (±5.9)	12.4 (±8.1)	H = 0.110	.946
Feeding		8.9 (±5.7)	9.5 (±6.3)	7.6 (±3.3)	9.7 (±7.0)	H = 1.646	.439
Parental Stress Scale (n = 101)		35.8 (±9.8) Range = 0–56	35.3 (±10.5)	35.5 (±8.8)	36.7 (±10.4)	F = 0.218	.805

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Abbreviations: BFPAS, Behavioural Pediatric Feeding Assessment Scale; TFS, Total Frequency Score; TPS, Total Problem Score.

^{^a}

Chi‐square test not able to be performed due to at least one cell being below the expected count.

Comparing feeding behaviours by age group, the proportion of concerned caregivers was lowest in the infant age group; the differences were not statistically significant (Table 3), however. The BFPAS‐TFS did not vary between age groups, but the BPFAS‐TPS was found to increase significantly across the age groups (p = .024). Post‐hoc testing revealed that the BPFAS‐TPS differed between the infant and toddler age group (mean difference = 2.7; U = 399.00; p = .011) and the infant and preschool age groups (mean difference = 3; U = 412.5; p = .023), but not between the toddler and preschool age groups (mean difference = 0.3; U = 698.5; p = .961), suggesting that caregivers of infants report fewer problematic feeding behaviours than caregivers of older children.

In a secondary analysis, individual responses to items on the BPFAS were compared between caregivers who reported general concerns regarding feeding (n = 29) to those who did not (n = 78). Overall, seven feeding behaviours measured by the BPFAS were reported significantly more frequently in the ‘concerned’ group. These included not enjoying eating (t = −3.655, p < .001), not being willing to try new foods (t = −3.734, p < .001), not coming readily to mealtimes (t = −3.735, p < .001), getting up from the table during the meal (t = −4.066, p < .001), not eating vegetables (t = −3.974, p < .001), having tantrums at mealtimes (t = −4.164, p < .001) and poor appetite (t = −4.756, p < .001).

3.3. Caregiver stress and feeding‐related quality of life

Among the 101 participants who completed the Parental Stress Scale (PSS), the mean score was 35.8 (Table 3), indicating that caregiver stress levels across the cohort were within the range typically expected for general caregiver‐related stress. The mean score on the FS‐IS was 30.5 for the whole cohort, which falls above the 95th percentile when compared to other published normative data, ⁴⁷ indicating that within this cohort the caregivers were experiencing negative impacts to their feeding‐related quality of life in relation to their child. The mean scores on the FS‐IS and PSS did not change with age (Table 3).

Secondary analysis was conducted on the PSS and FS‐IS scores of those children who did / did not exceed the BPFAS‐TFS cut‐score suggesting clinically significant feeding problems (Table 4). Analysis of the FS‐IS total score and subscales revealed the caregivers of children with significant feeding problems had worse feeding‐related quality of life. These caregivers also had significantly higher stress as measured by the PSS (Table 4).

TABLE 4.

Sub‐analyses of FS‐IS and PSS scores for children at risk/not at risk of PFD.

	BPFAS‐TFS ≤84 Mean (SD)	BPFAS‐TFS >84 Mean (SD)	Statistic	p‐value
FS‐IS TOTAL SCORE (n = 92)	28.13 (17.00)	43.93 (12.16)	U = 143.00	<.001
Daily activities	8.96 (5.56)	13.14 (4.88)	U = 261.50	.002
Worry	11.00 (7.02)	18.00 (4.64)	U = 137.00	<.001
Feeding	8.17 (5.54)	12.79 (5.29)	U = 219.50	<.001
PSS TOTAL SCORE (n = 101)	34.34 (9.24)	44.40 (8.81)	t = −4.05	<.001

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Abbreviations: BFPAS‐TPS, Behavioural Pediatric Feeding Assessment Scale‐Total Problem Score; FS‐IS, Feeding Swallowing‐Impact Scale; PSS, Parental Stress Scale.

