Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-sponsored expert panel report

Anaphylactic reaction in patient allergic to mango

Background

An allergy to mango is extremely rare. The antigenic composition of the fruit is not fully known. Profilin from mango has a structure similar to birch tree profiling: it is responsible for cross-reactions between mango and pear, apple, and peach. A panallergen with a structure similar to mugwort defensin (Art v 1) which cross-reacts with celery, carrot, peanuts, pepper, aniseed, and caraway has been previously described.

Case study

A female patient, 30 years old, was admitted in February 2017 because of recurrent allergic reactions following consumption of various foods. The most severe allergic reaction in the patient’s life occurred after eating a mango fruit. Within several minutes the patient developed a generalised urticaria, followed by facial oedema, strong stomach pain and watery diarrhoea. The diagnostics involved skin tests with a set of inhalatory and food allergens, including native skin tests. The patient also experienced symptoms of recurrent, generalized urticaria in connection with consumption of various types of food, especially complex dishes containing many different ingredients. Additionally, an interview revealed that the patient was experiencing symptoms of the oral allergy syndrome after ingesting various fruit and vegetables, especially during late summer and fall. Diagnostics was extended by determining the levels of IgE specific for allergen components, using the ImmunoCap ISAC method. In order to confirm the occurence of a cross-reaction between mugwort and mango allergens, we performed the inhibition test of IgE specific for mugwort using a mango allergen extract and ImmunoCap matrix.

Results

Skin prick tests (SPT) were positive for allergens of grass 7 mm; weeds 8 mm; cat’s fur 5 mm; mugwort 6 mm. SPT were also positive for mango. The level of specific IgE was increased for allergens of mugwort, grass, celery, pepper, carrot, mango, banana, peach, and apple. The ImmunoCap ISAC test demonstrated a high level of specific IgE rPhl p 1 (timothy grass) and Art v 1 (mugwort). We also performed the IgE inhibition test using both mango extract and ImmunoCap matrix and confirmed a cross-reaction with Art v 1 in the pathogenesis of symptoms observed in the patient.

Conclusions

An anaphylactic reaction to consumed mango, resulting from cross-allergy with mugwort Art v 1 was diagnosed in the patient. Acute urticarial in this case is a manifestation of IgE-mediated food allergy. During in vitro diagnostic procedures we found an elevated concentration of IgE specific to several food allergens (including celery, peppers, carrot, banana, peach, apple, shrimp). The elimination diet removing allergens the patient was allergic to was recommended. Considering the anaphylactic reaction the patient was instructed to carry a rescue set composed of an adrenaline autosyringe, steroids, and antihistamines.

Evaluation of Correlations Between Food-Specific Antibodies and Clinical Aspects of Hashimoto's Thyroiditis

OBJECTIVE

We have comprehensively evaluated an immunologic response to food antigens, mediated by immunoglobulin G (IgG) antibodies, on clinical aspects of Hashimoto's thyroiditis (HT).

METHODS

IgG antibodies to 125 food antigens were measured in serum samples of 74 HT patients and 245 controls using microarray-based enzyme-linked immunosorbent assay (ELISA) test. We analyzed differences in IgG levels between two groups and evaluated correlations between food-specific IgG levels and HT-related clinical phenotypes (thyroid hormones/antibodies, symptoms of hypothyroidism, measures of body size and blood pressure) and food consumption in HT patients.

RESULTS

We observed increased IgG levels to 12 different food antigens in either HT cases or controls, of which plum-specific IgG antibodies were significantly higher (p = 1.70 × 10^-8), and almond-specific IgG antibodies were significantly lower (p = 8.11 × 10^-5) in HT patients in comparison to controls, suggesting their possible roles in HT etiology or symptomatology. There was no significant correlation between any of 12 increased food-specific IgG antibodies, along with gluten-specific IgG, with clinically important phenotypes, such as thyroid hormones/antibodies or symptoms. Among other tested correlations, the most interesting is the negative correlation between coffee and tea combined IgG levels and number of symptoms, suggesting possible beneficial effect of tea and coffee on disease symptoms. We also found that food consumption is not correlated with IgG levels.

CONCLUSIONS

Distribution of food-specific IgG antibodies is comparable between HT patients and controls, with the exception of plum and almond. There is no evidence that increased food-specific IgG antibodies are associated with clinical aspects of HT. Clarification of biology behind formation of these antibodies is needed.

Non-IgE-mediated food hypersensitivity

Non-immunoglobulin E (IgE)-mediated food hypersensitivity includes a spectrum of disorders that predominantly affect the gastrointestinal tract. This review will focus on the following more common non-IgE-mediated food hypersensitivity syndromes: food protein-induced enterocolitis syndrome (FPIES), allergic proctocolitis (AP), food protein-induced enteropathy (FPE) and celiac disease. FPIES, AP and FPE typically present in infancy and are most commonly triggered by cow’s milk protein or soy. The usual presenting features are profuse emesis and dehydration in FPIES; blood-streaked and mucousy stools in AP; and protracted diarrhea with malabsorption in FPE. Since there are no confirmatory noninvasive diagnostic tests for most of these disorders, the diagnosis is based on a convincing history and resolution of symptoms with food avoidance. The mainstay of management for FPIES, AP and FPE is avoidance of the suspected inciting food, with periodic oral food challenges to assess for resolution, which generally occurs in the first few years of life. Celiac disease is an immune-mediated injury caused by the ingestion of gluten that leads to villous atrophy in the small intestine in genetically susceptible individuals. Serologic tests and small intestinal biopsy are required to confirm the diagnosis of celiac disease, and management requires life-long adherence to a strict gluten-free diet.

Cesarean delivery, preterm birth, and risk of food allergy: Nationwide Swedish cohort study of more than 1 million children

BACKGROUND

Little is known about early-life risk factors for food allergy in children.

OBJECTIVES

We examined the association between perinatal characteristics and future risk of food allergy in offspring.

METHODS

This nationwide Swedish cohort study of 1,086,378 children born in Sweden in 2001-2012 used prospectively recorded data from health care registers. Using Cox regression, we estimated hazard ratios (HRs) with 95% CIs for the association between perinatal characteristics (eg, cesarean delivery and preterm birth) and food allergy as defined by diagnoses in the National Patient Register, adjusting for infant sex and maternal factors (age at delivery, country of birth, parity, smoking, body mass index, and asthma/pulmonary disease).

