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\begin{document}

\title{Negative effect of dietary elimination on breastfeeding mothers having
infants with and without food allergy}



\author[1]{OZLEM YILMAZ}%
\author[1]{Anil Safak Kacar}%
\author[1]{Emre Gogebakan}%
\author[2]{Ceren Can}%
\author[1]{Isil Necef}%
\author[1]{Tuba Mutluer}%
\author[1]{Nuray Uslu Kızılkan}%
\author[1]{Ali Sarper Taskiran}%
\author[1]{Cansin Sackesen}%
\affil[1]{Koc University School of Medicine}%
\affil[2]{Istanbul Bakirkoy Dr Sadi Konuk Training and Research Hospital}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Abstract Background: There has been no trial evaluating the
psychopathology in breastfeeding mothers of infants with food allergy
(FA). Objective: To investigate the effect of dietary elimination on
maternal psychopathology, specifically stress/anxiety and
mother-to-infant bonding and explore the importance of sociodemographic
features on these variables. Methods: Breastfeeding mothers following an
elimination diet due to FA in their children aged 1-to-12 months were
compared with the healthy controls. Physician-diagnosed FA group were
divided into IgE-, non-IgE-mediated and infants with some minor symptoms
which were not enough to make the diagnosis of FA were classified as
Indecisive symptoms for FA group. Mothers completed standardized
questionnaires including Symptom Checklist 90R, Beck Depression/Anxiety
Inventories (BDI/BAI), Postpartum Bonding Questionnaire (Bonding).
Results: Of 179 mother-infants, 64 were healthy, 89 were FA, 16 were
indecisive symptoms for FA. The mean age of the mothers and infants were
31.1\selectlanguage{ngerman}±4.7 years and 6.3±3.6 months. The physician diagnosed FA groups had
higher scores for anxiety (p=0.008), anger (p=0.042), depression
(p\textless{}0.001), obsession (p=0.002), phobia (p=0.008), somatization
(p=0.002) and general symptom index (GSI) (p=0.001), BDI
(p\textless{}0.001), BAI (p=0.008) and Bonding {[}attachment (p=0.001),
anger (p=0.019) and total (p=0.036){]} than the healthy. The indecisive
symptoms for FA group had a similar score pattern to physician-diagnosed
FA except interpersonal sensitivity, BDI and attachment. Conclusion:
Breastfeeding mothers of infants with FA were anxious, depressive and
had many psychopathologies which affected bonding. Interventions
targeting negativity in caregivers' social relationships are urgently
needed.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{Negative effect of dietary elimination on breastfeeding mothers
having infants with and without food allergy}

Ozlem Yilmaz\textsuperscript{1}, An\selectlanguage{polish}ı\selectlanguage{english}l Safak Kacar\textsuperscript{2},
Emre Gogebakan\textsuperscript{3}, Ceren Can\textsuperscript{4}, Isil
Necef\textsuperscript{5}, Tuba Mutluer\textsuperscript{5}, Nuray Uslu
Kizilkan\textsuperscript{6}, Ali Sarper Taskiran\textsuperscript{5,7},
Cansin Sackesen\textsuperscript{1}

\textsuperscript{1}Koc University, School of Medicine, Division of
Pediatric Allergy, Istanbul

\textsuperscript{2}Koc University, Graduate School of Health Sciences,
Koc University Research Center for Translational Medicine, Istanbul

\textsuperscript{3}Koc University, School of Medicine, \selectlanguage{polish}İ\selectlanguage{english}stanbul

\textsuperscript{4} Bakirkoy Dr. Sadi Konuk Education and Research
Hospital, Pediatric Allergy and Immunology Clinic, Istanbul

\textsuperscript{5}Koc University, School of Medicine, Department of
Child and Adolescent Psychiatry, Istanbul

\textsuperscript{6}Koc University, School of Medicine, Division of
Pediatric Gastroenterology, Istanbul, Turkey

