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Kakumanu S, Szefler S, Pappalardo AA, Sales AE, Baptist AP, Stern J, Nyenhuis SM. Applying the dissemination and implementation sciences to allergy and immunology: A Work Group Report from the AAAAI Quality, Adherence, and Outcomes Committee. J Allergy Clin Immunol 2024:S0091-6749(24)00745-0. [PMID: 39162669 DOI: 10.1016/j.jaci.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 06/04/2024] [Accepted: 07/18/2024] [Indexed: 08/21/2024]
Abstract
Translating evidence-based practice (EBP) into real-world clinical settings often takes a considerable amount of time and resources. In allergy and immunology, the dissemination and implementation (D&I) sciences facilitate the study of how variations in knowledge, resources, patient populations, and staffing models lead to differences in the clinical care of asthma, allergic disease, and primary immunodeficiency. Despite the need for validated approaches to study how to best apply EBP in the real world, the D&I sciences are underutilized. To address this gap, an American Academy of Allergy, Asthma & Immunology (AAAAI) work group was convened to provide an overview for the role of the D&I sciences in clinical care and future research within the field. For the D&I sciences to be leveraged effectively, teams should be multidisciplinary and inclusive of community and clinical partners, and multimethods approaches to data collection and analyses should be used. Used appropriately, the D&I sciences provide important tools to promote EBP and health equity as well as optimization of clinical practice in allergy and immunology.
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Affiliation(s)
- Sujani Kakumanu
- University of Wisconsin School of Medicine and Public Health, Madison, Wis; William S. Middleton Veterans Memorial Hospital, Madison, Wis.
| | - Stanley Szefler
- Department of Pediatrics, Section of Pediatric Pulmonary and Sleep Medicine, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, Colo; Breathing Institute, Children's Hospital Colorado, Aurora, Colo
| | - Andrea A Pappalardo
- Departments of Medicine and Pediatrics, Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois, Chicago, Ill
| | - Anne E Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri, Columbia, Mo; Veterans Affairs, Ann Arbor Healthcare System, Ann Arbor, Mich
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Henry Ford Health, Detroit, Mich
| | - Jessica Stern
- Division of Allergy, Immunology, and Rheumatology, Division of Pediatric Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sharmilee M Nyenhuis
- Department of Pediatrics, Section of Allergy, Immunology, and Pulmonology, University of Chicago, Chicago, Ill
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Wang J, Bird JA, Cleary K, Doucette J, du Toit G, Groetch M, Gupta R, Hathaway KH, Klein S, Lack G, Leeds S, Leon T, Lewis MO, Lieberman J, Nowak-Wegrzyn A, Scribner P, Vickery BP, Warren CM. Awareness and Application of US Food Allergy Prevention Guidelines Among Pediatricians and Other Clinicians. J Pediatr 2024:114218. [PMID: 39074733 DOI: 10.1016/j.jpeds.2024.114218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/27/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE To characterize the awareness of, adherence to, and barriers to the 2017 National Institute of Allergy and Infectious Diseases (NIAID) peanut allergy prevention guidelines among the pediatrics health care workforce STUDY DESIGN: Pediatricians, family physicians, advanced practice providers (APPs), and dermatologists who provide care for infants were solicited for a population-based online survey, administered from June 6, 2022, through July 3, 2022. The survey collected information about NIAID guideline awareness, implementation, and barriers as well as concerns related to the guidelines. RESULTS A total of 250 pediatricians, 250 family physicians, 504 advanced practice practitioners (APPs), and 253 dermatologists met inclusion criteria. Self-reported guideline awareness was significantly higher for pediatricians (76%) compared with dermatologists (58%), family physicians (52%), and APPs (45%) (P < .05). Among participants who were aware of the guidelines, most reported using part or all of the guidelines in their clinical practices. Reported practice patterns for peanut introduction in 6-month-old infants were variable and did not always align with guidelines, particularly for infants with mild-to-moderate atopic dermatitis. CONCLUSIONS Although pediatricians have the highest self-reported level of NIAID guideline awareness, awareness was suboptimal irrespective of provider type. Education for all pediatric clinicians is urgently needed to promote evidence-based peanut allergy prevention practices.
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Affiliation(s)
- Julie Wang
- Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Andrew Bird
- Department of Pediatrics, UT Southwestern Medical Center; Food Allergy Center at Children's Health, Dallas, TX
| | - Kelly Cleary
- Food Allergy Research & Education (FARE), McLean, VA
| | - Julianne Doucette
- Primary Care Pediatric Nurse Practitioner DNP Program, RUSH University, Chicago, IL
| | | | - Marion Groetch
- Division of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ruchi Gupta
- Center for Food Allergy and Asthma Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Sara Klein
- Food Allergy Research & Education (FARE), McLean, VA
| | - Gideon Lack
- Paediatric Allergy, King's College London, London, UK
| | - Stephanie Leeds
- Division of Pediatric Allergy and Immunology, Yale School of Medicine, New Haven, CT
| | - Tiffany Leon
- Food Allergy Research & Education (FARE), McLean, VA
| | - Megan O Lewis
- Food Allergy Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jay Lieberman
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Anna Nowak-Wegrzyn
- Hassenfeld Children's Hospital, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA; Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Paul Scribner
- Food Allergy Research & Education (FARE), McLean, VA
| | - Brian P Vickery
- Emory University and Children's Healthcare of Atlanta, Atlanta, GA
| | - Christopher M Warren
- Center for Food Allergy and Asthma Research, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Rowland AF, Nguyen TH, Cunha PP, Ezhuthachan I, Orenstein E, Kandaswamy S, Lee T. Implementing a clinical decision support tool to increase early peanut introduction guidance. J Allergy Clin Immunol 2024:S0091-6749(24)00712-7. [PMID: 38996876 DOI: 10.1016/j.jaci.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/15/2024] [Accepted: 07/09/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND General pediatric providers are the front line for early peanut introduction discussions, but many providers believe that they are ill-equipped to handle such discussions, as the guidelines have changed quickly. OBJECTIVE We hypothesized that a clinical decision support (CDS) tool could improve discussions of peanut introduction. METHODS CDS tools were designed by stakeholders, improved through usability testing, and integrated into the current note templates. On the basis of queries of electronic health records, we did a preperformance versus postperformance evaluation of conversations regarding peanut introduction, barriers to peanut introduction, and percentage of 12-month well-child checkups (WCCs) that resulted in successful introduction of peanut. Providers completed surveys before and after intervention to assess their awareness of early peanut introduction and comfort using the CDS tools. RESULTS Providers' awareness of early peanut introduction guidelines increased from 17.8% to 66.7% after the CDS tool was implemented; 79.1% of the providers were comfortable using the tool. The CDS tool improved peanut introduction conversations at the 4-month WCC from 2.4% to 81.2%, at the 6-month WCC from 3.0% to 84.2%, and at the 12-month WCC from 2.7% to 82.9%. In all, 56.6% of families had a plan to introduce peanut at the 4-month WCC. Of those who did not have a plan, the most common barrier was the family's unawareness of the benefits of early peanut introduction. At the 12-month WCC, 62.8% of families had introduced peanut without concerns. CONCLUSION A point-of-care CDS tool encouraged more discussions of early peanut introduction between general pediatric providers and all patients. CDS tools should be considered in quality improvement projects as an implementation method for the most up-to-date guidelines.
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Affiliation(s)
| | - Thinh H Nguyen
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Priscila P Cunha
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Idil Ezhuthachan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga; Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Tricia Lee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
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Soriano VX, Allen KJ, Dharmage SC, Shifti DM, Perrett KP, Wijesuriya R, Koplin JJ, Peters RL. Prevalence and Determinants of Food Allergy in the Era of Early Allergen Introduction: the EarlyNuts Population-Based Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00689-5. [PMID: 38992429 DOI: 10.1016/j.jaip.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Infant feeding guidelines in Australia changed in 2016 to recommend introducing common allergy-causing foods by age 1 year to prevent food allergy. Although most Australian infants now eat peanut and egg by age 6 months, some still develop food allergy despite the early introduction of allergens. OBJECTIVES To describe the prevalence of food allergy in a cohort recruited after introducing the nationwide allergy prevention recommendations; identify characteristics of infants who developed allergy despite early introduction of allergens; and estimate the causal effect of modifiable exposures on food allergy prevalence and whether this differed between infants who were introduced to allergens before or after age 6 months. METHODS We recruited a population-based sample of 12-month-old infants in Melbourne, Australia. Infants had skin prick tests to four foods and parents completed questionnaires. Infants with evidence of sensitization were offered oral food challenges. Prevalence estimates were adjusted using inverse probability weighting. RESULTS In a cohort of infants (n = 1,420) in which nearly all infants had been introduced to common allergens such as egg, milk, and peanut by age 1 year, the prevalence of food allergy remained high at 11.3% (95% CI, 9.6-13.4). Infants who developed food allergy despite introduction of the allergen by age 6 months were more likely to have Asian-born parents. Early-onset moderate or severe eczema was associated with an increased odds of food allergy irrespective of whether allergens were introduced before or after age 6 months. Among infants who were introduced to peanut at age 6 months or earlier, antibiotic use by age 6 months was associated with an increased odds of peanut allergy (adjusted odds ratio = 6.03; 95% CI, 1.15-31.60). CONCLUSIONS In a cohort in which early allergen introduction was common, the prevalence of food allergy remained high. Infants who developed food allergy despite introduction of the respective allergen by age 6 months were more likely to have had Asian parents and early-onset eczema. New interventions are needed for infants with a phenotype of food allergy that is not amenable to early allergen introduction.
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Affiliation(s)
- Victoria X Soriano
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Katrina J Allen
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Shyamali C Dharmage
- Allergy and Lung Health Unit, School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Desalegn Markos Shifti
- Child Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Kirsten P Perrett
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Rushani Wijesuriya
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Child Health Research Centre, University of Queensland, South Brisbane, Queensland, Australia
| | - Rachel L Peters
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.
