Food allergy is defined as an adverse immune response to specific foods, typically proteins [3]. In children, there are eight foods that cause 90% of food allergy [7]. The diagnosis is based on clinical history and can be supported by testing, such as skin prick testing, specific IgE and oral food challenges. IgE-mediated food allergy can lead to anaphylaxis [8] and anaphylaxis has been shown to recur in 93% of food-allergic children who experience an anaphylactic reaction [9]. It is estimated that 150 Americans die each year due to food allergy [10], with most death occurring among adolescents and young adults [11]. Currently, management of food allergy primarily consists of strict avoidance of the offending food allergen and the initiation of therapy in case of an ingestion [4,6,12].

Organizations like the Food Allergy and Anaphylaxis Network (FAAN) and local parent support groups have been advocating for increased knowledge and awareness of food allergy nationally and at the community level [13,14]. However, previous research shows that misconceptions around food allergy prevalence exist among the general public [4,15], and that physicians' knowledge of food-induced anaphylaxis is lacking [16].

Moreover, it has been well-established that families of children with food allergy have a lower quality of life [17-21]. Food allergy has been shown to lower general health perception, limit family activities, and have a significant emotional as well as economic impact on the parent [17,18]. Delayed diagnosis by physicians and social stigmatization by the general public may be factors leading to further difficulties which parents of children with food allergy face in dealing with the daily fear of a life-threatening reaction.

The most striking aspect of the parent focus group discussions was how managing a child's food allergy had a significant negative impact on personal and familial quality of life. Parents felt that food allergy impacted not only their daily social lives but their relationships with their spouses and extended family. Parents confirmed that food allergy affected their child psychologically and socially, as described in previous studies [27].

A novel finding from this study was the mothers' assertions that their child's food allergy caused them to stop working outside the home. They described the need to remain at home full-time to keep their child safe. It was difficult for many mothers to entrust others with the care of their child. Consistent with previous quality of life studies, parents in our focus groups confirmed that food allergy had a significant impact on their general health perception, their emotional state, and their social activities [17,18]. Mothers also seemed to experience a considerably stronger negative impact on quality of life when compared with fathers.

Prior study has documented the short-comings of medical professionals in the provision of medical information and practical recommendations to parents concerning their child's food allergy [28]. Our study reiterated this concern, emphasizing parents' dissatisfaction with their primary care physicians' ability to diagnose and manage their child's food allergy. Parents felt physician knowledge was poor and inconsistent across specialties.

Physicians had basic knowledge of food allergy and anaphylaxis but differed in their approach to diagnosis and the advice they offered families about breastfeeding and introduction of solids. Existing research confirms that recommendations vary among experts with regard to diagnostic evaluations for food allergy and food-induced anaphylaxis [5,29-32]. High rates of misdiagnosis have also been described in the emergency room setting [33]. There was considerable variation among recommendations given by physicians as reported by our focus groups. For example, parents reported being told by physicians that eczema was not a manifestation of food allergy (Table ​(Table2).2). In fact, approximately 35% of young children with atopic dermatitis have food allergy, particularly in infants and toddlers whose disease is more severe or recalcitrant to therapy [34,35].

Guidelines for diagnosis and management have been published, including practice parameters for food allergy [36] and anaphylaxis [37]. Moreover, delay of solid food introduction until after 4 months of age and the use of extensively or partially hydrolyzed formulas have been recommended as evidence-based guidelines for infants at high risk for development of atopic disease [38,39]. However, delaying introduction of highly allergenic foods, although historically prescribed as a prevention tactic [40], is not evidence-based [38,39]. In spite of the availability of these published guidelines, there is a need for improved continuing medical education among physicians with regard to food allergy.

The general public varied in its knowledge of the definition, symptoms, and triggers of food allergy. They tended to overestimate food allergy prevalence, which is consistent with previous literature [4]. Participants also reported having a food-allergic child absent a formal diagnosis; prior study shows that only approximately 40% of patients' histories of food-induced allergic reactions can be verified [41-43] and that individuals are inclined to overdiagnose food allergies in themselves or in their children [44]. However, participants reporting a fruit allergy absent a formal physician diagnosis may be an exception. These reports may indicate oral allergy syndrome (or pollen-food allergy), which is an IgE-mediated phenomenon, resulting in immediate oral pruritus after ingesting certain fresh fruits or vegetables [45]. These patients typically have a history of seasonal allergic rhinitis (hay fever) as the sensitizing pollens have proteins that are homologous to certain fruits and/or vegetables. Because these proteins are labile to heat, individuals typically react only to fresh forms of these foods. Moreover, systemic reactions are averted as these proteins are easily digested.

The misconceptions among the general public support the perception that the plight of parents of children with food allergy is not well understood. Parents (of children without food allergy) will likely come in contact with food-allergic children in their neighborhoods or through schools and camps. It is vital for those in contact with children to have accurate awareness of food allergen avoidance and treatment in order to prevent serious, or even fatal, allergic reactions.

There are limitations to the study design. Selection bias is inherent as participants in the focus groups volunteered themselves and may therefore be more motivated or more knowledgeable than the average person in each targeted population. Particularly, parent participants were selected from a food allergy support organization, and may therefore be more knowledgeable about food allergy and have more severely food-allergic children [46]. The total number of individuals in each focus group was small and based in the Chicago area and therefore not necessarily representative of parents, physicians, or the general public across the US. However, even in this select population, we found a substantial lack of knowledge and a considerable amount of misinformation.