Tree Nut Allergy, Egg Allergy, and Asthma in Children Jonathan M. Gaffin, MD,1,2 William J. heehan, MD,1,2 Ja!

lyn Morrill,1 Mune""er Cinar,1 #rene M. $orras Coughlin,1 Gregory . a%i!&i, MD, M'(,1,2 )ran& J. T%arog, MD, 'hD,1,2 Mi!hael C. *oung, MD,1,2 +ynda C. !hneider, MD,1,2 and Wanda 'hi,atana&ul, MD, M 1,2 1 Children-s (os,ital $oston, $oston, MA, . A 2 (ar"ard Medi!al !hool, $oston, MA, . A Corres,onding Author/ Wanda 'hi,atana&ul, Children-s (os,ital $oston, Di"ision of #mmunology, )egan 0, 122 +ong%ood A"e, $oston, MA 22113, . A, Email/ %and.,hi,atana&ul4!hildrens.har"ard.edu The ,u5lisher6s final edited "ersion of this arti!le is a"aila5le at Clin 'ediatr 7'hila8 9ther e!tions: A5stra!t $a!&ground Children %ith food allergies often ha"e !on!urrent asthma. 95;e!ti"e The authors aimed to determine the ,re"alen!e of asthma in !hildren %ith food allergies and the asso!iation of s,e!ifi! food allergies %ith asthma. Methods 'arental <uestionnaire data regarding food allergy, !orro5orated 5y allergi! sensiti=ation %ere !om,leted for a !ohort of >?? !hildren %ith food allergies. Multi"ariate regression analysis tested the asso!iation 5et%een food allergy and re,orted asthma. @esults #n this !ohort, the ,re"alen!e of asthma %as A3.0B. After ad;usting for ea!h food allergy, en"ironmental allergies, and family history of asthma, !hildren %ith egg allergy 7odds ratio C9@D E 2.2F ?3B !onfiden!e inter"al CC#D E 1.1G1.2F P H .218 or tree nut allergy 79@ E 2.2F ?3B C# E 1.1G1.0F P E .228 had signifi!antly greater odds of re,ort of asthma. Con!lusion There is a high ,re"alen!e of asthma in the foodIallergi! ,ediatri! ,o,ulation. Egg and tree nut allergy are signifi!antly asso!iated %ith asthma, inde,endent of other ris& fa!tors. Jey%ords/ asthma, food allergy, food hy,ersensiti"ity, nut allergy, nut hy,ersensiti"ity, egg allergy, egg hy,ersensiti"ity, ,ediatri!s, allergy, asthma e,idemiology 9ther e!tions: #ntrodu!tion The ,ast 1 de!ades ha"e seen a dramati! rise in the ,re"alen!e of allergi! diseases, in!luding asthma and food allergies.1G3 Current estimates of !lini!ally rele"ant food hy,ersensiti"ity range from 1B to 1.2B in !hildren and adults in the general ,o,ulation. 0G ? Children tend to 5e allergi! to mil&, eggs, %heat, and ,eanuts,12 %hereas adults ,rimarily rea!t to ,eanuts, tree nuts, and seafood.1,0 Asthma ,re"alen!e has mirrored this in!rease, and it is !urrently estimated that K.3B of !hildren suffer from asthma.1 )or those %ith food allergy, the ,re"alen!e of asthma is as high as 2?B.2 Many studies ha"e sho%n the ,re"alen!e and influen!e of allergi! ,henoty,es in !ohorts of ,atients %ith asthma.11G1A These studies suggest that ,atients %ith food allergies are at

higher ris& for asthma diagnosis13 and asthma mor5idity. 12G1A,10 (o%e"er, fe% studies ha"e fo!used on asthma out!omes in !ohorts of !hildren %ith food allergy.1> Mil&, egg,1K and %heat sensiti=ation has 5een asso!iated %ith the de"elo,ment of asthma in "ery young !hildren.1?G21 (o%e"er, !lini!ally rele"ant food allergy in !hildren s,anning all ages and the relationshi, to asthma has 5een less %ell des!ri5ed. The aims of this study %ere to define the ,re"alen!e of asthma in a large !ohort of !hildren %ith food allergies and determine if indi"idual food allergies %ere s,e!ifi!ally asso!iated %ith asthma. We hy,othesi=ed that there is a high ,re"alen!e of asthma in the foodIallergi! ,o,ulation and that indi"idual food allergies differentially asso!iate %ith asthma ris&. 