\textsuperscript{7}Child Mind Institute, New York, USA

\textbf{Corresponding Author:}

\textbf{Cansin Sackesen, MD, Prof. Dr.}

Koc University School of Medicine, Division of Pediatric Allergy

E-mail: csackesen@ku.edu.tr; csackesen@yahoo.com

Davutpasa Street No: 4, Topkapi 34010 /Istanbul/Turkey

\textbf{Ozlem Yilmaz, MD, Assoc. Prof.}

Koc University School of Medicine, Division of Pediatric Allergy

e-mail: drozlemyilmaz09@gmail.com

\textbf{Anil Safak Kacar, MD}

Koc University Graduate School of Health Sciences, Koc University
Research Center for Translational Medicine, Istanbul

e-mail: akacar@ku.edu.tr

\textbf{Emre Gogebakan} ,

Koc University School of Medicine, \selectlanguage{polish}İ\selectlanguage{english}stanbul

e-mail: egogebakan15@ku.edu.tr

\textbf{Ceren Can, MD}

Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Pediatric
Allergy and Immunology Clinic, Istanbul

e-mail: cereni35@yahoo.com

\textbf{Isil Necef, MA}

Koc University School of Medicine, Department of Child and Adolescent
Psychiatry, Istanbul

e-mail: isilnecef@gmail.com

\textbf{Tuba Mutluer, MD}

Koc University School of Medicine, Department of Child and Adolescent
Psychiatry, Istanbul

e-mail: tmutluer@kuh.ku.edu.tr

\textbf{Nuray Uslu Kizilkan, Assoc. Prof.}

Koc University School of Medicine, Division of Pediatric
Gastroenterology, Istanbul, Turkey

e-mail: nurayu74@yahoo.com

\textbf{Ali Sarper Taskiran} , \textbf{MD}

Koc University School of Medicine, Department of Child and Adolescent
Psychiatry, Istanbul

Child Mind Institute, New York

e-mail:sarper.taskiran@childmind.org

\textbf{Cansin Sackesen, MD, Prof. Dr.}

Koc University School of Medicine, Division of Pediatric Allergy

E-mail: csackesen@ku.edu.tr; csackesen@yahoo.com

\textbf{There is no funding for the study.}

\textbf{Word count for the abstract:} 234

\textbf{Word count for the article:} 2994

\textbf{Highlights box:}\selectlanguage{english}
\begin{longtable}[]{@{}l@{}}
\toprule
Children, adolescents and adults with FA and their families were
observed to have low quality of life. This trial evaluated the
psychosocial well-being of breastfeeding mothers having infants with FA
for the first time and showed that these mothers were anxious,
depressive and had many psychosocial symptoms which affected
mother-to-infant bonding and interpersonal relationships. The
psychosocial assessment of breastfeeding mothers with psychosocial
distress is important to generate new approaches in future
studies.\tabularnewline
\bottomrule
\end{longtable}

\textbf{Key Words:} Anxiety, breastfeeding, bonding, elimination diet,
food allergy, IgE-mediated, Non-IgE mediated, psychopathology, stress

\textbf{Abbreviations:}

\textbf{BAI:} Beck Anxiety Inventory

\textbf{BDI:} Beck Depression Inventory

\textbf{Bonding:} Brockington Postpartum Bonding Questionnaire

\textbf{FA:} Food allergy

\textbf{False-FA:} False food allergy

\textbf{IgE:} IgE-mediated

\textbf{Non-IgE:} Non-IgE-mediated

\textbf{QoL:} Quality of life

\textbf{True-FA:} True food allergy

\textbf{SCL-90R:} Symptom Checklist 90

\textbf{Negative effect of dietary elimination on breastfeeding mothers
having infants with and without food allergy}

\textbf{Abstract}

\textbf{Background:} There has been no trial evaluating the
psychopathology in breastfeeding mothers of infants with food allergy
(FA).

\textbf{Objective:} To investigate the effect of dietary elimination on
maternal psychopathology, specifically stress/anxiety and
mother-to-infant bonding and explore the importance of sociodemographic
features on these variables.

\textbf{Methods:} Breastfeeding mothers following an elimination diet
due to FA in their children aged 1-to-12 months were compared with the
healthy controls. Physician-diagnosed FA group were divided into IgE-,
non-IgE-mediated and infants with some minor symptoms which were not
enough to make the diagnosis of FA were classified as Indecisive
symptoms for FA group. Mothers completed standardized questionnaires
including Symptom Checklist 90R, Beck Depression/Anxiety Inventories
(BDI/BAI), Postpartum Bonding Questionnaire (Bonding).

