1. Introduction
Food allergies are becoming more common around the world, with a troubling 3–6% prevalence among children in developed countries [
1]. A food allergy is caused by genetic factors, but environmental factors, which may also cause epigenetic changes, appear to be the cause of this rapid increase [
1,
2]. Large population-based observational studies have also identified several factors that may contribute to an increased risk of developing a food allergy, such as the delayed introduction of allergenic foods to an infant’s diet, early skin barrier impairment, low levels of vitamin D in infants, and altered or reduced microbial exposure [
3,
4]. According to Gonzalez-González et al. [
5], milk, egg, soy, and wheat are the four most prevalent dietary allergies in children. The most prevalent foods that cause allergies differ by country. For example, cow milk, hen egg, and peanut allergies are the most common allergies in the United Kingdom and Australia, whereas cow milk, hen egg, and wheat allergies are the most common in Japan [
6]. Furthermore, differences in the type and number of trigger foods have been observed among various ethnic groups residing in the same country [
6]. Common food allergens in Saudi Arabia include peanuts, hen eggs, and cow milk (12.9%) [
7].
Many interventions tried in pregnant or breastfeeding women and infants appear to have little to no benefit in preventing food allergies, including dietary avoidance of food allergens, vitamin supplements, fish oil, probiotics, prebiotics, and symbiotics; however, it should be noted that the evidence in many cases remains uncertain [
8]. In a randomized trial, six allergenic foods—peanut, cooked egg, cow’s milk, sesame, whitefish, and wheat—were systematically introduced to 1303 infants either at 3 months (early introduction) or 6 months (standard introduction), and the primary outcome of that study was the development of a food allergy to one or more of the six foods between 1 year and 3 years of age [
9]. A significant decrease in the prevalence of peanut and egg allergies was seen in the subset of the early introduction group that ingested at least 2 g of each food protein per week, despite the study’s limitations due to high rates of non-adherence to dietary guidelines [
9]. Although these findings were not statistically significant, the early introduction group showed a 20% overall reduction in food allergy in the primary analysis [
9].
According to a separate investigation, introducing gluten between the ages of 4 and 6 months was associated with a lower prevalence of celiac disease [
10]. Early introduction of other allergens such as peanuts during the early ages was also negatively correlated with the prevalence of asthma and atopic dermatitis among children [
11]. Delaying the introduction of some foods, such as oats (>5 months) and wheat (>6 months), was significantly related to an elevated risk of allergy sensitization to food and inhalant allergens, according to data from a Finnish birth cohort that included 994 kids [
12]. According to one study, it is possible to lower the risk of peanut and hen egg allergies in children if such foods are introduced into infants’ weaning diets early and consumed regularly [
13]. Since the earlier advice to delay the introduction of such foodstuffs did not diminish the prevalence of food allergies, postponing the introduction of allergenic food into a child’s diet has come under scrutiny [
14]. As an alternative, early oral doses may result in tolerance, according to preclinical and clinical research [
15,
16]. The introduction of non-allergenic supplementary foods at the appropriate time is another dietary factor in preventing allergic disorders. However, there are currently no precise guidelines from the standpoint of allergy risk [
14].
Although avoiding allergic foods seldom impacts the nutritional quality of the diet, many processed foods contain substances comparable to those found in eggs and soy, which further restricts the variety of meals available and may affect the diet’s nutritional quality (17). A developing child’s diet mostly consists of milk and wheat, but other sources with comparable nutrients should also be included [
17]. Energy is provided by the macronutrients of protein, carbohydrates, and fats in one’s diet. Inadequate substitution can raise the risk of certain macronutrient shortages and result in insufficient energy intake [
18]. Avoidance diets must be carefully planned to ensure that protein and fat requirements are satisfied because foods like milk, eggs, and soy are significant sources of protein and fat [
17]. Poor growth and morbidities associated with protein deficiency can also result from protein-deficient diets [
19].
The significance of food allergy education has been highlighted not only for patients and caregivers but also for communities and families [
20]. In particular, improving parent knowledge regarding recognizing and managing acute reactions may help reduce their severity in the future, and parents’ understanding of the ingredients listed on food packages is crucial [
21,
22]. Parents and families should understand how to manage food allergies and have a clear action plan in the event of accidental exposure to reduce the stress of a food allergy diagnosis. For instance, Gomaa et al. [
23] studied the knowledge and awareness of food allergies among mothers of children with allergies. They reported that mothers with children previously diagnosed with food allergies generally had poor knowledge and awareness [
23]. Moreover, parents were found to be ill-prepared to handle exclusion diets and unable to appropriately administer epinephrine in emergencies [
24,
25]. This may lead to further problems, as children with food sensitivities may have insufficient nutrient intake and growth, which is most commonly observed in children with cow milk allergies [
26].
Additionally, parents of children with food allergies have a lower health-related quality of life than the general population [
27]. Thus, the current study was conducted to determine how eliminating specific food allergens may affect the growth of Saudi children with a history of allergies to selected foods.