9ther e!tions: Methods tudy 'arti!i,ants This study %as a !rossIse!tional analysis of >?? !hildren %ith s&in ,ri!& test or s,e!ifi! immunoglo5ulin E 7s#gE8 !orro5orating ,arental re,ort of food allergy from a !ohort of 1A11 !hildren %ith ,hysi!ianIdiagnosed food allergy. Throughout, %e ha"e used the term parent to in!lude all ,rimary !aregi"ers and subject to refer to the foodIallergi! !hild in <uestion. The study in!luded !hildren %ith Allergy 'rogram "isits at Children-s (os,ital $oston or 2 su5ur5an ,ediatri! allergy ,ra!ti!es. #f ,arental re,ort %as ,ositi"e for the su5;e!t ha"ing a !lini!al history of allergi! rea!tion to one or more foods, then, the ,arent %as as&ed to ,arti!i,ate in the study. 'arents %ere eL!luded if they %ere not intimately familiar %ith the !hild-s !on!e,tion and 5irth 5e!ause the ,rimary ,ur,ose of this !ohort %as to e"aluate ,renatal fa!tors ,redi!ting !hildhood food allergy. Data for si5lings of the ,rimary su5;e!t %ere not in!luded in the analysis. After o5taining %ritten informed !onsent from the su5;e!t-s ,arent, a <uestionnaire regarding the su5;e!t-s food allergy history, en"ironmental allergies, family history, and demogra,hi!s %as distri5uted. Data %ere !olle!ted ,ros,e!ti"ely o"er a AIyear ,eriod from May 2223 through 9!to5er 222?. The study %as a,,ro"ed 5y the institutional re"ie% 5oard of the Children-s (os,ital $oston. Definition of 'redi!tor Maria5les 'arental re,ort of food allergy %as determined 5y ans%ering <uestionnaire items ,hrased, NThe follo%ing <uestions ,ertain to your C!hild-sD food allergy history,O %ith res,onse o,tions, Nne"er ate this food,O Nno,O or Nyes.O +isted foods %ere Neggs,O NdairyPmil& ,rodu!ts,O Nseafood,O Ntree nuts 7tree nuts in!lude %alnuts, ma!adamia nuts, almonds, ,ista!hios, !ashe%s, ,e!ans, 5ra=il nuts, ha=elnuts8,O N,eanutsP,eanut 5utter,O and Nsesame seeds.O )ood allergy %as defined in this study as re,ort of allergy and e"iden!e of sensiti=ation 5y s&in ,ri!& test or s#gE. Those %ith re,ort of food allergy not !orro5orated 5y e"iden!e of allergi! sensiti=ation, %hen treated as a se,arate grou,, did not affe!t the relationshi, of food allergy to asthma. As these su5;e!ts %ere ,ossi5ly mis!lassified and statisti!ally not informati"e, they %ere not in!luded in the final analysis. @e,ort of Nne"er trying the foodO or Nnot 5eing allergi!O %as analy=ed as su!h. Measurement of u5;e!t-s ensiti=ation to )ood Allergens The su5;e!ts- !harts %ere re"ie%ed retros,e!ti"ely for allergen s&in ,ri!& test and s#gE results. &in ,ri!& test to !ommer!ially a"aila5le eLtra!ts %as ,erformed on the 5a!& or "olar surfa!e of the forearm using standard methods. &in ,ri!& tests %ere re!orded as

