The prevalence of food allergy: a meta-analysis

Frequency of guideline-defined cow's milk allergy symptoms in infants: Secondary analysis of EAT trial data

BACKGROUND

Non-IgE-mediated Cow's Milk Allergy (CMA) has a prevalence of less than 1% in children. Guidelines developed to help non-specialists diagnose CMA may lead to misattribution of normal symptoms and contribute to overdiagnosis of CMA. We sought to establish the frequency of symptoms during infancy associated with non-IgE-mediated CMA, using the international Milk Allergy in Primary Care (iMAP) guideline as representative of CMA guidelines more generally.

METHOD

Secondary analysis of the Enquiring About Tolerance (EAT) randomized controlled trial (ISRCTN 14254740; 1303 exclusively breastfed 3-month-old healthy infants). Key outcomes were ≥2 iMAP symptoms associated with 'mild-moderate' and 'severe' non-IgE-mediated CMA.

RESULTS

Whilst breastfeeding and parental atopy rates were higher than the general population, participants were otherwise similar to the population of England and Wales. Two or more non-IgE CMA symptoms were reported by 25% families for mild-moderate and 1.4% for severe symptoms each month between ages 3 and 12 months, peaking at 38% with ≥2 mild-moderate and 4.3% ≥2 severe symptoms at three months, when participants were not directly consuming cow's milk. 74% of participants reported ≥2 mild-moderate symptoms and 9% ≥2 severe symptoms in at least one month during this period. At six months there was no evidence of difference in the proportion of children with ≥2 symptoms between those consuming (29.5% mild-moderate, 1.8% severe) and not consuming cow's milk (35.3% mild-moderate, 2.2% severe). Mean monthly reporting of ≥2 symptoms was also no different between those with (15.8% mild-moderate, 1.1% severe) or without eczema at baseline (16.7% mild-moderate, 1.3% severe).

CONCLUSIONS

Guideline-defined symptoms of non-IgE-mediated CMA are very common in infants. Guidelines may promote milk allergy overdiagnosis by labelling normal infant symptoms as possible milk allergy.

Food Allergies and Intolerances: A Clinical Approach to the Diagnosis and Management of Adverse Reactions to Food

Food allergy is an aberrant immunological response to food antigen, which can result in potentially life-threatening reactions. It is often challenging to differentiate food allergy from other adverse reactions to food because their presentations can be indistinguishable. The purpose of this article is to give an overview of the classification, evaluation, and management of adverse food reactions, key differentiating features of food allergy, roles and limitations of various food allergy testing, and promising areas of emerging research. Case studies are used to highlight some of the clinical pearls in diagnosing and managing food-related diseases.

Differential Cytokine Expression in the Duodenum and Rectum of Children with Non-Immunoglobulin E-Mediated Cow's Milk Protein Allergy

BACKGROUND

Cow's milk protein allergy (CMPA) is the most prevalent food allergy in children, and its pathogenesis remains poorly understood. It has been shown that the combination of genetic predisposition, perinatal factors, and intestinal imbalance of the immune response mediated by cytokines may play an essential role in CMPA pathogenesis.

AIM

To characterize the gene expression of Th1, Th2, and Th17 cytokines in the duodenum and rectum in patients with CMPA.

METHODS

This is an observational, descriptive, cross-sectional, prospective study. We used specific IgE (ImmunoCAP^®) in serum and biopsies from the rectum and duodenum for the detection of cytokine messenger RNA levels by real-time PCR in patients with a positive oral food challenge for CMPA. We analyzed the relative quantification of the gene expression of cytokines by real-time PCR, and we used the housekeeping gene GAPDH for normalization purposes.

RESULTS

Thirty children (13 male and 17 female) were evaluated. All patients had an open challenge for CMPA. IgE specific to casein, alfa-lactalbumin, and beta-lactoglobulin was negative in all patients. In terms of cytokine levels, the levels of TNFα, IL-6, IL-12 (Th1), IL-4, IL-10, IL-13 (Th2), and IL-17 were found to be higher in the rectum than in the duodenum (p < 0.05). IL-15 was found to be higher in the duodenum than in the rectum (p < 0.05).

CONCLUSIONS

In the present study we observed that the immune response in CMPA seems to be mediated by a Th1, Th2, and Th17 cytokine profile, with the rectum being the main affected site.

An Expert Panel Statement on the Beneficial Effects of Human Milk Oligosaccharides (HMOs) in Early Life and Potential Utility of HMO-Supplemented Infant Formula in Cow's Milk Protein Allergy

This review by pediatric gastroenterology and allergy-immunology experts aimed to address the biological roles of human milk oligosaccharides (HMOs) and the potential utility of HMOs in prevention of allergy with particular emphasis on cow^’s milk protein allergy (CMPA). The participating experts consider HMOs amongst the most critical bioactive components of human milk, which act as antimicrobials and antivirals by preventing pathogen adhesion to epithelial cells, as intestinal epithelial cell modulators by enhancing maturation of intestinal mucosa and intestinal epithelial barrier function, as prebiotics by promoting healthy microbiota composition and as immunomodulators by modulating immune cells indirectly and directly. Accordingly, the participating experts consider the proposed link between HMOs and prevention of allergy to be primarily based on the impact of HMO on gut microbiota, intestinal mucosal barrier, immunomodulation and immune maturation. Along with the lower risk of respiratory and gastrointestinal infections, HMO-supplemented formulas seem to be promising alternatives in the management of CMPA. Nonetheless, the effects of individual as well as complex mixtures of HMO in terms of clear clinical and immunological effects and tolerance development need to be further explored to fully realize the immunomodulatory mechanisms and the potential for HMOs in prevention of allergic diseases and CMPA.

Primary and pollen-associated hazelnut allergy in school-aged children in Germany: A birth cohort study

BACKGROUND

Primary hazelnut allergy is a common cause of anaphylaxis in children, as compared to birch-pollen associated hazelnut allergy. Population-based data on hazelnut and concomitant birch-pollen allergy in children are lacking. We aimed to investigate the prevalence of primary and pollen-associated hazelnut allergy and sensitization profiles in school-aged children in Berlin, Germany.

METHODS

1570 newborn children were recruited in Berlin in 2005-2009. The school-age follow-up (2014-2017) was based on a standardized web-based parental questionnaire and clinical evaluation by a physician including skin prick tests, allergen specific immunoglobulin E serum tests and placebo-controlled double-blind oral food challenges, if indicated.

RESULTS

1004 children (63.9% response) participated in the school-age follow-up assessment (52.1% male). For 1.9% (n = 19, 95%-confidence interval 1.1%-2.9%) of children their parents reported hazelnut-allergic symptoms, for half of these to roasted hazelnut indicating primary hazelnut allergy. Symptoms of birch-pollen allergy were reported for 11.6% (n = 116 95%-CI 9.7%-13.7%) of the children. Both birch-pollen allergy and hazelnut allergy associated symptoms affected 0.6% (n = 6, 95%-CI 0.2%-1.3%) of children. Assessment of allergic sensitization was performed in 261 participants and showed that almost 20% of these children were sensitized to hazelnut, being the most frequent of all assessed food allergens, or birch-pollen, the majority to both.

CONCLUSIONS

Based on parental reports hazelnut-allergic symptoms were far less common than sensitization to hazelnut. This needs to be considered by physicians to avoid unnecessary changes in diet due to sensitization profiles only, especially when there is a co-sensitization to hazelnut and birch-pollen.

