Canadian food ladders for dietary advancement in children with IgE-mediated allergy to milk and/or egg

Food ladders are clinical tools already widely used in Europe for food reintroduction in milk- and egg-allergic children. Previously developed milk and egg ladders have limited applicability to Canadian children due to dietary differences and product availability. Herein we propose a Canadian version of cow’s milk and egg food ladders and discuss the potential role that food ladders may have in the care of children with IgE-mediated allergies to cow’s milk and/or egg, as either a method of accelerating the acquisition of tolerance in those who would outgrow on their own, or as a form of modified oral immunotherapy in those with otherwise persistent allergy.

Demographic characteristics associated with food allergy in a Nationwide Canadian Study

INTRODUCTION

We conducted a nationwide Canadian telephone survey on food allergy prevalence between February 2016 and January 2017, targeting vulnerable populations (New, Indigenous, and lower-income Canadians).

OBJECTIVE

To examine the independent effect of demographic characteristics on food allergy.

METHODS

Canadian households with vulnerable populations were targeted using Canadian Census data and the household respondent reported whether each household member had a perceived (self-reported) or probable (self-report of a convincing history or physician diagnosis) food allergy. The association between perceived and probable food allergy and demographic characteristics was assessed through weighted multivariable random effects logistic regressions.

RESULTS

Children, females, Canadian-born participants, adults with post-secondary education, and those residing in smaller households were more likely to report perceived or probable food allergy. Although immigrant parents self-reported less food allergy, Canadian-born children of Southeast/East Asian immigrant versus other immigrant or Canadian-born parents reported more food allergy.

CONCLUSION

We have demonstrated clear associations between demographic characteristics and food allergy, which may provide important clues to the environmental determinants of food allergy.

Allergic reactions to emerging food allergens in Canadian children

Most Canadian food allergy data has focused on Health Canada’s priority food allergens. This study describes which non-priority (emerging) food allergens were most commonly reported by Canadian parents and categorized/confirmed by allergists. A secondary aim was to describe severity of allergic reactions to emerging allergens. Parents reported allergic reactions to emerging food allergens experienced by their child (< 18 years) which occurred in the past 12 months, and allergists categorized/confirmed them according to likelihood of IgE-mediated food allergy. Of 68 eligible patients completing the survey, the most commonly reported emerging allergens were fruits/vegetables (58.8%), seeds (22.1%), legumes (19.1%) and other (11.8%). Median allergist ranking for legumes was ‘probable’ IgE-mediated food allergy, ‘possible’ for seeds and fruits/vegetables, and ‘unlikely’ for other. Median reaction severity was mild for legumes, and moderate for seeds, fruits/vegetables, and other. Our study highlights that non-priority food allergens, namely legumes and seeds, can lead to probable/likely allergic reactions in Canadian children. These food allergens are increasing in popularity in the Canadian diet, which could lead to increasing reports of allergic reactions. More research is needed to confirm reports of reactions to emerging allergens, and to document their inclusion as ingredients in packaged foods.

A High Proportion of Canadian Allergists Offer Oral Immunotherapy but Barriers Remain

BACKGROUND

Limited data on clinical implementation of oral immunotherapy (OIT) have been reported with incomplete evaluation of barriers.

OBJECTIVE

To survey Canadian allergists on their current practice of OIT and barriers to implementation and expansion of OIT.

METHODS

A survey investigating current practice and logistical and clinical barriers to offering or expanding OIT was distributed to all Canadian Society of Allergy and Clinical Immunology allergists.

RESULTS

Of 90 responding allergists, 52.2% reported offering OIT, most commonly to peanut. Food sublingual immunotherapy was offered by 7% of allergists. Having received training for OIT was associated with currently performing OIT (P = .008); 44.7% of allergists offering OIT had received training on OIT, and 81.4% not offering OIT had no training. A total of 87% of allergists performing OIT reported lack of efficacy data and lack of support staff and clinic space, and concerns about increased oral challenges (84%) were "moderately" to "extremely" important barriers to expanding OIT. For clinicians not offering OIT, concerns about safety (95%), after-hours support (95%), efficacy (93%), medicolegal risk (93%), and long-term practice implications (93%) were prioritized as significant barriers. Qualitative assessment suggested concerns about the practical challenges associated with OIT, the need for increased safety and efficacy data, and a desire for OIT guidelines and training.