%heal and flare measurements andPor ,ositi"ePnegati"e for ea!h item tested. A %heal 1 mm greater than the negati"e !ontrol at 13 minutes %as !onsidered ,ositi"e. 'atients %ere eL!luded if they had a negati"e histamine !ontrol. The follo%ing s&in ,ri!& test allergens %ere used/ dairy 7mil&, !asein8, egg 7egg %hite8, tree nut 7almond, 5ra=il nut, !ashe%, ha=elnut, ,e!an, ,ista!hio, %alnut8, ,eanut, sesame seed, seafood 7!lam, !odfish, !ra5, flounder, lo5ster, salmon, s!allo,, shrim,, trout, tuna8. s#gE %as measured 5y #mmunoCA' assay 7'hadia . #n!, 'ortage, M#8. @esults of #mmunoICA' testing %ere deemed ,ositi"e for "alues Q2.13 &.AP+. All tests %ere ,erformed at a C+#AI!ertified la5oratory. When a"aila5le, the follo%ing s#gE tests %ere ordered for the food grou,s/ dairy 7mil&, R la!tal5umin, !asein, %hey8, egg 7egg %hite8, tree nut 7almond, !ashe%, ha=elnut, ,e!an, ,ista!hio, %alnut8, ,eanut, sesame seed, seafood 7!odfish, !ra5, lo5ster, haddo!&, salmon, shrim,8. When s&in ,ri!& or s#gE tests %ere re,eated, aggregate out!omes %ere used as Ne"er ,ositi"e,O Nne"er ,ositi"e,O or Nne"er testedO for ea!h allergen. Definition of 9ther 'redi!tor Maria5les 'otential !onfounders of the relationshi, 5et%een ,redi!tor "aria5les and asthma %ere !onsidered for in!lusion in the multi"ariate model. Maria5les related to allergy other than food allergy in!luded ,et allergy, ,ollen allergy, and e!=ema. Maria5les related to the family history of allergi! disease %ere o5tained for the su5;e!t-s mother and father and in!luded asthma, hayfe"erP,ollen allergy, and e!=ema. 're"iously des!ri5ed fa!tors asso!iated %ith asthma, su!h as age, gender, and le"el of maternal edu!ation, %ere also in!luded. The highest le"el of maternal edu!ation %as re!orded as Nsome high s!hool,O Nhigh s!hool degree,O Nasso!iates degree or te!hni!al s!hool,O N5a!helor-s degree,O Nmaster-s degree,O or N,rofessional degree 7'hD, MD, JD8.O Definition of 9ut!ome Maria5le The ,rimary out!ome of interest in this study %as ,arental re,ort of asthma. 9n the <uestionnaire, ,arents %ere instru!ted to ans%er <uestions N,ertaining to Cthe !hild-sD nonIfood allergy history.O 'resen!e or a5sen!e of asthma %as indi!ated 5y !he!&5oL/ NyesO or NnoO. Those %ho ans%ered yes to this <uestion %ere !ategori=ed as ha"ing asthma. tatisti!al Methods 're"alen!e of asthma %as determined 5y sim,le statisti!al analysis in!or,orating all !ases %ho ans%ered the <uestion a5out asthma. )or ea!h food grou,, 1 !ategoriesS allergi!, not allergi!, and ne"er triedS%ere indi"idually analy=ed for asso!iation %ith asthma 5y in!or,orating the 1 !ategories into a logisti! regression %ith Nnot allergi!O as the referen!e grou, and ad;usting for the Nne"er triedO grou,. .ni"ariate analysis of the relationshi, 5et%een 5inary !o"ariates, su!h as en"ironmental allergies, gender, ,arental history of asthma, e!=ema and hayfe"erP,ollen allergy, and the out!ome of asthma used 2 T 2 !ontingen!y ta5les. #n ea!h situation, odds ratios 79@s8 %ere used to measure the magnitude of effe!t, and a U2 test %as used to determine statisti!al signifi!an!e. Ea!h !o"ariate %as e"aluated for a,,ro,riate use in the analysis. Maternal edu!ation %as grou,ed into a 1I!ategory "aria5le/ less than or e<ual to high s!hool di,loma, 5a!helor-s or te!hni!al degree, and master-s or do!torate degree. )or all analyses, maternal edu!ation less than or e<ual to high s!hool di,loma %as used as the referen!e grou,. Age %as found to ha"e a nonlinear relationshi, %ith the out!ome and %as therefore !ategori=ed 5y <uartiles for further analysis, %ith the youngest age grou, as referen!e.