Allergen Risk Assessment for Specific Allergy to Small Ruminant's Milk: Development of Sensitive Immunoassays to Detect Goat's and Sheep's Milk Contaminations in Dairy Food Matrices

Despite a high level of sequence identity between cow's, goat's, and sheep's milk (CM, GM, and SM, respectively) proteins, some patients tolerant to CM are allergic to GM and SM. In most cases, this specificity is due to the presence of IgE antibodies that bind only to caprine and ovine caseins. The patients may then develop severe allergic reactions after ingestion of CM products contaminated with low amounts of GM or SM. We thus aimed to develop an assay able to detect traces of caprine/ovine β-caseins in different food matrices, irrespective of the presence of the bovine homolog. We produced monoclonal antibodies (mAbs) specific to caprine caseins in mice tolerized to the bovine whole casein then sensitized to the caprine whole casein. In order to develop a two-site immunometric assay, we selected mAbs that could discriminate the caprine β-casein from its bovine homolog. Characteristics and performances of two tests were determined with various dairy products. Results were analyzed in relation with the IgE-immunoreactivity of the food matrices, thanks to sera from CM, GM/SM allergic patients. Our two-site immunometric assays demonstrated a high sensitivity with a detection limit of 1.6–3.2 ng/mL of caprine and ovine β-caseins. The tests were able to detect contaminations of GM in CM at the ppm level. Heat-treatment, ripening and coagulation processes, usually applied to dairy products that exhibit a very high IgE-immunoreactivity, did not impair the test sensitivity. These quantitative assays could then be useful for the risk assessment of food products potentially contaminated with GM and SM in order to prevent adverse reactions in patients specifically allergic to these milks.

Partially Hydrolysed Whey Has Superior Allergy Preventive Capacity Compared to Intact Whey Regardless of Amoxicillin Administration in Brown Norway Rats

Background

It remains largely unknown how physicochemical properties of hydrolysed infant formulas influence their allergy preventive capacity, and results from clinical and animal studies comparing the preventive capacity of hydrolysed infant formula with conventional infant formula are inconclusive. Thus, the use of hydrolysed infant formula for allergy prevention in atopy-prone infants is highly debated. Furthermore, knowledge on how gut microbiota influences allergy prevention remains scarce.

Objective

To gain knowledge on (1) how physicochemical properties of hydrolysed whey products influence the allergy preventive capacity, (2) whether host microbiota disturbance influences allergy prevention, and (3) to what extent hydrolysed whey products influence gut microbiota composition.

Methods

The preventive capacity of four different ad libitum administered whey products was investigated in Brown Norway rats with either a conventional or an amoxicillin-disturbed gut microbiota. The preventive capacity of products was evaluated as the capacity to reduce whey-specific sensitisation and allergic reactions to intact whey after intraperitoneal post-immunisations with intact whey. Additionally, the direct effect of the whey products on the growth of gut bacteria derived from healthy human infant donors was evaluated by in vitro incubation.

Results

Two partially hydrolysed whey products with different physicochemical characteristics were found to be superior in preventing whey-specific sensitisation compared to intact and extensively hydrolysed whey products. Daily oral amoxicillin administration, initiated one week prior to intervention with whey products, disturbed the gut microbiota but did not impair the prevention of whey-specific sensitisation. The in vitro incubation of infant faecal samples with whey products indicated that partially hydrolysed whey products might confer a selective advantage to enterococci.

Conclusions

Our results support the use of partially hydrolysed whey products for prevention of cow’s milk allergy in atopy-predisposed infants regardless of their microbiota status. However, possible direct effects of partially hydrolysed whey products on gut microbiota composition warrants further investigation.

Allergy-related diseases in childhood and risk for abdominal pain-related functional gastrointestinal disorders at 16 years-a birth cohort study

BACKGROUND

Studies on allergy-related diseases in relation to abdominal pain-related functional gastrointestinal disorders (AP-FGIDs) in children are few and results are contradictory. We examined the associations between childhood allergy-related diseases and adolescent AP-FGIDs in general and irritable bowel syndrome (IBS) in particular.

METHOD

Prospective population-based birth cohort study of 4089 children born in Sweden 1994-1996. We analysed data from 2949 children with complete follow-up at 16 years (y) and no diagnosis of inflammatory bowel disease or coeliac disease at 12y or 16y. Asthma, rhinitis, eczema, and food hypersensitivity (FH) were assessed through questionnaires at 1-2y, 4y, 8y, 12y, and 16y. AP-FGIDs and IBS were assessed through questionnaires at 16y and defined according to the Rome III criteria. Associations between childhood allergy-related diseases and any AP-FGID and IBS and 16y respectively were examined using binomial generalized linear models with a log link function and described as relative risk with 95% confidence intervals.

RESULTS

The prevalence of any AP-FGID and IBS at 16y were 12.0% and 6.0% respectively. Eczema at 1-2y, 4y, and 8y, and FH at 12y and 16y were associated with an increased risk for any AP-FGID at 16y. Asthma and FH at 12y and 16y were associated with an increased risk for IBS at 16y. The relative risk for IBS at 16y increased with increasing number of concurrent allergy-related diseases at 16y, but linear trend for relative risk was only borderline statistically significant (P for trend = 0.05).

CONCLUSIONS

This prospective population-based study demonstrated positive associations between childhood allergy-related diseases and adolescent AP-FGIDs, including IBS, implicating shared pathophysiology among these disorders.

Validation of a Brief Screening Instrument for Chemical Intolerance in a Large U.S. National Sample

Background: Chemical intolerance (CI) is characterized by multisystem symptoms triggered by low levels of exposure to xenobiotics including chemicals, foods/food additives, and drugs/medications. Prior prevalence estimates vary from 8–33% worldwide. Clinicians and researchers need a brief, practical screening tool for identifying possible chemical intolerance. This large, population-based study describes the validation of a three-item screening questionnaire, the Brief Environmental Exposure and Sensitivity Inventory (BREESI), against the international reference standard used for assessing chemical intolerance, the Quick Environmental Exposure and Sensitivity Inventory (QEESI). Methods: More than 10,000 people in the U.S. responded to the BREESI and the QEESI in a population-based survey. We calculated the overall prevalence of CI in this sample, as well as by gender, age, and income. Common statistical metrics were used to evaluate the BREESI as a screener for CI against the QEESI. Results: The prevalence estimate for QEESI-defined chemical intolerance in the U.S. was 20.39% (95% CI 19.63–21.15%). The BREESI had 91.26% sensitivity (95% CI: 89.20–93.04%) and 92.89% specificity (95% CI: 91.77–93.90%). The positive likelihood ratio was 12.83 (95% CI: 11.07–14.88), and the negative likelihood ratio was 0.09 (95% CI: 0.08–0.12). Logistic regression demonstrates that the predicted probability of CI increased sharply with each increase in the number of BREESI items endorsed (Odds Ratio: 5.3, 95% CI: 4.90–5.75). Conclusions: Chemical intolerance may affect one in five people in the U.S. The BREESI is a new, practical instrument for researchers, clinicians, and epidemiologists. As a screening tool, the BREESI offers a high degree of confidence in case ascertainment. We recommend: screen with the BREESI, confirm with the QEESI.

Distinct differences in analytical performance of two commercially available assays for specific IgE to egg white and house dust mite allergens

Background

Measurements of allergen-specific IgE antibodies with different manufacturers’ assays show modest or poor agreement. This study compares analytical performance of specific IgE tests for whole allergen extracts and individual allergen components of two assay systems, IMMULITE and ImmunoCAP, using human sera as well as monoclonal antibodies.