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Chu DK, Koplin JJ, Ahmed T, Islam N, Chang CL, Lowe AJ. How to Prevent Atopic Dermatitis (Eczema) in 2024: Theory and Evidence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1695-1704. [PMID: 38703820 DOI: 10.1016/j.jaip.2024.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/06/2024]
Abstract
Atopic dermatitis (AD) or eczema is a chronic inflammatory skin disease characterized by dry, itchy, and inflamed skin. We review emerging concepts and clinical evidence addressing the pathogenesis and prevention of AD. We examine several interventions ranging from skin barrier enhancement strategies to probiotics, prebiotics, and synbiotics; and conversely, from antimicrobial exposure to vitamin D and omega fatty acid supplementation; breastfeeding and hydrolyzed formula; and house dust mite avoidance and immunotherapy. We appraise the available evidence base within the context of the Grades of Recommendation, Assessment, Development, and Evaluation approach. We also contextualize our findings in relation to concepts relating AD and individual-patient allergic life trajectories versus a linear concept of the atopic march and provide insights into future knowledge gaps and clinical trial design considerations that must be addressed in forthcoming research. Finally, we provide implementation considerations to detect population-level differences in AD risk. Major international efforts are required to provide definitive evidence regarding what works and what does not for preventing AD.
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Affiliation(s)
- Derek K Chu
- Evidence in Allergy Group, Department Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Jennifer J Koplin
- Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia; Centre for Food Allergy Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Tasnuva Ahmed
- Evidence in Allergy Group, Department Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nazmul Islam
- Evidence in Allergy Group, Department Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Chia-Lun Chang
- Centre for Food Allergy Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Adrian J Lowe
- Centre for Food Allergy Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Iglesia EGA, Fleischer DM, Abrams EM. Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1670-1683.e9. [PMID: 38796104 DOI: 10.1016/j.jaip.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/20/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.
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Affiliation(s)
- Edward G A Iglesia
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - David M Fleischer
- Section of Allergy and Immunology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Elissa M Abrams
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
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Shifti DM, Soriano VX, Perrett KP, Dharmage SC, Allen KJ, Peters RL, Koplin JJ. Milk and egg allergy are associated with increased risk of peanut allergy at age 1 in Australia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00670-6. [PMID: 38936663 DOI: 10.1016/j.jaip.2024.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Desalegn Markos Shifti
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.
| | - Victoria X Soriano
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kirsten P Perrett
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Shyamali C Dharmage
- School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Katrina J Allen
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Rachel L Peters
- Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
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Foong RX, Du Toit G, van Ree R, Bahnson HT, Radulovic S, Craven J, Kwok M, Jama Z, Versteeg SA, Brough HA, Logan K, Perkin MR, Flohr C, Lack G, Santos AF. Biomarkers of peanut allergy in children over time. Allergy 2024. [PMID: 38887787 DOI: 10.1111/all.16193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 04/02/2024] [Accepted: 05/01/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Various biomarkers are used to define peanut allergy (PA). We aimed to observe changes in PA resolution and persistence over time comparing biomarkers in PA and peanut sensitised but tolerant (PS) children in a population-based cohort. METHODS Participants were recruited from the EAT and EAT-On studies, conducted across England and Wales, and were exclusively breastfeed babies recruited at 3 months old and followed up until 7-12 years old. Clinical characteristics, skin prick test (SPT), sIgE to peanut and peanut components and mast cell activation tests (MAT) were assessed at 12 months, 36 months and 7-12 years. PA status was determined at the 7-12 year time point. RESULTS The prevalence of PA was 2.1% at 7-12 years. Between 3 and 7-12 year, two children developed PA and one outgrew PA. PA children had larger SPT, higher peanut-sIgE, Ara h 2-sIgE and MAT (all p < .001) compared to PS children from 12 months onwards. SPT, peanut-sIgE, Ara h 2-sIgE and MAT between children with persistent PA, new PA, outgrown PA and PS were statistically significant from 12 months onwards (p < .001). Those with persistent PA had SPT, peanut-sIgE and Ara h 2-sIgE that increased over time and MAT which was highest at 36 months. New PA children had increased SPT and peanut-sIgE from 36 months to 7-12 years, but MAT remained low. PS children had low biomarkers across time. CONCLUSIONS In this cohort, few children outgrow or develop new PA between 36 months and 7-12 years. Children with persistent PA have raised SPT, peanut-sIgE, Ara h 2-sIgE and MAT evident from infancy that consistently increase over time.
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Affiliation(s)
- Ru-Xin Foong
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - George Du Toit
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Ronald van Ree
- Department of Experimental Immunology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Henry T Bahnson
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Washington, USA
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Jo Craven
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Matthew Kwok
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Zainab Jama
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Serge A Versteeg
- Department of Experimental Immunology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Helen A Brough
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Kirsty Logan
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, London, UK
| | - Michael R Perkin
- Population Health Research Institute. St George's, University of London, London, UK
| | - Carsten Flohr
- St John's Institute of Dermatology, King's College London and Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
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Anagnostou A. Shared decision-making in food allergy: Navigating an exciting era. Ann Allergy Asthma Immunol 2024; 132:313-320. [PMID: 37742794 DOI: 10.1016/j.anai.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Shared decision-making (SDM) is increasingly used in food allergy. We review its use in the areas of prevention, diagnosis, and management. DATA SOURCES PubMed and online SDM resources. STUDY SELECTIONS Studies and reviews relevant to SDM and areas in food allergy that decision-making may be applied were selected for discussion. RESULTS Food allergy represents an area with multiple opportunities for SDM. Patients, on one hand, need to obtain the necessary information and understanding of existing options from the allergist. The allergist, on the other hand, needs to understand "where the patient is coming from," their needs, preferences, and values, so that jointly they can reach a decision that is responsive to these. Benefits of SDM include a better understanding of disease by patients, improved compliance with medication, better health outcomes, decreased health care costs, and improved ability of patients to manage their disease and make informed choices. CONCLUSION In food allergy prevention, diagnosis, and management, multiple preference-sensitive options exist for patients where SDM may be used during allergy consultations, alongside decision aids. Decision aids are tools that assist and support patients during the SDM process, by supplementing the patient-physician interaction.
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Affiliation(s)
- Aikaterini Anagnostou
- Division of Immunology, Allergy and Retrovirology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas; Division of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, Texas.
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10
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Nguyen A, du Toit G, Lack G, Marrs T. Optimising the management of peanut allergy by targeting immune plasticity. Clin Exp Allergy 2024; 54:169-184. [PMID: 38423799 DOI: 10.1111/cea.14454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 11/03/2023] [Accepted: 11/23/2023] [Indexed: 03/02/2024]
Abstract
Randomised controlled trials investigating the efficacy of oral tolerance induction to peanut have enabled detailed comparison of their clinical and immunological success. They have demonstrated that the regular consumption of peanut for at least 2 years by babies who are not allergic enables protection from developing peanut allergy. The LEAP study intervention tested the impact of regular peanut consumption for 4 years and demonstrated a sustained protection against the development of peanut allergy even after 12 months of peanut avoidance from 5 to 6 years of age. The PreventADALL trial introduced multiple allergens into babies' diets from early infancy and reduced the prevalence of food allergy at 3 years, especially by protecting against peanut allergy. Immunological studies from the LEAP cohort demonstrated that regular peanut consumption was associated with a prompt induction of peanut-specific IgG4 and reduced manufacture of peanut and Ara h 2-specific IgE. Even after stopping peanut consumption for 5 years, there continued to be a significant fall in peanut-specific Ara h 2 IgE in the consumption group from 5 to 6 years of age (p < .01). Children who developed peanut allergy by 5 years started to develop increasing sensitisation to linear sequential peanut epitopes from 2.5 years of age, suggesting that putative disease-modifying interventions should commence before 3 years. Data comparing clinical outcomes between children undergoing peanut immunotherapy from infancy suggest that younger children can consume higher portions of peanut without reaction on challenge whilst taking immunotherapy, have fewer side effects and are more likely to enjoy remission of PA. Peanut oral immunotherapy modulates T-cell populations in order to bring about hypo-responsiveness of allergy effector cells. Studies are now needed to characterise and compare different states of immunological tolerance. This will accelerate the design of interventions which can promote primary, secondary and tertiary levels of PA prevention across a range of age groups.
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Affiliation(s)
- Alan Nguyen
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - George du Toit
- Paediatric Allergy, Department of Women and Children's Health, King's College London, Strand, UK
- Children's Allergies, Evelina London, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Gideon Lack
- Paediatric Allergy, Department of Women and Children's Health, King's College London, Strand, UK
| | - Tom Marrs
- Paediatric Allergy, Department of Women and Children's Health, King's College London, Strand, UK
- Children's Allergies, Evelina London, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
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11
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Ryczaj K, Szczukocka-Zych A, Wawszczak M, Gawryjołek J, Krogulska A, Krawiec M, Horvath A, Szajewska H, Santos A, Bahnson HT, Kulus M. Development of peanut, sesame and tree nut allergy in Polish children at high risk of food allergy: a protocol for a cross-sectional study. BMJ Open 2023; 13:e074168. [PMID: 37973545 PMCID: PMC10660920 DOI: 10.1136/bmjopen-2023-074168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Peanut allergies cause serious health problems worldwide. A strong finding has shown that the early introduction of peanuts into the diet of infants at high risk of food allergy reduces the prevalence of peanut allergy. Allergies to peanuts, sesame and tree nuts have been shown to coexist in 60% of cases and vary according to geographical location and dietary habits. Insights into the prevalence of nut and seed allergies in societies with varying consumption levels are essential for developing population-specific weaning guidelines. Understanding the age at which peanut allergy develops is paramount for successful early introduction strategies. METHODS AND ANALYSIS We will perform a cross-sectional study at two tertiary allergy centres in Warsaw and Bydgoszcz. Two hundred forty children aged 4-36 months with eczema or egg allergy will undergo an extensive assessment of their peanut, sesame and tree nut allergy status through skin testing, specific IgE measurements and oral food challenges. The primary outcome is the prevalence of peanut, sesame and tree nut allergies in Polish children at high risk of food allergy. Additionally, the timing of the development of peanut, sesame and tree nut allergies in the first 3 years of life in a high-risk population will be assessed. ETHICS AND DISSEMINATION The Ethics Committee of the Medical University of Warsaw, Poland approved this protocol (KB/86/2021). The results of this study will be submitted to a peer-reviewed journal no later than 1 year after data collection. The abstract will be presented at relevant national and international conferences.Although the authors may be able to commit to journal submission no later than 1 year after data collection, publication dates remain beyond their control. TRIAL REGISTRATION NUMBER NCT05662800.