\textbf{Results:} Of 179 mother-infants, 64 were healthy, 89 were FA, 16
were indecisive symptoms for FA. The mean age of the mothers and infants
were 31.1\selectlanguage{ngerman}±4.7 years and 6.3±3.6 months. The physician diagnosed FA
groups had higher scores for anxiety (p=0.008), anger (p=0.042),
depression (p\textless{}0.001), obsession (p=0.002), phobia (p=0.008),
somatization (p=0.002) and general symptom index (GSI) (p=0.001), BDI
(p\textless{}0.001), BAI (p=0.008) and Bonding {[}attachment (p=0.001),
anger (p=0.019) and total (p=0.036){]} than the healthy. The indecisive
symptoms for FA group had a similar score pattern to physician-diagnosed
FA except interpersonal sensitivity, BDI and attachment.

\textbf{Conclusion:} Breastfeeding mothers of infants with FA were
anxious, depressive and had many psychopathologies which affected
bonding. Interventions targeting negativity in caregivers' social
relationships are urgently needed.

\textbf{Negative effect of dietary elimination on breastfeeding mothers
having infants with and without food allergy}

\textbf{Introduction}

Evidence indicates that the prevalence of food allergy (FA) has
increased in the last decade (1). However, the pathogenesis of FA has
not completely been understood, yet. There is currently no cure or
preventive treatment for FA (2). Previous studies showed that children,
adolescents and adults with FA and their families had low quality of
life (QoL) (3-5). However, the QoL in infants was investigated scarcely
and there has been no trial evaluating the psychosocial well-being in
breastfeeding mothers having infants with FA (6).

The first year of life is unique to the rest of life. There can be
several factors that may impact QoL in mother-infant dyads (7). Many
breastfeeding mothers believe that foods transferring through the breast
milk from mother to infant can lead to allergy. Due to this perspective,
many breastfeeding mothers who think that their infants had FA lean to
remove many nutrients from their diets. The diagnosis and suspicion of
FA and dietary elimination may cause stress, anxiety in and affect
psychosocial well-being of mothers.

The aim of this study was to investigate the effect of dietary
elimination on maternal psychopathology among mothers, specifically
stress/anxiety and mother-to-infant bonding. Our secondary aim was to
explore the importance of sociodemographic features on these variables
in this critical period of mother-to-infant bonding in order to provide
specific psychosocial approaches. The assessment of psychosocial status
of mothers in the first years of their children's life may be important
to understand maternal stress and to maintain a new approach and
behavior to the mothers who are anxious.

\textbf{Methods}

\textbf{Study population}

The study population was collected from three Pediatric allergy (Koc
University, Mersin City Hospital, Bakirkoy Dr. Sadi Konuk Research and
Training Hospital) and one Pediatric Gastroenterology (Koc University
Pediatric Gastroenterology) centers from Turkey. The study population
consisted of breastfeeding mothers who were on an elimination diet due
to a diagnosis of FA in their children aged 1-to-12 months. The
breast-feeding mothers presented to the study centers who were willing
to participate in the study were included, consecutively. Food allergy
was classified as IgE-mediated (IgE), non-IgE-mediated (Non-IgE) and
mixed (both IgE- and non-IgE-mediated FA) FA. The diagnosis of
IgE-mediated FA was established according to the following criteria: 1.
A consistent and clear-cut history of FA-related symptoms that developed
within minutes to hours following the ingestion of food, 2. Positive
serum levels of sIgE (\textgreater{} 0.35 kU\textsubscript{A}/L) for the
specific food, 3. Positive skin prick test (SPT) for the specific food
(a wheal diameter of 3 mm or greater than the negative control).The
diagnosis of non-IgE mediated FA was established according to the
following criteria: 1. The presence of blood in the stool after in
otherwise healthy infants and the disappearance of blood with the
elimination of the suspected food(s) from maternal diet within 1 week,
2. The presence of isolated gastrointestinal symptoms, such as
repetitive-to-profuse emesis and vomiting with diarrhea, which can lead
to dehydration, lethargy, hypotension, or shock, 1--3 hours after the
ingestion of the suspected food or with persistence of these symptoms
for 2 weeks without any other cause and also with resolution of symptoms
after the removal of the causative food(s) from the diet, with a
recurrence of symptoms when reintroducing the causative food(s).The
mothers on dietary elimination whose infants had a diagnosis of FA
according to the criteria specified above were called as FA.

The mothers following an elimination diet with the thought of FA in
their children despite the absence of diagnostic criteria and laboratory
findings consistent with FA in their children were called as
``Indecisive symptoms for food allergy''. The considerations regarded as
Indecisive symptoms for food allergy were as follows: 1. Mucous but no
blood in stool, 2. Colic, sleep problems, irritability but no vomiting,
diarrhea, loss of weight and percentiles for height \& weight were in
normal range and gain of weight were within normal limits.