RESULTS

During the 13-year follow-up, 26,732 (2.5%) children were given a diagnosis of food allergy. Food allergy was positively associated with cesarean delivery (HR, 1.21; 95% CI, 1.18-1.25), large for gestational age (HR, 1.15; 95% CI, 1.10-1.19), and low 5-minute Apgar score (HR, 1.22; 95% CI, 1.10-1.36) but negatively associated with very preterm birth (<32 weeks of gestation: HR, 0.74; 95% CI, 0.56-0.98). No association was found between food allergy and moderately preterm birth, low birth weight, or small for gestational age. Risk estimates were similar when the outcome was restricted to 2 records of diagnosed food allergy. In 1,000 children undergoing cesarean delivery, an extra 5 developed food allergy compared with the reference group, suggesting that 17% of food allergy in children born by means of cesarean delivery can be explained by this exposure (attributable fraction).

CONCLUSIONS

Cesarean delivery was associated with increased risk of food allergy, whereas very preterm birth decreased risk.

How does dose impact on the severity of food-induced allergic reactions, and can this improve risk assessment for allergenic foods?: Report from an ILSI Europe Food Allergy Task Force Expert Group and Workshop

Quantitative risk assessment (QRA) for food allergens has made considerable progress in recent years, yet acceptability of its outcomes remains stymied because of the limited extent to which it has been possible to incorporate severity as a variable. Reaction severity, particularly following accidental exposure, depends on multiple factors, related to the allergen, the host and any treatments, which might be administered. Some of these factors are plausibly still unknown. Quantitative risk assessment shows that limiting exposure through control of dose reduces the rates of reactions in allergic populations, but its impact on the relative frequency of severe reactions at different doses is unclear. Food challenge studies suggest that the relationship between dose of allergenic food and reaction severity is complex even under relatively controlled conditions. Because of these complexities, epidemiological studies provide very limited insight into this aspect of the dose-response relationship. Emerging data from single-dose challenges suggest that graded food challenges may overestimate the rate of severe reactions. It may be necessary to generate new data (such as those from single-dose challenges) to reliably identify the effect of dose on severity for use in QRA. Success will reduce uncertainty in the susceptible population and improve consumer choice.

Food Allergy Training for Schools and Restaurants (The Food Allergy Community Program): Protocol to Evaluate the Effectiveness of a Web-Based Program

Background

Food allergy is a growing public health concern. The literature suggests that a significant number of reactions occur in community services, such as schools and restaurants. Therefore, suitable training and education for education and catering professionals using viable and practical tools is needed.

Objective

The objective of this study is to evaluate the effectiveness of a Web-based food allergy training program for professionals working in schools and restaurants, designed to improve knowledge and good practices in the community.

Methods

Free learning programs which contain educational animated videos about food allergy were developed for professionals working at schools and restaurants. The learning programs comprise of nine 5-minute videos, developed in video animation format using GoAnimate, with a total course length of 45-60 minutes. The courses for professionals at both schools and restaurants include contents about food allergy epidemiology, clinical manifestations, diagnosis and treatment, dietary avoidance, emergencies, labelling, and accidental exposure prevention. Additionally, specific topics for work practices at schools and restaurants were provided. Food allergy knowledge survey tools were developed to access the knowledge and management skills about food allergy of school and restaurant staff, at baseline and at the end of the food allergy program. The courses will be provided on the e-learning platform of the University of Porto and professionals from catering and education sectors will be invited to participate.

Results

Data collection will take place between September 2017 and October 2017, corresponding to a 2-month intervention. Final results will be disseminated in scientific journals and presented at national and international conferences.

Conclusions

The Food Allergy Community Program intervention may improve school and restaurant professionals’ commitment and skills to deal with food allergy in the community. Furthermore, this e-intervention program will provide an innovative contribution to understanding the impact of electronic health technologies on the learning process and the development of strategies for community interventions.

Registered Report Identifier

RR1-10.2196/9770

Systematic Review of Hypersensitivity to Parenteral Nutrition

Hypersensitivity to the components of parenteral nutrition (PN) is a rare but important complication of PN. We performed a systematic review of hypersensitivity to PN to enable us to build an approach to the individual patient who presents with PN hypersensitivity. A systematic literature search was performed in Ovid Medline, CINAHL, Scopus, and Web of Science using terms for "hypersensitivity" AND "parenteral nutrition" and relevant synonyms. A total of 28 articles were analyzed, and 33 hypersensitivities to PN or components of PN were reported in these 28 articles. Reports of hypersensitivity and subsequent conclusions were based on the clinical observations made by each reporting author. These reactions were evenly split between pediatric and adult patients. Hypersensitivity to PN occurred on day of starting PN in 60.6% patients and after that time in 36.3% patients (range: 1-21 days). Of the hypersensitivities that occurred on day 1 of PN, 70% occurred in the first 30 minutes of initiation of PN. Cutaneous manifestations were the most common, followed by anaphylaxis, respiratory symptoms, and hemodynamic instability. The components most frequently identified as allergens were intravenous fat emulsion (48.4%), multivitamin solution (33.3%), and amino acid solution (9%). Based on this review, an algorithm was created to guide the practitioner on management of PN after the occurrence of such a reaction.

Upregulation of calprotectin in mild IgE-mediated ovalbumin hypersensitivity

Calprotectin, also known as S100A8/A9, has been linked to gut inflammation caused by IgE-mediated food hypersensitivities, but the pathophysiologic abnormalities it causes remain to be determined. We created a mild food hypersensitivity model through oral gavage of ovalbumin in Norway brown rats without using immune adjuvant. Changes in the levels of calprotectin and inflammation-associated cytokines were then observed over time. We found that fecal calprotectin as well as jejunal and liver TLR4, TNF-α, NF-κB, IL-1β, and IL-6 were upregulated in hypersensitive rats. Additionally, the influence of calprotectin on CD4⁺ T and dendritic cells was observed by co-culturing CD4⁺ T cells with dendritic cells, which revealed a shift toward increased Th2 T cells in calprotectin-treated cultures. These results suggest that calprotectin, along with other inflammatory factors, promotes the inflammation seen in mild food allergy.

Use of biologics in severe food allergies

PURPOSE OF REVIEW

Severe cases of food allergy account for the majority of the burden in terms of risks, quality of life, and resource expenditure. The traditional approach to these forms has been strict avoidance. More recently, Oral ImmunoTherapy (OIT) has gained a role in their management. However, in severe food allergies OIT is often infeasible.

RECENT FINDINGS

Case reports, observational, and prospective studies have recently proposed different approaches to severe food allergy. The majority of them include the use of biologics. Omalizumab has been the most studied drug for severe food allergies, and its role as adjuvant treatment to OIT is well established. Interest has been raised on other biologics, as dupilumab, reslizumab, and mepolizumab. Toll-like receptor agonists, and gene therapy using adeno-associated virus coding for Omalizumab are promising alternatives.