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Affiliation(s)
- Klaudia Ryczaj
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | | | - Maria Wawszczak
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Julia Gawryjołek
- Department of Paediatrics, Allergy and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Aneta Krogulska
- Department of Paediatrics, Allergy and Gastroenterology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Marta Krawiec
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Andrea Horvath
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Hania Szajewska
- Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Alexandra Santos
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Henry T Bahnson
- Benaroya Research Institute and the Immune Tolerance Network, Seattle, Washington, USA
| | - Marek Kulus
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
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12
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Abrams EM, Shaker M, Stukus D, Mack DP, Greenhawt M. Updates in Food Allergy Prevention in Children. Pediatrics 2023; 152:e2023062836. [PMID: 37818612 DOI: 10.1542/peds.2023-062836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 10/12/2023] Open
Abstract
Although significant evidence exists that feeding early has a role in the prevention of food allergy, this intervention in isolation may not be sufficient. Recent evidence highlights that early introduction of peanut specifically has had no significant impact on the populational prevalence of peanut allergy. Other factors that may contribute to food allergy prevention include regularity of ingestion once an allergen is introduced and consideration to the form in which the allergen is introduced (such as baked versus cooked egg). There are also many practicalities to early feeding and some discrepant viewpoints on these practicalities, which has led to poor implementation of early feeding strategies. In general, preemptive screening before food introduction is not recommended by most international allergy societies. Although there is little guidance to inform early introduction of allergens other than milk, egg, and peanut, the mechanism of sensitization is thought to be similar and there is no harm to early introduction. In terms of frequency and duration of feeding, there is little evidence to inform any concrete recommendations.
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Affiliation(s)
- Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada, and Halton Pediatric Allergy, Burlington, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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13
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Chow SJ, McWilliam V, Koplin JJ, Perrett KP. Australian Infant Food Allergy Emergency Presentations Following Updated Early Food Introduction Guidelines. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3473-3477. [PMID: 37479113 DOI: 10.1016/j.jaip.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The Australasian Society of Clinical Immunology and Allergy food allergy prevention guidelines were updated in 2016 to recommend home introduction of allergenic foods actively in the first year of life, including to infants at high risk of allergy. An important consideration for parents and providers is whether this practice increases food allergy reactions or anaphylaxis. OBJECTIVE We aimed to determine whether the 2016 update of food allergy prevention guidelines was associated with an increase in food allergy or anaphylaxis emergency department (ED) presentations. METHODS We obtained hospital electronic medical records for infants aged 4 to 12 months who attended the Royal Children's Hospital Melbourne ED in 2015 or in 2018 with a presenting problem or an encounter diagnosis of food allergy or anaphylaxis. RESULTS Emergency department presentations owing to food allergy increased from 1.0% (95% CI, 0.85-1.23) in 2015 to 1.4% (95% CI, 1.22-1.67) in 2018 (P = .006). There was no increase in the number of anaphylaxis presentations (28 in 2015 and 22 in 2018) or peanut anaphylaxis presentations (three in 2015 and three in 2018). Overall, the proportion of food allergy presentations attributed to IgE-mediated food allergy was similar (82.1% in 2015 and 84.1% in 2018), whereas peanut allergy presentations increased slightly, although not statically significantly, from 14.6% to 21.2% (P = .09). Food protein-induced enterocolitis syndrome ED presentations were five in 2015 (4.3%) and 12 in 2018(7.6%), although not statistically significant (P = .25). CONCLUSIONS Changes to food allergy prevention guidelines recommending the earlier introduction of allergenic food may have led to a small increase in ED presentations for food allergy but not anaphylaxis.
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Affiliation(s)
- Sing-Jill Chow
- Population Allergy Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Vicki McWilliam
- Population Allergy Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer J Koplin
- Population Allergy Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Kirsten P Perrett
- Population Allergy Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia; Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.
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14
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Kitamura K, Matsui T, Takasato Y, Sugiura S, Ito K. Jug r 1 sensitization in 0- to 35-month-old children with egg, milk, or wheat sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100168. [PMID: 38024848 PMCID: PMC10679771 DOI: 10.1016/j.jacig.2023.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 12/01/2023]
Abstract
Background The incidence of tree nut allergies in children is increasing, with walnut allergy being the most common in the United States and Japan. Allergic reactions, including anaphylaxis, frequently occur at the first intake of tree nuts, suggesting prior sensitization. Objective Our aim was to identify which children should be considered for workup for preexisting sensitization. Methods Juglans regia (Jug r) 1-specific IgE screening for 0- to 35-month-old children who had a positive specific IgE result for egg white, milk, or wheat and had never ingested walnuts was conducted at a food allergy referral hospital between November 2018 and December 2022. Clinical data regarding age; sex; allergic disease complications; and egg, milk, or wheat allergy were examined retrospectively. Results The rate of Jug r 1-specific IgE positivity (level > 0.34 kUA/L) of 205 children (125 of whom were boys) was 9.8%, with a median Jug r 1-specific IgE level of 12.5 kUA/L in patients with a positive test result. Eczema was observed in 119 patients (58%). The rate of Jug r 1-specific IgE positivity was significantly higher in the eczema-positive group (15.1% [18 of 119]) than in the eczema-negative group (2.3% [2 of 86]) (P = .002). In the eczema-positive group, the rates of Jug r 1-specific IgE positivity per sensitized antigen were 13.7% for egg, 17.0% for milk, and 17.1% for wheat. The rate of Jug r 1-specific IgE positivity was significantly higher in the group with severe eczema (26.6% [17 of 64]) than in the group with nonsevere eczema (1.8% [1 of 55]) (P < .001). Conclusion Even in children younger than 3 years, 15% of children with eczema and egg, milk, or wheat sensitization were sensitized to Jug r 1.
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Affiliation(s)
- Katsumasa Kitamura
- Aichi Children’s Health and Medical Center, Allergy and Immunology Center, Obu, Japan
| | - Teruaki Matsui
- Aichi Children’s Health and Medical Center, Allergy and Immunology Center, Obu, Japan
| | - Yoshihiro Takasato
- Aichi Children’s Health and Medical Center, Allergy and Immunology Center, Obu, Japan
| | - Shiro Sugiura
- Aichi Children’s Health and Medical Center, Allergy and Immunology Center, Obu, Japan
| | - Komei Ito
- Aichi Children’s Health and Medical Center, Allergy and Immunology Center, Obu, Japan
- Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Obu, Japan
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15
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Herlihy LE, Walters EM, D'Auria JP, Orgel K, Jordan KA. Early Peanut Introduction in Infants: Improving Guideline Adherence With EMR Standardization. Pediatrics 2023; 152:e2023062371. [PMID: 37873594 DOI: 10.1542/peds.2023-062371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 10/25/2023] Open
Abstract
OBJECTIVES Peanut allergy in children is a population health problem. Evidence suggests early peanut introduction (EPI) for infants can reduce the development of peanut allergy. Primary care settings have not widely adopted guidelines recommending EPI. Peanut allergy prevention depends on primary care providers incorporating EPI guidelines into well-child check (WCC) encounters. We aimed to improve guideline adherence in a primary care setting by implementing a bundle of clinical decision support (CDS) tools. METHODS Using quality improvement methodology, the team developed a standardized work protocol and CDS tools within an electronic medical record (EMR) at 4, 6, and 9-month WCC encounters. The team executed changes and modifications through plan-do-study-act cycles and analyzed results with statistical process control charts. RESULTS We collected data from 445 WCC encounters from baseline through sustainability. EMR documentation of EPI guidance at 4, 6, and 9-month WCCs shifted from 13.9% to 83.5% over 12 months. Provider adoption of smart lists and templates increased from 2% to 73%, the distribution of home peanut introduction handouts increased from 5.2% to 54.1%, and caregiver-reported peanut ingestion increased from 0% to 34.6%. Diphtheria-tetanus-acellular pertussis vaccination rates remained at 100% for 6-month visits, and patient in-room time remained at 65 minutes. CONCLUSIONS Quality improvement methodology improved documentation of EPI guidance and increased reported peanut ingestion at routine WCC encounters without impacting other measures. Broader use of bundled CDS tools and EMR standardization could further improve guideline adherence and increase early peanut introduction to prevent peanut allergy in infants.
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Affiliation(s)
- Lauren E Herlihy
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Jennifer P D'Auria
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kelly Orgel
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine A Jordan
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Nguyen TH, Cunha PP, Rowland AF, Orenstein E, Lee T, Kandaswamy S. User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study. JMIR Form Res 2023; 7:e47574. [PMID: 37606983 PMCID: PMC10481213 DOI: 10.2196/47574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/15/2023] [Accepted: 07/21/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities. OBJECTIVE In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting. METHODS We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS. RESULTS Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary. CONCLUSIONS User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.
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Affiliation(s)
- Thinh Hoang Nguyen
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States
| | - Priscila Pereira Cunha
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | | | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Tricia Lee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Department of Allergy and Immunology, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Swaminathan Kandaswamy
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
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Anagnostou A, Lieberman J, Greenhawt M, Mack DP, Santos AF, Venter C, Stukus D, Turner PJ, Brough HA. The future of food allergy: Challenging existing paradigms of clinical practice. Allergy 2023; 78:1847-1865. [PMID: 37129472 DOI: 10.1111/all.15757] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/05/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023]
Abstract
The field of food allergy has seen tremendous change over the past 5-10 years with seminal studies redefining our approach to prevention and management and novel testing modalities in the horizon. Early introduction of allergenic foods is now recommended, challenging the previous paradigm of restrictive avoidance. The management of food allergy has shifted from a passive avoidance approach to active interventions that aim to provide protection from accidental exposures, decrease allergic reaction severity and improve the quality of life of food-allergic patients and their families. Additionally, novel diagnostic tools are making their way into clinical practice with the goal to reduce the need for food challenges and assist physicians in the-often complex-diagnostic process. With all the new developments and available choices for diagnosis, prevention and therapy, shared decision-making has become a key part of medical consultation, enabling patients to make the right choice for them, based on their values and preferences. Communication with patients has also become more complex over time, as patients are seeking advice online and through social media, but the information found online may be outdated, incorrect, or lacking in context. The role of the allergist has evolved to embrace all the above exciting developments and provide patients with the optimal care that fits their needs. In this review, we discuss recent developments as well as the evolution of the field of food allergy in the next decade.