4. Discussion
The major finding of this study shows that restrictions on food allergen foods restrict children’s, especially boys, growth in Saudi Arabia. In accordance, the determination of the IgE for the respondents in this study showed that the majority of boys and girls were categorized as having class 3 allergies, with boys having significantly (
p ≤ 0.05) higher values than girls. Higher levels of specific IgE were observed in egg whites, cow milk, wheat, peanuts, and soybeans for boys, while for girls this was the case for cow milk and peanuts. Specific IgE against allergens is a defining feature of allergic disease [
32]. Therefore, the results revealed that both boys and girls had allergic symptoms, as indicated by the values obtained for IgE in their serum. According to Du Toit et al. [
33], the most well-known types of food hypersensitivity disorders are IgE-mediated reactions, which are also responsible for many allergy symptoms.
Moreover, to determine whether a patient has IgE antibodies to specific foods, skin prick tests and/or various in vitro tests (e.g., RAST) are used [
34]. Previous research, however, has found that patients with food specific IgE antibodies experience clinical symptoms when the food is consumed [
35]. Also, previous research on children with atopic dermatitis and allergies to cow’s milk, eggs, or peanuts found that high levels of allergen-specific IgE antibodies were predictive of food-induced clinical symptoms [
36]. In a study of food allergies in Swiss children using skin prick tests and the detection of specific IgE levels in sera, hen egg allergy was detected in 23.7% of the patients, which was the highest percentage among the studied allergies [
37]. Al-Ghonaim et al. [
38] discovered a significant increase in total and specific IgE levels in four wheat allergy patients. Cow milk and dairy products, hen eggs, peanuts, nuts, gluten-containing cereals (e.g., wheat, rye, barley), sesame, soybeans, mustard, fish, crustaceans, and shellfish have been identified as the most allergenic foods [
39].
The frequency distribution of children according to specific IgE sensitization against food allergens revealed that boys were more likely than girls to be more sensitive to egg white, cow milk, wheat, and soybeans, while girls were more sensitive to fish and peanuts. The results indicated that the sensitivity against food allergens differed between boys and girls, with higher percentages of allergic boys than girls. Most studies show that males have a higher prevalence of IgE-sensitization than females, at least until adolescence [
40,
41]. Regarding specific IgE sensitization, females and males differ [
42]. However, Chen et al. [
43] reported that the prevalence of allergic diseases varies between genders and can be higher in either gender depending on age and disease, which cannot be explained solely by differences in IgE-sensitization. Salo et al. [
44] compared specific IgE levels for 19 specific IgEs concerning sex in participants aged 6 and up and observed that only two specific IgEs differed by sex against milk and Aspergillus fumigatus allergens. Male sex is a risk factor for early sensitization to food and aeroallergens [
45], hypersensitivity reactions to food, and food-induced anaphylaxis in childhood [
46]. This may be explained by sex differences in immune response profiles during childhood [
47]. One possible explanation for the gender–food allergen relationship is that estrogens boost humoral immunity and antibody synthesis, while androgens and progesterone suppress immunity and inflammation [
43]. Increased estrogen in girls with age may increase the prevalence of food allergies with age [
43].
The frequency distribution of children with specific IgE against food allergens classified by age (years) revealed that boys and girls aged 5 to 10 years were more allergic regardless of allergen type. In both sexes, the percentages of allergic respondents decreased significantly with age. This can be explained by the fact that the majority of children developed a tolerance to these common allergens with age, as reported by Sicherer and Sampson [
48]. Furthermore, the median age at food–allergy onset was two years earlier in boys than in girls (5 years). Other studies have shown that, after puberty, female patients outnumber male patients in terms of IgE-mediated food allergies and hospitalizations for food-induced anaphylaxis [
46]. Kumata et al. [
49] discovered a link between IgE antibody concentrations in wheat and interaction with wheat. Also, age affected the outcome, with younger children having a stronger link between serum-specific IgE concentrations and challenge outcomes than older children. Shek et al. [
50] studied food-specific IgE levels in cow’s milk and hen’s egg allergies over time. They discovered a link between the degree of decrease in food-specific IgE antibody concentrations over time and the likelihood of developing tolerance.