Methods

Comparisons were performed for specific IgE to house dust mite (HDM, n = 44), egg white (EW, n = 36) and the allergen components rDer p 1, rDer p 2, nGal d 1, nGal d 2 and nGal d 4 in human sera and with monoclonal mouse/human chimeric IgE antibodies specific for the same allergen components. Competitive interference with IgE measurement was investigated using allergen-specific monoclonal IgG and IgG4 antibodies.

Results

Measurements of IgE to HDM and EW in serial dilutions of human sera revealed weaker dilution linearity with IMMULITE than with ImmunoCAP. Analysis of five different monoclonal IgE antibodies with total and specific IgE assays, expected to return similar levels, gave an average specific/total IgE ratio of 0.96 (range 0.71–1.14) with ImmunoCAP and 1.89 (range 0.76–2.85) with IMMULITE, indicating overestimation of specific IgE by IMMULITE. With the EW IgE tests of both assay systems, measurements of a chimeric anti-Gal d 2 IgE antibody were unaffected by a competing mouse IgG antibody. While the same was true for measurement of a chimeric anti-Der p 1 IgE antibody using the HDM test in ImmunoCAP, a suppression of measured concentrations by up to 42% was observed in IMMULITE. Similarly, measurement of HDM-specific IgE in human sera by ImmunoCAP was unaffected by a competing monoclonal anti-Der p 2 IgG4 antibody while IMMULITE displayed a reduction of HDM-specific IgE values by up to 30%.

Conclusions

In this evaluation of analytical performance of two widely used assay systems, ImmunoCAP showed higher accuracy in quantitation of specific IgE and greater resistance against competing allergen-specific non-IgE antibodies which may arise through natural or dietary exposure, or as a result of allergen immunotherapy treatment.

Using Large Aggregated De-Identified Electronic Health Record Data to Determine the Prevalence of Common Chronic Diseases in Pediatric Patients Who Visited Primary Care Clinics

OBJECTIVE

We used de-identified clinical data from multiple health care systems using different electronic health records (EHRs) to 1) quantify the prevalence of common pediatric chronic diseases, 2) investigate patent characteristics associated with common pediatric chronic diseases, and 3) compare the results of our methodology to determine chronic disease prevalence with traditional approaches.

METHODS

We used a HIPAA-compliant and de-identified web application (Explorys; IBM Watson Health Explorys Inc.) to identify patients 17 years old or younger from multiple health care systems in the US who were seen in primary care clinics between 2016-2018 to determine the most common chronic conditions in this age group. The prevalence of chronic conditions was compared between different age groups, genders, races/ethnicities, and insurance; odds ratios and confidence intervals were calculated and reported.

RESULTS

The top 6 chronic conditions identified by prevalence were: obesity/overweight (36.7%), eczema (15.8%), asthma (12.7%), food allergies (4.7%), attention deficit-hyperactivity disorder (4.09%) and hypertension (4.07%). Chronic conditions were generally more prevalent among relatively older pediatric patients, males, and African-American and multiracial groups.

CONCLUSIONS

Approximately 40% of children and adolescents have at least one chronic disease. Obesity/overweight, eczema, and asthma are the most common chronic diseases of childhood, in the US, among those seeking care in health care systems with EHRs. The work compiled herein demonstrates that aggregated, standardized, normalized and de-identified population-level EHR data can provide both sufficient insight and statistical power to calculate the prevalence of chronic diseases and the odds ratio of various risk factors.

Growth and tolerance of healthy, term infants fed lower protein extensively hydrolyzed or amino acid-based formula: double-blind, randomized, controlled trial

Background

Optimal protein level in hypoallergenic infant formulas is an area of ongoing investigation. The aim was to evaluate growth of healthy term infants who received extensively hydrolyzed (EH) or amino acid (AA)-based formulas with reduced protein.

Methods

In this prospective, multi-center, double-blind, controlled, parallel group study, infants were randomized to receive a marketed EH casein infant formula at 2.8 g protein/100 kcal (Control) or one of two investigational formulas: EH casein formula at 2.4 g protein/100 kcal (EHF) or AA-based formula at 2.4 g total protein equivalents/100 kcal (AAF). Control and EHF each had 2 × 10⁷ CFU Lactobacillus rhamnosus GG/100 kcal. Anthropometrics were measured and recall of formula intake, tolerance, and stool characteristics was collected at 14, 30, 60, 90, 120 days of age. Primary outcome was weight growth rate (g/day) between 14 and 120 days of age (analyzed by ANOVA). Medically confirmed adverse events were recorded throughout the study.

Results

No group differences in weight or length growth rate from 14 to 120 days were detected. With the exception of significant differences at several study time points for males, no group differences were detected in mean head circumference growth rates. However, mean achieved weight, length, and head circumference demonstrated normal growth throughout the study period. No group differences in achieved weight or length (males and females) and head circumference (females) were detected and means were within the WHO growth 25th and 75th percentiles from 14 to 120 days of age. With the exception of Day 90, there were no statistically significant group differences in achieved head circumference for males; means remained between the WHO 50th and 75th percentiles for growth at Days 14, 30, and 60 and continued along the 75th percentile through Day 120. No differences in study discontinuation due to formula were detected. The number of participants for whom at least one adverse event was reported was similar among groups.

Conclusions

This study demonstrated hypoallergenic infant formulas at 2.4 g protein/100 kcal were safe, well-tolerated, and associated with appropriate growth in healthy term infants from 14 to 120 days of age.

Trial registration

ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT01354366. Registered 13 May 2011.

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Update of the S2k guideline on the management of IgE-mediated food allergies

Not available.

Study protocol of a phase 2, dual-centre, randomised, controlled trial evaluating the effectiveness of probiotic and egg oral immunotherapy at inducing desensitisation or sustained unresponsiveness (remission) in participants with egg allergy compared with placebo (Probiotic Egg Allergen Oral Immunotherapy for Treatment of Egg Allergy: PEAT study)

INTRODUCTION

Egg allergy is the most common food allergy in children but recent studies have shown persistence or delayed resolution into adolescence. As there is currently no effective long-term treatment, definitive treatments that improve quality of life and prevent fatalities for food allergies are required. We have previously shown that a novel treatment comprising a combination of the probiotic Lactobacillus rhamnosus CGMCC 1.3724 with peanut oral immunotherapy (OIT) is highly effective at inducing sustained unresponsiveness, with benefit persisting to 4 years after treatment cessation in the majority of initial treatment responders. In this study, we plan to extend the probiotic food OIT platform to another allergen, namely egg. We describe the protocol for a phase 2, dual-centre, randomised, controlled trial evaluating the effectiveness of probiotic and egg OIT at inducing desensitisation or sustained unresponsiveness (remission) in participants with egg allergy compared with placebo.

METHODS AND ANALYSIS

80 participants aged 5-30 years of age with current egg allergy confirmed by double-blind placebo-controlled food challenge at study screening will be recruited from Australia and Singapore. There are two intervention arms-probiotic and egg OIT (active) or placebo. Interventions are administered once daily for 18 months. The primary outcome is the proportion of participants who attain 8-week sustained unresponsiveness in the active group versus placebo group.

ETHICS AND DISSEMINATION

This study has been approved by the Human Research Ethics Committees at the Royal Children's Hospital (HREC 2019.082) and the National Healthcare Group Domain Specific Review Board (2019/00029). Results will be published in peer-reviewed journals and disseminated via presentations at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12619000480189.