The control group involved breastfeeding mothers of healthy children at
the same age range having no allergic, chronic or systemic disease who
were admitted to well-child care outpatient clinic at the study centers.
This group was called as ``Healthy'' or ``Healthy controls'' throughout
the study. The Koc University Ethics Committee approved the study and
written informed consent were obtained from all participants.

\textbf{Tools}

The participants were asked to self-complete a standardized
questionnaire during their routine outpatient clinic visits. The
standardized questionnaire consisted of sociodemographic features
including age, number of siblings, primary and other caregivers of the
child, sociodemographic features of the mother, history of any allergic,
psychiatric or physical disease in the mother/family, any medications
used for psychiatric disease, detailed dietary history including number
and categories of foods eliminated from the mother's diet, source of
information for dietary recommendations, (physician/written
sources/internet/social environment/friends/relatives). Any weight loss
in the mother, change in volume, consistency or cessation of breast
milk, any changes in feeding frequency of infant and validated tools
assessing the psychosocial functioning of the mother were also
collected.

The validated tools were the following:

1. \emph{Symptom Checklist 90 (SCL-90R):} SCL-90R is a self-administered
psychiatric symptom checklist consisting of 90 items on a likert scale
ranged from 0-to-9. SCL-90R was developed by Derogatis et al (8). and
validated in Turkish by Dag et al (9).

2. \emph{Beck Depression Inventory (BDI):} BDI which evaluated the risk
and severity of depression in adults with a cut-off point of 17 points
was developed in 1961 by Beck et al. (10) and validated in Turkish by
Hisli et al. in 1989 (11).

3. \emph{Beck Anxiety Inventory (BAI):} BAI assesses the frequency of
anxiety symptoms composed of 21 items on a likert scale ranged from
0-to-3. BAI developed in 1998 by Beck et al (12) and validated in
Turkish by Ulusoy et al in 1998 (13).

4. \emph{Brockington Postpartum Bonding Questionnaire (Bonding):}Bonding
was developed to evaluate the problems of mother-to-infant relationship
on a 6-item likert scale described as ``every day'', ``very often'',
``often'', ``sometimes'', ``rare'', ``never'' pointed 0-5. The
questionnaire composed of 25-item, 17 of which were inversely associated
and validated (14-15). The scale consists of four subscales such as the
General factor (12 items), Rejection and Pathological Anger (7 items),
Infant-focused Anxiety (4 items) and Incipient Abuse (2 items). The
cut-off scores are General factor \selectlanguage{english}[?] 12, Rejection and Pathological Anger
\selectlanguage{english}[?] 17, Infant-focused Anxiety \selectlanguage{english}[?] 10 and Incipient Abuse \selectlanguage{english}[?] 3, respectively.

\textbf{Statistical Analysis}

Statistical analysis was performed using the Statistical Package for the
Social Sciences (SPSS) version 21.0 software statistical package program
(SPSS Inc., Chicago, IL). The variables were investigated to determine
whether or not they are normally distributed. Descriptive analyses were
presented using means and standard deviations for normally distributed
values and frequencies were presented as percentages. Mean and median
values of two-independent groups compared with independent samples
t-test or Mann Whitney U test where appropriate. Multiple groups were
compared with Kruskal Wallis test and The Jonckheere-Terpstra test was
used to determine if there was a statistically significant trend across
groups. The Chi-square or Fisher's exact test, where appropriate, was
used to compare proportions in different groups. A p-value of less than
0.05 was considered to show a statistically significant result.

\textbf{Results}

One hundred and sixty-nine mothers-infant dyads were recruited in the
study between January 2016 and August 2017. The mean age of the mothers
and the infants were 31.1 +- 4.7 years and 6.3 +- 3.6 months. Of the
infants, 48.6 \% were female.

Of the participants, 64 were healthy controls, 89 were FA, 16 were
Indecisive symptoms for FA. In the diagnosed FA group 84.2\%, 11.2\% and
4.5\% were Non-IgE-mediated FA (n=75), IgE-mediated FA (n=10) and mixed
FA (IgE and non-IgE-mediated FA, n=4), respectively. The demographic
features of the participants were presented on Table 1.