We used multi"ariate logisti! regression to study the relationshi, 5et%een ea!h indi"idual food allergy and asthma %hile !ontrolling for ,otential !onfounders. A for%ard sele!tion regression model in!luded all food allergies and !andidate !o"ariates. ignifi!ant asso!iations from the multi"ariate analysis %ere defined as those %ith 2Isided P "alue V.23. No !orre!tions for multi,le tests %ere made. A "ersion ?.2 7 A #nstitute, Cary, NC8 and ' "ersion 1>.2.2 7 ' #n!, Chi!ago, #+8 %ere used for analysis. A ,ost ho! analysis %as ,erformed to determine the effe!t of the num5er of food allergies on the ,re"alen!e of asthma. The num5er of food allergies %as !al!ulated as the sum of any ,ositi"e food allergies, as defined a5o"e, for an indi"idual su5;e!t. )or analysis, grou,s %ere !ategori=ed as 1, 2, 1, and greater than or e<ual to A of these 0 food allergies 5e!ause there %ere fe% su5;e!ts %ith 3 allergies and no su5;e!ts allergi! to all 0 tested foods. The !ontingen!y ta5le %as analy=ed 5y a U2 test and Co!hraneIArmitage trend test to eLamine the signifi!an!e of the trend. 9ther e!tions: @esults A total of 1322 <uestionnaires %ere distri5uted among the 1 ,arti!i,ating sites to 5e filled out in %aiting rooms or returned 5y mail. 9f the 1A11 7?1B8 <uestionnaires returned, 1112 7K>B8 su5;e!ts ans%ered the <uestion regarding the ,resen!e of asthma. 9f these, >?? 702B8 had s&in ,ri!& test or s#gE a"aila5le to !orro5orate the re,ort of food allergy. 9nly these su5;e!ts %ere in!luded in the final analysis. Ta5le 1 summari=es the distri5ution of ,redi!tor "aria5les and !o"ariates among su5;e!ts %ith and %ithout re,ort of asthma. #t also re,orts the results of the uni"ariate analysis for ea!h ,redi!tor and !o"ariate. The su5;e!ts %ere ,redominantly male and in their early s!hool age years. 'eanut %as the most !ommon food allergy re,orted 731B8, follo%ed 5y egg 7AAB8, dairy 71KB8, and tree nut 72AB8. E!=ema %as re,orted in three fourths of su5;e!ts, and hayfe"er and ,et allergy %ere ea!h ,resent in nearly half of this !ohort. Asthma %as re,orted in 103 su5;e!ts 7A3.0B8. Table 1 Demogra,hi! and .ni"ariate Analysis of Allergi! 'henoty,e and Asso!iation With Asthma

)or ea!h food allergy, after ad;usting for those %ho had Nne"er triedO the food, only !hildren %ith egg allergy and tree nut allergy had signifi!antly higher odds of ha"ing asthma than those %ithout the allergy. As eL,e!ted, se"eral of the !o"ariates %ere also ,ositi"ely and signifi!antly asso!iated %ith asthma, su!h as hayfe"er, ,et allergy, and family history of allergi! diseases. The ris& of asthma in!reased se<uentially 5y <uartile of age !om,ared %ith the youngest <uartile. $esides the effe!t of in!reasing age, hayfe"er and ,et allergy had the strongest asso!iations %ith asthma. .ni"ariate analysis of gender sho%ed that female gender %as negati"ely asso!iated %ith asthma. )igure 1 sho%s the ,re"alen!e of ea!h food allergy re,orted. Nearly half of the su5;e!ts had ne"er tried seafood, ,eanuts, or sesame seeds, more than 02B had ne"er tried tree nuts. When the Nne"er triedO grou, is remo"ed from ea!h food allergy, there %ere more

