The Epidemiology of Food Allergy in the Global Context

Archive for Research in Child Health (ARCH) and Baby Gut: Study Protocol for a Remote, Prospective, Longitudinal Pregnancy and Birth Cohort to Address Microbiota Development and Child Health

The infant gut microbiome is shaped by numerous factors such as diet and the maternal microbiota and is also associated with later atopy and obesity. The Archive for Research in Child Health and Baby Gut (ARCHBG) cohort was established in 2015 to (1) understand how the development of the infant gut microbiota is associated with atopy, obesity, and gastrointestinal disease and (2) characterize the associations of maternal pre-pregnancy BMI and infant diet with the development of the gut microbiota. Study participants for ARCHBG are convenience samples recruited through two pipelines in Lansing and Traverse City, Michigan: (1) Archive for Research in Child Health (ARCH_GUT) and (2) BABY_GUT. A total of (n = 51) mother–infant dyads have been enrolled to date. This prospective cohort study collects maternal pre-pregnancy fecal samples, maternal data, child fecal samples at four timepoints (one week, six months, 12 months, and 24 months), and child data up to five years of age. All samples and data are collected remotely by mail, phone, or drop-off at select locations. Of all participants enrolled, 76.5% (n = 39) of infants have a complete record of stool samples. At least 88.2% (n = 45) of fecal samples were submitted at each timepoint. ARCHBG will allow for a nuanced understanding of the temporal development of the infant gut microbiome and numerous child health outcomes.

Peanut allergy: Beyond the oral immunotherapy plateau

BACKGROUND

There are a lack of disease-modifying treatments for peanut allergy, which is lifelong in most instances. Oral immunotherapy has remained at the forefront of prospective treatments, though its efficacy is consistently undermined by the risk of adverse reactions and meager sustained effects.

AIM

This review discusses the current state of oral immunotherapy, its strengths and limitations, and the future of therapeutics for the treatment of peanut allergy.

CONCLUSION

The persistence of peanut allergy is currently attributed to reservoirs of peanut-specific memory B cells and Th2 cells, though the cellular and molecular interplay that facilitates the replenishment of peanut-specific IgE remains elusive. Uncovering these events will prove critical for identification of novel targets as we forge ahead to a new age of peanut allergy treatment with biotherapeutics.

Bioactive Compounds in Food as a Current Therapeutic Approach to Maintain a Healthy Intestinal Epithelium

The intestinal epithelium serves as an effective barrier against the external environment, hampering the passage of potentially harmful substances (such as pathogenic microbes) that could trigger an exacerbated host immune response. The integrity of this barrier is thus essential for the maintenance of proper intestinal homeostasis and efficient protective reactions against chemical and microbial challenges. The principal consequence of intestinal barrier defects is an increase in intestinal permeability, which leads to an increased influx of luminal stressors, such as pathogens, toxins, and allergens, which in turn trigger inflammation and immune response. The fine and fragile balance of intestinal homeostasis can be altered by multiple factors that regulate barrier function, many of which are poorly understood. This review will address the role of gut microbiota as well as food supplements (such as probiotics, prebiotics, and synbiotics) in modulating gut health and regulating intestinal barrier function. In particular, we will focus on three human pathologies: inflammatory bowel disease, irritable bowel syndrome, and food allergy.

Tick Saliva and the Alpha-Gal Syndrome: Finding a Needle in a Haystack

Ticks and tick-borne diseases are significant public health concerns. Bioactive molecules in tick saliva facilitate prolonged blood-feeding and transmission of tick-borne pathogens to the vertebrate host. Alpha-gal syndrome (AGS), a newly reported food allergy, is believed to be induced by saliva proteins decorated with a sugar molecule, the oligosaccharide galactose-⍺-1,3-galactose (α-gal). This syndrome is characterized by an IgE antibody-directed hypersensitivity against α-gal. The α-gal antigen was discovered in the salivary glands and saliva of various tick species including, the Lone Star tick (Amblyomma americanum). The underlying immune mechanisms linking tick bites with α-gal-specific IgE production are poorly understood and are crucial to identify and establish novel treatments for this disease. This article reviews the current understanding of AGS and its involvement with tick species.

Viability Status-Dependent Effect of Bifidobacterium longum ssp. longum CCM 7952 on Prevention of Allergic Inflammation in Mouse Model

The classical definition of probiotics states that bacteria must be alive to be beneficial for human organism. However, recent reports show that inactivated bacteria or their effector molecules can also possess such properties. In this study, we investigated the physical and immunomodulatory properties of four Bifidobacterium strains in the heat-treated (HT) and untreated (UN) forms. We showed that temperature treatment of bacteria changes their size and charge, which affects their interaction with epithelial and immune cells. Based on the in vitro assays, we observed that all tested strains reduced the level of OVA-induced IL-4, IL-5, and IL-13 in the spleen culture of OVA-sensitized mice. We selected Bifidobacterium longum ssp. longum CCM 7952 (Bl 7952) for further analysis. In vivo experiments confirmed that untreated Bl 7952 exhibited allergy-reducing properties when administered intranasally to OVA-sensitized mice, which manifested in significant suppression of airway inflammation. Untreated Bl 7952 decreased local and systemic levels of Th2 related cytokines, OVA-specific IgE antibodies and simultaneously inhibited airway eosinophilia. In contrast, heat-treated Bl 7952 was only able to reduce IL-4 levels in the lungs and eosinophils in bronchoalveolar lavage, but increased neutrophil and macrophage numbers. We demonstrated that the viability status of Bl 7952 is a prerequisite for the beneficial effects of bacteria, and that heat treatment reduces but does not completely abolish these properties. Further research on bacterial effector molecules to elucidate the beneficial effects of probiotics in the prevention of allergic diseases is warranted.

Seafood Allergy in Asia: Geographical Specificity and Beyond

Asian countries have unique ways of food processing and dietary habits that may explain the observed differences in the prevalence, natural history, epidemiology and sensitization pattern of food allergic diseases when compared to western countries. Per capita consumption of seafood, including fish and shellfish, is well above the global average for many Asian countries because of their coastal geographical location and rich seafood supply. The wide availability and high abundance of seafood in Asian countries have shaped a diverse way of processing and eating this major food group. Such unique features have significant impact on the sensitization profile and allergenicity of Asians to fish and shellfish. For example, fish and shellfish are eaten raw in some countries that may promote sensitization to heat-labile allergens not otherwise seen in other regions. Fermented fish sauce is commonly used as a condiment in some countries which may promote fish sensitization. Shrimp head and shrimp roe are regarded as delicacies in some countries, but their allergen profiles are yet to be characterized. Freshwater fish and shellfish are a common food source in many Asian countries but the allergenicity of many such species remains unknown. In this review, we discuss factors that may contribute to differences in molecular profile and sensitization pattern for fish and shellfish that are observed in Asian populations and revisit the current status of seafood allergy in this part of the world. Acknowledging the similarities and differences of seafood allergy patterns between Asian and western populations can help us refine a better strategy for diagnosing and managing seafood allergy.