The educational level of mothers and fathers (for the mothers p=0.001,
for the fathers p=0.009) was significantly higher in the Indecisive
symptoms for FA group as compared to the healthy group. Being the
primary caregiver as a mother was more frequently observed in Indecisive
symptoms for FA group than the healthy group (p=0.006).

\textbf{Dietary characteristics in FA vs Indecisive symptoms for FA and
IgE vs Non-IgE}

The mean durations of elimination diet of FA (103+-81 days) and
Indecisive symptoms for FA (81+-59 days) groups were similar (p=0.21).
The most common reason to begin an elimination diet was the
recommendation by a doctor. The written sources and internet were the
second most common reasons for both groups (Table 2).

We asked the mothers the significance of dietary elimination in their
lives. Of the mothers, 69\% of FA and 82\% Indecisive symptoms for FA
groups reported that the eliminated foods were very important for them
and avoidance of many foods affected their lives very seriously. In the
FA and Indecisive symptoms for FA groups, 77\% and 67\% of the mothers
reported that they lost weight after elimination diet. Of the mothers,
65\% of FA and 57\% of Indecisive symptoms for FA embodied a change in
their breast milk characteristics. The decrease in breast milk volume
and the increase in feeding frequency were the most frequent changes
reported by the mothers in both groups (Table 2).

Egg, milk, red meat and tree nuts which were the main source of protein
and calcium were the most common foods eliminated from mothers' diets.
Of the groups, 41\% of the FA and 29\% of the Indecisive symptoms for FA
excluded \textgreater{}20 nutrients from their diets. The number of
foods eliminated from diets of mothers was insignificant between the
groups of FA vs Indecisive symptoms for FA and IgE vs non-IgE mediated
FA (p\textgreater{}0.05) (Table 3). The number of eliminated foods were
presented for each group in Table 4.

\textbf{Comparisons among mothers of the Healthy, FA and Indecisive
symptoms for FA groups}

Psychosocial functioning of the mothers was evaluated by SCL90R, BDI,
BAI and Bonding.

Most of the scores for psychosomatic symptoms that were evaluated by
SCL-90R namely anxiety (p=0.008), anger (p=0.042), depression
(p\textless{}0.001), interpersonal sensitivity (p=0.001), obsession
(p=0.002), phobia (p=0.008), somatization (p=0.002) and general symptom
index (GSI) (p=0.001); scores for BDI (p=\textless{}0.001), BAI
(p=0.008) and Bonding {[}attachment (p=0.001), anger (p=0.019) and total
(p=0.036){]} were higher in the FA group than the healthy controls. The
mothers in the Indecisive symptoms for FA had also higher scores for
SCL-90R {[}anxiety (p=0.034), anger (p=0.045), depression (p=0.005),
obsession (p=0.009), phobia (p=0.024), somatization (p=0.029) and GSI
(p=0.037){]}, BAI (p=0.031), Bonding {[}anger (p=0.003){]} than the
healthy controls. The FA and Indecisive FA groups did not differ from
one another in any of the psychosocial functioning scores
(p\textgreater{}0.05 for all scores) (Table 5).

Cases with FA group were categorized into IgE- and Non-IgE-mediated FA.
We compared the healthy controls with the IgE- / Non-IgE-mediated and
Indecisive symptoms for FA groups. The SCL-90R {[}anxiety (p=0.02),
anger (p=0.005), depression (p=0.003), interpersonal sensitivity (p=
0.010), obsession (p\textless{}0.001), phobia (p=0.03), somatization
(p=0.001), GSI (p=0.001){]}, BDI (p=0.001), BAI (p= 0.007) and Bonding
{[}attachment (p= 0.006) and anger (p= 0.001){]} scores were higher in
Indecisive symptoms for FA than Non-IgE FA, and the scores of Non-IgE FA
were higher than those of IgE-mediated FA (scores of Indecisive symptoms
for FA \textgreater{} Non-IgE FA \textgreater{} IgE FA, p for trend is
significant for each mentioned score) (Table 6).

\textbf{Discussion}

The present study showed that FA is negatively linked to psychosocial
states of breastfeeding mothers. Psychosomatic symptoms, depression and
anxiety were more frequent in breastfeeding mothers of infants with FA
than healthy controls. The negative psychosocial changes were more
severe in mothers with Indecisive symptoms for FA than those of mothers
of infants with Diagnosed FA. The scores were also higher in
non-IgE-mediated FA than those of IgE-mediated. Doctor recommendation
was the most frequent reason for dietary elimination for the
breastfeeding mothers.