SUMMARY

The recent studies are deeply influencing the clinical practice. We review the modifications of the clinical approach to severe food allergies so far available. We indicate the possible evolutions of treatment with biologics in severe food allergies.

A Mouse Model of Peanut Allergy Induced by Sensitization Through the Gastrointestinal Tract

Animal models of disease enable the study of the pathology, biomarkers, and treatments for the disease being studied. These models become particularly useful in the study of diseases, such as peanut allergy, that currently have no FDA-approved therapy options. Here, we describe a mouse model of peanut allergy using a peanut extract and cholera toxin that can be applied to both BALB/c and C3H/HeJ mouse strains. Sensitization is induced through the gastrointestinal tract resulting in elevated levels of peanut-specific IgE and anaphylaxis upon challenge with peanut proteins. This model has been used to study the cells and molecules involved in the development of peanut allergy and to evaluate novel immunotherapy approaches and the underlying mechanisms of immunotherapy. Potential utilities of this model are numerous and may include studies on microbial influences on peanut allergy and discovery of biomarkers of anaphylaxis.

Histamine-releasing factor enhances food allergy

Food allergy occurs due to IgE- and mast cell-dependent intestinal inflammation. Previously, we showed that histamine-releasing factor (HRF), a multifunctional protein secreted during allergy, interacts with a subset of IgE molecules and that the HRF dimer activates mast cells in an HRF-reactive IgE-dependent manner. In this study, we investigated whether HRF plays any role in food allergy. Specifically, we determined that prophylactic and therapeutic administration of HRF inhibitors that block HRF-IgE interactions reduces the incidence of diarrhea and mastocytosis in a murine model of food allergy. Food allergy-associated intestinal inflammation was accompanied by increased secretion of the HRF dimer into the intestine in response to proinflammatory, Th2, and epithelial-derived cytokines and HRF-reactive IgE levels at the elicitation phase. Consistent with these data, patients with egg allergy had higher blood levels of HRF-reactive IgE compared with individuals that were not hypersensitive. Successful oral immunotherapy in egg-allergy patients and food-allergic mice reduced HRF-reactive IgE levels, thereby suggesting a pathological role for HRF in food allergy. Together, these results suggest that antigen and HRF dimer amplify intestinal inflammation by synergistically activating mast cells and indicate that HRF has potential as a therapeutic target in food allergy.

Deciphering the black box of food allergy mechanisms

OBJECTIVE

To review our current understanding of immunotherapy, the immune mechanisms underlying food allergy, and the methodological advances that are furthering our understanding of the role of immune cells and other molecules in mediating food allergies.

DATA SOURCES

Literature searches were performed using the following combination of terms: allergy, immunotherapy, food, and mechanisms. Data from randomized clinical studies using state-of-the-art mechanistic tools were prioritized.

STUDY SELECTIONS

Articles were selected based on their relevance to food allergy.

RESULTS

Current standard of care for food allergies is avoidance of allergenic foods and the use of epinephrine in case of severe reaction during unintentional ingestion. During the last few decades, great strides have been made in understanding the cellular and molecular mechanisms underlying food allergy, and this information is spearheading the development of exciting new treatments.

CONCLUSION

Immunotherapy protocols are effective in desensitizing individuals to specific allergens; however, recurrence of allergic sensitization is common after discontinuation of therapy. Interestingly, in a subset of individuals, immunotherapy is protective against allergens even after discontinuation of immunotherapy. Whether this protection is permanent is currently unknown because of inadequate long-term follow-up data. Research on understanding the underlying mechanisms may assist in modifying protocols to improve outcome and enable sustained unresponsiveness, rather than a temporary relief against food allergies. The cellular changes brought about by immunotherapy are still a black box, but major strides in our understanding are being made at an exciting pace.

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

BACKGROUND

Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.

METHODS

An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.

RESULTS

The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.

CONCLUSIONS

Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Precision medicine in allergic disease-food allergy, drug allergy, and anaphylaxis-PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology

This consensus document summarizes the current knowledge on the potential for precision medicine in food allergy, drug allergy, and anaphylaxis under the auspices of the PRACTALL collaboration platform. PRACTALL is a joint effort of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology, which aims to synchronize the European and American approaches to allergy care. Precision medicine is an emerging approach for disease treatment based on disease endotypes, which are phenotypic subclasses associated with specific mechanisms underlying the disease. Although significant progress has been made in defining endotypes for asthma, definitions of endotypes for food and drug allergy or for anaphylaxis lag behind. Progress has been made in discovery of biomarkers to guide a precision medicine approach to treatment of food and drug allergy, but further validation and quantification of these biomarkers are needed to allow their translation into practice in the clinical management of allergic disease.

The Development of a Clinical Decision Support System for the Management of Pediatric Food Allergy

Pediatricians are often first-line providers for children with food allergy. Food allergy management guidelines have been developed but are cumbersome and confusing, and significant variation exists in pediatricians' management practices. We therefore consolidated the guidelines into 5 key steps for pediatricians caring for patients with food allergy and used rapid-cycle improvement methods to create a clinical decision support system to facilitate the management of food allergy in the primary care setting. This report details the development of the Food Allergy Support Tool (FAST), its pilot testing in 4 primary care pediatric practices, and our ongoing efforts to improve its utility and ease of use. Key themes identified during these processes include the importance of both initial and ongoing provider education as well as the limitations of a tool that must be actively initiated by providers.

Outpatient Emergencies: Anaphylaxis

Anaphylactic fatalities are rare; however, mild reactions can rapidly progress to cardiovascular and respiratory arrest. The clinical course of anaphylaxis can be unpredictable. Prompt and early use of epinephrine should be considered. Most anaphylaxis episodes have an immunologic mechanism involving immunoglobulin E (IgE). Foods are the most common cause in children; medications and insect stings are more common in adults. When the cause is not completely avoidable or cannot be determined, a patient should be supplied with autoinjectable epinephrine and be instructed its use. They should keep the device with them at all times and taught the signs and symptoms of anaphylaxis.

Up-regulated expression of substance P in CD8+ T cells and NK1R on monocytes of atopic dermatitis

BACKGROUND

Large numbers of CD8⁺ T cells were observed in atopic dermatitis (AD) skin, and monocytes from AD patients showed increased prostaglandin E2 production. However, little is known about the expression of substance P (SP) and its receptor NK1R in blood leukocytes of patients with AD.