Anxiety-like behavior and intestinal microbiota changes as strain-and sex-dependent sequelae of mild food allergy in mouse models of cow's milk allergy

A number of studies have reported comorbidity of food allergies with various neuropsychiatric disorders, such as anxiety, depression, attention-deficit hyperactivity disorder, and autism. However, inconsistent results across clinical studies have left the association between food allergy and behavioral disorders inconclusive. We postulated that the heterogeneities in genetic background among allergic cohorts affect symptom presentation and severity of food allergy, introducing bias in patient selection criteria toward individuals with overt physical reactions. To understand the influence of genetic background on food allergy symptoms and behavioral changes beyond anaphylaxis, we generated mouse models with mild cow's milk allergy by sensitizing male and female C57BL/6J and BALB/cJ mice to a bovine whey protein, β-lactoglobulin (BLG; Bos d 5). We compared strain- and sex-dependent differences in their immediate physical reactions to BLG challenge as well as anxiety-like behavior one day after the challenge. While reactions to the allergen challenge were either absent or mild for all groups, a greater number of BLG-sensitized BALB/cJ mice presented visible symptoms and hypothermia compared to C57BL/6J mice. Interestingly, male mice of both strains displayed anxiety-like behavior on an elevated zero maze without exhibiting cognitive impairment with the cross maze test. Further characterization of plasma cytokines/chemokines and fecal microbiota also differentiated strain- and sex-dependent effects of BLG sensitization on immune-mediator levels and bacterial populations, respectively. These results demonstrated that the genetic variables in mouse models of milk allergy influenced immediate physical reactions to the allergen, manifestation of anxiety-like behavior, levels of immune responses, and population shift in gut microbiota. Thus, stratification of allergic cohorts by their symptom presentations and severity may strengthen the link between food allergy and behavioral disorders and identify a population(s) with specific genetic background that have increased susceptibility to allergy-associated behavioral disorders.

Innate lymphoid cells: The missing part of a puzzle in food allergy

Food allergy is an increasingly prevalent disease driven by uncontrolled type 2 immune response. Currently, knowledge about the underlying mechanisms that initiate and promote the immune response to dietary allergens is limited. Patients with food allergy are commonly sensitized through the skin in their early life, later on developing allergy symptoms within the gastrointestinal tract. Food allergy results from a dysregulated type 2 response to food allergens, characterized by enhanced levels of IgE, IL-4, IL-5, and IL-13 with infiltration of mast cells, eosinophils, and basophils. Recent studies raised a possible role for the involvement of innate lymphoid cells (ILCs) in driving food allergy. Unlike lymphocytes, ILCs lack They represent a group of lymphocytes that lack specific antigen receptors. ILCs contribute to immune responses not only by releasing cytokines and other mediators but also by responding to cytokines produced by activated cells in their local microenvironment. Due to their localization at barrier surfaces of the airways, gut, and skin, ILCs form a link between the innate and adaptive immunity. This review summarizes recent evidence on how skin and gastrointestinal mucosal immune system contribute to both homeostasis and the development of food allergy, as well as the involvement of ILCs toward inflammatory processes and regulatory mechanisms.

EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update)

BACKGROUND

This guideline from the European Academy of Allergy and Clinical Immunology (EAACI) recommends approaches to prevent the development of immediate-onset / IgE-mediated food allergy in infants and young children. It is an update of a 2014 EAACI guideline.

METHODS

The guideline was developed using the AGREE II framework and the GRADE approach. An international Task Force with representatives from 11 countries and different disciplinary and clinical backgrounds systematically reviewed research and considered expert opinion. Recommendations were created by weighing up benefits and harms, considering the certainty of evidence and examining values, preferences and resource implications. The guideline was peer-reviewed by external experts, and feedback was incorporated from public consultation.

RESULTS

All of the recommendations about preventing food allergy relate to infants (up to 1 year) and young children (up to 5 years), regardless of risk of allergy. There was insufficient evidence about preventing food allergy in other age groups. The EAACI Task Force suggests avoiding the use of regular cow's milk formula as supplementary feed for breastfed infants in the first week of life. The EAACI Task Force suggests introducing well-cooked, but not raw egg or uncooked pasteurized, egg into the infant diet as part of complementary feeding. In populations where there is a high prevalence of peanut allergy, the EAACI Task Force suggests introducing peanuts in an age-appropriate form as part of complementary feeding. According to the studies, it appears that the most effective age to introduce egg and peanut is from four to 6 months of life. The EAACI Task Force suggests against the following for preventing food allergy: (i) avoiding dietary food allergens during pregnancy or breastfeeding; and (ii) using soy protein formula in the first 6 months of life as a means of preventing food allergy. There is no recommendation for or against the following: use of vitamin supplements, fish oil, prebiotics, probiotics or synbiotics in pregnancy, when breastfeeding or in infancy; altering the duration of exclusive breastfeeding; and hydrolysed infant formulas, regular cow's milk-based infant formula after a week of age or use of emollients.

CONCLUSIONS

Key changes from the 2014 guideline include suggesting (i) the introduction of peanut and well-cooked egg as part of complementary feeding (moderate certainty of evidence) and (ii) avoiding supplementation with regular cow's milk formula in the first week of life (low certainty of evidence). There remains uncertainty in how to prevent food allergy, and further well-powered, multinational research using robust diagnostic criteria is needed.

Peripheral blood basophils are the main source for early interleukin-4 secretion upon in vitro stimulation with Culicoides allergen in allergic horses

Interleukin-4 (IL-4) is a key cytokine secreted by type 2 T helper (Th2) cells that orchestrates immune responses during allergic reactions. Human and mouse studies additionally suggest that basophils have a unique role in the regulation of allergic diseases by providing initial IL-4 to drive T cell development towards the Th2 phenotype. Equine Culicoides hypersensitivity (CH) is a seasonal immunoglobulin E (IgE)-mediated allergic dermatitis in horses in response to salivary allergens from Culicoides (Cul) midges. Here, we analyzed IL-4 production in peripheral blood mononuclear cells (PBMC) of CH affected (n = 8) and healthy horses (n = 8) living together in an environment with natural Cul exposure. During Cul exposure when allergic horses had clinical allergy, IL-4 secretion from PBMC after stimulation with Cul extract was similar between healthy and CH affected horses. In contrast, allergic horses had higher IL-4 secretion from PBMC than healthy horses during months without allergen exposure. In addition, allergic horses had increased percentages of IL-4⁺ cells after Cul stimulation compared to healthy horses, while both groups had similar percentages of IL-4⁺ cells following IgE crosslinking. The IL-4⁺ cells were subsequently characterized using different cell surface markers as basophils, while very few allergen-specific CD4⁺ cells were detected in PBMC after Cul extract stimulation. Similarly, IgE crosslinking by anti-IgE triggered basophils to produce IL-4 in all horses. PMA/ionomycin consistently induced high percentages of IL-4⁺ Th2 cells in both groups confirming that T cells of all horses studied were capable of IL-4 production. In conclusion, peripheral blood basophils produced high amounts of IL-4 in allergic horses after stimulation with Cul allergens, and allergic horses also maintained higher basophil percentages throughout the year than healthy horses. These new findings suggest that peripheral blood basophils may play a yet underestimated role in innate IL-4 production upon allergen activation in horses with CH. Basophil-derived IL-4 might be a crucial early signal for immune induction, modulating of immune responses towards Th2 immunity and IgE production.

Anaphylaxis caused by artisanal honey in a child: a case report

BACKGROUND

Honey is a rare cause of food allergy, especially in children, but it can cause severe systemic allergic reactions. In the pediatric age group, only a few cases have been reported in the literature. Honey allergy may be caused by pollen content or bee-derived proteins. A role for Compositae has been suggested among pollen allergens. Allergology workup of a patient with suspected honey allergy is not well defined. Here we describe a rare case of anaphylaxis in a 5-year-old boy, sensitized to Compositae pollen (ragweed and mugwort), after the ingestion of artisanal honey.

CASE PRESENTATION

The Slavic patient was referred to our hospital emergency department for generalized urticaria and breathing impairment. All the symptoms occurred approximately 30 minutes after the ingestion of a meal containing salmon and artisanal honey. The allergology workup revealed that a skin prick-by-prick test with the implicated artisanal honey was positive, while a variety of different commercial honey and salmon products yielded negative results. Skin prick test and serum-specific immunoglobulin E (IgE) results were also positive for Compositae pollen (ragweed and mugwort). Patients sensitized to weed pollens who ingest bee products may experience an immediate allergic reaction because of the cross-reaction between weed pollens and Compositae bee product pollen. In this case, primary sensitization may be due to airborne Compositae pollen. Commercial honey is heavily processed due to pasteurization and filtration, which removes most of the pollen. These observations highlight the role of Compositae pollen in the observed allergic reaction and suggest that the different pollen content in the artisanal honey relative to commercial honey was responsible for the allergic reaction in our patient.