4. DISCUSSION

This study provides new insights into the prevalence and characteristics of PFD, caregiver stress and feeding‐related quality of life for 107 children 0;6–4;11 years with IgE‐mediated food allergies. Based on the scores from the BPFAS, 16% of the children in this cohort were deemed to be at higher risk of PFD. More frequent caregiver‐reported difficult feeding behaviours were significantly correlated with higher caregiver stress and lower feeding‐related quality of life. These findings build upon existing literature indicating that food allergies may disrupt a child's feeding development, compounding the challenges faced by families navigating the complex demands of food allergy management during feeding.

Existing research has estimated PFD prevalence rates at 2.7%–4.1% in the general population, with the highest prevalence in children under 5 years of age. ⁴⁸ Using the BPFAS‐TFS, we found that 16% of children in our cohort with IgE‐mediated food allergies had results above the cut‐score for clinically significant feeding behaviours, suggesting they were at increased risk of PFD. This increased incidence aligns with previous research indicating heightened mealtime challenges among families managing food allergies. Herbert, Mehta, Sharma ⁸ reported that caregivers of children with food allergies described more frequent mealtime concerns than those with Type 1 diabetes, while Maslin, Dean, Arshad, Venter ⁹ similarly found significantly higher median fussy eating and feeding difficulty scores in children with cow's milk protein allergy (CMPA) compared to age‐matched controls without CMPA. This growing body of research suggests that PFD warrants greater consideration and potential intervention within the paediatric food allergy population.

It is already well‐established that caregivers of children with either food allergies or PFD experience considerable stress around feeding and mealtimes. ¹³ , ³³ , ⁴⁹ In our study, caregivers who reported higher frequency of difficult mealtime behaviours also reported higher levels of stress, suggesting there may be a cumulative effect. The mean PSS score among caregivers who reported clinically significant feeding behaviours on the BPFAS‐TFS was 45. This level of parenting stress is similar to that reported by caregivers of children with other chronic developmental and mental health conditions including children aged 3–5 years with developmental delay and behavioural or emotional difficulties ⁵⁰ ; children aged six to twelve with paediatric bipolar disorder ⁵¹ ; and children with autism. ⁵² It is imperative that clinicians recognise these potentially cumulative sources of stress so that development and provision of strategies for caregivers to manage and ameliorate them are incorporated into service planning. It is also essential that mental health support for caregivers is prioritised within multidisciplinary care.

Caregiver burden for children with PFD and/or food allergies has been likened to that of caregivers with children with chronic illness, ²⁹ , ⁵³ , ⁵⁴ despite both conditions often being ‘invisible’, and, in the case of food allergy, the child appearing well when not exposed to food allergens. ⁵⁵ The unpredictability of reactions to food allergies often compels caregivers to assume primary responsibility for managing risk rather than entrusting care to others. This can result in withdrawal from social situations and increased isolation. ⁵³ Likewise, caregivers of children with PFD experience similar feelings of isolation as they manage their child's feeding needs and mealtime behaviours away from others. ⁵⁶ , ⁵⁷ Effective care pathways should extend beyond a purely medical model, consider the potential for PFD in the food allergy population, and attend to the family's overall feeding‐related quality of life and relationship with food. ³²

5. LIMITATIONS

This study relied solely on caregiver‐reported data from families of children with food allergies, and no direct clinical assessment of the children's feeding skills was undertaken. The BPFAS is a caregiver‐reported tool and does not enable formal, comprehensive diagnosis of PFD, according to the consensus criteria proposed by Goday and colleagues, ⁶ as it does not capture the medical domain. Although procedural clarity regarding diagnosis of PFD is still being considered, current literature recommends a combination of both parent‐reported measures, clinical assessment, ⁵⁸ and involvement of a multidisciplinary team, ⁵⁸ , ⁵⁹ none of which was possible within the scope of this study. Rather, the BPFAS was used to identify children who may be at increased risk of PFD and may require further clinical assessment. It is also acknowledged that this cohort may have included children presenting with symptoms consistent with Avoidant/Restrictive Food Intake Disorder (ARFID), given the overlap between PFD and ARFID. ³⁴ However, as diagnosis was not the aim of this paper, this distinction cannot be made. Additionally, regression analysis to identify independent predictors of PFD risk was not undertaken due to the small number of children meeting the cut‐score threshold. Future research incorporating clinical assessment with a larger sample would provide a more comprehensive understanding of the true extent of feeding disorders in this population.