OBJECTIVE

To explore the expression of SP and NK1R in leukocytes of AD and the influence of allergens on SP and NK1R expression.

METHODS

The expression levels of SP and NK1R in patients with AD were examined by flow cytometry, ELISA and a mouse AD model.

RESULTS

The plasma SP level was 4.9-fold higher in patients with AD than in HC subjects. Both the percentage of SP expression in the population and mean fluorescence intensity (MFI) of SP expression were elevated in CD8⁺ T cells in the blood of AD patients. However, both the CD14⁺NK1R⁺ population and MFI of NK1R expression on CD14⁺ cells were enhanced in the blood of AD patients. Allergens ASWE, HDME and PPE failed to up-regulate SP expression in CD8⁺ T cells. However, allergens ASWE and HDME both enhanced NK1R expression on CD14⁺ blood leukocytes regardless of AD or HC subjects. OVA-sensitized AD mice showed an elevated proportion and MFI of SP-expressing CD8⁺ T cells in the blood, which agrees with the SP expression situation in human AD blood. Injection of SP into mouse skin did not up-regulate NK1R expression on monocytes.

CONCLUSIONS

An elevated plasma SP level, up-regulated expression of SP and NK1R indicate that the SP/NK1R complex is important in the development of AD. Therefore, SP and NK1R antagonist or blocker agents may help to treat patients with AD. Trial registration Registration number: ChiCTR-BOC-16010279; Registration date: Dec., 28, 2016; retrospectively registered.

Development of monoclonal antibody-based ELISA for the quantification of orange allergen Cit s 2 in fresh and processed oranges

The aim of this study was to develop a monoclonal antibody (mAb)-based enzyme-linked immunosorbent assay (ELISA) for the quantification of a major allergen (Cit s 2) in fresh and processed oranges. Purified recombinant Cit s 2 (rCit s 2)-small ubiquitin-like modifier (SUMO) was used for the production of mAbs. In the optimized ELISA, the recovery of rCit s 2 from Navel oranges or orange juice was 107-132%, and the intra- and inter-assay coefficients of variation were 3.1-8.8% and 4.4-11%, respectively. The Cit s 2 content in fresh oranges was determined to be 1,800±430ng/g, while this content was much lower in the processed foods. The developed ELISA demonstrated high reproducibility, sensitivity, and accuracy, and this assay may help individuals with orange allergy by determining Cit s 2 quantities in food products and controlling their Cit s 2 intake.

Awareness of food allergies: a survey of pediatricians in Kuwait

Background

Early diagnosis of food allergies (FA) is important for a favorable prognosis. This study aimed to determine the level of awareness of FA among pediatricians in Kuwait.

Method

A 43-item self-administered questionnaire was designed and distributed to pediatricians working at 4 government hospitals in Kuwait.

Results

A total of 140 pediatricians completed the questionnaire, with a participation rate of 51.1% (81 males and 59 females). The mean age of participants was 40.81 years, and the mean number of years working in pediatrics was 13.94 years. The mean overall knowledge score was 22.2. The pediatricians’ overall knowledge scores were found to be significantly associated with their age (older pediatricians had higher overall scores) and years of experience as a pediatrician but were independent from hospital site, gender, or rank. A multiple linear regression revealed pediatrician age and gender were the only variables that were significantly associated with the overall knowledge score. Only 16.4% of the participants answered at least 2/3 of the survey questions correctly. The questions that were correctly answered by ≤ 2/3 of the participants constituted 80% of clinical presentation questions, 66.6% of diagnostics questions, 77.7% of treatment questions, and 42.8% of prevention questions. Interestingly, among 68 pediatricians (48.5%) who determined that they felt comfortable evaluating and treating patients with FA, only 12 (17.6%) passed the questionnaire.

Conclusions

This survey demonstrates that there is a noteworthy deficiency of pediatricians’ awareness about FA. The implementation of strategies to improve pediatricians’ awareness is critical to diagnose food allergy patients early and improve their health and outcomes.

Establishing the prevalence of low vitamin D in non-immunoglobulin-E mediated gastrointestinal food allergic children in a tertiary centre

Background

There is no data on the prevalence of vitamin D deficiency in children with non-immunoglobulin-E (IgE) mediated gastrointestinal food allergy. The aims of our study were to understand the prevalence of vitamin D insufficiency and deficiency in children with non-IgE mediated gastrointestinal food allergy and identify predisposing factors.

Methods

This was a retrospective study which looked at data from Great Ormond Street Hospital from January 2002 to September 2015. Children 0–18 years old with a confirmed diagnosis of non-IgE mediated gastrointestinal food allergy who had a vitamin D level measured during the course of their disease were included. Low vitamin D levels were defined as <50 nmol/L; insufficient levels were defined as 25–50 nmol/L and deficient levels as <25 nmol/L. Patient characteristics and clinical factors were also recorded.

Results

Ninety-two patients met the study criteria; 49% were female and median age was 10 years 2 months [IQR: 4 years 8 months to 13 years 7 months]. Of the cohort, 26% (24/92) had low vitamin D levels; 16% had insufficient vitamin D levels and 10% had vitamin D deficiency. Gender (p = 0.043) and age (p = 0.035) were significantly associated with low vitamin D levels. Twelve percent of children who were on an amino acid formula (AAF) had low vitamin D compared to 31% of children who were not (p = 0.06). No other clinical factors were found to be significantly associated with low vitamin D levels.

Conclusions

Children with non-IgE mediated gastrointestinal food allergy are at risk of vitamin D insufficiency and deficiency. Further prospective studies need to be performed in all children with non-IgE mediated gastrointestinal food allergies.

Trial registration

The study was registered with the GOSH Research & Development department as a retrospective case note review. The Health Research Authority confirmed that NHS Research and Ethics Committee approval was not required; thus there is no trial registration number.