CONCLUSIONS

This is the first reported pediatric case of honey-induced anaphylaxis in a child under 6 years of age sensitized to Compositae pollen. Pediatricians should be aware of the potential risk of severe allergic reactions upon ingestion of honey and bee products, especially in patients sensitized to weed pollens. To diagnose honey allergy, obtaining a proper clinical history is essential. In addition, skin prick-by-prick tests are helpful, and may represent a simple method to screen for honey allergy in patients sensitized to Compositae pollen, in light of the potential risk.

Simultaneous quantitative profiling of clinically relevant immune markers in neonatal stool swabs to reveal inflammation

An aberrant immune response developed early in life may trigger inflammatory bowel disease (IBD) and food allergies (e.g., celiac disease). Fecal levels of immune markers categorize an inflammatory response (e.g., food allergy, autoimmune) paralleled with the initial microbial colonization. The immunoaffinity assays are routinely applied to quantify circulating immune protein markers in blood/serum. However, a reliable, multiplex assay to quantify fecal levels of immune proteins is unavailable. We developed mass spectrometry assays to simultaneously quantify fecal calprotectin, myeloperoxidase, eosinophil-derived neurotoxin, eosinophil cationic protein, alpha-1-antitrypsin 1, and adaptive immunity effectors in 134 neonatal stool swabs. We optimized extraction and proteolytic protocol and validated the multiplex assay in terms of linearity of response (> 100; typically 0.04 to 14.77 µg/mg of total protein), coefficient of determination (R²; > 0.99), the limit of detection (LOD; 0.003 to 0.04 µg/mg of total protein), the limit of quantification (LOQ; 0.009 to 0.122 µg/mg of total protein) and robustness. The median CV of intra- and interday precision was 9.8% and 14.1%, respectively. We quantified breast milk-derived IGHA2 to differentiate meconium from feces samples and to detect the first food intake. An early life profiling of immune markers reflects disrupted intestinal homeostasis, and it is perhaps suitable for pre-symptomatic interception of IBD and food allergies.

A scoping review of the caregiver burden of pediatric food allergy

OBJECTIVE

Although a number of articles have described the psychosocial impact of raising a child with a food allergy, recent attempts at synthesizing this literature have been narrow in focus or methodologically limited. Consequently, this study aimed to synthesize both the quantitative and qualitative literature to achieve a better understanding of the psychosocial and financial burdens faced by families who raise children with food allergy.

DATA SOURCES

Searches were performed on PubMed, Scopus, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature databases for articles related to the psychosocial and financial burden experienced by individuals who care for a child with food allergy.

STUDY SELECTIONS

English language, original research articles were included in this review.

RESULTS

A total of 54 articles were deemed eligible for review. Results from the quantitative literature revealed that parents of children with food allergy (ie, food allergy and food protein-induced enterocolitis, proctocolitis, and enteropathy) consistently reported lower quality of life than their comparison groups. Within-group analyses suggest that this burden is increased for parents who manage multiple food allergies, severe food allergy, and comorbid allergic conditions. Thematic synthesis of the qualitative literature suggests that the psychosocial burden shouldered by parents of children with food allergy stems, in part, from the unpredictable threat of exposure and the practical and social burdens of managing a food allergy. In addition to psychosocial burdens, a small but growing body of literature suggests that families with food allergy also incur greater financial costs.

CONCLUSION

Findings suggest that pediatric food allergy imposes considerable burdens on parents both quantitatively and qualitatively.

Cord Blood T Cells Expressing High and Low PKCζ Levels Develop into Cells with a Propensity to Display Th1 and Th9 Cytokine Profiles, Respectively

Low Protein Kinase C zeta (PKCζ) levels in cord blood T cells (CBTC) have been shown to correlate with the development of allergic sensitization in childhood. However, little is known about the mechanisms responsible. We have examined the relationship between the expression of different levels of PKCζ in CBTC and their development into mature T cell cytokine producers that relate to allergy or anti-allergy promoting cells. Maturation of naïve CBTC was initiated with anti-CD3/-CD28 antibodies and recombinant human interleukin-2 (rhIL-2). To stimulate lymphocyte proliferation and cytokine production the cells were treated with Phytohaemagglutinin (PHA) and Phorbol myristate acetate (PMA). Irrespective of the PKCζ levels expressed, immature CBTC showed no difference in lymphocyte proliferation and the production of T helper 2 (Th2) cytokine interleukin-4 (IL-4) and Th1 cytokine, interferon-gamma (IFN-γ), and influenced neither their maturation from CD45RA⁺ to CD45RO⁺ cells nor cell viability/apoptosis. However, upon maturation the low PKCζ expressing cells produced low levels of the Th1 cytokines, IFN-γ, IL-2 and tumour necrosis factor-alpha (TNF), no changes to levels of the Th2 cytokines, IL-4, IL-5 and IL-13, and an increase in the Th9 cytokine, IL-9. Other cytokines, lymphotoxin-α (LT-α), IL-10, IL-17, IL-21, IL-22 and Transforming growth factor-beta (TGF-β) were not significantly different. The findings support the view that low CBTC PKCζ levels relate to the increased risk of developing allergic diseases.

The global burden of illness of peanut allergy: A comprehensive literature review

Peanut allergy (PA) currently affects approximately 2% of the general population of Western nations and may be increasing in prevalence. Patients with PA and their families/caregivers bear a considerable burden of self‐management to avoid accidental peanut exposure and to administer emergency medication (adrenaline) if needed. Compared with other food allergies, PA is associated with higher rates of accidental exposure, severe reactions and potentially fatal anaphylaxis. Approximately 7%–14% of patients with PA experience accidental peanut exposure annually, and one‐third to one‐half may experience anaphylaxis, although fatalities are rare. These risks impose considerably high healthcare utilization and economic costs for patients with PA and restrictions on daily activities. Measures to accommodate patients with PA are often inadequate, with inconsistent standards for food labelling and inadequate safety policies in public establishments such as restaurants and schools. Children with PA are often bullied, resulting in sadness, humiliation and anxiety. These factors cumulatively contribute to significantly reduced health‐related quality of life for patients with PA and families/caregivers. Such factors also provide essential context for risk/benefit assessments of new PA therapies. This narrative review comprehensively assessed the various factors comprising the burden of PA.

Butyrate: A Link between Early Life Nutrition and Gut Microbiome in the Development of Food Allergy

Increased prevalence of food allergies in the last thirty years has been attributed to lifestyle changes in Westernized countries. Among the environmental factors, nutritional factors and their interaction with the gut microbiome in early life are thought to have an important role in the observed epidemiological change. The gut microbiome synthesizes bacterial metabolites, which represent a link among gut microbiome, nutrition, and immune system. The main metabolites produced by gut microbiome are short-chain fatty acids (SCFAs). SCFAs have multiple beneficial effects on human health including protective effects in autoimmune and inflammatory diseases. Among SCFAs, butyrate is essential for maintaining gut immune homeostasis and exerts a pivotal role in immune tolerance with strong anti-inflammatory effects in allergic diseases. Recent findings suggest that butyrate takes part in the development of immunological tolerance to food, especially in the first 1000 days of life. Herein, we provide a critical review of the scientific literature on the role of butyrate for prevention and treatment of food allergies with focus on the complex interplay among early life nutrition, gut microbiome, and immune system.