The importance of the link between feeding and bonding have long been
explored (16). It has been shown that mothers' attachment style was
associated with postpartum psychological well-being and feeding
preferences (17). When putting these points into consideration, it is
not surprising that FA has many impacts on multiple aspects of
psychological well-being. The diagnosis of FA, daily management of
allergen avoidance, anxiety and fear about an unpredictable risk of
allergic reactions bring a greater psychological burden to both the
patients and their families (18-21). The negative impact of FA on QoL as
well as emotional states such as anxiety and depression has been shown
on several studies conducted on children, adolescents, adults and their
families (3, 18). However, the impact of FA on psychosocial aspects in
the first year of life was not investigated, previously.

This study evaluated FA in the first year of life which was a very
sensitive and vulnerable period of mother-to infant bonding and showed
that the diagnosis of FA was related to the psychosocial well-being of
breastfeeding mothers, negatively. When compared with the healthy
controls, the consideration of FA, irrespective of the diagnosis is FA-
or Indecisive symptoms for FA caused anxiety, depression, anger, phobia,
somatization symptoms, feeling of inadequacy with increased expectation
of rejection and criticism. Furthermore, this study showed that FA
affected mother-to-infant bonding inducing anxiety and anger in the
mother and also increased interpersonal sensitivity of the mothers.

In QoL research on FA, mothers reported a significantly greater impact
on psychological and physical QoL than fathers (3, 23-25). Various
studies also showed that mothers felt the pressure of being primarily
responsible for the state of health and safety of their children (25,
26). Therefore, it is highly likely that breastfeeding mothers may feel
guilty themselves due to food allergens passing via their breast milk.
When the possibility of harming their infants come together with the
great responsibility of feeding, mothers may experience stress and feel
helpless. They may be afraid of harming their infants and begin
extensive elimination diets with great desperation. There may be such a
huge intra-psychic conflict among mothers that they may develop some
psychotic and somatic symptoms, which disturb mother-to-infant bonding.
Dieting can also play a negative role in mother and infant relationship
due to its difficulty in implementing through the daily routine for a
breastfeeding mother (27).

According to a previous study, anxiety and depression of parents began
even before the establishment of the FA diagnosis (28). The psychosocial
scores in this study were higher in the Indecisive symptoms for FA group
than in the Physician Diagnosed FA group. The Indecisive symptoms for FA
group consisted of parents with higher education levels. And also, a
higher ratio of the mothers in the Indecisive symptoms for FA group were
the primary caregivers. These results may be related with the
oversensitivity of the mothers about the symptoms in their infants
actually not related with FA. Another possibility may be the
psychological factors intrinsic to these mothers that may lead them to
think that their children had FA (29).

The scores were also higher in non-IgE-mediated FA than those of
IgE-mediated. This result may be related with the absence of a
laboratory test to confirm non-IgE-mediated FA or diagnostic delays with
the longer periods waiting in anxiety for the mothers. This may also be
associated with the nature of symptoms. Seeing blood in stool may be
very worrisome for a mother. In a study which found poorer physical QoL
in non-IgE-mediated FA than that in IgE-mediated, the authors concluded
that extra manifestations such as pain, hypermobility and fatigue and
delays in diagnosis due to absence of laboratory tests may had an impact
on the emotional psychological health of children (30). In another
study, poor physical and emotional functioning associated with
non-IgE-mediated FA was thought to be related with poor symptom
recognition, delay in diagnosis and noxious symptoms such as sleep
deprivation due to abdominal pain and feeding difficulties (31).

External stimuli affecting maternal feelings may affect the
breastfeeding period. Nearly 50\% of mothers reported that their breast
milk had a change in color, volume, consistency and even more than two
thirds of mothers in this study stated that their breast milk were
decreased. Changes in breastmilk may also be due to extensive dietary
eliminations. Almost half of True-FA group and 1/3 of False-FA group
said to exclude \textgreater{}20 nutrients from their diets. Moreover,
uncommon allergens such as vegetables and fruits were excluded by almost
20-30\% of mothers. The ultimate allergens responsible for the reactions
were actually just one type of food, for many it was only milk and not
more than two in the majority of the cases. As thought from the
perspective that relatively small number of allergens cause a high
proportion of FA, it was obvious that mothers followed extensive
unnecessary elimination diets (2). Extensive number of foods being
avoided may also be a factor increasing maternal stress (32).