Eosinophilic Gastroenteritis and Colitis: a Comprehensive Review

Eosinophilic gastrointestinal disorders, including eosinophilic esophagitis, gastroenteritis, and colitis, refer to a spectrum of clinical diseases that present with variable degrees of infiltration of the gastrointestinal tract by eosinophils in the absence of other known causes of tissue eosinophilia. Clinical symptoms and laboratory findings are usually non-specific and may or may not be accompanied by peripheral blood eosinophilia. The extent of eosinophilic infiltration of the gastrointestinal wall varies from mucosal to transmural and serosal involvement. Diagnosis requires presence of gastrointestinal symptoms, demonstration of gastrointestinal eosinophilia by biopsy, and exclusion of other known causes of tissue eosinophilia. Many studies have pointed toward the eosinophil as the major offender; however, the exact functional role of the eosinophil in the pathogenesis of eosinophilic gastrointestinal disorders remains unclear. The roles of T-helper-2 cytokines and other mediators, such as eotaxin-1 and interleukin-5, have gained significant importance in the pathobiology of eosinophilic gastrointestinal disorders. Current understanding of treatment is based on case reports and a few case series, as there is a lack of large prospective studies. Steroids are currently the mainstay of therapy, but the roles of other drugs such as leukotriene inhibitors, mast cell stabilizers, interleukin-5 inhibitors, and anti-immunoglobulin E, along with other targets in the immune pathway, are currently being explored.

New pharmaceutical approaches for the treatment of food allergies

INTRODUCTION

Allergic diseases constitute one of the most common causes of chronic illness in developed countries. The main mechanism determining allergy is an imbalance between Th1 and Th2 response towards Th2.

AREAS COVERED

This review describes the mechanisms underlying the natural tolerance to food components and the development of an allergic response in sensitized individuals. Furthermore, therapeutic approaches proposed to manage these abnormal immunologic responses food are also presented and discussed.

EXPERT OPINION

In the past, management of food allergies has consisted of the education of patients to avoid the ingestion of the culprit food and to initiate the therapy (e.g. self-injectable epinephrine) in case of accidental ingestion. In recent years, sublingual/oral immunotherapies based on the continuous administration of small amounts of the allergen have been developed. However, the long periods of time needed to obtain significant desensitization and the generation of adverse effects, limit their use. In order to solve these drawbacks, strategies to induce tolerance are being studied, such as the use of either adjuvant immunotherapy in order to facilitate the reversion of the Th2 response towards Th1 or the use of monoclonal antibodies to block the main immunogenic elements.

Pilot study: assessing the clinical diagnosis of allergy in atopic children using a microarray assay in addition to skin prick testing and serum specific IgE

Background

Children with atopic dermatitis (AD) are at risk of developing allergy. Alongside clinical history, testing modalities include skin prick tests (SPT), specific immunoglobulin-E (sp-IgE) and recently, microarray assays. The aim of this pilot study was to assess current tests and the ISAC sIgE-112 system in the diagnosis of food and aeroallergen allergy.

Methods

Children aged 0–11 years with moderate to severe AD were included. An initial allergy assessment including clinical history, SPT and sp-IgE was performed to determine food and aeroallergen sensitization. A second independent clinical assessment using the same information given to the first assessor and ISAC test results for food and aeroallergen sensitization was also made for each participant. The results from both were compared.

Results

30 children [mean age 3.91 years (SD 3.3)] were included; 53.3 and 46.7 % had moderate and severe AD, respectively. Sp-IgE tests had a higher percentage of positive results compared to SPT and ISAC tests for common allergens. There was a significant difference between the three tests in detecting aeroallergen sensitization (p = 0.038), especially between sp-IgE and ISAC tests, but no significant difference between the tests for food allergen sensitization. There was good agreement between the two assessors; 70 % of the children had a change in diagnosis, with 60 % having at least one diagnosis added and 40 % having at least one diagnosis removed.

Conclusions

There is a role for the use of ISAC testing in diagnosing sensitization and allergy in children with AD as it leads to a change in diagnosis for many patients. Further work is required to assess its clinical and cost effectiveness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12948-016-0046-z) contains supplementary material, which is available to authorized users.

The impact of the elimination diet on growth and nutrient intake in children with food protein induced gastrointestinal allergies

Background

Non immunoglobulin E (IgE) mediated allergies affecting the gastrointestinal tract require an elimination diet to aid diagnosis. The elimination diet may entail multiple food eliminations that contribute significantly to macro- and micro-nutrient intake which are essential for normal growth and development. Previous studies have indicated growth faltering in children with IgE-mediated allergy, but limited data is available on those with delayed type allergies. We therefore performed a study to establish the impact on growth before and after commencing an elimination diets in children with food protein induced non-IgE mediated gastrointestinal allergies.

Methods

A prospective, observational study was performed at the tertiary gastroenterology department. Children aged 4 weeks–16 years without non-allergic co-morbidities who were required to follow an elimination diet for suspected food protein induced gastrointestinal allergies were included. Growth parameters pre-elimination were taken from clinical notes and post-elimination measurements (weight and height) were taken a minimum of 4 weeks after the elimination diet. A 3-day estimated food diary was recorded a minimum of 4 weeks after initiating the elimination diet, including also any hypoallergenic formulas or over the counter milk alternatives that were consumed.

Results

We recruited 130 children: 89 (68.5 %) boys and a median age of 23.3 months [IQR 9.4–69.2]. Almost all children (94.8 %) in this study eliminated CM from their diet and average contribution of energy in the form of protein was 13.8 % (SD 3.9), 51.2 % (SD 7.5) from carbohydrates and 35 % (SD 7.5) from fat. In our cohort 9 and 2.8 % were stunted and wasted respectively. There was a statistically significant improvement in weight-for-age (Wtage) after the 4 week elimination diet. The elimination diet itself did not improve any of the growth parameters, but achieving energy and protein intake improved Wtage and WtHt respectively, vitamin and/or mineral supplements and hypoallergenic formulas were positively associated with WtHt and Wtage.

Conclusion

With appropriate dietary advice, including optimal energy and protein intake, hypoallergenic formulas and vitamins and mineral supplementation, growth parameters increased from before to after dietary elimination. These factors were positively associated with growth, irrespective of the type of elimination diet and the numbers of foods eliminated.

Effect of extrusion processing on immune activation properties of hazelnut protein in a mouse model

Although food processing can alter food allergenicity, the impact of extrusion processing on in vivo hazelnut allergenicity is unknown. Here, we tested the hypothesis that extrusion processing will alter the immune activation properties of hazelnut protein (HNP) in mice. Soluble extrusion-processed HNP (EHNP) was prepared and evaluated for immune response using an established transdermal sensitization mouse model. Mice were sensitized with identical amounts of EHNP versus raw HNP. After confirming systemic IgE, IgG1 and IgG2a antibody responses, oral hypersensitivity reaction was quantified by hypothermia shock response (HSR). Mechanism was studied by measuring mucosal mast cell (MMC) degranulation. Compared to raw HNP, the EHNP elicited slower but similar IgE antibody (Ab) response, lower IgG1 but higher IgG2a Ab response. The EHNP exhibited significantly lower oral HSR as well as MMC degranulation capacity. These results demonstrate that the extrusion technology can be used to produce soluble HNP with altered immune activation properties.