Some children take certain types of milk while breastfeeding, and when the breastfeeding period ends, the children gradually begin to take food. Some of these children develop allergies while breastfeeding, while others develop allergies after the breastfeeding period ends. The developed allergies force their families to exclude foods associated with those allergies. The main foods that are excluded are egg white, cow milk, peanuts, wheat, soybeans, and a few others. Although avoiding allergic foods has little effect on nutritional quality, many processed foods contain substances similar to those found in eggs and soy, further limiting the variety of meals available [
17]. A growing child’s diet consists primarily of milk and wheat, but other sources of comparable nutrients should also be included [
17]. The macronutrients protein, carbohydrates, and fats in one’s diet provide energy. Inadequate substitution can increase the risk of certain macronutrient shortages and insufficient energy intake [
51]. Because foods like milk, eggs, and soy are high in protein and fat, they must be carefully planned for a child’s diet to ensure that protein and fat requirements are met. A separate study [
47] found that introducing gluten between the ages of 4 and 6 months was associated with a lower prevalence of celiac disease. Moreover, according to data from a Finnish birth cohort of 994 children, delaying the introduction of some foods, such as oats (>5 months) and wheat (>6 months), was significantly associated with an increased risk of allergy sensitization to food and inhalant allergens [
21]. In contrast, asthma and atopic dermatitis were two other allergy disorders discovered to be allergen-specific and unaffected by the early introduction of peanuts [
26].
Despite removing some foods from the children’s diet, with most removing some foods from the children’s diet, most boys and girls had normal BMI-for-age and height-for-age ratios based on WHO reference values and Saudi national growth reference values. There was a significant difference between boys and girls in terms of thin, overweight, and obese; boys were thinner than girls, while the number of overweight or obese boys outnumbered that of girls. The majority of studies on the relationship between food allergies and children’s development have found that food sensitivity is a risk factor for developmental impairment due to the elimination of diets associated with food allergies. [
52,
53]. Visness et al. [
54] discovered a link between obesity and atopy in American children aged 2 to 19. Furthermore, they reported that the associations for most of the outcomes were stronger for the obese category than for the overweight category, indicating a dose-response for weight, and the analysis of continuous BMI with total IgE levels supports the concept that increased weight is associated with increased allergic general tendency. Total IgE levels were higher in girls than in boys in the overweight category but higher in boys than in girls in the obese category, and the relationship between BMI and total IgE levels was stronger in girls than in boys [
54]. Hayashi et al. [
55] investigated the relationship between obesity and the prevalence of food allergies and discovered a positive relationship between obesity and the prevalence of food allergies in girls. A previous study in the United States that looked at the relationship between obesity, serum IgE, and allergic symptoms concluded that obesity might be a factor in the increased prevalence of allergic disease in children, particularly food allergies [
54]. In contrast, a study of Vietnamese children found no significant link between obesity and food allergies [
56].
Spearman correlation and simple regression analysis were used to determine the factors associated with children with impaired growth. The results showed that the absence of hen eggs, cow milk, wheat, and peanuts from the diet significantly negatively impacted BMI-for-age and height-for-age ratios in both boys and girls, with cow milk having a stronger association than other allergens. According to ref. [
41], children with food restrictions have lower calories, proteins, carbohydrates, fats, riboflavin, vitamin B12, phosphorus, calcium, and iron intake, which hampers their growth. Allergy severity was an independent risk factor for height and weight. The children with food restrictions had significantly lower height, weight, head circumference, and mid-upper arm circumference than those in the non-food-restricted group. More stunted and underweight children were found in the food-restricted group [
41]. Despite the negative effects of food allergen exclusion on child growth, it appears that the effect is limited to children with lower BMI and height-to-age ratios. We anticipate that the children did not receive any food to compensate for the nutrient shortage.
This study emphasizes the importance of intensive food allergy health education programs for managing food allergies and potential treatments for mothers whose children have suffered from growth impairment. On the other hand, child age, age at diagnosis, mother’s education, and family monthly income had a significant positive impact on BMI-for-age and height-for-age ratios in normal, overweight, and obese boys and girls. The authors propose that boys and girls with normal growth, overweightness, and obesity received food to compensate for the nutrient shortage as indicated by the demographic characteristics that favor their nutritional status. A well-educated mother, reasonable family income, and the mother’s presence at home throughout the day, as well as the child’s age, all contributed to the children eating a balanced diet. Internal factors, such as the child’s taste and food preferences, as well as external factors, such as peers, media, and parents, influence eating habits. Parents play an important role in early childhood because they serve as providers, enforcers, and role models for children who are still very dependent on them [
57]. Some of these efforts succeed in meeting the parent’s objectives. For example, feeding practices such as making healthy foods available and modeling healthy food consumption have been shown to facilitate healthy eating behaviors in young children [
58]. Furthermore, a recent prospective observational study found that tracking a child’s intake of high energy-dense foods at the age of two was associated with a healthier weight status one year later [
59]. Kröller and Warschburger [
60] discovered that mothers with higher education used more monitoring of their children’s food intake.
This study’s limitations include the: Food allergy patients were located through the King Fahad Medical City Hospital database in Riyadh, and the children under investigation may not have been completely representative of the local population. Furthermore, a significant number of children were recruited directly through hospital emergency departments. Therefore, it can be speculated that the children included in this study represented a subset of infants and young children with more severe food allergies. Furthermore, it should be noted that the purpose of this study was not to determine the prevalence of food allergies in Saudi children but to examine the clinical manifestations and distribution of allergens that are most commonly involved in cases confirmed with food allergies.