Oral immunotherapy in food allergies: A practical update for pediatricians

Mobile App/Web Platform for Monitoring Food Oral Immunotherapy in Children: Longitudinal Clinical Validation Study

BACKGROUND

Milk and egg allergies significantly impact the quality of life, particularly in children. In this regard, food oral immunotherapy (OIT) has emerged as an effective treatment option; however, the occurrence of frequent adverse reactions poses a challenge, necessitating close monitoring during treatment.

OBJECTIVE

This study aims to evaluate the ability of a new mobile/web app called OITcontrol to monitor milk and egg OIT.

METHODS

Patients undergoing milk or egg OIT were recruited and divided into 2 groups: the active group used the OITcontrol app in conjunction with standard written monitoring methods, whereas the control group relied solely on written diaries. Investigators documented hospital doses, hospital reactions, and administered treatments on the website. Patients recorded their daily allergen home-dose intake, home reactions, and administered treatments using the app. The following variables were compared between both groups: number and severity of hospital and reported home reactions, patient's adhesion to the OITcontrol app or written diary or both in terms of daily home-dose intake and home reactions recording, and treatment and dose adjustment compliance at home in case of reaction.

RESULTS

Sixteen patients were assigned to be monitored using the OITcontrol app along with additional written methods (active group), while 14 patients relied solely on a written paper diary (control group). A similar distribution was observed in terms of sex, age, basal characteristics, allergen treated in OIT, premedication, and sensitization profile. Active patients reported a comparable number of hospital and home reactions compared with the control group. In terms of recording system usage, 13/16 (81%) active patients used the OITcontrol app, while 10/14 (71%) control patients relied on the written diary. Among active patients, 6/16 (38%) used both methods, and 1 active patient used only written methods. However, control patients recorded home reactions more frequently than active patients (P=.009). Among active patients, the app was the preferred method for recording reactions (59/86, 69%), compared with the written diary (15/86, 17%) or both methods (12/86, 14%; P<.001). Treatment compliance in home-recorded reactions was similar between both groups (P=.15). However, treatment indications after an adverse reaction were more frequently followed (P=.04) in reactions recorded solely in the app (36/59, 61%) than in the written diary (29/71, 41%) or both systems (4/12, 33%). Moreover, compliance with dose adjustments after a moderate-severe reaction in home-recorded reactions was higher in the active group than in the control group (P<.001). Home reactions recorded only in the app (16/19, 84%) were more likely to follow dose adjustments (P<.001) than those recorded in the written diary (3/20, 15%) or using both methods (2/3, 67%).

CONCLUSIONS

The OITcontrol app appears to be a valuable tool for monitoring OIT treatment in children with food allergies. It proves to be a suitable method for recording daily home dose intakes and reactions, and it seems to enhance adherence to treatment indications following an adverse reaction as well as compliance with dose adjustments in home reactions. However, additional studies are necessary to comprehensively grasp the benefits and limitations of using the OITcontrol app in the management of OIT.

Practical issues of oral immunotherapy for egg or milk allergy

Oral immunotherapy (OIT) has been recommended to reduce parental burden related to strict allergen avoidance and induce desensitization and immune tolerance for patients with long-lasting allergies to hen's eggs (HE) or cow's milk (CM). OIT should be monitored by pediatric allergists specializing in OIT and oral food challenge tests to manage allergic reactions. Although a previous history of anaphylaxis or multiple food allergies is not a contraindication to OIT, it is contraindicated if the patient has uncontrolled asthma, a malignancy, active systemic autoimmune disorders, or diseases requiring treatment with beta-blockers. A variety of OIT protocols have been de veloped to ensure better outcomes and safe up-dosing, including adjunctive therapies with biologics. This review provides insight into the practical issues of various immunotherapy options for children with HE or CM allergies.

An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy

A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.

The origins and longevity of IgE responses as indicated by serological and cellular studies in mice and humans

The existence of long-lived IgE antibody-secreting cells (ASC) is contentious, with the maintenance of sensitization by the continuous differentiation of short-lived IgE+ ASC a possibility. Here, we review the epidemiological profile of IgE production, and give an overview of recent discoveries made on the mechanisms regulating IgE production from mouse models. Together, these data suggest that for most individuals, in most IgE-associated diseases, IgE+ ASC are largely short-lived cells. A subpopulation of IgE+ ASC in humans is likely to survive for tens of months, although due to autonomous IgE B cell receptor (BCR) signaling and antigen-driven IgE+ ASC apoptosis, in general IgE+ ASC probably do not persist for the decades that other ASC are inferred to do. We also report on recently identified memory B cell transcriptional subtypes that are the likely source of IgE in ongoing responses, highlighting the probable importance of IL-4Rα in their regulation. We suggest the field should look at dupilumab and other drugs that prohibit IgE+ ASC production as being effective treatments for IgE-mediated aspects of disease in most individuals.