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Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Houston, Texas, USA
- Section of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, Texas, USA
| | - Jay Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tennessee, USA
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Douglas Paul Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK
| | - Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, Colorado, USA
| | - David Stukus
- Section of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, Texas, USA
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Ohio, USA
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Helen A Brough
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, UK
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Sever ML, Calatroni A, Roberts G, du Toit G, Bahnson HT, Radulovic S, Larson D, Byron M, Santos AF, Huffaker MF, Wheatley LM, Lack G. Developing a Prediction Model for Determination of Peanut Allergy Status in the Learning Early About Peanut Allergy (LEAP) Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2217-2227.e9. [PMID: 37146884 DOI: 10.1016/j.jaip.2023.04.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/09/2023] [Accepted: 04/12/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND The Learning Early About Peanut Allergy (LEAP) study team developed a protocol-specific algorithm using dietary history, peanut-specific IgE, and skin prick test (SPT) to determine peanut allergy status if the oral food challenge (OFC) could not be administered or did not provide a determinant result. OBJECTIVE To investigate how well the algorithm determined allergy status in LEAP; to develop a new prediction model to determine peanut allergy status when OFC results are not available in LEAP Trio, a follow-up study of LEAP participants and their families; and to compare the new prediction model with the algorithm. METHODS The algorithm was developed for the LEAP protocol before the analysis of the primary outcome. Subsequently, a prediction model was developed using logistic regression. RESULTS Using the protocol-specified algorithm, 73% (453/617) of allergy determinations matched the OFC, 0.6% (4/617) were mismatched, and 26% (160/617) participants were nonevaluable. The prediction model included SPT, peanut-specific IgE, Ara h 1, Ara h 2, and Ara h 3. The model inaccurately predicted 1 of 266 participants as allergic who were not allergic by OFC and 8 of 57 participants as not allergic who were allergic by OFC. The overall error rate was 9 of 323 (2.8%) with an area under the curve of 0.99. The prediction model additionally performed well in an external validation cohort. CONCLUSION The prediction model performed with high sensitivity and accuracy, eliminated the problem of nonevaluable outcomes, and can be used to estimate peanut allergy status in the LEAP Trio study when OFC is not available.
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Affiliation(s)
- Michelle L Sever
- PPD Government and Public Health Services, Morrisville, NC; Rho Federal Systems Division, Durham, NC
| | | | - Graham Roberts
- University of Southampton and Southampton NIHR Biomedical Research Centre, Southampton, United Kingdom; David Hide Centre, Isle of Wight, United Kingdom
| | - George du Toit
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, London, United Kingdom; Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Henry T Bahnson
- The Immune Tolerance Network, Benaroya Research Institute at Virginia Mason, Seattle, Wash
| | - Suzana Radulovic
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, London, United Kingdom; Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Alexandra F Santos
- Department of Pediatric Allergy, School of Life Course Sciences, King's College London and Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, United Kingdom; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Michelle F Huffaker
- Immune Tolerance Network, University of California San Francisco, San Francisco, Calf.
| | - Lisa M Wheatley
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Gideon Lack
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, London, United Kingdom; Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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Ng PPLC, Tham EH, Lee BW. Primary Prevention of Allergy - Is It Feasible? ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:419-436. [PMID: 37469241 PMCID: PMC10359645 DOI: 10.4168/aair.2023.15.4.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/14/2023] [Accepted: 05/20/2023] [Indexed: 07/21/2023]
Abstract
The allergy epidemic has been attributed to environmental influences related to urbanization and the modern lifestyle. In this regard, various theories exploring the role of microbes (hygiene, old friends, microbiota, and biodiversity hypotheses), and the epithelial barrier (epithelial, dual allergen exposure and vitamin D hypotheses) have been proposed. These hypotheses have guided clinical studies that led to the formulation of intervention strategies during the proposed window of opportunity dubbed as the "first thousand days." The most significant intervention is a paradigm shift from allergen avoidance to early introduction of allergenic foods, particularly egg and peanut, around 6 months of age for the prevention of food allergy. This recommendation has been adopted globally and included in allergy prevention guidelines. Other strategies with less robust clinical evidence include: encouraging a healthy balanced diet, rich in fish, during pregnancy; continuing allergenic food intake during pregnancy and lactation; vitamin D supplementation in pregnant women with asthma; discouraging social indications for caesarean section delivery; judicious use of antibiotics in early childhood; daily emollient use from birth in high risk babies; and avoiding cow's milk formula use in the first week of life. However, if early supplementation with cow's milk formula is required, continuing at least 10 mL of formula daily until age 2 months may be considered. Translating these strategies to public health and clinical practice is still a work in progress. Long-term population studies are crucial to assess the feasibility of these measures on allergy prevention.
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Affiliation(s)
- Pauline Poh-Lin Chan Ng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System (NUHS), Singapore
| | - Elizabeth Huiwen Tham
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System (NUHS), Singapore
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bee-Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore.
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Graf MD, Wasser H, Lynn MR, Karp SM, Lutenbacher M, Hodges EA. Parental food selection questionnaire - Infant version. Appetite 2023; 186:106548. [PMID: 36977445 PMCID: PMC10286103 DOI: 10.1016/j.appet.2023.106548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/28/2023]
Abstract
PURPOSE Complementary feeding practices (CFPs) are associated with health outcomes (e.g., obesity and food allergies). Understanding how parents select foods for their infant is limited. This study's purpose was to develop a psychometrically sound measure of parents' food selection motives for their infant during the complementary feeding period. METHODS Development and testing of the Parental Food Slection Questionnaire-Infant Version (PFSQ-I) occurred in three phases. English-speaking, U.S. mothers of healthy infants, aged 6-19 months old participated in a semi-structured, face-to-face interview (Phase 1) or a web-based survey (Phases 2 & 3). Phase 1 was a qualitative study of maternal beliefs and motives surrounding complementary feeding. Phase 2 involved adaptation and exploratory factor analysis of the original Food Choice Questionnaire (Steptoe et al., 1995). Phase 3 involved validity testing of the relationships among PFSQ-I factors and CFPs (timing/type of complementary food introduction, frequency of feeding method, usual texture intake, and allergenic food introduction) using bivariate analyses, and multiple linear and logistic regression analyses. RESULTS Mean maternal age was 30.4 years and infant age was 14.1 months (n = 381). The final structure of the PFSQ-I included 30 items and 7 factors: Behavioral Influence, Health Promotion, Ingredients, Affordability, Sensory Appeal, Convenience, and Perceived Threats (Cronbach's α = 0.68-0.83). Associations of factors with CFPs supported construct validity. DISCUSSION The PFSQ-I demonstrated strong initial psychometric properties in a sample of mothers from the U.S. Mothers who rated Behavioral Influence as more important were more likely to report suboptimal CFPs (e.g., earlier than recommended complementary food introduction, delayed allergenic food introduction, and prolonged use of spoon-feeding). Additional psychometric testing in a larger, more heterogenous sample is needed, along with examination of relationships between PFSQ-I factors and health outcomes.
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Affiliation(s)
- Michelle Dorsey Graf
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Heather Wasser
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Mary R Lynn
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Sharon M Karp
- School of Nursing, Vanderbilt University, Nashville, TN, 37235, USA
| | | | - Eric A Hodges
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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21
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Roberts G, Bahnson HT, Du Toit G, O'Rourke C, Sever ML, Brittain E, Plaut M, Lack G. Defining the window of opportunity and target populations to prevent peanut allergy. J Allergy Clin Immunol 2023; 151:1329-1336. [PMID: 36521802 PMCID: PMC10689252 DOI: 10.1016/j.jaci.2022.09.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Peanut allergy affects 1% to 2% of European children. Early introduction of peanut into the diet reduces allergy in high-risk infants. OBJECTIVE We aimed to determine the optimal target populations and timing of introduction of peanut products to prevent peanut allergy in the general population. METHODS Data from the Enquiring About Tolerance (EAT; n = 1303; normal risk; 3-year follow-up; ISRCTN14254740) and Learning Early About Peanut Allergy study (LEAP; n = 640; high risk; 5-year follow-up; NCT00329784) randomized controlled trials plus the Peanut Allergy Sensitization (PAS; n = 194; low and very high risk; 5-year follow-up) observational study were used to model the intervention in a general population. Peanut allergy was defined by blinded peanut challenge or diagnostic skin prick test result. RESULTS Targeting only the highest-risk infants with severe eczema reduced the population disease burden by only 4.6%. Greatest reductions in peanut allergy were seen when the intervention was targeted only to the larger but lower-risk groups. A 77% reduction in peanut allergy was estimated when peanut was introduced to the diet of all infants, at 4 months with eczema, and at 6 months without eczema. The estimated reduction in peanut allergy diminished with every month of delayed introduction. If introduction was delayed to 12 months, peanut allergy was only reduced by 33%. CONCLUSIONS The preventive benefit of early introduction of peanut products into the diet decreases as age at introduction increases. In countries where peanut allergy is a public health concern, health care professionals should help parents introduce peanut products into their infants' diet at 4 to 6 months of life.
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Affiliation(s)
- Graham Roberts
- University of Southampton and Southampton NIHR Biomedical Research Centre, Southampton, and the David Hide Centre, Isle of Wight, United Kingdom
| | - Henry T Bahnson
- Benaroya Research Institute and the Immune Tolerance Network, Seattle, Wash
| | - George Du Toit
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College, and the Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Colin O'Rourke
- Benaroya Research Institute and the Immune Tolerance Network, Seattle, Wash
| | - Michelle L Sever
- Rho Federal Systems Division, Durham, and PPD Government and Public Health Services, Wilmington, NC
| | - Erica Brittain
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Gideon Lack
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College, and the Children's Allergy Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
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22
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Vale SL, Murray K, Netting MJ, Ong R, Clifford R, Stiles S, Campbell DE, Salter SM. Impact of public health interventions for food allergy prevention on rates of infant anaphylaxis. Ann Allergy Asthma Immunol 2023; 130:347-354.e1. [PMID: 36122889 DOI: 10.1016/j.anai.2022.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Eleven percent of Australian infants have confirmed food allergy. We hypothesized earlier introduction may lead to higher rates of infant anaphylaxis, irrespective of whether the overall rate of food allergy in the population was ultimately reduced. OBJECTIVE To determine whether a public health campaign, targeting earlier introduction of allergenic foods, affected rates of infant anaphylaxis. METHODS Data were obtained from St John Ambulance (SJA) Western Australia and Western Australian emergency departments (ED) on infant (≤12 months) anaphylaxis over a 5-year period (July 1, 2015 to June 30, 2020). Adrenaline administration data were collected in the SJA dataset. Poisson regression was undertaken to assess trends in anaphylaxis over time. Segmented regression analysis was undertaken to assess differences in anaphylaxis rates before and after intervention. RESULTS The SJA and ED datasets included 172 and 294 events, respectively, coded as infant anaphylaxis. Rates of infant anaphylaxis increased over time for both SJA and ED datasets, with a 1-year increase rate ratio of 1.21 (95% confidence interval, 1.09-1.35; P value < .01) and 1.11 (95% confidence interval, 1.02-1.20; P = .01), respectively. Segmented regression indicated no significant difference in rates after intervention. Adrenaline was not coded as being administered in 109 of the 172 anaphylaxis events. CONCLUSION Rates of infant anaphylaxis increased over the 5-year reporting period; however, there was no clear increase related to the timing of the public health campaign implementation. Reported adrenaline use was suboptimal. Assessing rates of food allergy in all age groups is required to determine whether there has been an overall reduction in food allergy owing to the intervention.