Recipe Components and Parents' Infant and Young Child Feeding Concerns: A Mixed-Methods Study of Recipe Posts Shared in Thai Facebook Groups for Parents

Social media is increasingly becoming a significant source of information for parents, including about feeding young children. However, little attention has been given to the characteristics of recipes for infants and young children and how they interact with parental perceptions regarding food decisions shared by users on social media. Building on findings related to shared recipe components and parental food choices, between December 2019 and July 2020, this study retrospectively collected 80 shared recipes each from five Thai Facebook groups. This extraction created 379 shared recipes with 1751 peers’ commentaries on the shared recipes’ posts. The shared recipes were classified and components quantified across child age groups, then the textual contents around the reasons behind the food choices were described qualitatively. The results showed that there were differences in meal types, food ingredients, and seasoning used across child age groups. Further analysis found that food allergy awareness was one driving concern behind parental perceptions on food choices in children’s diets. These concerns resulted in delays in the introduction of animal-source foods. Moreover, peers’ commentaries on shared recipes offered a venue for exchanging experiences with food products. Because of the potential influence on parental beliefs and perceptions, further studies are required to understand the impact of existing online communities on actual feeding practices.

Protocols for Managing Food Allergies in Elementary and Secondary Schools

The prevalence of food allergies is on the rise; nearly 8% of children worldwide are affected. The most common allergens-milk, eggs, peanuts, tree nuts, shellfish, fish, and wheat-account for 90% of serious allergic reactions. A literature review of online databases in CINAHL, PubMed Central, Education Resources Information Center (ERIC), Google Scholar, Health Resource Center Academic, and archival searching was performed to identify evidenced-based practices for managing food allergies in schools. There is no cure for food allergies. The current management standard is to avoid the allergen, treat a mild reaction with antihistamine and observation, and treat anaphylaxis with an intramuscular injection of epinephrine. Due to COVID-19 social distancing recommendations, food consumption in schools has moved from cafeterias and lunchrooms into classrooms and other spaces. This in turn necessitates strict adherence to hand washing and disinfecting all surfaces that come in contact with food. Managing food allergies in schools requires cooperation among school administrators, nurses, teachers, staff, families, and health care providers. Resources for managing food allergies in schools are presented offering information for parents, school administrators, nurses, teachers, and staff for planning and implementing strategies for preventing and reducing allergic reactions and treating life-threatening food allergy reactions.

Thermoneutrality Alters Gastrointestinal Antigen Passage Patterning and Predisposes to Oral Antigen Sensitization in Mice

Food allergy is an emerging epidemic, and the underlying mechanisms are not well defined partly due to the lack of robust adjuvant free experimental models of dietary antigen sensitization. As housing mice at thermoneutrality (Tn) - the temperature of metabolic homeostasis (26-30°C) - has been shown to improve modeling various human diseases involved in inflammation, we tested the impact of Tn housing on an experimental model of food sensitization. Here we demonstrate that WT BALB/c mice housed under standard temperature (18-20°C, Ts) conditions translocated the luminal antigens in the small intestine (SI) across the epithelium via goblet cell antigen passages (GAPs). In contrast, food allergy sensitive Il4raF709 mice housed under standard temperature conditions translocated the luminal antigens in the SI across the epithelium via secretory antigen passages (SAPs). Activation of SI antigen passages and oral challenge of Il4raF709 mice with egg allergens at standard temperature predisposed Il4raF709 mice to develop an anaphylactic reaction. Housing Il4raF709 mice at Tn altered systemic type 2 cytokine, IL-4, and the landscape of SI antigen passage patterning (villus and crypt involvement). Activation of SI antigen passages and oral challenge of Il4raF709 mice with egg antigen under Tn conditions led to the robust induction of egg-specific IgE and development of food-induced mast cell activation and hypovolemic shock. Similarly, Tn housing of WT BALB/c mice altered the cellular patterning of SI antigen passage (GAPs to SAPs). Activation of SI antigen passages and the oral challenge of WT BALB/c mice with egg antigen led to systemic reactivity to egg and mast cell activation. Together these data demonstrate that Tn housing alters antigen passage cellular patterning and landscape, and concurrent oral exposure of egg antigens and SAP activation is sufficient to induce oral antigen sensitization.

The evidence for interventions in early childhood allergy prevention - towards a living systematic review: protocol

Background: Research in early childhood allergy prevention (ECAP) is flourishing and new intervention strategies have proven to be promising. Due to the dynamic nature of ECAP, gaps between what is known and how guidelines inform practice are likely. A living systematic review (LSR) can narrow this gap by incorporating new evidence as it becomes available. No efficacy comparisons across various ECAP interventions for similar outcomes have been carried out. Networks of randomised clinical trials can be evaluated in the context of a network meta-analysis (NMA). We aim to establish a LSR on the efficacy and safety of any intervention investigated in randomised controlled trials (RCT) to prevent the occurrence of allergic sensitisation (AS), symptoms or diagnoses of allergic diseases in infancy and early childhood (0-3 years). Methods: A baseline SR will synthesise the evidence from existing SRs of RCTs as well as RCTs not yet considered in these. After completion of the baseline SR we propose to conduct a LSR. Using this methodology, we aim to undertake constant evidence surveillance, three-monthly search updates, and review updates every three months, should new evidence emerge. Conclusions: The ECAP evidence landscape has undergone dramatic transformations and this process is likely to continue. As a response to this, a LSR offers the potential to allow more timely synthesis of new evidence as it emerges. Long gaps between updates of SRs makes it harder for guidelines and recommendations to be up to date. Users of information, such as parents, may be confused if they encounter new evidence that is not part of a trusted guideline. A LSR approach allows us to continuously search the literature and update the evidence-base of existing ECAP interventions resulting in a decreased timespan from evidence accrual to informing clinical practice.

The evidence for interventions in early childhood allergy prevention - towards a living systematic review: protocol

Background: Research in early childhood allergy prevention (ECAP) is flourishing and new intervention strategies have proven to be promising. Due to the dynamic nature of ECAP, gaps between what is known and how guidelines inform practice are likely. A living systematic review (LSR) can narrow this gap by incorporating new evidence as it becomes available. No efficacy comparisons across various ECAP interventions for similar outcomes have been carried out. Networks of randomised clinical trials can be evaluated in the context of a network meta-analysis (NMA). We aim to establish a LSR on the efficacy and safety of any intervention investigated in randomised controlled trials (RCT) to prevent the occurrence of allergic sensitisation (AS), symptoms or diagnoses of allergic diseases in infancy and early childhood (0-3 years). Methods: A baseline SR will synthesise the evidence from existing SRs of RCTs as well as RCTs not yet considered in these. After completion of the baseline SR we propose to conduct a LSR. Using this methodology, we aim to undertake constant evidence surveillance, three-monthly search updates, and review updates every three months, should new evidence emerge. Conclusions: The ECAP evidence landscape has undergone dramatic transformations and this process is likely to continue. As a response to this, a LSR offers the potential to allow more timely synthesis of new evidence as it emerges. Long gaps between updates of SRs makes it harder for guidelines and recommendations to be up to date. Users of information, such as parents, may be confused if they encounter new evidence that is not part of a trusted guideline. A LSR approach allows us to continuously search the literature and update the evidence-base of existing ECAP interventions resulting in a decreased timespan from evidence accrual to informing clinical practice.

IgE-Reactivity Pattern of Tomato Seed and Peel Nonspecific Lipid-Transfer Proteins after in Vitro Gastrointestinal Digestion

The influence of gastrointestinal digestion on the immunological properties of three different nonspecific lipid-transfer proteins (nsLTPs) described in tomato fruit has been assessed using an in vitro system mimicking the stomach and intestine digestion conditions. Tomato peel/pulp nsLTP, Sola l 3, was degraded after digestion, although the immunoglobulin E (IgE) recognition of intact protein and a 10 kDa band were still observed after 30 min of duodenal digestion in the presence of phosphatidylcholine. The tomato seed nsLTP, Sola l 7, showed a higher stability than the other seed allergen, Sola l 6, during digestion. Sola l 7 showed an IgE immunoreactive 6.5 kDa band in immunoblotting analysis, retaining up to 7% of its IgE-binding capacity in inhibition ELISA test after 60 min of duodenal digestion and keeping intact its ability to activate basophils after digestion. These results suggest that the tomato seed allergen Sola l 7 might be considered as an important allergen in the induction of allergic responses to tomato due to its high stability against gastrointestinal digestion.