Food Allergens: When Friends Become Foes-Caveats and Opportunities for Oral Immunotherapy Based on Deactivation Methods

Food allergies represent a serious health concern and, since the 1990s, they have risen gradually in high-income countries. Unfortunately, the problem is complex because genetic, epigenetic, and environmental factors may be collectively involved. Prevention and diagnoses have not yet evolved into efficacious therapies. Identification and control of allergens present in edible substances hold promise for multi-purpose biomedical approaches, including oral immunotherapy. This review highlights recent studies and methods to modify the otherwise innocuous native proteins in most subjects, and how oral treatments targeting immune responses could help cancel out the potential risks in hypersensitive individuals, especially children. We have focused on some physical methods that can easily be conducted, along with chemo-enzymatic modifications of allergens by means of peptides and phytochemicals in particular. The latter, accessible from naturally-occurring substances, provide an added value to hypoallergenic matrices employing vegetal wastes, a point where food chemistry meets sustainable goals as well.

Intestinal proline is a potential anti-allergy factor for allergy diagnosis and therapy

Allergy has become a public health problem worldwide, but effective diagnostic and therapeutic approaches are limited currently. Amino acids are essential macronutrients that potentially participated in the allergy process. This work aimed to investigate whether amino acids can be applied as a mediator for allergy diagnosis and therapy. Two cohort studies were performed to investigate the correlation between fecal amino acids and allergy responses, and a spleen cell model was used to validate the role of amino acids in regulating allergy. In a cohort study with 193 volunteers, fecal proline was found to be negatively correlated with serum IgE, and detailed data analysis revealed that people with high-IgE-mediated allergy had decreased odds of high intestinal proline. In another cohort study with distinct allergic and non-allergic individuals, proline concentration was significantly lower in the allergic group. Daily diet and metagenomics analysis showed that the proline intake and microbiota amino acid metabolism were not significantly different, implying that the body’s proline metabolism might be different between allergic and non-allergic individuals. Furthermore, the spleen cell model demonstrated that proline specifically targeted Th2 and Treg activity. Overall, this work revealed a tight correlation between gut proline and serum IgE, indicating proline as a promising biomarker and a potential therapeutic method for allergic diseases.

Oral immunotherapy for Immunoglobulin E‐mediated cow's milk allergy in children: A systematic review and meta analysis

Backgound

Cow's milk allergy (CMA) is the most common allergy in infants that decreases the quality of life of patients and their families. Standard treatment for CMA is the strict avoidance of milk; new treatment strategies such as oral immunotherapy (OIT) have been sought for patients with CMA. We aimed to assess the clinical efficacy and safety of OIT in the treatment of children with immunoglobulin E‐mediated CMA (IMCMA).

Methods

We searched all randomized controlled trials in which OIT is used to treat children with IMCMA from five international electronic databases. We estimated a pooled risk ratio (RR) for each outcome using a Mantel–Haenzel fixed‐effects model if statistical heterogeneity was low.

Results

Eleven studies were chosen for meta‐analysis, including a total of 469 children (242 OITs, 227 controls). One hundred and seventy‐six patients (72.7%) in the OIT were desensitized compared with 49 patients (21.6%) in the control group (RR: 7.35, 95% confidence interval (CI): 2.82–19.13, p < .0001). The desensitization effect of OIT was particularly significant in children over 3 years old (RR: 18.05, 95% CI: 6.48–50.26, p < .00001). Although adverse effects were common, they usually involved mild reactions, but epinephrine use was more common in the OIT group (RR: 7.69, 95% CI: 2.16–27.33, p < .002).

Conclusion

OIT can lead to desensitization in the majority of individuals with IMCMA, especially in patients over 3 years old. A major problem of OIT is the frequency of adverse events, although most are mild. OIT may be an alternative treatment in the future.

Vegan Egg: A Future-Proof Food Ingredient?

Vegan eggs are designed with the aim to provide a healthier and more sustainable alternative to regular eggs. The major drivers of this industry are the increasing prevalence of egg allergies, awareness towards environmental sustainability, and the shift to vegan diets. This study intends to discuss, for the first time, the vegan egg market, including their formulation, nutritional aspects, and some applications (i.e., mayonnaise and bakery products). Recreating the complete functionality of eggs using plant-based ingredients is very challenging due to the complexity of eggs. Current, but scarce, research in this field is focused on making mixtures of plant-based ingredients to fit specific food formulations. Nutritionally, providing vegan eggs with similar or higher nutritional value to that of eggs can be of relevance to attract health-conscious consumers. Claims such as clean labels, natural, vegan, animal-free, gluten-free, and/or cholesterol-free can further boost the position of vegan eggs in the market in the coming year. At present, this market is still in its infancy stages, and clear regulations of labeling, safety, and risk assessment are deemed mandatory to organize the sector, and protect consumers.