The evaluation of breastfeeding mothers with infants \textless{}1 year
separately from older ages, comparison with a healthy control group,
comparisons between Physician diagnosed FA vs Indecisive symptoms for
FA, IgE- vs non-IgE-mediated FA using multiple standardized validated
tools were the strengths of the study. The small number of patients
within subgroups and lack of re-evaluation after remission of FA were
the limitations. It is not well-known that the negative psychosocial
functioning is caused by FA itself or by dietary elimination. Even
though it was planned to include the cases with FA but without dietary
elimination, this group is missing in the study due to the very few
numbers of cases admitted to the study clinics.

In further studies, re-assessment of the mothers after remission of FA
may answer the question of whether the psychosocial problems in mothers
are pertinent to mothers themselves or related with burdensome aspects
of FA.

In conclusion, breastfeeding mothers having children with FA were
anxious, depressive and had many psychosocial symptoms which affected
mother-to-infant bonding and interpersonal relationships. The Indecisive
symptoms for FA and non-IgE-mediated FA groups had worse scores that the
physician diagnosed FA and IgE-mediated FA groups, respectively.

Psychologic and social support and changes in the attitude of the
physicians to the mothers who avoid major foods form their diet to care
their infants in allergy clinics should be re-visited.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
  Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by
  anaphylactic reactions to food, 2001--2006. J Allergy Clin Immunol
  2007;119:1016--18.
\item
  Sampson HA, Aceves S, Bock SA, James J, Jones S, Lang D, et al. Food
  allergy: a practice parameter update-2014. J~Allergy~Clin Immunol
  2014;134:1016-25.e43.
\item
  Cummings AJAJ, Knibb RC,~King RM,~Lucas JS.
  The~psychosocial~impact~of~food allergy~and~food
  hypersensitivity~in~children,~adolescents~and their~families:
  a~review. Allergy 2010;65(8):933-45.
\item
  Abdurrahman ZB, Kastner M, Wurman C, Harada L, Bantock L, Cruickshank
  H et al. Experiencing~a~first~food~allergic~reaction:
  a~survey~of~parent~and~caregiver perspectives Allergy Asthma Clin
  Immunol 2013;9(1):18.
\item
  Ferro MA, Van Lieshout RJ, Ohayon J, Scott JG. Emotional and
  behavioral problems in adolescents and young adults with food allergy.
  Allergy 2016;71:532-40.
\item
  Feng C,~Kim JH. Beyond~Avoidance: the Psychosocial Impact of Food
  Allergies. Clin Rev Allergy Immunol.~2019;57:74-82.
\item
  Reddy K, Kearns M, Alvarez-Arango S, Carrillo-Martin I, CuervoPardo N,
  Cuervo-Pardo L, et al. YouTube and food allergy: an appraisal of the
  educational quality of information. Pediatr Allergy Immunol
  2018;29:410--6.
\item
  Derogatis, LR, Cleary, PA. Confirmation of the dimensional structure
  of the SCL\selectlanguage{english}-90: A study in construct validation. Journal of clinical
  psychology 1977; 33:981-89.
\item
  Da\selectlanguage{polish}ğ İ. \selectlanguage{english}Belirti Tarama Listesi (Scl-90-R)'nin \selectlanguage{ngerman}Üniversite Ö\selectlanguage{polish}ğ\selectlanguage{english}rencileri
  i\selectlanguage{ngerman}çin güvenirli\selectlanguage{polish}ğ\selectlanguage{english}i ve ge\selectlanguage{ngerman}çerli\selectlanguage{polish}ğ\selectlanguage{english}i.~T\selectlanguage{ngerman}ürk Psikiyatri Dergisi 1991;
\item
  Beck AT. An inventory for measuring depression. Arch Gen Psychiatry
  1961;4:561-71.
\item
  Hisli N. Beck depresyon envanterinin universite ogrencileri icin
  gecerliligi, guvenilirligi.(A reliability and validity study of Beck
  Depression Inventory in a university student sample).~J Psychol
  1989;7:3-13.
\item
  Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring
  clinical anxiety: Psychometric properties. J Consult Clin Psychol
  1998;56:893-97.