Tolerability of a new amino acid-based formula for children with IgE-mediated cow's milk allergy

BACKGROUND

Amino acid-based formula (AAF) is a relevant dietary strategy for paediatric patients affected by cow's milk allergy (CMA). The present study was designed to evaluate the hypoallergenicity of a new AAF in children with immunoglobulin (Ig)E-mediated CMA.

METHODS

According to the criteria provided by the American Academy of Pediatrics Subcommittee on Nutrition and Allergic Diseases, we designed a prospective trial in CMA children (aged 1-36 months) aimed to demonstrate the hypoallergenicity of the new AAF in 90% of subjects with 95% confidence during the double-blind, placebo-controlled challenge (DBPCFC). A skin prick test (SPT) with the new AAF was also performed.

RESULTS

Twenty-nine children [all Caucasian, 55.2% male, mean age (±SD) 16.9 ± 5.7 months] were enrolled. The SPT and the DBPCFC with the new AAF were negative in all study subjects.

CONCLUSIONS

The study results support the hypoallergenicity of the new AAF. This formula could be considered an additional dietary option for non-breastfed children affected by CMA.

TRIAL REGISTRATION

The trial was registered in the ClinicalTrials.gov Protocol Registration System (ID number: NCT03909113 ).

Dietary Management of Food Allergy

Worldwide food allergy prevalence is increasing, especially in children. Food allergy management strategies include appropriate avoidance measures and identifying suitable alternatives for a nutritionally sound diet. Individualized dietary intervention begins teaching label reading, which differs among countries or regions. Dietary intervention must result in a nutritionally sound plan including alternatives to support optimal growth and development. Inappropriate or incomplete dietary advice may increase the risk of adverse reactions, growth faltering, and nutrient deficiencies. Evidence indicates input from a registered dietitian improves nutritional outcomes. Nutritional input plays a critical role managing nutritional disorders related to food allergy.

The Impact of Formula Choice for the Management of Pediatric Cow's Milk Allergy on the Occurrence of Other Allergic Manifestations: The Atopic March Cohort Study

OBJECTIVES

To compare the impact of different formulas on the occurrence of other atopic manifestations and the time of immune tolerance acquisition.

STUDY DESIGN

In a 36-month prospective cohort study, the occurrence of other atopic manifestations (eczema, urticaria, asthma, and rhinoconjunctivitis) and the time of immune tolerance acquisition were comparatively evaluated in immunoglobulin E-mediated children with cow's milk allergy (CMA) treated with extensively hydrolyzed casein formula containing the probiotic L. rhamnosus GG (EHCF + LGG), rice hydrolyzed formula, soy formula, extensively hydrolyzed whey formula (EHWF), or amino acid-based formula.

RESULTS

In total, 365 subjects were enrolled into the study, 73 per formula cohort. The incidence of atopic manifestations was 0.22 (Bonferroni-corrected 95% CI 0.09-0.34) in the EHCF + LGG cohort; 0.52 (0.37-0.67) in the rice hydrolyzed formula cohort; 0.58 (0.43-0.72) in the soy formula cohort; 0.51 (0.36-0.66) in the EHWF cohort; and 0.77 (0.64-0.89) in the amino acid-based formula cohort. The incidence of atopic manifestations in the rice hydrolyzed formula, soy formula, EHWF, and amino acid-based formula cohorts vs the EHCF + LGG cohort was always greater than the prespecified absolute difference of 0.25 at an alpha-level of 0.0125, with corresponding risk ratios of 2.37 (1.46-3.86, P < .001) for rice hydrolyzed formula vs EHCF + LGG; 2.62 (1.63-4.22, P < .001) for soy formula vs EHCF + LGG; 2.31 (1.42-3.77, P < .001) for EHWF vs EHCF + LGG; and 3.50 (2.23-5.49, P < .001) for amino acid-based formula vs EHCF + LGG. The 36-month immune tolerance acquisition rate was greater in the EHCF + LGG cohort.

CONCLUSIONS

The use of EHCF + LGG for CMA treatment is associated with lower incidence of atopic manifestations and greater rate of immune tolerance acquisition.

Cow's Milk Protein Allergy as a Model of Food Allergies

Cow's milk allergy (CMA) is one of the most common food allergies in infants, and its prevalence has increased over recent years. In the present paper, we focus on CMA as a model of food allergies in children. Understanding the diagnostic features of CMA is essential in order to manage patients with this disorder, guide the use of an elimination diet, and find the best moment to start an oral food challenge (OFC) and liberalize the diet. To date, no shared tolerance markers for the diagnosis of food allergy have been identified, and OFC remains the gold standard. Recently, oral immunotherapy (OIT) has emerged as a new therapeutic strategy and has changed the natural history of CMA. Before this, patients had to strictly avoid the food allergen, resulting in a decline in quality of life and subsequent nutritional, social, and psychological impairments. Thanks to the introduction of OIT, the passive approach involving rigid exclusion has changed to a proactive one. Both the heterogeneity in the diagnostic process among the studies and the variability of OIT data limit the comprehension of the real epidemiology of CMA, and, consequentially, its natural history. Therefore, well-planned randomized controlled trials are needed to standardize CMA diagnosis, prevention, and treatment strategies.

Effect of Processing on Fish Protein Antigenicity and Allergenicity

Fish allergy is a life-long food allergy whose prevalence is affected by many demographic factors. Currently, there is no cure for fish allergy, which can only be managed by strict avoidance of fish in the diet. According to the WHO/IUIS Allergen Nomenclature Sub-Committee, 12 fish proteins are recognized as allergens. Different processing (thermal and non-thermal) techniques are applied to fish and fishery products to reduce microorganisms, extend shelf life, and alter organoleptic/nutritional properties. In this concise review, the development of a consistent terminology for studying food protein immunogenicity, antigenicity, and allergenicity is proposed. It also summarizes that food processing may lead to a decrease, no change, or even increase in fish antigenicity and allergenicity due to the change of protein solubility, protein denaturation, and the modification of linear or conformational epitopes. Recent studies investigated the effect of processing on fish antigenicity/allergenicity and were mainly conducted on commonly consumed fish species and major fish allergens using in vitro methods. Future research areas such as novel fish species/allergens and ex vivo/in vivo evaluation methods would convey a comprehensive view of the relationship between processing and fish allergy.

Seafood Intake as a Method of Non-Communicable Diseases (NCD) Prevention in Adults

Seafood (fish in particular) is one of the main food groups in nutrition models with proven health benefits. Seafood has long been considered a very valuable dietary component, mainly due to presence of n-3 polyunsaturated fatty acids (n-3 PUFA) but it is also an important source of protein (including collagen), anserine, taurine, iodine, selenium, vitamin A, vitamin K, vitamin D, tocopherols, B vitamins and astaxanthin. Considering the beneficial effects of these ingredients on blood pressure, lipid profile and the inflammatory process, seafood should be an essential component of the diet. Non-communicable diseases (NCD) such as cardiovascular diseases, cancer, diabetes and mental disorder, chronic respiratory diseases are common diseases associated with advanced age. Promotion of a healthy lifestyle (including proper nutritional behavior) and prevention of diseases are the most effective and efficient ways to decrease premature mortality from NCD and to maintain mental health and well-being. This review article shows the potential preventive and therapeutic effects of seafood with an emphasis on fish. Our narrative review presents the results of systematic reviews and meta-analysis.