Food allergen ladders: A need for standardization

INTRODUCTION

The process of gradually reintroducing food allergens into an individual's diet is referred to as food allergen "ladders". There remain many questions regarding the foods chosen, structure and composition of the ladder, and medical and safety considerations. The COVID-19 pandemic has propelled us into an era where medicine is increasingly practiced via online platforms, highlighting the need for standardized food allergen ladder approaches for successful and safe introduction of food allergens.

METHODS

We performed a search of currently published food allergen ladders and obtained published information and clinical expertise to summarize current knowledge and suggest future standardized approaches for using food allergen ladders.

RESULTS

There are currently a limited number of published milk, egg, wheat, and soy ladders. We suggest the following points should be considered when developing food ladders: (1) Food allergen: dose, time, and temperature of heating of the food allergen, simplicity of the ladder and recipes, the possible role of the wheat matrix, and testing for allergenic protein levels to standardize doses; (2) Nutritional factors: health and nutritional value of the foods in the ladder, taste, texture, and cultural appropriateness of foods should be considered; and (3) Medical aspects: consideration of which patients are safe to undergo ladders outside of the clinical setting, other safety aspects and risk factors for severe reactions, number of days suggested per steps, and availability and provision of rescue medication. Written instructions and recipes should be provided to families who wish to use food allergen ladders.

DISCUSSION

Food allergen ladders used for gradual reintroduction of food allergens into a food allergic individual's diet are increasingly being used internationally. Standardization regarding the foods included in the ladder and medical considerations are required to practice patient-centered care, best assist patients and families, and ensure safety.

Advances, Practical Implementation, and Unmet Needs Regarding Oral Immunotherapy for Food Allergy

Treatment of food allergy is a rapidly changing landscape, with arguably, the most significant advancement in recent years, the transition of oral immunotherapy (OIT) to clinical practice. As an innovation, OIT is a phase of rapidly increasing demand, particularly for some allergens such as peanut, egg, and milk, which have substantial evidence of efficacy. However, significant questions remain about how to best treat multiple food allergies and less common food allergies and how to optimize long-term safety and efficacy. This review summarizes the currently available resources for integrating food allergy OIT into clinical practice and focuses on the multiple remaining unmet needs such as providing an approach for OIT to food allergens for which there is no or limited evidence; practical issues related to food allergy treatment particularly when it is not going well; long-term outcomes and follow-up after OIT; and strategies to help meet the impending increase in demand.

Current Guidelines and Future Strategies for the Management of Cow's Milk Allergy

Abstract

Exclusive breast feeding is recommended in all guidelines as the first choice feeding. Cow milk allergy (CMA) can be diagnosed by a diagnostic elimination diet for 2 to 4 weeks with a hypo-allergenic formula, followed by a challenge test with intact cow milk protein. The most often used hypo-allergenic formula for the diagnostic elimination diet and the therapeutic diet is a CM based extensive hydrolysate. CM-based partial hydrolysates cannot be recommended in the management of CMA because of insufficient efficacy and possible reactions, but about half of the infants with CMA may tolerate a partial hydrolysate. The pros and cons of other dietary options are discussed in this paper. The use of an amino acid-based formula and/or rice based hydrolysate formula during the diagnostic elimination and therapeutic diet is debated. When available, there is sufficient evidence to consider rice hydrolysates as an adequate alternative to CM-based hydrolysates, since some infants will still react to the CM hydrolysate. The pros and cons of dietary options such as soy formula, buckwheat, almond, pea or other plant based dietary products are discussed. Although the majority of the plant-based beverages are nutritionally inadequate, some are nutritionally adapted for toddlers. However, accessibility and content vary by country and, thus far there is insufficient evidence on the efficacy and tolerance of these plant-based drinks (except for soy formula and rice hydrolysates) to provide an opinion on them.

Conclusion

A diagnostic elimination diet, followed by a challenge remains the diagnostic standard. The use of an awareness tool may result in a decrease of delayed diagnosis. Breastmilk remains the ideal source of nutrition and when not available a CM extensively hydrolyzed formula, rice hydrolysate or amino acid formula should be recommended. More evidence is needed regarding plant-based drinks.