CONCLUSION

The implementation of OIT faces many barriers, both clinical and logistical. Increasing high-quality safety and efficacy data may support those hesitant to offer OIT, and improving funding may address the practical infrastructure challenges. In addition, training will help expand access for allergists interested in performing OIT.

First pediatric electronic algorithm to stratify risk of penicillin allergy

Beta-lactam allergy is reported in 5–10% of children in North America, but up to 94–97% of patients are deemed not allergic after allergist assessment. The utility of standardized skin testing for penicillin allergy in the pediatric population has been recently questioned. Oral drug challenges when appropriate, are preferred over skin testing, and can definitively rule out immediate, IgE-mediated drug allergy. To our knowledge, this is the only pediatric study to assess the reliability of a penicillin allergy stratification tool using a paper and electronic clinical algorithm. By using an electronic algorithm, we identified 61 patients (of 95 deemed not allergic by gold standard allergist decision) as low risk for penicillin allergy, with no false negatives and without the need for allergist assessment or skin testing. In this study, we demonstrate that an electronic algorithm can be used by various pediatric clinicians when evaluating possible penicillin allergy to reliably identify low risk patients. We identified the electronic algorithm was superior to the paper version, capturing an even higher percentage of low risk patients than the paper version. By developing an electronic algorithm to accurately assess penicillin allergy risk based on appropriate history, without the need for diagnostic testing or allergist assessment, we can empower non-allergist health care professionals to safely de-label low risk pediatric patients and assist in alleviating subspecialty wait times for penicillin allergy assessment.

First Real-World Effectiveness Analysis of Preschool Peanut Oral Immunotherapy

BACKGROUND

We previously described safety of preschool peanut oral immunotherapy (P-OIT) in a real-world setting; 0.4% of patients experienced a severe reaction, and 4.1% received epinephrine, during build-up.

OBJECTIVE

To determine the effectiveness of preschool P-OIT after 1 year of maintenance.

METHODS

Preschoolers (9-70 months) with at least 1 objective reaction to peanut (during baseline oral food challenge (OFC) or P-OIT build-up) received a follow-up OFC to cumulative 4000 mg protein after 1 year on 300 mg peanut daily maintenance. Effectiveness of desensitization was defined as proportion of patients with a negative follow-up OFC. Symptoms and treatment at follow-up OFC were recorded.

RESULTS

Of the 117 patients who successfully completed 1 year of P-OIT and subsequently underwent a cumulative 4000-mg follow-up OFC, 92 (78.6%) had a negative OFC and 115 (98.3%) tolerated a cumulative dose of greater than or equal to 1000 mg. For the 25 (21.4%) who reacted, their threshold increased by 3376 mg (95% CI, 2884-3868) from baseline to follow-up; 17 (14.5%) patients experienced grade 1 reactions, 7 (6.00%) grade 2, and 1 (0.85%) grade 3. Two patients (1.71%) received epinephrine associated with P-OIT, and 1 (0.85%) went to the emergency department.

CONCLUSIONS

Our data demonstrate that real-world preschool P-OIT is effective after 1 year of maintenance for those who received a follow-up OFC. For those who reacted, their threshold increased sufficiently to protect against accidental exposures. P-OIT should be considered for preschoolers as an alternative to current recommendations to avoid peanut.

Aiming for a shorter time to diagnosis: pediatric eosinophilic esophagitis in British Columbia

Longer time to diagnosis for patients with eosinophilic esophagitis can lead to adverse patient outcomes, but the length of diagnostic delay has not been quantified for patients with eosinophilic esophagitis in Canada. Our study defines the time to diagnosis (TTD) for pediatric patients with eosinophilic esophagitis in British Columbia and identifies factors that predict increased time to diagnosis. The median TTD was 21 months (1.75 years; IQR = 7, 45) with a median age at EoE diagnosis of 105 months (8.75 years; IQR = 44, 156). Caucasians experienced significantly longer TTD compared to other ethnicities (24 months (IQR = 7, 52) and 12 months (IQR = 4.5, 23) respectively, p = 0.008). Caucasian ethnicity (p = 0.037) and older age at the time of diagnosis (p = 0.006) predicted increased TTD. Our model explained 7.9% (Adjusted R² = 0.079) of the total variance for our cohort.