It is also acknowledged that families were recruited during a potentially stressful moment in time, where their child was undergoing oral food challenges with risk of anaphylaxis. This unpredictable context, combined with the difficulties of managing their young child's food refusal or fear of eating their allergen, may have influenced both responses and completion rates. The potential influence of self‐selection bias, whereby caregivers with greater concern about their child's feeding skills were more likely to participate, may also have led to higher numbers of caregivers with concerns participating in this study. The proportion of children with a history of anaphylaxis was also higher in this cohort than the general population ⁶⁰ and these caregivers may subsequently have reported greater levels of stress and concern. Finally, participants were recruited exclusively from metropolitan services. Given the reduced access to specialist health services in regional and remote parts of Australia, further research across wider contexts is warranted.

6. CONCLUSIONS

This study found that 16% of young children with diagnosed IgE‐mediated food allergies scored in the clinically significant range on the BPFAS‐TFS, suggesting that a notable proportion of this population may be at risk of PFD and warrant further clinical investigation. Caregivers reporting more frequent adverse mealtime behaviours also reported higher stress and lower feeding‐related quality of life.

The results of this study underscore the need for health services to recognise and address PFD as a potential comorbidity in children with food allergies and to ensure care pathways are equipped to provide holistic, family‐centred support. Future research with larger participant numbers, a more diverse sample and the inclusion of clinical assessment of feeding skills in children with food allergies may help to further characterise PFD in this population.

AUTHOR CONTRIBUTIONS

Jennifer Kefford: Conceptualization; investigation; funding acquisition; writing – original draft; formal analysis; project administration; writing – review and editing; methodology. Elizabeth C. Ward: Conceptualization; formal analysis; writing – review and editing; supervision; methodology. Rebecca L. Packer: Conceptualization; writing – review and editing; supervision; methodology. Merryn Netting: Writing – review and editing. Shruti Swamy: Project administration; writing – review and editing. Lara S. Ford: Project administration; writing – review and editing. Jeanne Marshall: Conceptualization; formal analysis; writing – review and editing; supervision; writing – original draft; methodology.

FUNDING INFORMATION

This work was supported by a Speech Pathology Australia New Researcher Grant, awarded in 2021.

CONFLICT OF INTEREST STATEMENT

None.

Supporting information

Data S1. Supporting Information.

File S1. It's the Demographic questionnaire in word doc form. We then uploaded the quesitons to RedCAP for caregivers to complete via their smart device.

PAI-37-e70508-s001.docx^{(8.4MB, docx)}

ACKNOWLEDGEMENTS

Dr. Katie Frith (Paediatric Immunologist, Sydney Children's Hospital Randwick); Betina Altavilla (CNC, Sydney Children's Hospital Randwick); Kylie Jacobsen (CNC, The Children's Hospital at Westmead); Reina Zaragoza (CNC, Royal North Shore Hospital); Gloria Tzannes (Head of Department, Speech Pathology, The Children's Hospital at Westmead); Katie Mooy (Speech Pathologist/Research Assistant, The Children's Hospital at Westmead). Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australasian University Librarians.

Kefford J, Ward EC, Packer RL, et al. Feeding characteristics in young children with IgE‐mediated food allergies: A cross‐sectional observational study. Pediatr Allergy Immunol. 2026;37:e70508. doi: 10.1111/pai.70508

Editor: Vicki McWilliam

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

REFERENCES

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1. Supporting Information.

File S1. It's the Demographic questionnaire in word doc form. We then uploaded the quesitons to RedCAP for caregivers to complete via their smart device.