Self-reported prevalence and risk factors associated with food hypersensitivity in Mexican young adults

BACKGROUND

Food hypersensitivity (FH) is defined as any unfavorable reaction after the ingestion, contact, or inhalation of a food. Few FH prevalence studies have been performed in the Mexican adult population.

OBJECTIVE

To determine the prevalence of self-reported FH and probable food allergy (FA) among a sample of Mexican young adults and to determine the most commonly involved foods, associated symptoms, and risk factors.

METHODS

We designed an observational, cross-sectional study in which 1,253 young adults (aged 18-25 years) born in the State of Mexico answered a questionnaire concerning FH. We obtained information on personal and familial histories of allergic diseases, the involved foods, and the subsequent adverse reactions to their consumption.

RESULTS

The prevalence of FH was 30.1% and was significantly higher in women than in men (P < .001). The prevalence of probable FA was 5.9% and was also higher in women (P = .02). Gastrointestinal symptoms were reported in 83.1% of FH cases, whereas cutaneous symptoms and oral allergy syndrome were reported in FA cases. The food groups most associated with FH were dairy products (13.2%), vegetables (10.0%), and fruits (8.0%). The food groups most associated with FA were fruits (3.0%) and seafood (1.8%). Female sex, personal history of allergic diseases, maternal history of atopic dermatitis, and parental history of urticaria were significantly associated (P < .05) with the presence of FH.

CONCLUSION

FH in young adults might be more common than previously thought, especially in women. However, further studies are needed to confirm this situation in the Mexican population.

Development of a real-time quantitative PCR assay using a TaqMan minor groove binder probe for the detection of α-lactalbumin in food

Here, we report the development of a real-time PCR assay using a TaqMan minor groove binder (MGB, Genecore, NCBI: AF249896.1, 806-820) probe and primer sets designed to recognize the α-lactalbumin gene from the cow (Bos taurus). We evaluated the efficacy of this assay for detecting and quantifying cow α-lactalbumin in commercial foods. Our results demonstrated that the developed method was highly sensitive and showed high specificity for cow milk, with consistent detection of 0.05 ng of bovine DNA. We tested 42 commercial food samples with or without cow milk listed as an ingredient by using the developed assay. Among the 42 samples, 26 products that listed milk as an ingredient and 3 products might contain milk showed positive signals, whereas the other 9 products that did not contain milk and 4 products that might contain milk tested negative. Therefore, this method could be widely used for the detection of cow milk allergens in food.

Food Avoidance Diets for Dermatitis

Food allergy is relatively common in both children and adults, and its prevalence is increasing. Early exposure of food allergens onto skin with an impaired epidermal barrier predisposes to sensitization and prevents the development of oral tolerance. While immediate-type food allergies are well described, less is known about delayed-type food allergies manifesting as dermatitis. This is due, in part, to limitations with current diagnostic testing for delayed-type food allergy, including atopy patch testing. We conducted a systematic review of food avoidance diets in delayed-type food allergies manifesting as dermatitis. While beneficial in some clinical circumstances, avoidance diets should be used with caution in infants and children, as growth impairment and developmental delay may result. Ultimately, dermatitis is highly multifactorial and avoidance diets may not improve symptoms of delayed-type food allergy until combined with other targeted therapies, including restoring balance in the skin microbiome and re-establishing proper skin barrier function.

Guidelines for the use and interpretation of diagnostic methods in adult food allergy

Food allergy has an increasing prevalence in the general population and in Italy concerns 8 % of people with allergies. The spectrum of its clinical manifestations ranges from mild symptoms up to potentially fatal anaphylactic shock. A number of patients can be diagnosed easily by the use of first- and second-level procedures (history, skin tests and allergen specific IgE). Patients with complex presentation, such as multiple sensitizations and pollen-food syndromes, frequently require a third-level approach including molecular diagnostics, which enables the design of a component-resolved sensitization profile for each patient. The use of such techniques involves specialists' and experts' skills on the issue to appropriately meet the diagnostic and therapeutic needs of patients. Particularly, educational programs for allergists on the use and interpretation of molecular diagnostics are needed.

Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part I): General Management and Topical Treatment

Background

Since the treatment guidelines for atopic dermatitis (AD) were released by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been several advances in AD management.

Objective

We aimed to establish updated evidence- and experience-based treatment guidelines for Korean AD.

Methods

We collected a database of references from relevant systematic AD reviews and guidelines regarding general AD management such as bathing and skin care, avoidance of exacerbating factors, education and psychosocial support, and the use of moisturizers and topical anti-inflammatory and antipruritic drugs. Evidence for each statement was graded and the strength of the recommendation for each statement classified. Thirty-nine KADA council members participated in three rounds of voting to establish an expert consensus of recommendations.

Results

Basic AD treatment includes proper bathing and skin care, avoidance of exacerbating factors, proper education and psychosocial support, and use of moisturizers. The regular use of moisturizer has a steroid-sparing effect and reduces relapse episodes. The short- and long-term use of topical corticosteroids and calcineurin inhibitors improves AD symptoms and should be encouraged to use in an active and proactive treatment. Wet-wrap therapy can be used for rapid recovery of acute exacerbation. Topical antipruritic drugs cannot be recommended for the treatment of AD.

Conclusion

This report provides up-to-date evidence- and experience-based treatment guidelines for AD regarding general management and topical treatment. In addition, the average agreement scores obtained by a panel of experts based on the Korean healthcare system and patient adherence are presented.

Monitoring the impact of cow's milk allergy on children and their families with the FLIP questionnaire--a six-month follow-up study

BACKGROUND

Many children with cow's milk allergy (CMA) develop tolerance, but, challenges in daily life may remain. Using the Food hypersensitivity famiLy ImPact questionnaire (FLIP), we sought to monitor changes in the impact of CMA over time.

METHODS

Families of children with CMA, who participated in the validation of the FLIP, were re-approached 6 months later for follow-up. Change in reported difficulties was assessed by paired sample t-test and mixed models, stratifying by outgrown vs. persistent CMA.

RESULTS

Impact on families with children who had outgrown CMA (n = 20) decreased in the FLIP's total score (p = 0.0001) and in two subscales; Health and Emotions (p = 0.0001) and Everyday Life (p = 0.0001). In contrast, no significant improvements were registered in nutritional concerns. Impact on the group with persistent CMA (n = 57) was unchanged at follow-up except for more impact on Everyday Life (p = 0.001). In the final analysis comparing longitudinal changes in the groups, the strongest differences were observed for the subscales Health & Emotions and Everyday Life; for the Nutrition subscale, the between-group changes also differed, but to lesser extent.

