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

Biomarkers of peanut allergy in children over time

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.

Experiences and perceptions of people with celiac disease, food allergies and food intolerance when dining out

Introduction

Eating out is a common practice in modern society. Celiac disease (CeD) and food allergy (FA) are among the most common conditions responsible for adverse reactions to food. Despite their different origins, both require treatment with restrictive diets (avoidance of gluten and/or specific allergens) and this results posing similar challenges when eating out. Our objective was to learn about the experiences/perceptions of consumers with CeD and FA when dining out, as well as the challenges they face in food service environments.

Methods

An ad hoc questionnaire was used to record consumer perceptions, food service characteristics and resulting adverse reactions.

Results

377 individuals living in Santiago, Chile, provided complete information and were analyzed (160 CeD, 105 FA). 301 participants (79.8%) declared eating out, 33.6% reported experiencing an adverse reaction at least once while eating out. 94.4% of the 377 participants believed that the serving staff had little or no knowledge about his/her condition. Consumers reporting symptoms as severe adverse reactions were more common among celiac than allergic patients (p < 0.001).

Discussion

The study showed no significant differences based on consumer-related characteristics (p:NS). The consequences of eating out did not vary based on individual's data, including diagnosis, age, frequency of eating out, adverse reactions experienced, or intensity. These findings suggest that the most important determinants of risk associated with eating out are characteristics of the food service, like availability of information, staff training, and establishment's facilities like equipment available, exclusive utensils for customers with special dietary needs and kitchen and bathrooms organization.

Exploratory immunogenicity outcomes of peanut oral immunotherapy: Findings from the PALISADE trial

BACKGROUND

Immunoglobulin E (IgE) and immunoglobulin G4 (IgG4) to peanut and its components may influence the clinical reactivity to peanut. Allergen-specific immunotherapy is known for modifying both IgE and IgG4. Peanut oral immunotherapy may influence these serological parameters.

METHODS

Exploratory analyses of serological data from participants receiving peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) and placebo in the double-blind, randomized, phase 3 PALISADE trial were conducted to evaluate potential relationships between peanut-specific and peanut component-specific (Ara h 1, Ara h 2, Ara h 3, Ara h 6, Ara h 8, and Ara h 9) IgE and IgG4 levels and clinical outcomes.

RESULTS

A total of 269 participants (PTAH, n = 202; placebo, n = 67) were analyzed. No relationship was observed between specific IgE and IgG4 levels at screening and maximum tolerated peanut protein dose during screening or response status during exit double-blind placebo-controlled food challenge (DBPCFC). In PTAH-treated participants, no relationship was observed between IgE and IgG4 levels at screening and maximum symptom severity during exit DBPCFC. Postscreening ratios (ie, postscreening/screening) in the PTAH group were significant at the end of updosing and exit visit for most components. Postscreening changes in specific IgE levels were more pronounced with PTAH versus placebo for most components.

CONCLUSIONS

Specific IgE and IgG4 levels at screening are not correlated with screening or exit DBPCFC results, and are not predictive of clinical response to PTAH. Peanut (Arachis hypogaea) allergen powder-dnfp contains the relevant and immunodominant allergens, inducing immunological changes with the treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02635776.

Natural history of cow's milk allergy in children aged 6-12 years

BACKGROUND

Approximately 50%-90% of children with immediate-type cow's milk allergy (CMA) acquire tolerance by pre-school age. We aimed to investigate the acquisition rate of CMA tolerance in children aged 6-12 years.

METHODS

We included children with CMA who persisted until the age of 6. Tolerance was defined as passing an oral food challenge with 200 mL of unheated cow's milk (CM) or consuming 200 mL of CM without symptoms, whereas persistent CMA was defined as fulfilling neither of these criteria by 12 years old. Children receiving oral immunotherapy (OIT) were excluded from the primary analysis. Risk factors associated with persistent CMA were assessed using Cox regression analysis.

RESULTS

Of 80 included children, 30 (38%) had previous CM anaphylaxis, and 40 (50%) had eliminated CM completely from their diet. The median CM-specific immunoglobulin E (sIgE) level at 6 years old was 12.0 kUA /L. Tolerance was acquired by 25 (31%) and 46 (58%) children by the age of 9 and 12 years, respectively. At baseline, persistent CMA was associated with higher CM-sIgE levels (hazard ratio 2.29, 95% confidence interval 1.41-3.73, optimal cutoff level 12.7 kUA /L), previous CM anaphylaxis (2.07, 1.06-4.02), and complete CM elimination (3.12, 1.46-6.67). No children with CMA who had all three risk factors (n = 14) acquired tolerance.