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Affiliation(s)
- Sandra L Vale
- The University of Western Australia, Crawley, Western Australia, Australia.
| | - Kevin Murray
- The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Royston Ong
- Saint John Ambulance Western Australia, Belmont, Western Australia, Australia
| | - Rhonda Clifford
- The University of Western Australia, Crawley, Western Australia, Australia
| | - Samantha Stiles
- The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Sandra M Salter
- The University of Western Australia, Crawley, Western Australia, Australia
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23
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Koplin JJ, McWilliam V, Soriano VX, Peters RL. Early peanut introduction: To test or not to test? Ann Allergy Asthma Immunol 2023; 130:565-570. [PMID: 36791959 DOI: 10.1016/j.anai.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To review recent evidence and international guidelines on early peanut introduction for preventing peanut allergy and provide an update on the status of the debate around testing before early peanut introduction. DATA SOURCES Review of published literature documenting: infant feeding guidelines; impact of early peanut introduction on peanut allergy; risk factors for peanut allergy; and impact of early peanut introduction guidelines on infant feeding practices and allergy. STUDY SELECTION We used a narrative approach and present both pro and con arguments for testing before peanut introduction. Data from randomized controlled trials and post-hoc analyses of these trials and observational studies were included. RESULTS Allergy prevention guidelines around the world now consistently recommend introducing peanut into an infant's diet before 12 months of age for countries with high peanut allergy prevalence. In the US, guidelines recently shifted away from recommending allergy testing before introduction for those at risk of peanut allergy. There is evidence primarily from Australia that recommending early introduction without prior testing is safe and effective in increasing early peanut introduction for both high and low-risk infants, although the subsequent reduction in peanut allergy prevalence at the population level was less than expected. CONCLUSION Current evidence supports recommending early peanut introduction without routinely testing for peanut allergy. If testing is offered, this should be based on shared decision making between families and practitioners and only be undertaken where there is provision for rapid access to definitive diagnosis including oral food challenges.
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Affiliation(s)
- Jennifer J Koplin
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia.
| | - Vicki McWilliam
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Victoria, Australia
| | | | - Rachel L Peters
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.
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24
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Shah H, Yanishevski D, Ouyang Y, Lieberman JA. The health disparities of early introduction of allergenic foods. Ann Allergy Asthma Immunol 2023; 130:111-112. [PMID: 36241019 DOI: 10.1016/j.anai.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Heema Shah
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee
| | - David Yanishevski
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee
| | - Ying Ouyang
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee
| | - Jay Adam Lieberman
- University of Tennessee Health Science Center and LeBonheur Children's Hospital, Memphis, Tennessee.
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25
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McWilliam V, Venter C, Greenhawt M, Perrett KP, Tang MLK, Koplin JJ, Peters RL. A pragmatic approach to infant feeding for food allergy prevention. Pediatr Allergy Immunol 2022; 33:e13849. [PMID: 36156814 PMCID: PMC9540872 DOI: 10.1111/pai.13849] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/05/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022]
Abstract
Early introduction of allergenic foods into an infant's diet is currently the most promising strategy to prevent food allergy, with infant guidelines around the world shifting from promoting avoidance to actively encourage the introduction of allergenic foods in the infant diet. Infant feeding guidelines vary according to regional public health priorities, and knowledge gaps remain, resulting in ongoing challenges for clinicians and families to translate guidelines into practical strategies for the introduction of complementary foods for food allergy prevention. Evidence from Australia demonstrates high community support and uptake of revised guidelines with most parents introducing allergenic foods in the first year of life, although this has not had the expected impact on substantially reducing food allergy prevalence. To uptake of guidelines from other countries is less clear, and several barriers have been noted in infant feeding RCTs, which may warrant intervention strategies. Further research is needed to understand additional strategies for food allergy prevention, particularly in infants who develop food allergy prior to when they are developmentally ready to commence solids. Several RCTs are underway investigating preventative strategies that target the window before allergen ingestion, such as vitamin D supplementation, emollient use, and immunizations that prime the immune response away from a Th2-driven allergic phenotype. Further research is also needed to understand the role of the environment and the host environment in the development of tolerance to foods.
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Affiliation(s)
- Vicki McWilliam
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Carina Venter
- Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Boulder, Colorado, USA
| | - Matthew Greenhawt
- Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado, Boulder, Colorado, USA
| | - Kirsten P Perrett
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Mimi L K Tang
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Allergy and Immunology, Royal Children's Hospital, Parkville, Australia
| | - Jennifer J Koplin
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Rachel L Peters
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
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26
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Soriano VX, Peters RL, Moreno-Betancur M, Ponsonby AL, Gell G, Odoi A, Perrett KP, Tang MLK, Gurrin LC, Allen KJ, Dharmage SC, Koplin JJ. Association Between Earlier Introduction of Peanut and Prevalence of Peanut Allergy in Infants in Australia. JAMA 2022; 328:48-56. [PMID: 35788795 PMCID: PMC9257582 DOI: 10.1001/jama.2022.9224] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Randomized clinical trials showed that earlier peanut introduction can prevent peanut allergy in select high-risk populations. This led to changes in infant feeding guidelines in 2016 to recommend early peanut introduction for all infants to reduce the risk of peanut allergy. OBJECTIVE To measure the change in population prevalence of peanut allergy in infants after the introduction of these new guidelines and evaluate the association between early peanut introduction and peanut allergy. DESIGN Two population-based cross-sectional samples of infants aged 12 months were recruited 10 years apart using the same sampling frame and methods to allow comparison of changes over time. Infants were recruited from immunization centers around Melbourne, Australia. Infants attending their 12-month immunization visit were eligible to participate (eligible age range, 11-15 months), regardless of history of peanut exposure or allergy history. EXPOSURES Questionnaires collected data on demographics, food allergy risk factors, peanut introduction, and reactions. MAIN OUTCOME AND MEASURES All infants underwent skin prick tests to peanut and those with positive results underwent oral food challenges. Prevalence estimates were standardized to account for changes in population demographics over time. RESULTS This study included 7209 infants (1933 in 2018-2019 and 5276 in 2007-2011). Of the participants in the older vs more recent cohort, 51.8% vs 50.8% were male; median (IQR) ages were 12.5 (12.2-13.0) months vs 12.4 (12.2-12.9) months. There was an increase in infants of East Asian ancestry over time (16.5% in 2018-2019 vs 10.5% in 2007-2011), which is a food allergy risk factor. After standardizing for infant ancestry and other demographics changes, peanut allergy prevalence was 2.6% (95% CI, 1.8%-3.4%) in 2018-2019, compared with 3.1% in 2007-2011 (difference, -0.5% [95% CI, -1.4% to 0.4%]; P = .26). Earlier age of peanut introduction was significantly associated with a lower risk of peanut allergy among infants of Australian ancestry in 2018-2019 (age 12 months compared with age 6 months or younger: adjusted odds ratio, 0.08 [05% CI, 0.02-0.36]; age 12 months compared with 7 to less than 10 months: adjusted odds ratio, 0.09 [95% CI, 0.02-0.53]), but not significant among infants of East Asian ancestry (P for interaction = .002). CONCLUSIONS AND RELEVANCE In cross-sectional analyses, introduction of a guideline recommending early peanut introduction in Australia was not associated with a statistically significant lower or higher prevalence of peanut allergy across the population.
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Affiliation(s)
- Victoria X. Soriano
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Rachel L. Peters
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Margarita Moreno-Betancur
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Anne-Louise Ponsonby
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Grace Gell
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Alexsandria Odoi
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kirsten P. Perrett
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Mimi L. K. Tang
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Allergy and Immunology, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Lyle C. Gurrin
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | | | - Shyamali C. Dharmage
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer J. Koplin
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Centre for Food and Allergy Research (CFAR), Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
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27
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Abrams EM, Watson W, Vander Leek TK, Atkinson A, Primeau MN, Francoeur MJ, McHenry M, Lavine E, Orkin J, Cummings C, Blair B, Chan ES. Dietary exposures and allergy prevention in high-risk infants. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:36. [PMID: 35501827 PMCID: PMC9063186 DOI: 10.1186/s13223-021-00638-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022]
Abstract
Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow's milk protein formula has been introduced in an infant's diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early-at around 6 months, but not before 4 months of age-can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada.
| | - Wade Watson
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Timothy K Vander Leek
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Adelle Atkinson
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Marie-Noel Primeau
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Marie-Josee Francoeur
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Mary McHenry
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Elana Lavine
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Julia Orkin
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Carl Cummings
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Becky Blair
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
| | - Edmond S Chan
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, MB, R2A 5L9, Canada
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28
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Koplin JJ, Soriano VX, Peters RL. Real-World LEAP Implementation. Curr Allergy Asthma Rep 2022; 22:61-66. [PMID: 35394609 PMCID: PMC8990270 DOI: 10.1007/s11882-022-01032-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review In 2015, findings from the Learning Early About Peanut allergy (LEAP) trial provided the first convincing evidence that peanut allergy may be preventable through early peanut introduction into the infant diet. Here we discuss implementation of the LEAP study findings around the world and emerging evidence of the impacts on infant feeding and food allergy. Recent Findings The LEAP findings led to rapid changes in allergy prevention guidelines internationally to recommend early peanut introduction. There is now emerging evidence that this has been followed by a substantial increase in early peanut introduction to infants. Studies investigating the impact of these changes in infant feeding practices on the prevalence of peanut allergy are underway. Summary The LEAP trial represented a significant step forwards in food allergy prevention and new research over the past 5 years has provided insights into how best to implement this intervention in the real world.