Using oral food challenges to provide clarity and confidence when diagnosing food allergies

A verified food allergy can be an impactful life event that leads to increased anxiety and measurable effects on quality of life. Allergists play a key role in framing this discussion and can help alleviate underlying fears by promoting confidence and clarifying safety concerns. Correctly diagnosing a patient with an immunoglobulin E (IgE) mediated food allergy remains a nuanced process fraught with the potential for error and confusion. This is especially true in situations in which the clinical history is not classic, and allergists rely too heavily on food allergy testing to provide a confirmatory diagnosis. A comprehensive medical history is critical in the diagnosis of food allergy and should be used to determine subsequent testing and interpretation of the results. Oral food challenge (OFC) is a critical procedure to identify patients with an IgE-mediated food allergy when the history and testing are not specific enough to confirm the diagnosis and can be a powerful teaching tool regardless of outcome. Although the safety and feasibility of performing OFC in a busy allergy office have always been a concern, in the hands of an experienced and trained provider, OFC is a safe and reliable procedure for patients of any age. With food allergy rates increasing and analysis of recent data that suggests that allergists across the United States are not providing this resource consistently to their patients, more emphasis needs to be placed on food challenge education and hands-on experience. The demand for OFCs will only continue to increase, especially with the growing popularity of oral immunotherapy programs; therefore, it is essential that allergists become familiar with the merits and limitations of current testing modalities and open their doors to using OFCs in the office.

The Use of Fecal Calprotectin Testing in Paediatric Disorders: A Position Paper of the European Society for Paediatric Gastroenterology and Nutrition Gastroenterology Committee

OBJECTIVES

The aim of the study was to review the evidence regarding the clinical use and value of fecal calprotectin (FC) measurements in different gastrointestinal disorders in children.

METHODS

A literature search was conducted in the PubMed, MEDLINE, EMBASE, and Cochrane databases until October 31, 2019. Subtopics were identified and each assigned to individual authors.

RESULTS

A total of 28 recommendations were voted on using the nominal voting technique. Recommendations are given related to sampling, measurement methods, and results interpretation. The 14 authors anonymously voted on each recommendation using a 9-point scale (1 strongly disagree to 9 fully agree). Consensus was considered achieved if at least 75% of the authors voted 6, 7, 8, or 9.

CONCLUSIONS

Consensus was reached for all recommendations. Limitations for the use of FC in clinical practice include variability in extraction methodology, performance of test kits as well as the need to establish local reference ranges because of the influence of individual factors, such as age, diet, microbiota, and drugs. The main utility of FC measurement at present is in the diagnosis and monitoring of inflammatory bowel disease (IBD) as well as to differentiate it from functional gastrointestinal disorders (FAPDs). FC, however, has neither utility in the diagnosis of infantile colic nor to differentiate between functional and organic constipation. A rise in FC concentration, may alert to the risk of developing necrotizing enterocolitis and help identifying gastrointestinal involvement in children with Henoch-Schönlein purpura. FC measurement is of little value in Cow's Milk Protein Allergy, coeliac disease (CD), and cystic fibrosis. FC does neither help to distinguish bacterial from viral acute gastroenteritis (AGE), nor to diagnose Helicobacter Pylori infection, small intestinal bacterial overgrowth (SIBO), acute appendicitis (AA), or intestinal polyps.

Functional properties of ovotransferrin from chicken egg white and its derived peptides: a review

With emerging trends in the food and pharmaceutical industries, potential applications of egg-derived bioactive compounds were recognized. Ovotransferrin is a major egg white functional protein responsible for multiple bioactivities. The objectives of this review are to provide scientific evidence of the functional properties of chicken ovotransferrin and its derived peptides and to identify future research approaches and applications. Various easy, economical, and non-toxic methods have been reported to produce ovotransferrin with high yield and purity, and chemical and enzymatic approaches have been employed to release bioactive peptides. The native ovotransferrin is known to have antimicrobial, antioxidant, anticancer, and immunomodulatory activities. The peptides produced from ovotransferrin also are reported to have antioxidant, antimicrobial, antihypertensive, and anticancer properties. However, little or no application of these compounds in the food and pharmaceutical areas is available yet. Therefore, the practical application of OTF in nutraceutical and pharmaceutical areas are among the emerging areas of research.

Assessing daily food allergy self-management among adolescents using a 24-hour recall interview

BACKGROUND

Severe food allergic reactions can be life-threatening or fatal and are experienced by up to 40% of children with food allergies, with adolescents at greatest risk. There are no comprehensive measures to assess food allergy management behaviors that could prevent allergic reactions.

OBJECTIVE

To describe food allergy self-management behaviors as reported by adolescents on a 24-hour recall measure and identify related factors.

METHODS

Adolescents aged 10 to 14 years with immunoglobulin E-mediated food allergy completed the Food Allergy Management 24-Hour Recall as an interview. Participants answered questions on each food they ate on the previous day and food allergy self-management behaviors.

RESULTS

Participants were a diverse sample (28% White) of 101 adolescents (mean age = 11.80 years; 53% male sex). Most meals and snacks (76%) were observed by adults. Epinephrine autoinjectors (EAIs) were reportedly available for almost all meals and snacks (93%). Almost all foods had been eaten before (95%) and were verified as allergen free (92%). Furthermore, 35% of the time, past experience with the food was the only method used to verify safety. Child age, number of food allergies, or time since allergic reaction was not related to self-management behavior. EAI availability and ingredient verification were most common at home and in school; adult observation was least likely in the home.

CONCLUSION

Adolescents reported that EAIs were frequently available, but they relied on past experience with food to determine safety. Appropriate assessment of food safety should be a primary intervention target. The Food Allergy Management 24-Hour Recall may be a useful tool to assess and track food allergy self-management.

The self-management work of food hypersensitivity

Background

Food hypersensitivity (FH) has received considerable attention in the scientific community in recent years. However, little attention has been given to the efforts people make to manage their FH. We aimed to explore these efforts by using Normalization Process Theory, which is a conceptual framework formerly used to describe the self-management ‘work’ of long-term conditions.

Methods

We carried out qualitative individual interviews with 16 women with FH. Transcripts from recorded interviews were analyzed using template analysis.

Results

16 women participated; some had diagnoses from conventional medicine (celiac disease, lactose intolerance, food allergies, irritable bowel syndrome) and some did not. Participants described carrying out several tasks, some of which were time-consuming, to manage their FH. Women who had clarified once and for all what food(s) caused symptoms, described that they could concentrate on carrying out a restricted diet, which could become routine. Conversely, participants who had not achieved such clarification described carrying out tasks to identify what food(s) caused symptoms, and to implement and evaluate a tentative diet. Participants’ descriptions also revealed a heightened vigilance when they ate food that others had prepared, and some made efforts to conceal their FH.

Conclusions

Self-management of FH may, like the self-management of other long-term conditions, imply a large workload and burden of treatment. Efforts made to conceal FH may be considered part of this workload, while help in clarifying which food(s) cause symptoms has the potential to reduce the workload.

Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy

BACKGROUND

Whether to screen high-risk groups before early peanut introduction is controversial.

OBJECTIVE

We sought to determine the risk of peanut allergy (PA) before peanut introduction for infants with (1) moderate-severe eczema, (2) another food allergy (FA), and/or (3) a first-degree relative with peanut allergy (FH).

METHODS

Infants aged 4 to 11 months with no history of peanut ingestion, testing, or reaction and at least 1 of the above risk factors received peanut skin prick test and, depending on skin prick test wheal size, oral food challenge or observed feeding.