Innate Lymphoid Cells and Adaptive Immune Cells Cross-Talk: A Secret Talk Revealed in Immune Homeostasis and Different Inflammatory Conditions

The inflammatory immune response has evolved to protect the host from different pathogens, allergens, and endogenous death or damage-associated molecular patterns. Both innate and adaptive immune components are crucial in inducing an inflammatory immune response depending on the stimulus type and its duration of exposure or the activation of the primary innate immune response. As the source of inflammation is removed, the aggravated immune response comes to its homeostatic level. However, the failure of the inflammatory immune response to subside to its normal level generates chronic inflammatory conditions, including autoimmune diseases and cancer. Innate lymphoid cells (ILCs) are newly discovered innate immune cells, which are present in abundance at mucosal surfaces, including lungs, gastrointestinal tract, and reproductive tract. Also, they are present in peripheral blood circulation, skin, and lymph nodes. They play a crucial role in generating the pro-inflammatory immune response during diverse conditions. On the other hand, adaptive immune cells, including different types of T and B cells are major players in the pathogenesis of autoimmune diseases (type 1 diabetes mellitus, rheumatoid arthritis, psoriasis, and systemic lupus erythematosus, etc.) and cancers. Thus the article is designed to discuss the immunological role of different ILCs and their interaction with adaptive immune cells in maintaining the immune homeostasis, and during inflammatory autoimmune diseases along with other inflammatory conditions (excluding pathogen-induced inflammation), including cancer, graft-versus-host diseases, and human pregnancy.

An Approach to the Office-Based Practice of Food Oral Immunotherapy

Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.

Understanding Asthma and Allergies by the Lens of Biodiversity and Epigenetic Changes

Exposure to different organisms (bacteria, mold, virus, protozoan, helminths, among others) can induce epigenetic changes affecting the modulation of immune responses and consequently increasing the susceptibility to inflammatory diseases. Epigenomic regulatory features are highly affected during embryonic development and are responsible for the expression or repression of different genes associated with cell development and targeting/conducting immune responses. The well-known, "window of opportunity" that includes maternal and post-natal environmental exposures, which include maternal infections, microbiota, diet, drugs, and pollutant exposures are of fundamental importance to immune modulation and these events are almost always accompanied by epigenetic changes. Recently, it has been shown that these alterations could be involved in both risk and protection of allergic diseases through mechanisms, such as DNA methylation and histone modifications, which can enhance Th2 responses and maintain memory Th2 cells or decrease Treg cells differentiation. In addition, epigenetic changes may differ according to the microbial agent involved and may even influence different asthma or allergy phenotypes. In this review, we discuss how exposure to different organisms, including bacteria, viruses, and helminths can lead to epigenetic modulations and how this correlates with allergic diseases considering different genetic backgrounds of several ancestral populations.

Lower Functional and Proportional Characteristics of Cord Blood Treg of Male Newborns Compared with Female Newborns

Understanding the early events involved in the induction of immune tolerance to harmless environmental antigens and microbiota compounds could reveal potential targets for allergic disease therapy or prevention. Regulatory T cells (Treg), particularly induced Treg (iTreg), are crucial for the induction and maintenance of tolerance against environmental antigens including allergens. A decrease in the number and/or function of Treg or iTreg could represent an early predictor of allergy development. We analyzed proportional and functional properties of Treg in the cord blood of children of allergic mothers (neonates at high risk of allergy development) and healthy mothers (neonates with relatively low risk of allergy development). We observed a higher number of induced Treg in the cord blood of females compared to males, suggesting an impaired capacity of male immunity to set up tolerance to allergens, which could contribute to the higher incidence of allergy observed in male infants. The decreased proportion of iTreg in cord blood compared with maternal peripheral blood documents the general immaturity of the neonatal immune system. We observed a positive correlation in the demethylation of the Treg-specific demethylated region (TSDR) and the proportion of Treg in cord blood. Our data suggest that immaturity of the neonatal immune system is more severe in males, predisposing them to increased risk of allergy development.

Patients' Perspectives and Needs on Novel Food Allergy Treatments in the United States

PURPOSE

Food allergy management places a daily psychosocial burden on patients and their caregivers. New food allergy treatments may positively impact their lives, but also introduce new stressors. The purpose of this paper is to provide an overview of the current state of the literature regarding patients' and caregivers' food allergy experiences and needs within the United States as well as a set of recommendations regarding how best to proceed with patient-centered development and evaluation of new food allergy treatments.

RECENT FINDINGS

The first pharmaceutical-grade product for peanut oral immunotherapy was approved in the United States for children aged 4-17 years following a successful international Phase 3 trial. This new treatment is only the first of several food allergy treatments currently under development. Patients will soon be presented with multiple options for food allergy treatment and will need to make decisions about what treatment is best for them.

SUMMARY

Allergy researchers and providers are encouraged to consider patients' perspectives and needs when developing and evaluating new food allergy treatments. Recommendations regarding next steps include the development of new patient-reported outcome tools, focus on psychosocial support, health disparities, and financial implications, and research harmonization and interdisciplinary collaboration.

Prevalence of Self-Reported Food Allergies and Their Association with Other Health Conditions among Adults in Saudi Arabia

Food allergies are a potentially life-threatening health issue, and few studies have determined their prevalence throughout Saudi Arabia. The main objective of our study was to estimate the prevalence and distribution of self-reported food allergies, and explore their association with other health conditions among adults in Saudi Arabia. This study was a nationwide cross-sectional survey conducted via phone interviews in June 2020. A proportional quota-sampling technique was used to obtain equal distributions of participants by age and gender across the 13 regions of Saudi Arabia. Self-reported food allergy, height, weight, health conditions, mental health status, and demographic variables were collected. Of the 6239 participants contacted, 4709 (75.48%) participants responded and completed the interview. Furthermore, 50.1% of the participants were female, with a mean age of 36.4 ± 13.5 years (18-90 years). The prevalence of food allergies was 19.7%. The most self-reported food allergies were egg, shellfish and shrimp, and peanuts, with a prevalence of 3.7%, 3.1%, and 3.0%, respectively. There was an association between the presence of food allergies and reported bariatric surgery, asthma, colon disease, and being at risk of depression. Bariatric surgery was significantly associated with lower likelihood of self-reported allergy (OR 1.69, 95% CI 1.22-2.34, p = 0.002). This study revealed, for the first time, a high prevalence of self-reported food allergies among adults in Saudi Arabia in a large nationwide sample, and food allergy association with bariatric surgery, asthma, colon disease, and being at risk of depression. This information is valuable for clinicians and policymakers, particularly in terms of food allergen labeling.

From Birth to Overweight and Atopic Disease: Multiple and Common Pathways of the Infant Gut Microbiome

BACKGROUND & AIMS

Few studies, even those with cohort designs, test the mediating effects of infant gut microbes and metabolites on the onset of disease. We undertook such a study.

METHODS

Using structural equation modeling path analysis, we tested directional relationships between first pregnancy, birth mode, prolonged labor and breastfeeding; infant gut microbiota, metabolites, and IgA; and childhood body mass index and atopy in 1667 infants.

RESULTS

After both cesarean birth and prolonged labor with a first pregnancy, a higher Enterobacteriaceae/Bacteroidaceae ratio at 3 months was the dominant path to overweight; higher Enterobacteriaceae/Bacteroidaceae ratios and Clostridioides difficile colonization at 12 months were the main pathway to atopic sensitization. Depletion of Bifidobacterium after prolonged labor was a secondary pathway to overweight. Influenced by C difficile colonization at 3 months, metabolites propionate and formate were secondary pathways to child outcomes, with a key finding that formate was at the intersection of several paths.