Current tools measuring anxiety in parents of food-allergic children are inadequate

BACKGROUND

In the context of food allergy, excessive parental anxiety can be maladaptive and lead to unnecessary restriction of social activities. No validated tool exists to measure food allergy-associated anxiety (FAAA). This study sought to explore factors associated with parental FAAA, determine sensitivity and specificity of using generic state anxiety measure-State-Trait Anxiety Inventory (STAI) versus FAAA, and determine whether validated tools for generalized anxiety or food allergy-specific quality of life (QoL) could be used as surrogates for FAAA.

METHODS

Canadian parents of food-allergic children completed an online survey. Without a validated tool for FAAA, a visual analogue scale was used to assess parent-reported FAAA. Multivariable linear regression was performed with FAAA as the outcome. Sensitivity and specificity analysis of state anxiety vs. FAAA, and factor analysis of state anxiety and QOL, was performed to determine whether these could be used as surrogates for FAAA.

RESULTS

A total of 548 of 1244 parents (44.1%) completed the survey. Factors positively associated with FAAA included parental burden, risk perception, state anxiety, intolerance of uncertainty and perceived severity of child's food allergy; personal/family history of mental health was negatively associated. Sensitivity and specificity of state anxiety were 68.6% and 70.0%. Factor analysis revealed that state anxiety and QOL were correlated (r = 0.54, P < .001) but distinct constructs.

CONCLUSION

Our study identified factors associated with FAAA, and determined that generic anxiety and QOL tools do not accurately categorize parents with self-reported high FAAA. Future research will develop a validated screening tool to help allergists identify anxious parents and provide psychosocial resources.

Parents of children with food allergy: A qualitative study describing needs and identifying solutions

BACKGROUND

Parents experience a wide range of emotions, specifically stress and anxiety, when their child receives a diagnosis of a food allergy. Managing this health condition and coping with emotions require professional and peer support. Currently, there is a lack of resources and a lack of awareness of the resources that are required to help assist parents in managing their child's food allergy.

OBJECTIVE

To describe parental experiences when caring for a child with food allergy and to review the resources parents need to manage living with a child with food allergy and more specifically how they would want these resources delivered.

METHODS

A total of 7 semistructured focus groups were conducted in British Columbia, Canada. Parents were asked to describe their experiences with managing their child's food allergy and identify helpful resources.

RESULTS

A total of 40 parents (33 females) participated in the focus groups. Participant demographics were collected. The following 3 main themes emerged: (1) anxiety (an emotional roller coaster); (2) a transformational journey (the waiting game, loss of normalcy, strained relationships and mistrust, and financial challenges); and (3) the need for resources (day to day management, ages and stages, mental health supports, and "the dream").

CONCLUSION

An in-person allied health care team is needed to provide an integrated, patient-centered approach for how families can live and manage food allergies. Credible information and resources, such as medically reviewed websites, support groups, and counseling services, with a goal of reducing child and parental anxiety, should be provided by health care professionals.

Billing fees for various common allergy tests vary widely across Canada

Background

The prevalence of food allergy in Canada is high and has increased over time. To date, there are no Canadian data on the healthcare costs of visits to allergists.

Methods

We sent an anonymous survey to allergist members of the Canadian Society of Allergy and Clinical Immunology (CSACI) between October and December 2019. Survey questions included demographic information and billing fees for various types of allergy visits and diagnostic testing.

Results

Of 200 allergists who are members of CSACI, 43 allergists responded (21.5% response rate). Billing fees varied widely. The greatest ranges were noted for oral immunotherapy (OIT; both initial consultation [mean $198.70; range $0 to $575] and follow up/build up visits [mean $125.74; range: $0 to $575]). There were significant provincial differences in billing fees, as well as significant billing fee differences between hospital versus community allergists (e.g. oral food challenge [OFC]: $256.38 vs. $134.94, p < 0.01). Billing fees were higher outside of Ontario, with the exception of specific Immunoglubulin E (sIgE) testing and OIT visits.

Conclusions

Greater standardization of billing fees across provinces and between hospital versus community allergy could result in more consistency of billing fees for OFC and OIT across Canada. Further knowledge of exact costs will help inform practice and policy in the diagnosis and management of food allergy.