RESULTS

A total of 321 subjects completed the enrollment visit (median age, 7.2 months; 58% males); 78 had eczema only, 11 FA only, 107 FH only, and 125 had multiple risk factors. Overall, 18% of 195 with eczema, 19% of 59 with FA, and 4% of 201 with FH had PA. Only 1% of 115 with FH and no eczema had PA. Among those with eczema, older age (odds ratio [OR], 1.3; 95% CI, 1.04-1.68 per month), higher SCORing Atopic Dermatitis score (OR, 1.19; 95% CI, 1.06-1.34 per 5 points), black (OR, 5.79; 95% CI, 1.92-17.4 compared with white), or Asian race (OR, 6.98; 95% CI, 1.92-25.44) and suspected or diagnosed other FA (OR, 3.98; 95% CI, 1.62-9.80) were associated with PA.

CONCLUSIONS

PA is common in infants with moderate-severe eczema, whereas FH without eczema is not a major risk factor, suggesting screening only in those with significant eczema. Even within the first year of life, introduction at later ages is associated with a higher risk of PA among those with eczema, supporting introduction of peanut as early as possible.

A systematic review of psychological, clinical and psychosocial correlates of perceived food intolerance

OBJECTIVE

Perceived food intolerance (PFI) is a distressing condition reported by 3% - 35% of individuals, whereas prevalence of food allergy is 0.9%-3%. The present paper aims to systematically review the evidence for psychological, clinical and psychosocial factors associated with PFI in order to advance the current understanding.

METHODS

Articles published from 1970 until October 2020 were identified. Case-control, prospective cohort, cross-sectional and retrospective studies published in English that a) included a subject population of adults over 18 with PFI and b) examined psychological, clinical and/or psychosocial factors of PFI were reviewed against inclusion criteria. Methodological quality was assessed, data extracted, and a narrative synthesis conducted.

RESULTS

Of 2864 abstracts identified, thirty-six articles met inclusion criteria. Evidence consistently found PFI is associated with female sex, and individuals with PFI often report physical health complaints including gastrointestinal and extraintestinal symptoms, and gastrointestinal and atopic conditions. Evidence for an association between psychological factors and PFI was inconsistent, although some suggested increased levels of common mental disorders and distress. Findings regarding psychosocial factors were mixed and sociodemographic data were infrequently collected.

CONCLUSIONS

PFI is associated with female sex and gastrointestinal and extraintestinal complaints. Limited high-quality evidence supports the role of psychological factors associated with PFI. High-quality research using prospective and longitudinal designs with multivariate analyses is needed. Future research should explore modifiable psychological factors as potential targets for intervention and identify clinical and psychosocial risk factors of PFI to aid in formulating a biopsychosocial model of PFI.

Orthorexia nervosa is associated with positive body image and life satisfaction in Chinese elderly: Evidence for a positive psychology perspective

OBJECTIVE

Obsessive attention to healthy eating might paradoxically lead to physical and psychosocial impairments, a potential eating disorder termed orthorexia nervosa (ON). An ongoing debate concerns whether ON should be categorized as an eating disorder, an obsessive-compulsive disorder, or a mental disorder at all. A missing voice in this debate is ON in the elderly, which remains unknown, despite health being a more central issue in everyday life during old age. Similarly missing is ON in East Asia, which remains largely unexplored.

METHOD

The current study investigated ON in 313 Chinese elderly (M = 67.90, SD = 7.94) using the Chinese version of the Düsseldorf Orthorexia Scale (C-DOS). Questionnaires were used to measure traditional eating disorder symptomatology, body image (body dissatisfaction, body appreciation, and functionality appreciation), lifestyle behaviors (fruit and vegetable consumption and time spent on physical activity), and indexes of well-being (psychological distress, food-related quality of life, and life satisfaction).

RESULTS

ON symptoms were positively related to physical activity, fruit and vegetable (F&V) consumption, body appreciation, functionality appreciation, and life satisfaction, but negatively related to body dissatisfaction. Compared with those without ON, the elderly with ON scored higher on positive psychological/lifestyle measures but lower on negative psychological measures.

DISCUSSION

Contrary to the dominant characterization of ON as a variant of disordered eating, in Chinese elderly ON was associated with several positive lifestyle and psychological measures. Thus, ON in the elderly might not be viewed as a form of disordered eating but can be protective and beneficial.

Recent advances in the management of nut allergy

Peanut/tree nut allergy is common and has been associated with particularly severe reactions. Epidemiological data have shown that the prevalence ranges between 0.05% and 4.9% for tree nut and between 0.5% and 3% for peanut. These large variations can be explained by differences in the age of included patients and the geographical region. In addition, the food consumption modality (ie, raw versus roasted) plays a major role, as heat treatment has the capacity to modify the allergenicity of nuts and legumes. Nut allergies tend to persist into adulthood and consequently have a high impact on quality of life.

Recently, it has been demonstrated that a significant proportion of nut allergic patients are able to tolerate other nuts. As opposed to the avoidance of all nuts, this approach is currently proposed in several tertiary allergy centers. However, diagnosis of nut allergy is particularly difficult due to co-sensitization leading to high rate of false positive skin prick tests and/or specific IgE to whole allergen extracts. The use of component resolved diagnosis leads to major improvement of diagnosis, particularly to distinguish between primary and secondary nut allergies. The basophil activation test has been suggested to be useful but is still used mainly as a research tool. Thus, diagnosis remains mainly based on the oral food challenge, which is considered as the gold standard.

Regarding treatment, avoidance remains the cornerstone of management of nut allergy. Oral immunotherapy is increasingly proposed as an alternative management strategy.

Milk consumption and multiple health outcomes: umbrella review of systematic reviews and meta-analyses in humans

In order to recapitulate the best available evidence of milk consumption and multiple health-related outcomes, we performed an umbrella review of meta-analyses and systematic reviews in humans. Totally, 41 meta-analyses with 45 unique health outcomes were included. Milk consumption was more often related to benefits than harm to a sequence of health-related outcomes. Dose–response analyses indicated that an increment of 200 ml (approximately 1 cup) milk intake per day was associated with a lower risk of cardiovascular disease, stroke, hypertension, colorectal cancer, metabolic syndrome, obesity and osteoporosis. Beneficial associations were also found for type 2 diabetes mellitus and Alzheimer's disease. Conversely, milk intake might be associated with higher risk of prostate cancer, Parkinson’s disease, acne and Fe-deficiency anaemia in infancy. Potential allergy or lactose intolerance need for caution. Milk consumption does more good than harm for human health in this umbrella review. Our results support milk consumption as part of a healthy diet. More well-designed randomized controlled trials are warranted.

Allergenicity and Stability of 6 New Korean Bony Fish Extracts

Purpose

Diagnostic tests for allergen sensitization should reflect real exposure. We made 6 new bony fish extracts, which are consumed popularly in Korea, and evaluated their allergenicity and stability.

Methods

We manufactured fish extracts from codfish, mackerel, common eel, flounder, cutlass, and catfish. Protein and parvalbumin (PV) were evaluated by Bradford assay, 2-site enzyme-linked immunosorbent assay, sodium dodecyl sulphate–polyacrylamide gel electrophoresis (SDS-PAGE), and anti-PV immunoblotting. The immunoglobulin E (IgE) reactivities of the extracts were evaluated with ImmunoCAP and IgE immunoblotting using sera from 24 Korean fish allergy patients, 5 asymptomatic sensitizers, and 11 non-atopic subjects. Stability of the extracts stored in 4 different buffers were evaluated for up to a year.