CONCLUSION

Except for OIT patients, more than half of children with CMA at 6 years old acquired tolerance by 12 years old. Children with CMA who have the risk factors are less likely to acquire tolerance.

Salivary interleukin-17A and interferon-γ levels are elevated in children with food allergies in China

Introduction

Food allergies have a substantial impact on patient health, but their mechanisms are poorly understood, and strategies for diagnosing, preventing, and treating food allergies are not optimal. This study explored the levels of and relationship between IL-17A and IFN-γ in the saliva of children with food allergies, which will form the basis for further mechanistic discoveries as well as prevention and treatment measures for food allergies.

Methods

A case-control study with 1:1 matching was designed. Based on the inclusion criteria, 20 case-control pairs were selected from patients at the Skin and Allergy Clinic and children of employees. IL-17A and IFN-γ levels in saliva were measured with a Luminex 200 instrument. A general linear model was used to analyze whether the salivary IL-17A and IFN-γ levels in the food allergy group differed from those in the control group.

Results

The general linear model showed a significant main effect of group (allergy vs. healthy) on the levels of IL-17A and IFN-γ. The mean IL-17A level (0.97 ± 0.09 pg/ml) in the food allergy group was higher than that in the healthy group (0.69 ± 0.09 pg/ml). The mean IFN-γ level (3.0 ± 0.43 pg/ml) in the food allergy group was significantly higher than that in the healthy group (1.38 ± 0.43 pg/ml). IL-17A levels were significantly positively related to IFN-γ levels in children with food allergies (r=0.79) and in healthy children (r=0.98).

Discussion

The salivary IL-17A and IFN-γ levels in children with food allergies were higher than those in healthy children. This finding provides a basis for research on new methods of diagnosing food allergies and measuring the effectiveness of treatment.

The epidemiology of food allergy in primary care clinic: A cross-sectional study

Food allergy (FA) is an increasing global public health concern. Little is known about FA counsel in primary care clinics. The objective of this study is to describe the characteristics of FA in primary care clinics. It also aims to report the national primary care physicians' current knowledge and practices. An electronic cross-sectional questionnaire was distributed to primary care physicians working at the Ministry of Health primary care clinics, across Kuwait's' 6 health districts, between May and June 2023. The questionnaire was made of 3 sections: participants' demographic, FA counsel characteristics, participants' knowledge and practices during FA counsel, and 37 variable tools. Eight-seven percent of primary care physicians counseled a patient with FA within the last 12 months. Most FA patients were children and infants. Approximately 2 out of 10 primary physicians counseled > 1 FA case/week. Prevalence of clinical presentation was: angioedema (23%), many skin hives (21%), few skin hives (19%), and mouth itch (9.4%). Prevalence of allergens was; peanuts (46%), shellfish (37%), eggs (36%), and tree nuts (36%), respectively. The mean of primary care physicians' correct answers about FA was 58% and only 26% of primary care physicians acquired a sufficient amount of knowledge about FA, scoring above 67%. Their Knowledge scores about FA: clinical presentation 7 ± 1.6, diagnostic tests 2 ± 1, treatment 2.6 ± 1, and prevention 3 ± 1. In practice, correct treatment was offered by 30% of physicians, and 55% made the right referrals 86% are longing for training about FA. FA is a common counsel in primary care clinics. The most common FA presentation is a severe allergic reaction in the pediatric population. The current primary care physicians have insufficient knowledge about counseling FA and long for further training. Collectively, protocols and training for FA counseling should be launched in primary care.

Sesame allergy in children: New insights into diagnosis and management

Sesame is a potentially potent allergen that can trigger skin, gastrointestinal, and respiratory tract symptoms, and anaphylaxis. Only 20% to 30% of sesame-allergic children develop tolerance. The prevalence of sesame allergy depends on local diets and ranges from 0.1% to 0.9%. A high risk of accidental exposure to sesame has resulted in mandatory food labeling in many countries. More than half of patients with sesame allergy are also allergic to peanut/tree nuts. Serum-specific IgE testing with a quantitative Ses i 1 component can be performed safely and has higher clinical specificity and better positive predictive value for oral food challenge (OFC) than whole sesame extract or skin prick testing (SPT). Compared with SPT or OFC, in vitro Ses i 1 testing requires no special techniques and carries no risk of reactions. Diagnosis of suspected sesame allergy begins with a thorough history and physical examination. A positive sesame extract test (≥0.1 kUA /L) should prompt further testing. In patients with a high probability of reacting, results of component testing may facilitate a decision about performing an OFC. In a Japanese study of OFC and Ses i 1, there was a 5% probability of a positive OFC with Ses i 1 sIgE levels <0.13 kUA /L, and a 50% probability of a positive OFC with levels >32.0 kUA /L. Most patients could safely consume sesame if sIgE levels were <0.13 kUA /L. Ses i 1 testing can be used to guide appropriate management (avoidance, emergency medication, and oral immunotherapy).

