The reported incidence of doctor-diagnosed food allergy (FA) is 1–6% among children in the U.S. and Europe.1,2 However, up to 30% of parents report their child as having this condition.3 Furthermore, as many as 50% of families intentionally exclude various foods from a child's diet.4 This discrepancy may reflect difficulties in interpreting the symptoms and a lack of adequate information provided by health care professionals.

Over the past several decades, infant feeding guidelines have changed more than once,5 and a plethora of ever-changing clinical care guidelines, expert opinion statements, booklets, and online material regarding FA and atopic dermatitis (AD) has been produced for both health care professionals and the public during the same period. This thicket of information has the potential to foment confusion and heterogeneous guidance practices.

Different countries have different occupational groups that provide frontline guidance to families. They include nutritionists, nurses, nurse practitioners, general practitioners, and pediatricians. In Finland, the public health nurses (PHNs) work independently, in collaboration with primary care physicians.6 PHNs provide the primary information to families regarding feeding practices, and are usually the first to be contacted in cases of food-related symptoms and eczema. They also decide whether there is a need to arrange an extra consultation or referral to a doctor. The primary goal of the present survey was to characterize knowledge, attitudes, and perceptions concerning infant feeding practices, FA, and AD among PHNs and general practitioners (GPs). In addition, we carried out a small survey on the parents’ information sources and the incidence of food-related symptoms, dietary restrictions, FA, and AD among one-year-old children in the general population.

International and national guidelines offer health care professionals the best available information to ensure optimal growth and development of the baby and to ensure evidence-based diagnostics and treatment of FA and AD in children. Whether these guidelines confer real health benefits in practice at the population level has not been deeply studied. Our results show high individual and occupational variability in acquaintance with the guidelines. Furthermore, both health care professionals and families use additional sources of information that are not consistent with each other. These habits, together with the changing nature of the guidelines, seem to result in contradictory information and remarkable confusion among the families, as one mother in our survey told us (illustrated in Fig. 4).

Figure 4.

A parent's real-life description of parental confusion caused by discrepancies among health professionals’ provision of instructions regarding infant feeding, food allergy and atopic dermatitis in a child. L: a photo of the original Finnish handwritten free comment in the questionnaire booklet; R: free translation of the text into English.

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There are very few published studies from any country into the knowledge and perceptions on childhood food allergies in primary care settings. All of these have reported passable or poor areas of knowledge. In the U.S. study, 61% of 407 primary care physicians answered FA-related knowledge-based items correctly.8 The authors concluded that the overall knowledge was fair but that significant knowledge gaps existed and needed to be addressed. In a Turkish study, knowledge of FA and anaphylaxis among primary care physicians was found to be unsatisfactory, as the average percentage of correct answers was only 47% among the 297 participants.9 An Australian survey that included GPs reported significant gaps and variability in knowledge of the diagnosis and management of FA, potentially resulting in clinical practices inconsistent with international guidelines.10 A Brazilian study of 300 physicians and 220 nutritionists revealed many gaps in their knowledge of primary FA prevention.11 Our present study is the first to focus on knowledge and perceptions among primary care professionals while taking three factors together—infant nutrition, AD and FA. The overall knowledge of 77% is somewhat better than reported in other studies, but is still unsatisfactory in several areas.

The study's most serious finding is that frontline health care professionals are poor at recognizing many significant symptoms of FA. Most importantly, only 14% of the PHNs and 18% of the GPs knew that severe airway symptoms can be caused by an allergic reaction to food. Correspondingly, only 33% of the PHNs, compared to 73% of the GPs, recognized severe cardiovascular symptoms as potentially FA-related. These gaps of knowledge are alarming, as they indicate that frontline professionals cannot teach parents to recognize the symptoms themselves. This may delay the treatment of acute allergic reactions.

Another remarkable observation is a clear discrepancy between professionals’ knowledge and the perceptions of their own skills regarding FA and AD in small children. A very large proportion thought that they knew how to instruct families in the diagnosis, interpretation, and treatment of food-related symptoms in a child, even though we observed clear knowledge gaps in these areas. Furthermore, the results of the survey into AD treatment knowledge are contradictory, as they show that roughly 90% of participants reported their ability to instruct families in the treatment of AD in children under the age of one, even though 56% answered that moisturizers and emollients were adequate treatments for the condition. On the other hand, the majority agreed on the difficulty of diagnosing and interpreting food-related symptoms, and believed that they did not have enough training and practical tools to instruct families in the treatment of AD and food allergies.

Nearly all the frontline public health care professionals in our study recognized guidance on nutrition as an essential, although time-consuming, part of infant health care. Eighty percent of the participants had also seen that food-related symptoms cause significant anxiety and always (or at least often) result in an elimination diet. A similar proportion reported that potentially food-related symptoms or eczema in a child under the age of one year resulted in an extra call or a visit to health care. Therefore, it is likely that matters related to infant nutrition, FA, and AD cause a significant burden to families with small children and to the health care system.

Although our survey for the parents of 1-year-old children was fairly small (n=248), it offers three important and timely observations at the population level: Firstly, all but three babies had received breast milk and 65% of them were exclusively breastfed until at least the age of four months and 17% until the age of six months (data not shown). Secondly, at least one food substance was intentionally avoided in a quarter of the children (57/248) during the first year of life. Four percent of all the babies had experienced immediate symptoms potentially related to food ingestion (any food) and close to 40% had experienced delayed symptoms during their first year of life, resulting in avoidance of one or more food substances in about 40% of these children. Furthermore, the incidence of parent-reported, doctor-diagnosed FA was 4% by the age of one year (only half of these had experienced immediate symptoms). Therefore, more than 80% of the avoidance diets (including 13 subjects without symptoms and 34 subjects without doctor-verified FA diagnoses) are unnecessary, according to current national and international clinical care guidelines. These children make up as much as 20% of the subjects in the present study. Thirdly, parent-reported, doctor-diagnosed AD was present in 13% by the age of one year, and most had been treated with topical corticosteroids. However, these treatments were also used in 10% of children with no skin symptoms, a remarkable divergence from current care guidelines. Taken together, these results might reflect the lack of practical tools in frontline health care or poor acquaintance with and knowledge of the current care guidelines.

The availability of the health care system's primary care services is homogeneous throughout Finland, in both rural and urban areas. Therefore, it is very likely that the current results can be extrapolated to apply to the whole country. On the other hand, as only 64% of the PHNs, 37% of the GPs and 31% of the families returned the questionnaires, we cannot be certain that the respondents are fully representative of the population. Their self-selection as participants may indicate a higher confidence of knowledge or a higher level of education and so may be somewhat biased.

In conclusion, professionals working in primary health care have a crucial role in providing information to families regarding infant feeding practices, food-related symptoms, FA, and AD. However, our present results suggest that the observed significant variation in knowledge, attitudes and beliefs may result in heterogeneous guidance practices, person-to-person variation, and confusion among both professionals and families. We also found several alarming gaps and heterogeneity in many areas of knowledge; these may jeopardize the treatment of FA and AD. In addition to further postgraduate training,12–14 simple and unambiguous practical tools, designed for primary care, are urgently needed in order to translate current guidelines into the practical health benefits at the population level.

No conflicts of interest.