CONCLUSIONS

We have documented the varying impact of CMA on parents and children over time. Families who were still affected continued to experience impact in daily life. Despite development of tolerance, families who were no longer affected revealed continuing nutritional concerns. Follow-ups should be offered even after outgrown CMA to encourage progression to unrestricted diet, to prevent eating disorders and to promote healthy growth.

Histological findings in infants with Gastrointestinal food allergy are associated with specific gastrointestinal symptoms; retrospective review from a tertiary centre

BACKGROUND

Gastrointestinal food allergy (GIFA) occurs in 2 to 4 % of children, the majority of whom are infants (<1 year of age). Although endoscopy is considered the gold standard for diagnosing GIFA, it is invasive and requires general anaesthesia. Therefore, we aimed to investigate whether in infants with GIFA, gastrointestinal symptoms predict histological findings in order to help optimise the care pathway for such patients.

METHODS

All infants <1 year of age over a 20 year period who underwent an endoscopic procedure gastroscopy or colonoscopy for GIFA were evaluated for the study. Symptoms at presentation were reviewed and compared with mucosal biopsy histological findings, which were initially broadly classified for study purposes as "Normal" or "Abnormal" (defined as the presence of any mucosal inflammation by the reporting pathologist at the time of biopsy).

RESULTS

Of a total of 1319 cases, 544 fitted the inclusion criteria. 62 % of mucosal biopsy series in this group were reported as abnormal. Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without. Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively. Conversely, children presenting with faltering growth or reflux/vomiting showed any abnormal mucosal histology in only 50.8 % and 45.3 % (OR: 1.04 and 0.82) respectively.

CONCLUSIONS

Food allergy may occur in very young children and is difficult to diagnose. Since endoscopy in infants has significant risks, stratification of decision-making may be aided by symptoms. At least one mucosal biopsy demonstrated an abnormal finding in around half of cases in this selected population. Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.

Potential effector and immunoregulatory functions of mast cells in mucosal immunity

Mast cells (MCs) are cells of hematopoietic origin that normally reside in mucosal tissues, often near epithelial cells, glands, smooth muscle cells, and nerves. Best known for their contributions to pathology during IgE-associated disorders such as food allergy, asthma, and anaphylaxis, MCs are also thought to mediate IgE-associated effector functions during certain parasite infections. However, various MC populations also can be activated to express functional programs--such as secreting preformed and/or newly synthesized biologically active products--in response to encounters with products derived from diverse pathogens, other host cells (including leukocytes and structural cells), damaged tissue, or the activation of the complement or coagulation systems, as well as by signals derived from the external environment (including animal toxins, plant products, and physical agents). In this review, we will discuss evidence suggesting that MCs can perform diverse effector and immunoregulatory roles that contribute to homeostasis or pathology in mucosal tissues.

Analysis of total immunoglobulin E and specific immunoglobulin E of 3,721 patients with allergic disease

Due to the increase in the prevalence and incidence of allergic diseases, improving the sensitivity and specificity of screening indexes is critical. Total immunoglobulin E (IgE) is a traditional index for judging allergic diseases, while its specificity is relatively poor. Serum-specific IgE (sIgE) is an objective index with high specificity in the diagnosis of allergic diseases. In the present research, the total IgE and sIgE of 3,721 patients with allergic diseases were analyzed to further illuminate the association between them. The data were derived from 3,721 patients. The serum-sIgE to 14 types of common allergens and total IgE were detected. A total of 2,419 cases (65.0%) of 3,721 patients exhibited increasing total IgE and 1,215 patients (32.7%) exhibited positive sIgE. The consistency rate of the two indexes was 60.4%, and the κ-value was 0.28. In 135 patients with normal total IgE, 82.2% exhibited one sIgE positive and 17.8% exhibited two or more sIgE positive. While the number of positive sIgE increased and the detecting level enhanced, the number of positive total IgE markedly increased. Patients (84.1%) with increasing total IgE were associated with positive sIgE, but the increase of total IgE could not be completely explained by the total accumulation of sIgE. Total IgE may play an important role on screening allergic disease while sIgE could be used as crucial evidence for allergy diagnosis. Although the consistency of the two methods was poor, neither total IgE nor sIgE could replace each other. Combining the two indexes with clinical manifestations together will improve the method.

A practical approach to vitamin and mineral supplementation in food allergic children

Background

The management of food allergy in children requires elimination of the offending allergens, which significantly contribute to micronutrient intake. Vitamin and mineral supplementation are commonly suggested as part of dietary management. However a targeted supplementation regime requires a complete nutritional assessment, which includes food diaries. Ideally these should be analysed using a computerised program, but are very time consuming. We therefore set out to evaluate current practice of vitamin and mineral supplementation in a cohort of children with non-Immunoglobulin E (IgE) mediated food allergies.

Methods

This prospective, observational study recruited children aged 4 weeks – 16 years, who required to follow an elimination diet for non-IgE mediated allergies. Only children that improved according to a symptom score and were on a vitamin and/or mineral supplement were included. A 3-day food diary including vitamin and mineral supplementation was recorded and analysed using Dietplan computer program. We assessed dietary adequacy with/without the supplement using the Dietary Reference Values.

Results

One hundred-and-ten children had completed food diaries and of these 29% (32/110) were taking vitamin and/or mineral supplements. Children on hypoallergenic formulas were significantly (p = 0.007) less likely to be on supplements than those on alternative over-the-counter milks. Seventy-one percent had prescribable supplements, suggested by a dietitian/physician. Sixty percent of those without a vitamin supplement had a low vitamin D intake, but low zinc, calcium and selenium was also common. Of the supplemented cohort many continued to be either under or over-supplemented.

Conclusion

This study has raised the question for the first time, whether clinicians dealing with paediatric food allergies should consider routine vitamin and/or mineral supplements in the light of deficient intake being so common in addition to being so difficult to predict.

Food and environmental allergies

Immunoglobulin E-mediated allergic responses to food and environmental allergens can cause symptoms ranging from mild allergic rhinitis and rashes to gastrointestinal distress and, most seriously, anaphylaxis. The diagnosis can be difficult, as it relies on complex interplay between patient history and diagnostic tests with low specificity. Adding to the difficulty in confirming the diagnosis is an increased public interest in food intolerances, which can be inappropriately attributed to an allergic response. Treatment of allergic diseases with avoidance strategies and pharmacologic treatments can improve quality of life and control of other chronic conditions, such as asthma and eczema.