CONCLUSIONS

Pathways from cesarean section and first pregnancy to child overweight and atopy share many common mediators of the infant gut microbiome, notably C difficile colonization.

Food Allergy: Searching for the Modern Environmental Culprit

Food allergy is a modern disease. Its exponential increase in prevalence in the last 70 years cannot be explained by genetic factors alone. In this review we discuss the hypotheses that have been suggested previously, and the evidence that supports them, to explain this rise in prevalence as well as the medical treatments that have developed as a result of basic exploration within these paradigms. We argue that one major area of fruitful exploration that would help generate new ideas may be systematic analyses of the unknown factors of the modern environment that may contribute to the formation of food allergy. Through this lens, we review the current understanding of food allergy pathogenesis and propose novel research directions, with implications for the current strategies for managing food allergy.

Food allergy, airborne allergies, and allergic sensitisation among adolescents living in two disparate socioeconomic regions in Ecuador: A cross-sectional study

Background

Allergic diseases are under-investigated and overlooked health conditions in developing countries. We measured the prevalence of food allergy (FA), airborne allergic disease, and allergic sensitisation among adolescents living in 2 socio-demographically disparate regions in Ecuador. We investigated which risk factors are associated with these conditions.

Methods

A cross-sectional study involved 1338 students (mean age: 13 ± 0.9 years old) living in Cuenca (n = 876) and Santa Isabel (n = 462). History of allergic symptoms (noted by parents or doctor) to food, house dust mites (HDM), pollen, and pets were recorded. Sociodemographic characteristics, environmental exposures, and parental history of allergic disorders data were collected. Sensitisation to 19 food and 20 aeroallergens was measured by skin-prick testing (SPT). FA and airborne allergic diseases (to HDM, pollen, cat, or dog) were defined as a report of allergic symptoms noted by doctor, together with a positive SPT (wheal size ≥3 mm). Logistic regression models were used to identify environmental and parental factors associated with allergic conditions.

Results

FA was prevalent among 0.4% (95% CI 0.2%–0.9%), and food sensitisation among 19.1% of the adolescents. Shrimp was the most frequent food linked with FA and food sensitisation. Risk factors associated with FA could not be evaluated due to the low prevalence. Food sensitisation was higher among adolescents exposed to family smoking (OR 1.63, 95% CI 1.14–2.34, p = 0.008) and those with parental history of allergic disorders (OR 1.68, 95% CI 1.13–2.49, p = 0.01), but less common among adolescents owning dogs (OR 0.59, 95% CI 0.41–0.84, p = 0.003).

Airborne allergic diseases were prevalent amongst 12.0% of the adolescents (95% CI: 10.4–13.9, n = 1321), with HDM as the primary allergen (11.2%). Airborne allergic diseases were less common among adolescents with more siblings (OR 0.79, 95% CI 0.65–0.96, p = 0.02) and those who lived with farm animals in the first year of life (OR 0.47, 95% CI 0.23–0.95, p = 0.04), but, most common among adolescents with a smoking family (OR 1.67, 95% CI 1.04–2.70, p = 0.03) and with a parental history of allergic disorders (OR self-perceived: 2.62, 95% CI 1.46–4.71, p = 0.001; OR diagnosed by a doctor: 4.07, 95% CI 2.44–6.80, p < 0.001).

Conclusions

FA and airborne allergies are less prevalent in Ecuador than in developed regions; there is a great dissociation between the prevalence of allergic disease and allergic sensitisation. Shrimp and HDM were the most prevalent allergens. Risk factors identified in this study to be related to allergic diseases should be considered by physicians, health practitioners, and epidemiologists in Ecuador.

Anti-allergic effects of vitamin E in allergic diseases: An updated review

Allergic diseases are caused by the immune system's response to innocent antigens called allergens. Recent decades have seen a significant increase in the prevalence of allergic diseases worldwide, which has imposed various socio-economic effects in different countries. Various factors, including genetic factors, industrialization, improved hygiene, and climate change contribute to the development of allergic diseases in many parts of the world. Moreover, changes in lifestyle and diet habits play pivotal roles in the prevalence of allergic diseases. Dietary changes caused by decreased intake of antioxidants such as vitamin E lead to the generation of oxidative stress, which is central to the development of allergic diseases. It has been reported in many articles that oxidative stress diverts immune responses to the cells associated with the pathogenesis of allergic diseases. The aim of this short review was to summarize current knowledge about the anti-allergic properties of vitamin E.

The Challenge by Multiple Environmental and Biological Factors Induce Inflammation in Aging: Their Role in the Promotion of Chronic Disease

The aging process is driven by multiple mechanisms that lead to changes in energy production, oxidative stress, homeostatic dysregulation and eventually to loss of functionality and increased disease susceptibility. Most aged individuals develop chronic low-grade inflammation, which is an important risk factor for morbidity, physical and cognitive impairment, frailty, and death. At any age, chronic inflammatory diseases are major causes of morbimortality, affecting up to 5-8% of the population of industrialized countries. Several environmental factors can play an important role for modifying the inflammatory state. Genetics accounts for only a small fraction of chronic-inflammatory diseases, whereas environmental factors appear to participate, either with a causative or a promotional role in 50% to 75% of patients. Several of those changes depend on epigenetic changes that will further modify the individual response to additional stimuli. The interaction between inflammation and the environment offers important insights on aging and health. These conditions, often depending on the individual's sex, appear to lead to decreased longevity and physical and cognitive decline. In addition to biological factors, the environment is also involved in the generation of psychological and social context leading to stress. Poor psychological environments and other sources of stress also result in increased inflammation. However, the mechanisms underlying the role of environmental and psychosocial factors and nutrition on the regulation of inflammation, and how the response elicited for those factors interact among them, are poorly understood. Whereas certain deleterious environmental factors result in the generation of oxidative stress driven by an increased production of reactive oxygen and nitrogen species, endoplasmic reticulum stress, and inflammation, other factors, including nutrition (polyunsaturated fatty acids) and behavioral factors (exercise) confer protection against inflammation, oxidative and endoplasmic reticulum stress, and thus ameliorate their deleterious effect. Here, we discuss processes and mechanisms of inflammation associated with environmental factors and behavior, their links to sex and gender, and their overall impact on aging.

Preventing food allergy in infancy and childhood: Systematic review of randomised controlled trials

BACKGROUND

This systematic review of ways to prevent immediate-onset/IgE-mediated food allergy will inform guidelines by the European Academy of Allergy and Immunology (EAACI).

METHODS

The GRADE approach was used. Eleven databases were searched from 1946 to October 2019 for randomized controlled trials (and large prospective cohort studies in the case of breastfeeding). The studies included heterogeneous interventions, populations, and outcomes and so were summarized narratively.

RESULTS

Forty-six studies examined interventions to reduce the risk of food allergy in infancy (up to 1 year) or early childhood. The following interventions for pregnant or breastfeeding women and/or infants may have little to no effect on preventing food allergy, but the evidence is very uncertain: dietary avoidance of food allergens, vitamin supplements, fish oil, probiotics, prebiotics, synbiotics, and emollients. Breastfeeding, hydrolyzed formulas, and avoiding cow's milk formula may not reduce the risk of cow's milk protein allergy; however, temporary supplementation with cow's milk formula in the first week of life may increase the risk of cow's milk allergy. Introducing well-cooked egg, but not pasteurized raw egg, from 4 to 6 months probably reduces the risk of hen's egg allergy. Introducing regular peanut consumption into the diet of an infant at increased risk beginning from 4 to 11 months probably results in a large reduction in peanut allergy in countries with a high prevalence. These conclusions about introducing peanut are based on moderate certainty evidence, from single trials in high-income countries.