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions

Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country's response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Food allergy knowledge, attitudes and beliefs of kindergarten teachers in Kuwait: a cross-sectional study

BACKGROUND

Food allergy (FA) affects up to 10% of children globally, with clinical symptoms varying from mild to severe, and in rare instances, it is life-threatening. Approximately one in five children with FA experience a food-induced allergic reaction in school, leaving teachers as the first line of intervention. This study aimed to assess kindergarten teachers' knowledge, attitudes and beliefs regarding FA.

METHODS

This cross-sectional study enrolled kindergarten teachers in Kuwait using stratified cluster sampling. The Chicago Food Allergy Research Survey for the General Public was used to assess teachers' knowledge, attitudes and beliefs regarding FA. The overall FA knowledge score was calculated for each participant. The χ² test was used to assess the differences in the distribution of categorical variables.

RESULTS

Responses were obtained from 882 public kindergarten teachers from 63 kindergartens. Most teachers (81.9%) encountered students with FA in their classrooms. Only 13.5% of the teachers reported receiving training in FA. Overall, participants scored an average of 52.2% on the FA knowledge assessment, with participants receiving prior training in FA scoring on average higher than those with no prior training in FA (55.9% vs 51.6%, p=0.005). A few teachers (10.7%) were aware that lactose intolerance was not equivalent to milk allergy. In terms of attitudes regarding FA, only 14.9% of the participants acknowledged that children with FA are teased/stigmatised due to their condition, and 33.7% recognised that avoidance of allergenic food is difficult. Moreover, only 9.9% of the teachers self-reported their ability to use an epinephrine autoinjector.

CONCLUSIONS

Improved knowledge and awareness of FA among public kindergarten teachers in Kuwait are needed to ensure the safety of children with FA in schools. Teachers should be trained to prevent, recognise and manage FA-related allergic reactions.

Nutritional Management of Children with Food Allergies

Purpose of the Review

The purpose of the review is to review the evidence for the nutritional management of paediatric food allergy and provide a practical approach for healthcare professionals working in this area.

Recent Findings

Dietary elimination remains the mainstay for management of food allergies in children. However, the elimination of food allergens increases the risk for growth faltering, micronutrient deficiencies and feeding difficulties. Breastmilk remains the ideal source of nutrition for infants, but when not available, the vast majority will tolerate an extensively hydrolysed formula, and rice hydrolysate has also been suggested as a suitable alternative. Only in severe cases, including anaphylaxis, eosinophilic oesophagitis and growth faltering, is an amino acid formula indicated. The early introduction of peanut and egg and avoiding the delay in the introduction of other allergens, when not already allergic, has been highlighted by recent studies.

Summary

Whilst the elimination of allergens increases the risk of developing poor growth, micronutrient deficiencies and feeding difficulties, optimal, early dietary input, including advice on active introduction of allergens and alternative feeds, ideally from a registered dietitian/nutritionist, may be prevent and improve outcomes.

The links between allergen exposure and sensitization in children and adolescents: an overview for the clinician

INTRODUCTION

The links between allergen exposure and sensitization are complex and depend not only on the type of allergen but on various genetic and environmental factors.

AREAS COVERED

This review discusses the link between allergen exposure and atopic sensitization for different types of allergens and the factors that mediate or affect this link. For the purposes of this review search of PubMed was undertaken to identify English language articles using the terms 'sensitization' and 'allergen exposure' and 'children/or adolescents.'

EXPERT OPINION

Regarding food sensitization, the available data for peanuts and eggs suggest that there is a window period between 4 and 6 months of age when the introduction of these foods may limit sensitization and clinically overt allergy to the respective foods. As far as it concerns aeroallergens, it seems that there is a complex and variable relationship between mite exposure and specific sensitization especially if the exposure occurs early in life. Early exposure to dog allergens does not seem to be associated with specific sensitization; regarding cats, the results are still inconsistent. Several factors may mediate the relationship between early exposure to allergens and the development of sensitization or clinical allergy.