A198 EOSINOPHILIC ESOPHAGITIS WITH STRICTURE PRESENTING SHORTING AFTER INITIATION OF ORAL PEANUT IMMUNOTHERAPY

Background

Oral immunotherapy (OIT) is increasingly practiced outside of research settings with reasonable success (Soller 2019).

With OIT, a patient eats their food allergen daily, gradually increasing the dose, with the goal to prevent or reduce the severity of an anaphylactic reaction.

One of the described adverse events of OIT is a risk of developing Eosinophilic Esophagitis (EoE), with cited frequency of 2.7% (Lucendo 2014). In addition, OIT is typically contraindicated in patients with known EoE but patients are not routinely screened for EoE prior to initiation of OIT.

Aims

To present a case of a 12 year old boy with peanut anaphylaxis who developed eosinophilic esophagitis and an esophageal stricture shortly after starting peanut immunotherapy

Methods

Patient chart review was conducted. A literature review was done using the words “eosinophilic esophagitis” and “immunotherapy”.

Results

A12 year old boy with asthma, allergic rhinitis and multiple anaphylactic food allergies, started peanut OIT with an allergist. Prior to OIT, the patient had no symptoms suggestive of EoE such as dysphagia, heartburn, chest pain or washing of food. Approximately 3.5 weeks into treatment, the patient developed daily vomiting. The patient was advised to stop the peanut OIT three days after symptom onset, but the vomiting continued for another 8 days. By the time of endoscopy (16 days after onset of vomiting), the vomiting had completely subsided for the previous five days.

The upper GI endoscopy demonstrated signs of EoE throughout the length of the esophagus. In the mid esophagus there was resistance where the 9.8 mm gastroscope was unable to pass. A smaller gastroscope with a 5.9 mm width was easily able to pass through the stricture. Histology showed marked eosinophilia throughout the esophagus with basal cell hyperplasia, spongiosis, superficial microabscesses and stromal fibrosis consistent with EoE. The patient continued to be ‘asymptomatic’ at the time of endoscopy and after despite the presence of a stricture. After discussion, the patient was started on oral viscous budesonide (OVB) 1mg PO BID.

The patient was re-scoped 4 weeks into OVB therapy with complete resolution of the stricture with neither macroscopic nor histologic findings of EoE. Patient is now off OVB for over a month, remains asymptomatic, and will undergo repeat endoscopy in the upcoming month to ensure normal histology

Conclusions

This is the first case describing EoE with an esophageal stricture shortly after initiation of OIT. Pediatric Gastroenterologists need to be increasingly aware that patients undergoing OIT are at an increasing risk of ‘developing’ or at least ‘unmasking’ EoE. More research is required to evaluate whether EoE screening, by symptom questionnaire or endoscopy is warranted prior to beginning OIT, and whether OIT is truly needed.

Funding Agencies

CAG

Poor Correlation of Oral Swabs with Esophageal Eosinophil Counts

Eosinophilic esophagitis (EoE) is a chronic condition that requires repeated endoscopies/biopsies to track the disease and treatment response. This invasive procedure involves risk to the patient and has significant costs. We studied whether the detection of specific proteins (cytokines and eosinophil degranulation products) from oral swabs could serve as a minimally invasive test for EoE. Swabs of the oral cavity (buccal and oropharyngeal) were obtained prior to endoscopy/biopsies in patients with EoE, possible EoE, and non-EoE patients in addition to obtaining additional esophageal biopsy tissue. ELISAs measuring the levels of cytokines IL-5, IL-8, IL-13, and eosinophil degranulation products including major basic protein (MBP), eosinophil derived neurotoxin (EDN), and eosinophil peroxidase (EPO) were performed on the samples. Comparisons were made to peak esophageal eosinophil counts. Tolerability of the swabs was evaluated. 43 patients, 4-17 years old, participated in the study. Swabs were well tolerated and all showed measurable protein. 26 patients had EoE [14 active (> 15 eosinophils/high power field), 12 non-active], 17 patients did not have EoE. Results obtained from oral swabs showed poor correlation with those from esophageal tissue. Only measurement of eosinophil degranulation products EDN and EPO from esophageal tissues showed strong correlations with eosinophil counts. In this study, the levels of cytokines and eosinophil degranulation products detected from oral swabs did not correlate with esophageal eosinophilia, and their detection would be insufficient to displace endoscopy/biopsies.