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Affiliation(s)
- Jennifer J Koplin
- Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia. .,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
| | - Victoria X Soriano
- Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Rachel L Peters
- Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Rd, Parkville, VIC, 3052, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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29
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Brough HA, Lanser BJ, Sindher SB, Teng JMC, Leung DYM, Venter C, Chan SM, Santos AF, Bahnson HT, Guttman‐Yassky E, Gupta RS, Lack G, Ciaccio CE, Sampath V, Nadeau KC, Nagler CR. Early intervention and prevention of allergic diseases. Allergy 2022; 77:416-441. [PMID: 34255344 DOI: 10.1111/all.15006] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/09/2021] [Indexed: 12/12/2022]
Abstract
Food allergy (FA) is now one of the most common chronic diseases of childhood often lasting throughout life and leading to significant worldwide healthcare burden. The precise mechanisms responsible for the development of this inflammatory condition are largely unknown; however, a multifactorial aetiology involving both environmental and genetic contributions is well accepted. A precise understanding of the pathogenesis of FA is an essential first step to developing comprehensive prevention strategies that could mitigate this epidemic. As it is frequently preceded by atopic dermatitis and can be prevented by early antigen introduction, the development of FA is likely facilitated by the improper initial presentation of antigen to the developing immune system. Primary oral exposure of antigens allowing for presentation via a well-developed mucosal immune system, rather than through a disrupted skin epidermal barrier, is essential to prevent FA. In this review, we present the data supporting the necessity of (1) an intact epidermal barrier to prevent epicutaneous antigen presentation, (2) the presence of specific commensal bacteria to maintain an intact mucosal immune system and (3) maternal/infant diet diversity, including vitamins and minerals, and appropriately timed allergenic food introduction to prevent FA.
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Affiliation(s)
- Helen A. Brough
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | - Bruce Joshua Lanser
- Division of Pediatric Allergy‐Immunology Department of Pediatrics National Jewish Health Denver CO USA
| | - Sayantani B. Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
- Division of Allergy, Immunology and Rheumatology Department of Medicine Stanford University Stanford CA USA
| | - Joyce M. C. Teng
- Department of Dermatology Lucile Packard Children's Hospital at the Stanford University School of Medicine Palo Alto CA USA
| | - Donald Y. M. Leung
- Division of Pediatric Allergy‐Immunology Department of Pediatrics National Jewish Health Denver CO USA
| | - Carina Venter
- Section of Allergy & Immunology School of Medicine University of Colorado DenverChildren's Hospital Colorado Aurora CO USA
| | - Susan M. Chan
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | - Alexandra F. Santos
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Henry T. Bahnson
- Benaroya Research Institute and Immune Tolerance Network Seattle WA USA
| | - Emma Guttman‐Yassky
- Department of Dermatology and the Immunology Institute Icahn School of Medicine at Mount Sinai New York NY USA
- Laboratory for Investigative Dermatology The Rockefeller University New York NY USA
| | - Ruchi S. Gupta
- Center for Food Allergy and Asthma Research Northwestern University Feinberg School of Medicine Chicago IL USA
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago IL USA
| | - Gideon Lack
- Department Women and Children’s Health (Pediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children’s Hospital Guy’s and St. Thomas’s NHS Foundation Trust London UK
| | | | - Vanitha Sampath
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
| | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Division of Pulmonary and Critical Care Medicine Department of Medicine Stanford University Stanford CA USA
- Division of Allergy, Immunology and Rheumatology Department of Medicine Stanford University Stanford CA USA
| | - Cathryn R. Nagler
- Department of Pathology and Pritzker School of Molecular Engineering University of Chicago Chicago IL USA
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The Role of Diet Modification in Atopic Dermatitis: Navigating the Complexity. Am J Clin Dermatol 2022; 23:27-36. [PMID: 34687433 DOI: 10.1007/s40257-021-00647-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 02/06/2023]
Abstract
Diet has long been understood to have an intricate association with atopic dermatitis, although much remains unelucidated. Skin barrier dysfunction with dysbiosis and consequent impairment of immune tolerance likely underly the pathogenesis of coincident atopic dermatitis and food allergy. There is a wide range of possible skin reactions to food, complicating the diagnosis and understanding of food allergies. Many patients, parents, and providers incorrectly suspect diet as causative of atopic dermatitis symptoms and many have tried elimination diets. This frequently leads to inaccurate labeling of food allergies, contributing to a dangerous spiral of inappropriate testing, referrals, and dietary changes, while neglecting established atopic dermatitis treatment essentials. Alternatively, certain dietary supplements or the introduction of certain foods may be beneficial for atopic dermatitis management or prevention. Greater consensus on the role of diet among providers of patients with atopic dermatitis is strongly encouraged to improve the management of atopic dermatitis.
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31
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Abrams EM, Sicherer SH. Tree nut introduction in a peanut-allergic child: To eat, to screen, or to avoid? Pediatr Allergy Immunol 2022; 33:e13669. [PMID: 34553798 DOI: 10.1111/pai.13669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 02/03/2023]
Abstract
There is no defined standard of care around tree nut introduction in a peanut-allergic child, and the role of screening prior to tree nut introduction is controversial. There is some evidence that peanut-allergic children are at increased risk of tree nut allergy, with approximately 23-68% of children with co-existent peanut/tree nut allergy. In some studies, it has been shown that tree nut allergy in children has the potential to be a severe allergy. However, this appears to be age-specific as infant anaphylaxis in general tends to be milder, and there has been no fatality reported on the first ingestion of an allergen in infancy. Familial hesitancy has been identified as a possible condition for undertaking screening tests prior to allergen introduction. Indeed, there has been limited evidence that caregiver hesitancy may exist in peanut-allergic families with tree nut introduction. However, pre-emptive screening has the potential to overdiagnose tree nut allergy and delay introduction (which could paradoxically increase risk). As a result, the decision is best made in the context of shared decision-making and patient preference-sensitive care.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.,Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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32
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Ramsey N, Wang J. Management of Anaphylaxis in Infants and Toddlers. Immunol Allergy Clin North Am 2021; 42:77-90. [PMID: 34823752 DOI: 10.1016/j.iac.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylaxis is a systemic allergic reaction that can be caused by food, drugs, insect bites, or unknown triggers in infants and toddlers. Anaphylaxis rates are increasing. Infants and toddlers may have increased exposure to known and unknown allergens, decreased ability to describe their symptoms, and an expanded differential diagnosis for consideration on presentation. The most common symptoms in these age groups are cutaneous and gastrointestinal. Age-specific language may be helpful for caregivers to identify and describe the symptoms of anaphylaxis in infants and toddlers. Long-term management of anaphylaxis includes allergy evaluation to guide avoidance and assess prognosis and education on allergic reaction management; this incorporates the prescription of epinephrine autoinjector and provision of an allergy emergency plan.
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Affiliation(s)
- Nicole Ramsey
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
| | - Julie Wang
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA.
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33
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Chua GT, Chan ES, Soller L, Cook VE, Vander Leek TK, Mak R. Home-Based Peanut Oral Immunotherapy for Low-Risk Peanut-Allergic Preschoolers During the COVID-19 Pandemic and Beyond. FRONTIERS IN ALLERGY 2021; 2:725165. [PMID: 35387028 PMCID: PMC8974914 DOI: 10.3389/falgy.2021.725165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/23/2021] [Indexed: 12/03/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has led to the deprioritization of non-emergency services, such as oral food challenges and the initiation of oral immunotherapy (OIT) for food-allergic children. Recent studies have suggested that home-based peanut OIT could be a safe and effective option for low-risk peanut-allergic children. In the period between September 1, 2020, and January 31, 2021, nine preschoolers with a history of mild allergic reactions to peanut underwent home-based peanut OIT. Eight of them (88.9%) completed the build-up phase at home in 11–28 weeks, tolerating a daily maintenance dose of 320 mg peanut protein. During the build-up, six patients (75.0%) reported urticaria, three (33.3%) reported gastrointestinal tract symptoms, and one (14.3%) reported oral pruritis. None of the patients developed anaphylaxis, required epinephrine, or attended emergency services related to OIT. One or two virtual follow-up visits were completed per patient during the build-up phase. Our case series shows that home-based OIT could be offered to the low-risk preschoolers during the COVID-19 pandemic when non-emergency services are limited and could be considered beyond the pandemic, especially for the families living in the rural or remote areas that may otherwise be unable to access OIT.
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Affiliation(s)
- Gilbert T. Chua
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR China
- *Correspondence: Gilbert T. Chua
| | - Edmond S. Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Lianne Soller
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Victoria E. Cook
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
- Community Allergy Clinic, Victoria, BC, Canada
| | - Timothy K. Vander Leek
- Pediatric Allergy and Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Raymond Mak
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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34
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Krawiec M, Fisher HR, Du Toit G, Bahnson HT, Lack G. Overview of oral tolerance induction for prevention of food allergy-Where are we now? Allergy 2021; 76:2684-2698. [PMID: 33539570 DOI: 10.1111/all.14758] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 01/10/2023]
Abstract
Oral tolerance induction through early introduction of allergenic food has proven effective in randomized controlled trials. This new approach to weaning has been incorporated into many national and international infants' feeding guidelines. However, there are questions that require further discussion, such as, which foods should be introduced early, should the intervention be targeted to infants at high-risk or to the general population, and what is the ideal timing for early food introduction. This review examines the extent to which recent trials address these critical questions and highlights areas where further research is required.
