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Response by T. F. Leung, on behalf of the authors

We appreciate the feedback by Flokstra-de Blok and colleagues on our article [1] that validated the Food Allergy Quality of Life-Parental Burden (FAQL-PB) questionnaire and assessed quality of life (QoL) of Chinese families whose children had parent-reported adverse food reactions (AFRs). This study was performed as an epidemiological survey on AFRs in a non-selected group of 3677 young children from 21 nurseries and kindergartens in Hong Kong [2]. Parents of participants were asked to complete the study questionnaire, part of which contained the Chinese translated version of FAQL-PB. Our study was among the few articles that validated disease-specific QoL tool for food allergy (FA) in Asia. Flokstra-de Blok and colleagues pointed out that our study inappropriately applied disease-specific FAQL-PB on families without the target condition of FA. As mentioned above, our study was initially designed to delineate the prevalence and clinical spectrum of parent-reported AFRs in Hong Kong children. The assessment of diseasespecific QoL was only one of its secondary outcomes. One consideration for the usefulness of any QoL tool would be whether it discriminates the diseased subjects from those without the target condition. Our non-selected childhood population offered an excellent opportunity to address this issue as both the parents of children with and without AFRs completed the FAQL-PB. On the other hand, all our subsequent analyses on FAQL-PB were performed only in the subgroup of children with parent-reported AFRs. In line with Flokstra-de Blok and colleagues, we advocate that FAQL-PB should be used clinically to assess disease-specific QoL in families with children who have AFRs. Concerning their comment about the minimal important difference (MID), there has actually been much controversy about its concept, defining criteria and clinical applicability. MID is commonly set as about 0.5 for any seven-point Likert scale [3, 4]. This threshold score is applicable to both disease-specific and generic QoL tools, which provides an indicator of the change that is compatible with a clinically significant change for the patient. Although MID is most commonly applied at the population level, Jones suggested that it may also be applied to identify the number of individuals exceeding the threshold [5]. Thus, we would disagree with Flokstra-de Blok and colleagues that MID was inappropriately used in our study. In fact, we looked at this issue in both ways. MID was used in our study as an index to interpret differences in diseasespecific QoL between the families with and without children who had AFRs. We showed that disease-specific QoL score reached MID for families with children who had AFRs to more than three foods. In addition, we assigned the cut-off score to each family so as to facilitate our analysis for the risk factors that were associated with poorer QoL in our study population. Lastly, we support Flokstra-de Blok and colleagues that generic QoL tools may provide useful and complementary information on which to judge the impact of having children with AFRs on the overall QoL of their families [6]. The assessment of QoL is especially crucial for FA as no objective disease parameters are available in most patients to reflect the severity of their ongoing disease. Our study has just started to facilitate the evaluation of disease-specific QoL in Chinese families and unravel the influence of childhood FA on their QoL. The results improve our understanding of the psychosocial burden of childhood FA in Asia, and also open up the way to monitor the management of these families with children who have AFRs.