,eanutIallergi! su5;e!ts than nonI,eanutIallergi! su5;e!ts, and for tree nuts, the ,ro,ortion of allergi! and not allergi! su5;e!ts %as nearly e<ual. Figure 1 're"alen!e of food allergy status/ 5ar !hart illustrating re,ort of food allergy res,onse to ea!h allergen/ 5la!&, allergi!F gray, not allergi!F %hite, ne"er tried Ta5le 2 summari=es the results of the multi"ariate analysis of food allergy and asthma in this !ohort of foodIallergi! !hildren. A total of >1K su5;e!ts %ere in!luded in the final model. After ad;usting for ea!h food allergy and those %ho had Nne"er triedO ea!h ,otential allergen as %ell as for en"ironmental allergies, e!=ema, age, and ,arental history of asthma, those %ith egg allergy or tree nut allergy had t%i!e the odds of ha"ing asthma 7egg, 9@ E 2.2, ?3B !onfiden!e inter"al CC#D E 1.1G1.2, P H .21F tree nut allergy, 9@ E 2.2, ?3B C# E 1.1G1.0, P E .228. 9ther &no%n ris&s for asthma, su!h as en"ironmental allergies, ,arental history, and in!reasing age also ,ro"ed to 5e inde,endently asso!iated %ith asthma, %hereas female gender remained negati"ely asso!iated %ith asthma. A regression model that in!luded those %ith re,ort of food allergy not !orro5orated 5y allergi! sensiti=ation as a se,arate grou, 75e!ause this grou,-s allergi! status is un!lear and is highly su5;e!t to mis!lassifi!ation8 demonstrated similar results 7n E 1111F egg, 9@ E 1.0, P E .21F tree nut, 9@ E 2.1, P E .2238. Table 2 Multi"ariate Analysis of Allergi! 'henoty,e and Asso!iation With Asthma

)igure 2 demonstrates the ,ositi"e effe!t of multi,le food allergies on the ,re"alen!e of asthma 7U2 P H .221F Co!hraneIArmitage test for linear trend P H .2218. Figure 2 Trend in re,ort of asthma 5y num5er of food allergies/ num5er of food allergies limited to ,eanut, tree nut, seafood, dairy, egg, or sesame seed allergyF U2 for the distri5ution, P H .221F Co!hraneIArmitage test for linear trend P H 7more ...8

9ther e!tions:

Dis!ussion This study sho%s that nearly half of !hildren %ith food allergies re,ort ha"ing a diagnosis of asthma. )urthermore, through a "ery !onser"ati"e analysis in %hi!h ea!h food allergy ,redi!tor %as ad;usted for all the ,otential food allergies and Nnot ha"ing triedO ea!h of the foods as %ell as for &no%n asthma ris& fa!tors, %e demonstrate that a !lini!al history of egg and tree nut allergy are strongly and signifi!antly asso!iated %ith asthma.