Results

The protein concentrations of commercial SPT fish extracts varied with up to a 7.5-fold difference. SDS-PAGE showed marked differences in the PV concentrations of commercial SPT reagents. Specific IgE measurements for the following investigatory fish extracts—iCodfish, iMackerel, and iEel—were concordant with that of their corresponding Phadia ImmunoCAP measurements. ImmunoCAP results showed marked IgE cross-reactivity among the fish species, and the overall sensitivity of ImmunoCAP with the investigatory fish extracts for identification of culprit fish species was 85.7%. The protein and PV concentrations in the investigatory extracts were highly stable in saline with 0.3% phenol–50% glycerol at 4°C for up to a year.

Conclusions

The commercial SPT fish extracts exhibited considerable variation in terms of allergenicity, which may impact on diagnostic accuracy. Our new fish extracts have sufficient allergenicity and stability and may be adequate to various clinical applications.

Consensus statement on the epidemiology, diagnosis, prevention, and management of cow's milk protein allergy in the Middle East: a modified Delphi-based study

BACKGROUND

This study aimed to develop an expert consensus regarding the epidemiology, diagnosis, and management of cow's milk protein allergy (CMPA) in the Middle East.

METHODS

A three-step modified Delphi method was utilized to develop the consensus. Fifteen specialized pediatricians participated in the development of this consensus. Each statement was considered a consensus if it achieved an agreement level of ≥ 80%.

RESULTS

The experts agreed that the double-blind placebo-controlled oral challenge test (OCT) should be performed for 2-4 weeks using an amino acid formula (AAF) in formula-fed infants or children with suspected CMPA. Formula-fed infants with confirmed CMPA should be offered a therapeutic formula. The panel stated that an extensively hydrolyzed formula (eHF) is indicated in the absence of red flag signs. At the same time, the AAF is offered for infants with red flag signs, such as severe anaphylactic reactions. The panel agreed that infants on an eHF with resolved symptoms within 2-4 weeks should continue the eHF with particular attention to the growth and nutritional status. On the other hand, an AAF should be considered for infants with persistent symptoms; the AAF should be continued if the symptoms resolve within 2-4 weeks, with particular attention to the growth and nutritional status. In cases with no symptomatic improvements after the introduction of an AAF, other measures should be followed. The panel developed a management algorithm, which achieved an agreement level of 90.9%.

CONCLUSION

This consensus document combined the best available evidence and clinical experience to optimize the management of CMPA in the Middle East.

ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.

Changes in structure and allergenicity of shrimp tropomyosin by dietary polyphenols treatment

Here, the potential allergenicity of shrimp tropomyosin (TM) after conjugation with chlorogenic acid (CA) and (-)-epigallo-catechin 3-gallate (EGCG) was assessed. Conformational structures of TM-polyphenol complexes were detected using SDS-PAGE, circular dichroism (CD), and fluorescence. Potential allergenicity was assessed by immunological methods, a rat basophil leukemia cell model (RBL-2H3), and in vivo assays. Indirect ELISA showed that TM-polyphenol complexes caused a conformational change to TM structure, with decreased IgG/IgE binding capacity significantly fewer inflammatory mediators were released with EGCG-TM and CA-TM in a mediator-releasing RBL-2H3 cell line. Mice model showed low allergenicity to serum levels of TM-specific antibody and T-cell cytokine production. EGCG-TM and CA-TM might reduce the potential allergenicity of shrimp TM, which could be used to produce hypoallergenic food in the food industry.

Interdisciplinary Significance of Food-Related Adverse Reactions in Adulthood

Background: Adults frequently interpret food-associated adverse reactions as indicators of a food allergy. However, the public perception of food allergy may differ from a clinician's point of view. The prevalence of patient-reported food allergy tends to be higher than physician-confirmed cases. Dermatological manifestations (urticaria, pruritus, dermatitis, and edema) are frequently reported by patients. Objective: The aim of this study was to describe patient-reported symptoms related to suspected food allergies and particularly to characterize and highlight the volume of patients who visit Budapest allergy clinics with suspected food allergies. Methods: In this prospective study, adult (≥18 years) patients were examined at the Allergology Outpatient Unit of the Dept. of Dermatology, Venereology, and Dermatooncology, Semmelweis University, Budapest. The examination included a detailed medical history; physical examination; and when necessary the measurement of allergen-specific serum immunoglobulin E (IgE) levels. Results: Data from 501 patients (393 women, 108 men) were analyzed. Intolerance to dietary biogenic amines occurred in 250 cases (250/501, 50%). Oral allergy syndrome was confirmed in 71 patients (71/501, 14%). Allergy to food preservatives was diagnosed in 14 (14/501, 3%) cases by a dermatologist-allergist specialist. Five individuals (5/501, 1%) were diagnosed with IgE-mediated food allergy. In some cases (28/501, 6%), edema-inducing/enhancing side effects of drugs were observed which patients had misattributed to various foods. Among the food groups considered to be provoking factors, the most frequently mentioned were fruits (198/501, 40%), milk/dairy products (174/501, 35%), and nuts/oilseeds (144/501, 29%). Overwhelmingly, urticaria (47%) was the most common dermatological diagnosis, followed by dermatitis (20%) and allergic contact dermatitis (8%). Conclusion: Improvement is needed in food allergy, food intolerance, and general nutritional knowledge among the general public. According to our data, perceived/self-reported food allergies were overestimated by adults when compared against physician-confirmed food allergies; however, other diseases potentially responsible for food-related problems were underestimated. The prevalence of oral allergy syndrome was high in the cohort. Intolerance to dietary biogenic amines was common, and although the role of dietary histamine and biogenic amine is not entirely understood in eliciting patients' symptoms, improvements in complaints were reported during the control visits.

Systemic reaction to an extensively hydrolyzed formula in an infant with cow's milk anaphylaxis

Background

Cow's milk allergy is the most common cause of food allergy in young children. Ingestion of milk products in children with a milk protein allergy can lead to anaphylaxis and must be avoided. Some guidelines suggest the use of an extensively hydrolyzed formula (EHF) in these cases; however, rare allergic reactions can still occur. Here, we presented a 3-month-old boy who developed anaphylaxis to a cow's milk formula. Subsequently, he developed a rare systemic reaction to soy and to an EHF.

Case

The patient had an unremarkable medical history and presented with signs and symptoms consistent with anaphylaxis after being fed cow's milk formula for the first time. Symptoms included immediate vomiting, wheezing, stridor, angioedema of eyelids and lips. Although intramuscular epinephrine was given, the patient continued to clinically deteriorate, becoming more lethargic and necessitating admission to the pediatric intensive care unit. Subsequently, a trial of soy formula ingestion reproduced the symptoms and an EHF was given. However, immediately after taking an EHF, he developed facial angioedema and diffuse urticarial lesions.

Conclusion

In most patients with a cow's milk allergy, an extensively based formula can be tolerated safely due to a hydrolyzed protein chain. However, medical providers must be vigilant when switching formula because a rare systemic allergic reaction to EHF can still occur.

Use of Soy-Based Formulas and Cow's Milk Allergy: Lights and Shadows

Soybean (Glycine max) is a species of legume native to East Asia and used in childhood diet for over 2,000 years in the East. Soy protein formulas have been available for almost a century. Nowadays, the increase in cow's milk allergy and vegetarian dietary preferences are driving consumers toward cow's milk alternatives. In this paper, we reviewed the nutritional composition of soy-based infant formula and discussed their possible use in pediatric age, mainly focusing on prevention and treatment of cow's milk allergy. Protein quality is determined by digestibility and amino acid content. Purified or concentrated vegetable proteins (e.g., soy protein and gluten) have high digestibility (>95%), similar to those of animal ones. For some intact vegetable products (e.g., whole cereals and pulses), protein digestibility is lower (80-90%). Food processing and heat treatment also influence protein digestibility. Considering these data, we tried to evaluate the possible use of soybean and derivatives in pediatric age, including the nutritional composition of soy formulas and the clinical indications for their use. Moreover, since plant-based beverages are being perceived as healthy by consumers and their use is growing on the market, we recommend that soy drink should not be used as a substitute for infant formulas or cow's milk in children younger than 24 months.