CONCLUSIONS

Sixty percent of the included studies were published in the last 10 years, but much still remains to be understood about preventing food allergy. In particular, there is a need to validate the potential benefits of early introduction of food allergens in a wider range of populations.

The Global Rise and the Complexity of Sesame Allergy: Prime Time to Regulate Sesame in the United States of America?

Sesame allergy is a life-threatening disease that has been growing globally with poorly understood mechanisms. To protect sensitive consumers, sesame is regulated in many countries. There were four research goals for this work on sesame allergy: (i) to map the timeline, and the extent of its global rise; (ii) to dissect the complexity of the disease, and its mechanisms; (iii) to analyze the global regulation of sesame; and (iv) to map the directions for future research and regulation. We performed a literature search on PubMed and Google Scholar, using combinations of key words and analyzed the output. Regulatory information was obtained from the government agencies. Information relevant to the above goals was used to make interpretations. We found that: (i) the reports appeared first in 1950s, and then rapidly rose globally from 1990s; (ii) sesame contains protein and lipid allergens, a unique feature not found in other allergenic foods; (iii) it is linked to five types of diseases with understudied mechanisms; and (iv) it is a regulated allergen in 32 advanced countries excluding the USA. We also provide directions for filling gaps in the research and identify implications of possible regulation of sesame in the USA.

Oral immunotherapy for peanut allergy: The pro argument

Food allergy (FA) is a growing public health problem with personal, social, nutritional, and economic consequences. In the United States, it is estimated that 8% of children and 10.8% of adults have food allergies. Allergies to peanuts are particularly worrisome as unlike allergies to other allergenic foods, such as milk and egg, which are commonly outgrown by 5 or 10 years of age, 80% of peanut allergies persist into adulthood. The first drug for peanut allergy, Palforzia, was approved by the US Food and Drug Administration (FDA) in January 2020. For other food allergies, the current standard of care for the management of FA is suboptimal and is limited to dietary elimination of the offending allergen, vigilance against accidental ingestion, and treatment of allergic reactions with antihistamines and epinephrine. However, dietary avoidance can be challenging, and it is estimated that approximately 40% of patients with food allergies report at least one food allergy-related emergency department in their lifetime. Reactions, even from minimal exposures, can be life-threatening.

Oral immunotherapy (OIT) has been the best researched therapeutic approach for treating FA over the last decade, with clinical trials investigating its efficacy, safety, and ability to improve participants' quality of life (QoL). A number of studies and meta-analyses have shown that OIT treatment is effective in raising the threshold of reactivity to peanuts and other foods in addition to producing a measurable serum immune response to such therapy. Although OIT-related adverse events (AEs) are common during treatment, serious reactions are rare. In fact, while the majority of patients experience AEs related to dosing, most continue daily dosing in hopes of achieving protection against the culprit food. Moreover, the majority of participants report improvement of QoL after OIT and are positive about undergoing OIT. These results show patients’ commitment to OIT and their optimism regarding the benefits of treatment. As a first step in therapeutic options to protect from reactions to unintentional ingestion of allergenic foods, and importantly, to address the many psychosocial aspects of living with FA, OIT shows promise. Future research will focus on identifying optimal OIT regimens that maintain protection after therapy and allow for regular food consumption without allergic symptoms. Education and informed shared decision making between patients and providers are essential in optimizing current therapy regimens.

Histamine Sensitivity: An Uncommon Recognized Cause of Living Laryngopharyngeal Reflux Symptoms and Signs-A Case Report

A 45-year-old female who had undergone Nissen fundoplication for long-standing laryngopharyngeal reflux (LPR) developed episodes of coughing and throat clearing. Strobovideolaryngoscopy demonstrated evidence of LPR with a reflux finding score of 11. A cough workup including a chest X-ray and pulmonology consultation was negative. Consultation with a nutritionist revealed Histamine intolerance. Histamine-free diet resulted in marked improvement in patient's symptoms and examination.

Gestational Dysfunction-Driven Diets and Probiotic Supplementation Correlate with the Profile of Allergen-Specific Antibodies in the Serum of Allergy Sufferers

BACKGROUND

Maternal diet has significant effects on development of childhood atopic disease and hypersensitivity development. However, the gestational dysfunctions demanding special diets are becoming a widespread phenomenon, their immunological implications can be manifested in the profile of antibodies in the offspring's serum.

METHODS

153 allergic and 150 healthy individuals were diagnosed for allergy using specific antibody and cytokine immunoassay tests. The medical history of subjects along with mothers' course of pregnancy was completed by allergologist's anamnesis. A self-organizing neural network and multivariate analyses to complex data and pick basic interactions were used.

RESULTS

Two significant explanatory modules were determined. The first was formed by gestational diabetic and cholestatic diet, infant formula feeding type, probiotic supplementation and its BMI index, moderate IgE, increased IgG levels of antibodies and single or poly-food allergy type (7 clusters). The second was formed by gestational vegan/vegetarian and elimination diet, maternal probiotic supplementation, sex, high IgE total antibodies and food and mixed poly-allergy to aero- and food-origin allergens (19 clusters).

CONCLUSIONS

Significant associations were observed between special gestational diet intake underlying foetal programming and the mechanisms of childhood allergy. The novelty is the positive association between diabetic and cholestatic diet intake and IgE/IgG-mediated food hypersensitivity.

Comorbidity patterns and socioeconomic inequalities in children under 15 with medical complexity: a population-based study

Background

Children with medical complexity (CMC) denotes the profile of a child with diverse acute and chronic conditions, making intensive use of the healthcare services and with special health and social needs. Previous studies show that CMC are also affected by the socioeconomic position (SEP) of their family. The aim of this study is to describe the pathologic patterns of CMC and their socioeconomic inequalities in order to better manage their needs, plan healthcare services accordingly, and improve the care models in place.

Methods

Cross-sectional study with latent class analysis (LCA) of the CMC population under the age of 15 in Catalonia in 2016, using administrative data. LCA was used to define multimorbidity classes based on the presence/absence of 57 conditions. All individuals were assigned to a best-fit class. Each comorbidity class was described and its association with SEP tested. The Adjusted Morbidity Groups classification system (Catalan acronym GMA) was used to identify the CMC. The main outcome measures were SEP, GMA score, sex, and age distribution, in both populations (CMC and non-CMC) and in each of the classes identified.

Results

71% of the CMC population had at least one parent with no employment or an annual income of less than €18,000. Four comorbidity classes were identified in the CMC: oncology (36.0%), neurodevelopment (13.7%), congenital and perinatal (19.8%), and respiratory (30.5%). SEP associations were: oncology OR 1.9 in boys and 2.0 in girls; neurodevelopment OR 2.3 in boys and 1.8 in girls; congenital and perinatal OR 1.7 in boys and 2.1 in girls; and respiratory OR 2.0 in boys and 2.0 in girls.

Conclusions

Our findings show the existence of four different patterns of comorbidities in CMC and a significantly high proportion of lower SEP children in all classes. These results could benefit CMC management by creating more efficient multidisciplinary medical teams according to each comorbidity class and a holistic perspective taking into account its socioeconomic vulnerability.

Egg Allergy: Diagnosis and Immunotherapy

Hypersensitivity or an allergy to chicken egg proteins is a predominant symptomatic condition affecting 1 in 20 children in Australia; however, an effective form of therapy has not yet been found. This occurs as the immune system of the allergic individual overreacts when in contact with egg allergens (egg proteins), triggering a complex immune response. The subsequent instantaneous inflammatory immune response is characterized by the excessive production of immunoglobulin E (IgE) antibody against the allergen, T-cell mediators and inflammation. Current allergen-specific approaches to egg allergy diagnosis and treatment lack consistency and therefore pose safety concerns among anaphylactic patients. Immunotherapy has thus far been found to be the most efficient way to treat and relieve symptoms, this includes oral immunotherapy (OIT) and sublingual immunotherapy (SLIT). A major limitation in immunotherapy, however, is the difficulty in preparing effective and safe extracts from natural allergen sources. Advances in molecular techniques allow for the production of safe and standardized recombinant and hypoallergenic egg variants by targeting the IgE-binding epitopes responsible for clinical allergic symptoms. Site-directed mutagenesis can be performed to create such safe hypoallergens for their potential use in future methods of immunotherapy, providing a feasible standardized therapeutic approach to target egg allergies safely.