e"eral !ohorts of asthmati! !hildren ha"e 5een %ell !hara!teri=ed for allergi! diatheses, and it is !lear that food allergy in asthmati! !hildren is highly ,re"alent.11G1A,22,21 ., to A3B of !hildren %ith asthma ha"e food sensiti"ity 5y food s#gE.22 We hy,othesi=ed that the ,re"alen!e of asthma in this study %ould 5e ele"ated gi"en the shared immunologi!al ,redis,osition to ato,i! diseases. We found the ,re"alen!e of asthma to 5e A3.0B in our foodIallergi! ,ediatri! !ohort. This is mar&edly higher than the 2?B ,re"alen!e of asthma in foodIallergi! !hildren found 5y the . National Center for (ealth er"i!es 7NC( 8 from data !olle!ted 5y national tele,hone sur"ey2 in an unsele!ted sam,le of the general ,o,ulation. This differen!e li&ely stems from the different ,o,ulations sam,led. Although 5oth studies rely on selfIre,ort for diagnosis of food allergy and asthma, su5;e!ts in our study %ere seen at referralI5ased allergy ,ra!ti!es, and re,ort of allergy %as !orro5orated 5y food allergy sensiti=ation. #t is li&ely that our su5;e!ts had more a!!urate determination of !lini!ally signifi!ant food allergy 5e!ause the !lini!al history %as "alidated 5y o5;e!ti"e food allergy tests. )ood allergy has 5een im,li!ated as a ris& fa!tor for asthma,11 a trigger for asthma eLa!er5ations,2A and a fa!tor determining asthma mor5idity. 11,1A This study sho%s s,e!ifi! food allergies to 5e inde,endently asso!iated %ith asthma in !hildren. #n our !ohort, egg and tree nut allergy !onfer signifi!antly higher ris& of asso!iated asthma in !hildren %ith food allergy after ad;ustment for &no%n ris& fa!tors. The statisti!al model !ontrols for ,otential !onfounders su!h as e!=ema, re,ort of allergies to !ommon aeroallergens, and family history of ato,y, %hi!h further strengthens the im,ortan!e of the interrelationshi, 5et%een egg and tree nut allergy and asthma inde,endently of other ato,i! ris& fa!tors. $y in!luding ea!h food allergy in the same model, %e a!!ount for its inde,endent effe!t on the out!ome, illustrating the strength of the asso!iation of egg and tree nut allergy %ith asthma. Early food sensiti=ation has 5een ,re"iously identified as a ,redi!tor for asthma. @hodes et al21 demonstrated ,ositi"e s&in ,ri!& test to egg or !o%-s mil& in infan!y to 5e ,redi!ti"e of adult asthma in a !ohort at ris& for asthma 5y "irtue of family history of ato,y. Nota5ly, these %ere the only food allergens tested in this !ohort. imilarly, hen-s egg sensiti=ation ,redi!ts later aeroallergen sensiti=ation in infants %ith e!=ema23 and, along %ith %heat sensiti=ation, is asso!iated %ith de"elo,ment of asthma in %hee=y infants.1? Although remar&a5le, these studies demonstrate sensiti=ation as a ris& %ithout eL,li!itly assessing the !lini!ally im,ortant "aria5le of sym,tomati! food allergy. #n !hildren %ith !lini!al food allergies, Tari< et al20 found infantile sym,tomati! egg allergy to 5e strongly ,redi!ti"e of asthma in a large ,o,ulationI5ased !ohort in the #sle of White. This asso!iation held through multi,le regression analysis that in!luded im,ortant demogra,hi! ris& fa!tors. #n a smaller study, !hroeder et al1> also re,orted signifi!ant asso!iations 5et%een se"eral food allergies and asthma in a ,ediatri! !ohort in an ad;usted model 5ut did not re,ort inde,endent effe!ts of ea!h food allergy in relation to the other food allergens. The !urrent study lends strength to the asso!iation 5et%een !lini!al egg allergy, do!umented 5y re,ort and sensiti=ation, and asthma in the !onteLt of ad;usting for other food allergens and aeroallergens. Tree nut allergy or sensiti=ation has infre<uently 5een eL,lored in asso!iation %ith asthma in food allergi! !hildren2> and has not 5een sho%n to ha"e an inde,endent effe!t %hen ad;usting for other food allergies. The !urrent analysis demonstrates tree nut allergy to 5e strongly and signifi!antly asso!iated %ith asthma inde,endent of other food allergies.