Information and support from dietary consultation for mothers of children with food allergies

BACKGROUND

Professional dietetic input is essential to ensure that children with diagnosed food allergies have an individualized avoidance plan and nutritionally adequate diet. However, it is not clear what dietary information and support parents require.

OBJECTIVE

To explore what information and support parents of children with food allergies require from a dietary consultation.

METHODS

Focus groups were conducted with 17 mothers who attend an allergy center for dietary advice for their food allergic child. A number of issues around food allergy dietary advice needs were explored and analyzed using thematic analysis.

RESULTS

Six themes were identified. The mothers described how they sought to protect their child from harm, to maintain normality for their child, and to promote child independence. They described needing to become an expert in their child's food allergy and fight their corner when needed. The dietitian supported their needs by ensuring their child's diet was safe and nutritionally adequate and giving information and support to help them provide a normal life for their child. Dietitians also taught mothers about food allergy and provided advocacy and emotional support.

CONCLUSION

Mothers of children with food allergies want to understand how to provide a nutritionally adequate, allergen-safe diet while maintaining a normal life. Hence, mothers value a range of support from dietitians, including monitoring their child's health and providing information, practical advice and support, and emotional support.

Feeding difficulties in children with food protein-induced gastrointestinal allergies

BACKGROUND AND AIM

There is paucity of data on the prevalence of feeding difficulties in Food Protein-Induced Gastrointestinal Allergies (FPIGA) and their clinical characteristics. However, it is a commonly reported problem by clinicians. We set out to establish the occurrence of feeding difficulties in children with FPIGA, the association with gastrointestinal and extra-intestinal symptoms and number of foods eliminated from the diet.

METHODS

This retrospective observational analysis was performed in patients seen between 2002 and 2009 at Great Ormond Street Children's Hospital, Gastroenterology Department, London. Medical records where FPIGA was documented using the terms from the National Institute of Allergy and Infectious Disease and National Institute of Clinical Excellence and confirmed using an elimination diet, followed by a challenge were included. Feeding difficulties were assessed using a criteria previously used in healthy toddlers in the UK.

RESULTS

Data from 437 children (203 female) were collected. Significantly more children with feeding difficulties presented with abdominal distention and bloating (P = 0.002), vomiting (P < 0.0001), weight loss (P < 0.0001), rectal bleeding (P = 0.025), and constipation (P < 0.0001). We also found that having extra-intestinal manifestations were significantly (P < 0.0001) associated with the presence of feeding difficulties. Additionally, a significantly higher number of foods eliminated from the diet in the children with/without feeding difficulties (P = 0.028).

CONCLUSIONS

Clinical manifestations like vomiting, constipation, rectal bleeding, weight loss, and the presence of extra-intestinal manifestations in addition to the number of foods avoided are in our FPIGA population linked to feeding difficulties.

Methods report on the development of the 2013 revision and update of the EAACI/GA2 LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of urticaria

This methods report describes the process of guideline development in detail. It is the result of a systematic literature review using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) methodology and a structured consensus conference held on 28 and 29 November 2012, in Berlin. It is a joint initiative of the Dermatology Section of the European Academy of Allergy and Clinical Immunology (EAACI), the EU-funded network of excellence, the Global Allergy and Asthma European Network (GA(2) LEN), the European Dermatology Forum (EDF), and the World Allergy Organization (WAO) with the participation of delegates of 21 national and international societies. This guideline covers the definition and classification of urticaria, taking into account the recent progress in identifying its causes, eliciting factors and pathomechanisms. In addition, it outlines evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS) and is published in Allergy 2014; 69:868-887.

Systematic review of outcome measures in trials of pediatric anaphylaxis treatment

BACKGROUND

Considerable heterogeneity has been observed in the selection and reporting of disease-specific pediatric outcome measures in randomized controlled trials (RCTs). This makes interpretation of results and comparison across trials challenging. Outcome measures in pediatric anaphylaxis trials have never previously been systematically assessed. This systematic review (SR) identified and assessed outcome measures used in RCTs of anaphylaxis treatment in children. As a secondary objective, this SR assessed the evidence for current treatment modalities for anaphylaxis in the pediatric population.

METHODS

We searched MEDLINE, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL from 2001 until December 2012. We also searched websites listing ongoing trials. We included randomized and controlled trials of anaphylaxis treatment in patients 0-18 years of age. Two authors independently assessed articles for inclusion.

RESULTS

No published studies fulfilled the inclusion criteria.

CONCLUSIONS

There is an alarming absence of RCTs evaluating the treatments for anaphylaxis in children. High quality studies are needed and are possible to design, despite the severe and acute nature of this condition. Consensus about the selection and validation of appropriate outcome measures will enhance the quality of research and improve the care of children with anaphylaxis.

TRIAL REGISTRATION

CRD42012002685.

Food-specific serum IgE and IgG reactivity in dogs with and without skin disease: lack of correlation between laboratories

BACKGROUND

Despite conflicting data on their utility and no reports on interlaboratory reproducibility, serum food-specific antibodies are commonly assayed in first-opinion canine practice.

HYPOTHESIS/OBJECTIVES

To determine both the variability of test results between two laboratories and the frequencies and magnitudes of food reactivity in dogs of different disease status.

ANIMALS

Sera were obtained from eight dogs with cutaneous adverse food reaction (Group A), 22 with nonfood-induced atopic dermatitis (Group B), 30 with an allergic/inflammatory phenotype (Group C), 12 with miscellaneous skin diseases (Group D) and nine healthy dogs (Group E).

METHODS

Paired sera were submitted to two laboratories (A and B) for assays of food-specific IgE and IgG antibodies.

RESULTS

Numbers of positive IgE and IgG tests determined by each laboratory in Groups A, B, D and E were comparable (Group C not included). Significant differences in the magnitude of IgE reactivity between groups for each allergen were seen only for lamb (Laboratory A, P = 0.003); lamb reactivity in Group D exceeded Group E (P = 0.004) but was comparable between all other groups. Agreement (kappa statistic) between the two laboratories' tests was 'moderate' for one antigen (potato IgE), 'fair' for four (corn IgE, rice IgE and IgG and soya bean IgG), 'slight' for eight (six IgE and two IgG) and 'less than chance' for the remaining six antigens (three IgE and three IgG).

CONCLUSIONS AND CLINICAL IMPORTANCE

These laboratories' tests appear to have dubious predictive clinical utility because they neither correlate nor distinguish between dogs of different disease status.