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Affiliation(s)
- Marta Krawiec
- Department of Women and Children’s Health (Paediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Children’s Allergy Service Evelina London Guy’s and St Thomas’ Hospital London UK
| | - Helen R. Fisher
- Department of Women and Children’s Health (Paediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Children’s Allergy Service Evelina London Guy’s and St Thomas’ Hospital London UK
| | - George Du Toit
- Department of Women and Children’s Health (Paediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Children’s Allergy Service Evelina London Guy’s and St Thomas’ Hospital London UK
- Asthma UK Centre in Allergic Mechanisms of Asthma London UK
| | - Henry T. Bahnson
- Benaroya Research Institute and the Immune Tolerance Network Seattle USA
| | - Gideon Lack
- Department of Women and Children’s Health (Paediatric Allergy) School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Children’s Allergy Service Evelina London Guy’s and St Thomas’ Hospital London UK
- Peter Gorer Department of Immunobiology School of Immunology and Microbial Sciences King’s College London London UK
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35
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Fanning L, Woods E, Hornung CJ, Perrett KP, Tang MLK, Dalziel K. Cost-Effectiveness of Food Allergy Interventions in Children: A Systematic Review of Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1360-1376. [PMID: 34452717 DOI: 10.1016/j.jval.2021.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To identify published economic evaluations of interventions aimed at preventing, diagnosing, or treating food allergies in children. METHODS We examined economic evaluations published from 2000 to 2019. Data analyzed included: food allergy type, study population/setting, intervention/comparator, and economic evaluation details. Quality assessment used reporting and economic modeling checklists. Two reviewers simultaneously undertook article screening, data extraction, and quality assessment. RESULTS 17 studies were included: 8 peanut allergy (PA) studies, 8 cow's milk allergy (CMA) studies, and 1 egg allergy (EA) study. All PA studies reported incremental costs per quality-adjusted life-year gained for diagnostic strategies, management pathways for peanut exposure, and immunotherapies. Immunotherapies rendered inconsistent cost-effectiveness results. CMA studies reported costs per symptom-free day or probability of developing CMA tolerance. Cost-effectiveness of extensively hydrolyzed casein formula for CMA treatment was consistently demonstrated. Early introduction of cooked egg in first year of life dominated all EA prevention strategies. Quality assessment showed average noncompliance for 3.5 items/study (range 0-11) for modeling methods and 3.4 items/study (range 0-8) for reporting quality. Key quality concerns included limited justification for model choice, evidence base for model parameters, source of utility values, and representation of uncertainty. CONCLUSION Recent cost-effectiveness literature of interventions in PA, CMA, and EA is limited and diverse. Interventions for diagnosis and treatment of CMA and prevention of EA were generally cost-effective; however, results for PA were variable and dependent on effectiveness and utility values used. There is a need to expand economic evaluation of interventions for childhood food allergy and to improve methods and reporting.
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Affiliation(s)
- Laura Fanning
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Centre for Health Economics, Monash Business School, Monash University, Victoria, Australia
| | - Ekaterina Woods
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Kirsten P Perrett
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi L K Tang
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kim Dalziel
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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36
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Abrams EM, Shaker M, Greenhawt M, Mack DP. International Peanut Allergy Prevention, 6 Years After the Learning Early About Peanut Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:71-77. [PMID: 34311123 DOI: 10.1016/j.jaip.2021.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/26/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
Six years ago, the Learning Early About Peanut (LEAP) trial findings helped fundamentally shift the paradigm of peanut allergy prevention. Although the results of LEAP are well accepted, policy-makers, caregivers, and clinicians struggle with how best to implement and apply the study's key findings in clinical practice. Differences in guidelines highlight issues related to peanut allergy prevention implementation, including caregiver acceptability, cost, fidelity, feasibility, appropriateness, and adoption. The goals of this rostrum are to review how the LEAP study has informed international peanut allergy prevention policy, as well as to review the strengths and ongoing controversies in peanut allergy prevention implementation.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth, Hanover, NH
| | - Matthew Greenhawt
- Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Halton Pediatric Allergy, Burlington, Ontario, Canada
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37
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Abrams EM, Greenhawt M, Alqurashi W, Singer AG, Shaker M. The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3911-3917. [PMID: 34147680 DOI: 10.1016/j.jaip.2021.05.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022]
Abstract
Overdiagnosis of anaphylaxis risk is an underappreciated aspect of anaphylaxis prevention. Whereas the benefits of anaphylaxis-risk prevention are well known, potential harms resulting from preemptive approaches to mitigate anaphylaxis-risk are not insignificant. Still, great progress has been made in recent years to avoid the unintended consequences of anaphylaxis-risk overdiagnosis. Reflection on recent advances in the use of diagnostic testing, as well as the application of diagnostic labels, provides an important perspective to understand how far the specialty of allergy and immunology has come in improving the lives of patients and families. Examples of recent paradigm shifts in anaphylaxis-risk management include approaches to peanut allergy prevention without screening, deferral of corticosteroids to prevent biphasic anaphylaxis reactions, reevaluation of reflex use of emergency medical services for resolved community anaphylaxis, and an approach to penicillin allergy delabeling with direct oral challenge. Routine medical practices to decrease anaphylaxis risk can have lifelong impacts for patients-beyond just preventing anaphylaxis. As our understanding of these trade-offs evolves, it becomes necessary to weigh both the benefits and the harms of past management approaches. Because medicine remains a science of uncertainty and an art of probability, a critical approach to risk mitigation remains necessary to find the often-elusive balance in anaphylaxis prevention.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | | | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH.
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Kennedy K, Alfaro MKC, Spergel ZC, Dorris SL, Spergel JM, Capucilli P. Differences in oral food challenge reaction severity based on increasing age in a pediatric population. Ann Allergy Asthma Immunol 2021; 127:562-567.e1. [PMID: 34010700 DOI: 10.1016/j.anai.2021.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/16/2021] [Accepted: 05/07/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Food allergy reactions range from mild to severe with differences in age appearing to be an important factor associated with reaction severity. OBJECTIVE To define differences in oral food challenge (OFC) reaction severity in pediatric patients from infancy to adolescence using objective clinical outcomes and standardized reaction grading tools. METHODS Retrospective review of all positive OFC results at 2 large institutions between September 2016 and February 2019. Reaction severity was defined by presence of cardiovascular, neurologic, lower respiratory, or laryngeal symptoms, epinephrine requirement, and grading using 2 established food allergy reaction scales. RESULTS Infants and toddlers had fewer reactions involving cardiovascular, neurologic, lower respiratory, or laryngeal symptoms compared with older age groups. Epinephrine was also required less frequently during reactions in infants and toddlers, compared with older age groups. There was no difference in reaction severity in infants and toddlers based on clinical history of eczema. Increasing age was significantly correlated with increased epinephrine requirement (R2 = 0.12, P = .002), elevated Consortium of Food Allergy Research score (R2 = .012, P = .003), and approached significance for increased Practical Allergy score (R2 = .005, P = .05). History of asthma and sesame allergy were identified to be positively correlated with more severe reactions. CONCLUSION Infants and young toddlers have less severe reactions during OFCs compared with older age groups supporting early food introduction practices. In children under 12 months of age, severe reactions are most rare calling into question screening practices using specific allergy testing before food introduction. Standardized reaction grading tools may be valuable instruments to categorize reaction severity during OFCs.
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Affiliation(s)
- Katie Kennedy
- Division of Allergy and Clinical Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Maria Katerina C Alfaro
- Division of Allergy and Clinical Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Stacy L Dorris
- Division of Allergy and Clinical Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan M Spergel
- Division of Allergy and Clinical Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Peter Capucilli
- Division of Allergy and Clinical Immunology, Rochester Regional Health, Rochester, New York
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Fisher HR, Lack G, Roberts G, Bahnson HT, Du Toit G. Medical algorithm: Early introduction of food allergens in high-risk populations. Allergy 2021; 76:1592-1594. [PMID: 33346913 DOI: 10.1111/all.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/23/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Helen R. Fisher
- Department of Women and Children's Heath Paediatric Allergy Group School of Life Course Sciences King’s College London London UK
- Peter Gorer Department of Immunobiology Paediatric Allergy Group School of Immunology and Microbial Sciences King’s College London London UK
| | - Gideon Lack
- Department of Women and Children's Heath Paediatric Allergy Group School of Life Course Sciences King’s College London London UK
- Peter Gorer Department of Immunobiology Paediatric Allergy Group School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children's Hospital, Guy’s and St. Thomas’ NHS Foundation Trust London UK
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre St Mary’s Hospital Newport UK
- NIHR Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
- Faculty of Medicine, Clinical and Experimental Sciences Human Development in Health Academic Units University of Southampton Southampton UK
| | - Henry T. Bahnson
- Immune Tolerance Network Benaroya Research Institute Seattle WA USA
| | - George Du Toit
- Department of Women and Children's Heath Paediatric Allergy Group School of Life Course Sciences King’s College London London UK
- Peter Gorer Department of Immunobiology Paediatric Allergy Group School of Immunology and Microbial Sciences King’s College London London UK
- Children’s Allergy Service Evelina Children's Hospital, Guy’s and St. Thomas’ NHS Foundation Trust London UK
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40
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Keet C, Pistiner M, Plesa M, Szelag D, Shreffler W, Wood R, Dunlop J, Peng R, Dantzer J, Togias A. Age and eczema severity, but not family history, are major risk factors for peanut allergy in infancy. J Allergy Clin Immunol 2021; 147:984-991.e5. [PMID: 33483153 PMCID: PMC8462937 DOI: 10.1016/j.jaci.2020.11.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether to screen high-risk groups before early peanut introduction is controversial. OBJECTIVE We sought to determine the risk of peanut allergy (PA) before peanut introduction for infants with (1) moderate-severe eczema, (2) another food allergy (FA), and/or (3) a first-degree relative with peanut allergy (FH). METHODS Infants aged 4 to 11 months with no history of peanut ingestion, testing, or reaction and at least 1 of the above risk factors received peanut skin prick test and, depending on skin prick test wheal size, oral food challenge or observed feeding. RESULTS A total of 321 subjects completed the enrollment visit (median age, 7.2 months; 58% males); 78 had eczema only, 11 FA only, 107 FH only, and 125 had multiple risk factors. Overall, 18% of 195 with eczema, 19% of 59 with FA, and 4% of 201 with FH had PA. Only 1% of 115 with FH and no eczema had PA. Among those with eczema, older age (odds ratio [OR], 1.3; 95% CI, 1.04-1.68 per month), higher SCORing Atopic Dermatitis score (OR, 1.19; 95% CI, 1.06-1.34 per 5 points), black (OR, 5.79; 95% CI, 1.92-17.4 compared with white), or Asian race (OR, 6.98; 95% CI, 1.92-25.44) and suspected or diagnosed other FA (OR, 3.98; 95% CI, 1.62-9.80) were associated with PA. CONCLUSIONS PA is common in infants with moderate-severe eczema, whereas FH without eczema is not a major risk factor, suggesting screening only in those with significant eczema. Even within the first year of life, introduction at later ages is associated with a higher risk of PA among those with eczema, supporting introduction of peanut as early as possible.