\item
  Ulusoy M, Sahin, NH, Erkmen H. The Beck anxiety inventory:
  psychometric properties.~Journal of cognitive
  psychotherapy~1998;12:163-72.
\item
  Brockington IF, Oates J, George S, et al. A screening questionnaire
  for mother-infant bonding disorders. Arch Womens Ment Health
  2001;3:133-40.
\item
  Brockington IF, Fraser C, Wilson D. The Postpartum Bonding
  Questionnaire: a validation. Arch Womens Ment Health 2006; 9:233-42.
\item
  Bowlby J. The nature of the child's tie to his mother.~International
  journal of psycho-analysis 1958;39:350-73.
\item
  Akman \selectlanguage{polish}İ, \selectlanguage{english}Kuscu MK, Yurdakul Z, \selectlanguage{ngerman}Özdemir N, Solako\selectlanguage{polish}ğ\selectlanguage{english}lu M, Orhon L, et al.
  Breastfeeding duration and postpartum psychological adjustment: role
  of maternal attachment styles.~Journal of paediatrics and child
  health~2008;44:369-73.
\item
  Herbert L, Shemesh E, Bender B. Clinical Management of Psychosocial
  Concerns Related to Food Allergy. J~Allergy~Clin Immunol
  Pract~2016;4:205-13.
\item
  Fedele DA, McQuaid EL, Faino A, Strand M, Cohen S, Robinson J, et al.
  Patterns of adaptation to children's food allergies. Allergy
  2016;71:505-13.
\item
  Quigley J, Sanders GM.
  Food~Allergy~in~Patients~Seeking~Mental~Health~Care: What
  the~Practicing~Psychiatrist~Should~Know. Curr Psychiatry Rep
  2017;19:99.
\item
  Polloni L,~Schiff S,~Ferruzza E,~Lazzarotto F,~Bonaguro R,~Toniolo
  A,~et
  al.Food~allergy~and~attitudes~to~close~interpersonal~relationships:An~exploratory
  study~on~attachment. Pediatr~Allergy~Immunol~2017;28:458-63.
\item
  Williams NA, Hankey M: Support and negativity in interpersonal
  relationships impact caregivers'quality of life in pediatric food
  allergy. Qual Life Res 2015;24:1369-78.
\item
  King RM, Knibb RC, Hourihane JO. Impact of peanut allergy on quality
  of life, stress and anxiety in the family. Allergy 2009;64:461-88.
\item
  Warren CM, Gupta RS, Sohn MW, Oh EH, Lal N, Garfield CF, et al.
  Differences in empowerment and quality of life among parents of
  children with food allergy. Ann Allergy Asthma Immunol
  2015;114:117-25.
\item
  Lebovidge JS, Strauch H, Kalish LA, Schneider LC. Assessment of
  psychological distress among children and adolescents with food
  allergy. Allergy Clin Immunol. 2009;124:1282-8.
\item
  Rouf K, White L, Evans K. A qualitative investigation into the
  maternal experience of having young child with severe food allergy.
  Clin Child Psychol Psychiatry 2012;17:49-64.
\item
  Reichenberger J,~Smyth JM,~Kuppens P,~Blechert J. ''I will fast
  \ldots{} tomorrow'': Intentions to restrict eating and actual
  restriction in daily life and their person-level predictors.
  Appetite.~2019 Apr 27;140:10-8. doi: 10.1016/j.appet.2019.04.019.
  {[}Epub ahead of print{]}
\item
  Birdi G, Cooke R, Knibb R. Quality of life, stress, and mental health
  in parents of children with parentally diagnosed food allergy compared
  to medically diagnosed and health controls. J Allergy (Cairo)
  2016:1497375.
\item
  Knibb RC. Effectiveness of Cognitive Bahaviour Therapy for Mothers of
  Children with Food Allergy: A case series. Healthcare 2015;3:1194-211.
\item
  Foong RX, Meyer R, Godwin H, Dziubak R, Lozinsky AC, Reeve K, et al.
  Parental perception of their child's quality of life in children with
  non-immunoglobulin-E-mediated allergies. Pediatr Allergy Immunol
  2017;28:251-6.
\item
  Meyer R, Godwin H, Dziubak R, Panepinto JA, Foong RM, Bryon M, et al.
  The impact of life on families of children on an elimination diet for
  Non-immunoglobulin E mediated gastrointestinal food allergies. World
  Allergy Organ J 2017;10:8.
\item
  Sicherer SH, Noone SA, Munoz-Furlong A. The impact of childhood food
  allergy on quality of life. Ann Allergy Asthma Immunol 2001;87:461-4.
\end{enumerate}

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