$e!ause this study only re!ruited !hildren from su5s,e!ialty allergy !lini!s %ith re,orted food allergies, it is not unusual that many of the su5;e!ts had not yet tried some of the foods in <uestion. This may 5e a result of general food introdu!tion guidelines,2K %hi!h re!ommended delaying the introdu!tion of !ommon allergens in highIris& !hildren. Additionally, some families may ha"e 5een instru!ted to a"oid introdu!ing foods to %hi!h the !hild sho%ed la5oratory or s&inI,ri!& test sensiti"ity ,rior to first ingestion. #n multi"ariate analyses, those %ho had ne"er tried ,eanut and sesame seed had signifi!ant asso!iation %ith asthma, %hi!h may 5e eL,lained 5y su!h a"oidan!e. #t is diffi!ult to inter,ret data for su5;e!ts %ho had not tried a food %ithout information regarding %hy they had not tried itF ho%e"er, %e ad;usted for all the Nne"er triedO res,onses in our multi"ariate regression analysis. The ,ositi"e findings of this study ta&e into a!!ount this grou, for %hom %e ha"e limited information. Though u, to ?B of !hildren may ha"e foodIindu!ed %hee=e as their only allergi! manifestation to a food allergen,2?,12 it is unli&ely that this a!!ounts for the magnitude and signifi!an!e of the egg and tree nut effe!t found here. The foods most often asso!iated %ith foodIindu!ed %hee=e in asthmati!s are eggs, mil&, and fish,2? %hi!h %ould not eL,lain the effe!t of tree nut in our study. Additionally, se"eral studies ha"e sho%n that indi"iduals %ith s,e!ifi! food allergies, ,arti!ularly to ,eanut 5ut also to egg and dairy, ha"e greater mor5idity, in!luding 5ron!hodilator use, steroid use, and se"ere asthma eLa!er5ations, inde,endently of !on!urrent eL,osure to these allergens.11,11 #t has 5een suggested that the ris& for asthma in!reases %ith the num5er of food allergies.1> 9ur findings su,,ort the mounting e"iden!e that greater num5er of food allergies is also an im,ortant fa!tor asso!iated %ith asthma. This study in"estigated allergies to 0 food items in a ,o,ulation of !hildren sele!ted for re,ort of any food allergy. When e"aluating the !umulati"e num5er of food allergies out of the 0 <ueried, %e o5ser"ed a highly signifi!ant ,ositi"e trend %ith re,ort of asthma. 9ur study is limited 5y the la!& of information on some ,ossi5le !onfounding fa!tors su!h as ra!e and dire!t indi!ators of so!ioe!onomi! status 7 E 8. Maternal le"el of edu!ation has 5een !orrelated %ith E in ,re"ious asthma studies12 and ser"es that ,ur,ose here. This "aria5le sho%ed a nonsignifi!ant ,ositi"e effe!t on in!reased asthma ris& %ith lo%er le"el of maternal edu!ation in the uni"ariate analysis, as %ould 5e eL,e!ted from an E Irelated "aria5le.12 'arental re,ort as the 5asis for the ,rimary ,redi!tor "aria5les tested allo% re!all 5ias, though ,otential o"erre,orting of allergi! rea!tion %as limited 5y !orro5orating e"iden!e of sensiti=ation. Dou5leI5lind food !hallenge %ould 5e ideal to identify those %ith true food allergyF ho%e"er, this %as 5eyond the s!o,e of this study. The re,ort of asthma %as not !orro5orated 5y o5;e!ti"e data and still may fall su5;e!t to re!all 5ias. Con!lusions There is a high ,re"alen!e of asthma among the ,ediatri! foodIallergi! ,o,ulation. We demonstrate that egg and tree nut allergy, inde,endent of other food allergies, are asso!iated %ith asthma in a large study of foodIallergi! !hildren. These findings suggest that !lini!ians should ha"e a lo% threshold to sus,e!t asthma in !hildren %ith food allergies, es,e!ially if the !hild is allergi! to eggs or tree nuts.