PAI-37-e70508-s001.docx^{(8.4MB, docx)}

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

[pai70508-bib-0001] 1. Tedner SG, Asarnoj A, Thulin H, Westman M, Konradsen JR, Nilsson C. Food allergy and hypersensitivity reactions in children and adults—A review. J Intern Med. 2022;291(3):283‐302. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0002] 2. Valenta R, Hochwallner H, Linhart B, Pahr S. Food allergies: the basics. Gastroenterology. 2015;148(6):1120‐1131.e1124. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pai70508-bib-0003] 3. Peters RL, Krawiec M, Koplin JJ, Santos AF. Update on food allergy. Pediatr Allergy Immunol. 2021;32(4):647‐657. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pai70508-bib-0004] 4. Collinson A, Waddell L, Freeman‐Hughes A, Hickson M. Impact of a dietitian in general practice: Paediatric food allergy. J Hum Nutr Diet. 2023;36(3):707‐715. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0005] 5. Osborne NJ, Koplin JJ, Martin PE, et al. Prevalence of challenge‐proven IgE‐mediated food allergy using population‐based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol. 2011;127(3):668‐676.e662. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0006] 6. Goday PS, Huh SY, Silverman A, et al. Pediatric feeding disorder: consensus definition and conceptual framework. J Pediatr Gastroenterol Nutr. 2019;68(1):124‐129. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pai70508-bib-0007] 7. Haas AM. Feeding disorders in food allergic children. Curr Allergy Asthma Rep. 2010;10(4):258‐264. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0008] 8. Herbert LJ, Mehta P, Sharma H. Mealtime behaviour among parents and their young children with food allergy. Ann Allergy Asthma Immunol. 2017;118:345‐350. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0009] 9. Maslin K, Dean T, Arshad SH, Venter C. Fussy eating and feeding difficulties in infants and toddlers consuming a cows' milk exclusion diet. Pediatr Allergy Immunol. 2015;26(6):503‐508. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0010] 10. Netting M, McWilliam V, Groetch M. Nutritional management of infants with food allergies. 2024.

[pai70508-bib-0011] 11. Kefford J, Marshall J, Packer R, Ward E. Feeding characteristics in children with food allergies: a scoping review. J Speech Lang Hear Res. 2024;67(1):132‐148. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0012] 12. Christian C, Levinson CA. An integrated review of fear and avoidance learning in anxiety disorders and application to eating disorders. New Ideas Psychol. 2022;67:100964. [Google Scholar]

[pai70508-bib-0013] 13. Skypala I, Bauer M, DunnGalvin A, Venter C. The challenges of managing multiple food allergies and consequent food aversions. J Allergy Clin Immunol Pract. 2022;10(1):35‐44. [DOI] [PubMed] [Google Scholar]

[pai70508-bib-0014] 14. Hörold M, Rohr M, Apfelbacher C, Brandstetter S. Food allergy diagnosis in early childhood: journey mapping study with parents and pediatricians. Clin Transl Allergy. 2026;16(2):e70158. [DOI] [PMC free article] [PubMed] [Google Scholar]

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[pai70508-bib-0025] 25. Preece K, Blincoe A, Grangaard E, et al. Paediatric non‐IgE mediated food allergy: guide for practitioners. N Z Med J. 2016;129(1430):78‐88. [PubMed] [Google Scholar]

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PERMALINK

Feeding characteristics in young children with IgE‐mediated food allergies: A cross‐sectional observational study

Jennifer Kefford

Elizabeth C Ward

Rebecca L Packer

Merryn Netting

Shruti Swamy

Lara S Ford

Jeanne Marshall

Abstract

Background

Objective

Methods

Results

Conclusion

Key message.

1. INTRODUCTION

2. METHODS

2.1. Setting

2.2. Participants

2.3. Data collection

2.3.1. Demographic questionnaire

2.3.2. Behavioural Pediatric Feeding Assessment Scale (BPFAS)

2.3.3. Parental Stress Scale (PSS)

2.3.4. Feeding Swallowing Impact Scale (FS‐IS)

2.4. Statistical methods

3. RESULTS

3.1. Demographics

TABLE 1.

TABLE 2.

3.2. Feeding behaviour

TABLE 3.

3.3. Caregiver stress and feeding‐related quality of life

TABLE 4.

4. DISCUSSION

5. LIMITATIONS

6. CONCLUSIONS

AUTHOR CONTRIBUTIONS

FUNDING INFORMATION

CONFLICT OF INTEREST STATEMENT

Supporting information

ACKNOWLEDGEMENTS

DATA AVAILABILITY STATEMENT

REFERENCES

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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