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Affiliation(s)
- Corinne Keet
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.
| | - Michael Pistiner
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Mihaela Plesa
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Daria Szelag
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Wayne Shreffler
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Robert Wood
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Joan Dunlop
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Roger Peng
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Jennifer Dantzer
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Md
| | - Alkis Togias
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md
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41
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Sugiura S, Hiramitsu Y, Futamura M, Kamioka N, Yamaguchi C, Umemura H, Ito K, Camargo CA. Development of a prediction model for infants at high risk of food allergy. Asia Pac Allergy 2021; 11:e5. [PMID: 33604275 PMCID: PMC7870367 DOI: 10.5415/apallergy.2021.11.e5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background Identification of risk factors for food allergy (FA) in infants is an active research area. An important reason is to identify optimal target infants for early introduction of specific food antigens. Although eczema has been used for this purpose, multivariable prediction scores have not been reported. Objective The aim of this research is to develop a multivariable prediction score for infants at high risk of FA. Methods We performed a cross-sectional analysis of a self-administered questionnaire for the parents of 18-month-old children at well-child visits between April 2016 and March 2017 (development dataset) and between April 2017 and March 2018 (validation dataset). We developed and validated the prediction score. Results The questionnaire collection rate was 18,549 of 20,198 (92%) in the development dataset and 18,620 of 19,977 (93%) in the validation dataset. Risk factors for FA were being born in August–December, first child, eczema, atopic dermatitis in father and mother, and FA in mother and sibling(s). For identifying infants with FA, the developed multivariable prediction score showed higher discrimination ability (area under the curve [AUC] = 0.75) than focusing on eczema (AUC = 0.70) in the validation dataset. The score was also useful for identifying infants with a history of anaphylaxis (AUC = 0.73) than focusing on eczema (AUC = 0.67) in the validation dataset. Conclusion The new prediction score enables more efficient identification of infants at high risk of FA, who may be the optimal target group for the early introduction of specific antigens.
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Affiliation(s)
- Shiro Sugiura
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Aichi Children's Health and Medical Center, Obu, Japan
| | - Yoshimichi Hiramitsu
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Nagoya City Public Health Research Institute, Nagoya City, Japan
| | - Masaki Futamura
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Division of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naomi Kamioka
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Department of Pediatrics, Nagoya City West Medical Center, Nagoya, Japan
| | - Chikae Yamaguchi
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Nagoya City University Graduate School of Nursing, Nagoya City, Japan
| | - Harue Umemura
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Department of Nutrition, Nagoya University of Arts and Sciences, Nissin, Japan
| | - Komei Ito
- Committee for the Prevention of Pediatric Allergic Disease, Nagoya City, Japan.,Aichi Children's Health and Medical Center, Obu, Japan
| | - Carlos A Camargo
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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42
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Abrams EM, Singer AG, Shaker M, Greenhawt M. What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:608-612. [PMID: 33253924 PMCID: PMC7691847 DOI: 10.1016/j.jaip.2020.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022]
Abstract
The coronavirus disease 2019 pandemic has forever changed how we view health care service delivery. Although there are undoubtedly some unintended consequences that will result from current health care service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. To determine what is "routine," what is "essential," and what is "exceptional," it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement definition of the dimensions of quality is based on whether the care is safe, effective, patient-centered, timely, efficient, and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the coronavirus disease 2019 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-coronavirus disease health care system.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.
| | - Alexander G Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcus Shaker
- Dartmouth-Hitchcok Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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43
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Lo RM, Purington N, McGhee SA, Mathur MB, Shaw GM, Schroeder AR. Infant Allergy Testing and Food Allergy Diagnoses Before and After Guidelines for Early Peanut Introduction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:302-310.e9. [DOI: 10.1016/j.jaip.2020.10.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022]
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Tsuang A, Chan ES, Wang J. Food-Induced Anaphylaxis in Infants: Can New Evidence Assist with Implementation of Food Allergy Prevention and Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:57-69. [DOI: 10.1016/j.jaip.2020.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 01/06/2023]
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An update on international practice variation in peanut introduction: conundrums, controversies, and a new direction. Curr Opin Pediatr 2020; 32:825-831. [PMID: 33060444 DOI: 10.1097/mop.0000000000000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Introduction of peanut during the first year of life is associated with an 81% relative risk reduction of developing peanut allergy in infants with severe eczema, egg allergy, or both. However, significant international variation exists in risk stratification prior to peanut introduction. RECENT FINDINGS A policy-level screening approach, such as the one in the United States, is not practical and is associated with higher costs and more cases of peanut allergy over time, in contrast to international models that recommend universal early introduction without prescreening. In Australia, population-level efforts to introduce peanut early without screening have demonstrated high rates of peanut introduction before 12 months of age and low rates of severe allergic reactions. In contrast, screening prior to peanut introduction in the United States is associated with 'screening creep' - the tendency of clinicians to test populations where screening is not recommended. SUMMARY Early peanut introduction can reduce the risk of developing food allergy and is more effective without a risk-based screening approach. In some circumstances, shared clinical decision-making can facilitate food allergy prevention in a manner consistent with family values and preferences.
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Fleischer DM, Chan ES, Venter C, Spergel JM, Abrams EM, Stukus D, Groetch M, Shaker M, Greenhawt M. A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:22-43.e4. [PMID: 33250376 DOI: 10.1016/j.jaip.2020.11.002] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
Recently published data from high-impact randomized controlled trials indicate the strong potential of strategies to prevent the development of food allergy in high-risk individuals, but guidance in the United States at present is limited to a policy for only the prevention of peanut allergy, despite other data being available and several other countries advocating early egg and peanut introduction. Eczema is considered the highest risk factor for developing IgE-mediated food allergy, but children without risk factors still develop food allergy. To prevent peanut and/or egg allergy, both peanut and egg should be introduced around 6 months of life, but not before 4 months. Screening before introduction is not required, but may be preferred by some families. Other allergens should be introduced around this time as well. Upon introducing complementary foods, infants should be fed a diverse diet, because this may help foster prevention of food allergy. There is no protective benefit from the use of hydrolyzed formula in the first year of life against food allergy or food sensitization. Maternal exclusion of common allergens during pregnancy and/or lactation as a means to prevent food allergy is not recommended. Although exclusive breast-feeding is universally recommended for all mothers, there is no specific association between exclusive breast-feeding and the primary prevention of any specific food allergy.
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Affiliation(s)
- David M Fleischer
- Section of Allergy & Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Edmond S Chan
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Carina Venter
- Section of Allergy & Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Elissa M Abrams
- Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - David Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Marion Groetch
- Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Greenhawt
- Section of Allergy & Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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47
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Mack DP, Chan ES, Shaker M, Abrams EM, Wang J, Fleischer DM, Hanna MA, Greenhawt M. Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:2851-2857. [PMID: 32721605 PMCID: PMC7382335 DOI: 10.1016/j.jaip.2020.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023]
Abstract
The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.
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Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
| | - Edmond S Chan
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Elissa M Abrams
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julie Wang
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David M Fleischer
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Mariam A Hanna
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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Abrams EM, Primeau MN, Kim H, Gerdts J, Chan ES. Increasing Awareness of the Low Risk of Severe Reaction at Infant Peanut Introduction: Implications During COVID-19 and Beyond. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3259-3260. [PMID: 32896651 PMCID: PMC7473022 DOI: 10.1016/j.jaip.2020.08.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/19/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada.
| | - Marie-Noel Primeau
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Harold Kim
- Division of Allergy and Clinical Immunology, Western University, London, ON, Canada; Division of Allergy and Clinical Immunology, McMaster University, Hamilton, ON, Canada
| | | | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Abrams EM, Brough HA, Keet C, Shaker MS, Venter C, Greenhawt M. Pros and cons of pre-emptive screening programmes before peanut introduction in infancy. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:526-535. [PMID: 32562634 DOI: 10.1016/s2352-4642(20)30029-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/29/2022]
Abstract
Peanut allergy is an important public health concern and causes substantial psychosocial comorbidity. Although fatal anaphylaxis is rare (occurring at 0·03-0·3 per million person-years in the general population), peanuts are one of the most frequent causes of food allergy mortality. The Learning Early About Peanut study transformed prevention of peanut allergy by showing that early introduction of peanut into the diet of children at high risk (ie, those with an egg allergy or severe eczema) reduced the relative risk of peanut allergy at age 5 years by 81%. Following publication of this study, the US National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, convened an expert panel, which recommended that, for infants with severe eczema or egg allergy, health professionals should strongly consider evaluation with peanut-specific serological IgE or skin prick test (or both) and, if necessary, an oral food challenge before peanut introduction. In the USA, depending on test results, peanut-containing foods are recommended to be introduced from age 4-6 months in infants with severe eczema or egg allergy. Early introduction to peanuts is also advocated for children with either mild to moderate or no eczema, and in children who are not allergic to egg, but without screening before peanut introduction. However, the NIAID addendum guidelines contrast with other international approaches that do not advocate for allergy screening at a population level before introducing peanuts into infants' diets. In this Review, we evaluate the advantages and disadvantages of a pre-emptive screening approach before the early introduction of peanuts in infants at high risk of peanut allergy.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Helen A Brough
- School of Life Course Sciences, King's College London, Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Corinne Keet
- Division of Pediatric Allergy and Immunology, Johns Hopkins School of Medicine, and Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Marcus S Shaker
- Department of Pediatrics, Section of Allergy, Asthma and Clinical Immunology, Dartmouth Geisel School of Medicine, Lebanon, NH, USA; Department of Pediatrics, Section of Allergy, Asthma and Clinical Immunology, Children's Hospital at Dartmouth-Hitchcock, Lebanon, NH, USA
| | - Carina Venter
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Greenhawt
- Section of Allergy and Immunology, University of Colorado Denver School of Medicine, Children's Hospital Colorado, Aurora, CO, USA.
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50
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Chan A, Feuille E, Schussler E. Outcomes of 88 infant food challenges conducted in the allergy office. Ann Allergy Asthma Immunol 2020; 125:609-611. [PMID: 32687986 DOI: 10.1016/j.anai.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/13/2020] [Accepted: 07/10/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Angela Chan
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Elizabeth Feuille
- Division of Pulmonary, Allergy and Immunology, Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Edith Schussler
- Division of Pulmonary, Allergy and Immunology, Department of Pediatrics, Weill Cornell Medicine, New York, New York.
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