Differences between pediatric and adult atopic dermatitis

Atopic dermatitis (AD) is a common disease with a broad spectrum of clinical manifestations. AD can manifest differently in adults than children. Core AD features are similar between children and adults overall, including lesions affecting flexural areas, presence of atopy, and xerosis. Adults have more signs of chronic disease, higher prevalence and different patterns of hand eczema, and a stronger relationship of disease activity with emotional factors, whereas children with AD have more exudative lesions, perifollicular accentuation, pityriasis alba, Dennie-Morgan folds, and seborrheic dermatitis-like presentation. These differences may be due in part to pathophysiologic differences in AD in children compared with adults. Atopic diseases commonly co-occur with AD, although most do not temporally have the "atopic march." Further research is warranted to better understand the differential roles of immune dysregulation, epidermal-barrier disruption, and dysbiosis between children and adults and determine whether such differences translate into differences in therapeutic efficacy.

The Economic Burden of Food Allergy: What We Know and What We Need to Learn

Purpose of Review

Food allergy management and treatment require dietary modification, are associated with significant burdens, and affect food choices and behaviours. Emerging therapies, such as oral immunotherapy (OIT), provide a glimmer of hope for those living with the condition. Some burdens have received substantial focus, whereas many knowledge gaps on the significance of other impacts, including economic burden, remain.

Recent Findings

Evidence from many countries, but disproportionately from the United States, supports that food allergy carries significant healthcare and societal costs. Early introduction for the prevention of food allergies is theoretically cost-effective, but remains largely undescribed. Unique considerations, such as those to cow’s milk protein allergy, which affects a substantial proportion of infants, and adrenaline autoinjectors, which have a high cost-per-use, require a balance between cost-effectiveness to the healthcare system and adverse outcomes. Household costs have largely been explored in two countries, but owing to different healthcare structures and costs of living, comparisons are difficult, as are generalisations to other countries. Stock epinephrine in schools may present a cost-effective strategy, particularly in economically disadvantaged areas. Costs relating to OIT must be examined within both immediate benefits, such as protection from anaphylaxis, and long-term benefits, such as sustained unresponsiveness.

Summary

Although the absolute costs differ by region/country and type of food allergy, a consistent pattern persists: food allergy is a costly condition, to those who live with it, and the multiple stakeholders with which they interact.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40521-022-00306-5.

Introduction of Heated Cow's Milk Protein in Challenge-Proven Cow's Milk Allergic Children: The iAGE Study

The introduction of baked milk products in cow’s milk (CM) allergic children has previously been shown to accelerate induction tolerance in a selected group of children. However, there is no standardized baked milk product on the market. Recently, a new standardized, heated and glycated cow’s milk protein (HP) product was developed. The aim of this study was to measure safety and tolerability of a new, well characterized heated CM protein (HP) product in cow’s milk allergic (CMA) children between the age of 3 and 36 months. The children were recruited from seven clinics throughout The Netherlands. The HP product was introduced in six incremental doses under clinical supervision. Symptoms were registered after introduction of the HP product. Several questionnaires were filled out by parents of the children. Skin prick tests were performed with CM and HP product, sIgE to CM and α-lactalbumin (Bos d4), β-lactoglobulin (Bos d5), serum albumin (Bos d 6), lactoferrin (Bos d7) and casein (Bos d8). Whereas 72% percent (18 out of 25) of the children tolerated the HP product, seven children experienced adverse events. Risk factors for intolerance to the HP product were higher skin prick test (SPT) histamine equivalent index (HEP) results with CM and the HP product, higher specific IgE levels against Bos d4 and Bos d8 levels and Bos d5 levels. In conclusion, the HP product was tolerated by 72% of the CM allergic children. Outcomes of SPT with CM and the HP product, as well as values of sIgE against caseins, α-lactalbumin, and β-lactoglobulin may predict the tolerability of the HP product. Larger studies are needed to confirm these conclusions.

Self-Efficacy Among Caregivers of Children With Food Allergy: A Cohort Study

Objective

The prevalence of pediatric food allergy (FA) is increasing and, due to early disease onset, requires significant caregiver management that is associated with psychosocial burden. Caregiver perception of how they cope and handle FA-related events (self-efficacy) has been linked to psychosocial outcomes in racially/geographically homogenous samples. This study explores FA-related caregiver self-efficacy and associations with FA-related caregiver quality of life (QoL) in a diverse cohort.