Immunological Outcomes of Allergen-Specific Immunotherapy in Food Allergy

IgE-mediated food allergies are caused by adverse immunologic responses to food proteins. Allergic reactions may present locally in different tissues such as skin, gastrointestinal and respiratory tract and may result is systemic life-threatening reactions. During the last decades, the prevalence of food allergies has significantly increased throughout the world, and considerable efforts have been made to develop curative therapies. Food allergen immunotherapy is a promising therapeutic approach for food allergies that is based on the administration of increasing doses of culprit food extracts, or purified, and sometime modified food allergens. Different routes of administration for food allergen immunotherapy including oral, sublingual, epicutaneous and subcutaneous regimens are being evaluated. Although a wealth of data from clinical food allergen immunotherapy trials has been obtained, a lack of consistency in assessed clinical and immunological outcome measures presents a major hurdle for evaluating these new treatments. Coordinated efforts are needed to establish standardized outcome measures to be applied in food allergy immunotherapy studies, allowing for better harmonization of data and setting the standards for the future research. Several immunological parameters have been measured in food allergen immunotherapy, including allergen-specific immunoglobulin levels, basophil activation, cytokines, and other soluble biomarkers, T cell and B cell responses and skin prick tests. In this review we discuss different immunological parameters and assess their applicability as potential outcome measures for food allergen immunotherapy that may be included in such a standardized set of outcome measures.

Production and characterization of eggs from hens with ovomucoid gene mutation

Ovomucoid is a major egg white protein which is considered as the most dominant allergen in chicken eggs. Owing to the difficulty of separating ovomucoid from egg whites, researchers have adopted genetic deletion for development of hypoallergenic eggs. Previously, we used CRISPR/Cas9 to establish chickens with ovomucoid gene (OVM) mutations, but it remained unknown whether such hens could produce eggs at maturity. Here, we have reported on eggs laid by OVM-targeted hens. Except for watery egg whites, the eggs had no evident abnormalities. Real-time PCR revealed alternative splicing of OVM mRNA in hens, but their expression was limited. Immunoblotting detected neither mature ovomucoid nor ovomucoid-truncated splicing variants in egg whites. Sixteen chicks hatched from 28 fertilized eggs laid by OVM-targeted hens, and fourteen of the sixteen chicks demonstrated healthy growth. Taken together, our results demonstrated that OVM knockout could almost completely eliminate ovomucoid from eggs, without abolishing fertility. Thus, the eggs developed in this study have potential as a hypoallergenic food source for most patients with egg allergies.

Depolymerized sulfated galactans from Eucheuma serra ameliorate allergic response and intestinal flora in food allergic mouse model

The ameliorative effect of depolymerized sulfated polysaccharides from Eucheuma serra (DESP) on ovalbumin (OVA)-caused induced food allergy was investigated in this work. Results showed that OVA stimulated the secretion of allergy-related cytokines (OVA-specific IgE, mMCP-1, IgA, TNF-α) and led to diarrhea, intestinal epithelial damage, and intestinal microflora dysbiosis in sensitized mice. After the administration of DESP, however, the anaphylactic symptoms (shortness of breath, hypothermia, diarrhea), along with the allergy-related cytokines, were effectively suppressed. Moreover, the reduced intestinal inflammation was discovered in the DESP-treated group. Additionally, 16S rRNA sequencing of fecal samples was performed, and gene count and α-diversity analysis revealed that DESP improved microbial community richness. Taxonomic composition analysis showed that DESP modulated the proportion of Firmicutes and Bacteroidetes/Proteobacteria. Particularly, DESP increased probiotics (Lactobacillaceae, Bifidobacteriaceae and Prevotellaceae) and decreased pathogenic bacteria (Helicobacteraceae and Desulfovibrionaceae). These findings, therefore, suggest that DESP may ameliorate food allergy through the regulation of intestinal microbiota.

Assessment of cows milk-related symptom scoring awareness tool in young Turkish children

BACKGROUND

The diagnosis of cows milk protein allergy (CMPA) is not always easy. Cow's Milk-related Symptom Score (CoMiSS) has been developed to raise the awareness of CMPA among the primary health-care providers. In this study, we aimed to evaluate the validity of CoMiSS as a diagnostic approach of CMPA in infants in our country.

METHODS

Infants with a CoMiSS of more than 12 points were included. An elimination diet was implemented in these infants for 4 weeks, and CoMiSS was reapplied. Infants with a reduction of ≥3 points in CoMiSS were considered responsive to the elimination diet, and an open oral challenge test was performed. Infants with symptom recurrence were diagnosed with CMPA.

RESULTS

The study included 168 infants. When they were included in the study, the first CoMiSS score was 13.6 ± 1.9. After the elimination diet, the number of responsive infants was 154 (91.7%). Of the infants, 91 (54.2%) were diagnosed with CMPA with positive challenge. The majority of the patients diagnosed with CMPA presented with gastrointestinal and/or dermatological symptoms (80.3%). Positive family history of allergy was more prevalent in CMPA(+) infants (P < 0.001). The mean atopic dermatitis score was higher in CMPA(+) infants (P = 0.001). Eosinophilia and cows milk-specific IgE (CM-sIgE) positivity were more prevalent in infants with CMPA (P = 0.01 and P < 0.001, respectively).

CONCLUSIONS

CoMiSS is a valuable tool to evaluate CMPA in primary care. The presence of multiple symptoms, especially skin involvement, helps to recognise infants with CMPA. Family history and eosinophilia also support the diagnosis of CMPA.

LTP allergy/sensitization in a pediatric population

Plant lipid transfer proteins (LTPs) are widespread plant food allergens, highly resistant to food processing and to the gastrointestinal environment, which have been described as the most common food allergens in the Mediterranean area. LTP allergy is widely described in adults, but it represents an emerging allergen also in the pediatric population. Little is known about the real prevalence and the clinical features of this allergy in children and it still often remains underdiagnosed in these patients. An early identification and a deeper knowledge of this allergy in childhood can avoid severe systemic reactions and improve the child's quality of life. Pediatricians should always consider the possibility of LTP involvement in cases of plant-derived food allergy.

A Bayesian multivariate meta-analysis of prevalence data

When conducting a meta-analysis involving prevalence data for an outcome with several subtypes, each of them is typically analyzed separately using a univariate meta-analysis model. Recently, multivariate meta-analysis models have been shown to correspond to a decrease in bias and variance for multiple correlated outcomes compared with univariate meta-analysis, when some studies only report a subset of the outcomes. In this article, we propose a novel Bayesian multivariate random effects model to account for the natural constraint that the prevalence of any given subtype cannot be larger than that of the overall prevalence. Extensive simulation studies show that this new model can reduce bias and variance when estimating subtype prevalences in the presence of missing data, compared with standard univariate and multivariate random effects models. The data from a rapid review on occupation and lower urinary tract symptoms by the Prevention of Lower Urinary Tract Symptoms Research Consortium are analyzed as a case study to estimate the prevalence of urinary incontinence and several incontinence subtypes among women in suspected high risk work environments.