Influence of different extraction conditions on the detection of glycinin and β-conglycinin in model processed foods by ELISA

The presence of undeclared soy proteins in food can cause severe reactions in soy allergic individuals. The extraction of target proteins from processed foods is a crucial step in allergen detection by immunoassays, as only successfully extracted target proteins can be detected by the specific antibodies. The effectiveness was studied of different conditions (type of buffer, temperature and time of incubation) on the extraction of total protein, and concentration of glycinin and β-conglycinin from different food matrices. The yields were determined using a soy protein isolate and three processed foods (sausage, bread and pâté) incurred with soy proteins. The yields were affected by the processing of analysed products and the composition and pH of the extraction buffers. Neutral and alkaline buffers (pH from 7.4 to 10.6) exhibited good protein extraction capacity and detectability of the specific target proteins. Denaturing additives and highly alkaline buffer (pH 12) extracted more crude protein but they were incompatible with the ELISA assay. Overall, the best results were obtained using phosphate (pH 7.4) and Tris/HCl (pH 8.5) buffers in the presence of 0.5 M NaCl. Crude protein yield of food extracts did not correlate with that of glycinin and β-conglycinin, whereas a good relationship was found between the yields of the two proteins.

Food allergens in skincare products marketed for children

BACKGROUND

The application of preparations containing food allergens can cause percutaneous sensitization and provocation. The prevalence of food allergens in children's cosmetics is unknown.

OBJECTIVES

To analyse the prevalence of food allergens in skincare products marketed for children and their association with marketing claims and product price.

METHODS

We reviewed 276 skincare product ingredient labels for the presence of milk, eggs, wheat, soy, oats, tree nuts, peanuts, and sesame.

RESULTS

More than one-third (108; 39.1%) of the products listed at least one allergen. A total of 156 allergens were recorded, of which 65 (41.7%) were almonds, 35 (22.4%) wheat, 24 (15.4%) soy, 16 (10.3%) oats, 13 (8.3%) sesame, 2 (1.3%) milk, and 1 (0.6%) peanuts. Products that claimed to be "natural" or "ecological" were more likely to contain food allergens than those not labelled so (P < .001). The prices were higher for products containing food allergens compared with allergen-free products (P = .028).

CONCLUSIONS

Food allergens are prevalent in children's cosmetics, especially those that claim to be natural or ecological. The most incorporated food allergens are almonds, wheat, and soy. Products containing food allergens cost more than allergen-free ones.

Outcomes for clinical trials of food allergy treatments

OBJECTIVE

Food allergy is a common condition that can have a significant impact on the quality of life of affected individuals and their caregivers. Recent years have witnessed an increased effort to identify new treatments for food allergy. Here, we review the need to identify core outcomes for measurement in clinical trials of food allergy treatments.

DATA SOURCES

We reviewed the literature regarding core outcome set development, the important role that these play in prioritizing patient-relevant outcomes, and the potential for core outcomes to accelerate the path to product marketing by allowing prompt and reliable evidence synthesis after trial publication.

STUDY SELECTIONS

We reviewed recent clinical trials of food allergy treatments to understand which outcomes have previously been measured, and also reviewed available core outcome set initiatives for other allergic conditions to understand which other outcomes might be explored in future trials.

RESULTS

Clinical trials of food allergy treatments have largely focused on outcomes that are relevant to investigators and commercial investors, especially the threshold of reactivity and immunologic changes. Future trials should consider addressing patient-important outcomes and should report the experiences of both adult and child participants and their caregivers.

CONCLUSION

There is a pressing need for core outcome set development for food allergy treatment trials.

Pitfalls in the Diagnosis of Coeliac Disease and Gluten-Related Disorders

The spectrum of gluten-related disorders (GRD) has emerged as a relevant phenomenon possibly impacting on health care procedures and costs worldwide. Current classification of GRD is mainly based on their pathophysiology, and the following categories can be distinguished: immune-mediated disorders that include coeliac disease (CD), dermatitis herpetiformis (DH), and gluten ataxia (GA); allergic reactions such as wheat allergy (WA); and non-coeliac gluten sensitivity (NCGS), a condition characterized by both gastrointestinal and extra-intestinal symptoms subjectively believed to be induced by the ingestion of gluten/wheat that has recently gained popularity. Although CD, DH, and WA are well-defined clinical entities, whose diagnosis is based on specific diagnostic criteria, a diagnosis of NCGS may on the contrary be considered only after the exclusion of other organic disorders. Neither allergic nor autoimmune mechanisms have been found to be involved in NCGS. Mistakes in the diagnosis of GRD are still a relevant clinical problem that may result in overtreatment of patients being unnecessary started on a gluten-free diet and waste of health-care resources. On the basis of our clinical experience and literature, we aim to identify the main pitfalls in the diagnosis of CD and its complications, DH, and WA. We provide a practical methodological approach to guide clinicians on how to recognize and avoid them.

Quantitative allergenicity risk assessment of food products containing yellow mealworm (Tenebrio molitor)

Insect-based foods are starting to enter the EU market, raising concerns about their safety. Allergic consumers might be exposed to even a greater risk, since insects have proven to trigger allergic symptoms, particularly in patients sensitised to crustaceans. Current legislation does not enforce producers to include insects in the list of allergenic ingredients. Food allergenicity risk assessment (FARA) is still at its infancy, and the debate on the need to define allergen thresholds is open. In this paper, we aimed at applying the concepts of stochastic quantitative FARA to describe present and future scenarios of exposure to foods containing Tenebrio molitor, the yellow mealworm. According to our risk characterisation, mealworm-based food products represent a major risk for individuals allergic to crustaceans to develop symptoms after the consumption of a dose lower than a serving size. Moreover, other allergic consumers might be at risk. A correct labelling of insect containing foods would help safeguarding the health of EU allergic consumers. Quantitatively assessing the risk of allergenicity provides a clear description of the problem, facilitating the decisional process of the risk manager, supporting the implementation of effective allergen management procedures and limiting the phenomenon of uninformative precautionary labelling.

The histone deacetylase inhibitor valproic acid attenuates phospholipase Cγ2 and IgE-mediated mast cell activation

Mast cell activation through the high-affinity IgE receptor (FcεRI) plays a central role in allergic reactions. FcεRI-mediated activation triggers multiple signaling pathways leading to degranulation and synthesis of different inflammatory mediators. IgE-mediated mast cell activation can be modulated by different molecules, including several drugs. Herein, we investigated the immunomodulatory activity of the histone deacetylase inhibitor valproic acid (VPA) on IgE-mediated mast cell activation. To this end, bone marrow-derived mast cells (BMMC) were sensitized with IgE and treated with VPA followed by FcεRI cross-linking. The results indicated that VPA reduced mast cell IgE-dependent degranulation and cytokine release. VPA also induced a significant reduction in the cell surface expression of FcεRI and CD117, but not other mast cell surface molecules. Interestingly, VPA treatment inhibited the phosphorylation of PLCγ2, a key signaling molecule involved in IgE-mediated degranulation and cytokine secretion. However, VPA did not affect the phosphorylation of other key components of the FcεRI signaling pathway, such as Syk, Akt, ERK1/2, or p38. Altogether, our data demonstrate that VPA affects PLCγ2 phosphorylation, which in turn decreases IgE-mediated mast cell activation. These results suggest that VPA might be a key modulator of allergic reactions and might be a promising therapeutic candidate.