Methods

Caregivers of children, diagnosed with IgE-mediated FA who identified as non-Hispanic Black or White, were recruited from U.S. academic allergy clinics. Caregivers completed demographic and medical questionnaires, the Food Allergy Self-Efficacy Scale for Parents (FASE-P), Food Allergy Independent Measure—Parent Form (FAIM), and the Food Allergy Quality of Life—Parental Burden (FAQL-PB). Bivariate and multivariate associations estimated relationships between study variables.

Results

Caregivers of 365 children (Mage = 5.8 years, 62.2% male, 31.1% Black) were enrolled. Caregivers reported high FA self-efficacy (M = 82.06/100), moderate perceptions of risk/FA severity (FAIM: M = 3.9/7), and some limitations on the FAQL-PB (M = 3.9/7). Self-efficacy was related to lower perceptions of risk/FA severity across all demographic groups (r = −.42, p &lt; .001). Caregivers who reported higher self-efficacy reported better QoL, particularly Black caregivers (r = .67).

Conclusions

In this sample of caregivers of children with FA, greater self-efficacy was related to improved QoL regardless of sociodemographic factors. Caregivers’ perception of risk was lower for those with greater self-efficacy. Future research into the impact of FA management on QoL among diverse caregivers is needed.

Efficacy and Safety of Baked Milk Oral Immunotherapy in Children with Severe Milk Allergy: A Randomized, Double-blind, Placebo-controlled Phase 2 Trial

BACKGROUND

Cow's milk allergy is the most common food allergy in young children and has no current treatment. Oral immunotherapy studies to date have shown efficacy but high rates of adverse reactions.

OBJECTIVE

We sought to evaluate the safety and efficacy of baked milk oral immunotherapy (BMOIT) in baked milk allergic children.

METHODS

Participants (3-18 years) were randomized to receive BMOIT or placebo for 12 months. Efficacy was assessed by double-blind placebo-controlled food challenge after 12 months of treatment. Safety, quality of life, and mechanistic parameters were also evaluated.

RESULTS

11/15 (73%) of the BMOIT participants reached the primary endpoint, tolerating 4044 mg of baked milk protein after 12 months of OIT, compared to 0/15 (0%) on placebo. The median maximal tolerated dose (MTD) and median change from baseline was significantly higher in the BMOIT group compared to placebo (median MTD 4044mg vs 144mg; p=0.001; median change in MTD of 3900mg vs 0mg, p=0.0001). Dose-related reactions were common but >95% in both groups were mild. There was no significant change in CM- or beta lactoglobulin-IgE from baseline for either group. CM-sIgG4 did significantly increase and casein IgE decreased in the BMOIT group. For proxy-reported food allergy quality of life, there was a significant difference in the emotional impact domain only with more improving while on placebo compared BMOIT. The majority of children and adolescents in the BMOIT group directly reported improvement in at least one domain.

CONCLUSION

BMOIT was well tolerated and induced a substantial level of desensitization after 12 months of treatment.

Cost-effectiveness Analysis of Hypoallergenic Milk Formulas for the Management of Cow's Milk Protein Allergy in the United Kingdom

Background: Cow's milk protein allergy (CMPA) is the most common food allergy in early childhood. In most children CMPA resolves by age 5 or 6; however, if not treated correctly can provoke nutritional deficiency resulting in poor growth. Management consists of excluding cow's milk from the diet, with hypoallergenic formulas (or non-dairy alternatives) being introduced to meet nutritional requirements. Objectives: To compare the cost-effectiveness of hypoallergenic formulas in reducing allergic manifestations and promoting immune tolerance in infants with immunoglobulin E (IgE)-mediated symptoms of CMPA. Methods: A trial-based decision analytic cohort model was developed to simulate the occurrence of urticaria, eczema, asthma, rhinoconjunctivitis, or being symptom-free in infants with CMPA in the United Kingdom. Amino acid-based formula (AAF), extensively hydrolysed casein formula containing Lactobacillus rhamnosus Gorbach Goldin (EHCF+LGG), extensively hydrolysed whey formula (EHWF), and soy formula (SF) were compared using the National Health Service (NHS) perspective, 3-year time horizon and 3.5% discount rate for cost and health consequences. Hypoallergenic formulas comparative efficacy was sourced from a prospective cohort study. Resources required to manage allergic symptoms were sourced from published literature, validated by a UK clinician, and applied to UK cost resources. Results were reported as cost per additional child free from allergic manifestations at 3 years and cost per additional immune tolerant child at 3 years. Results: In the base case, infants receiving EHCF+LGG were associated with lower NHS resource use and improved CMPA tolerance. Over the 3-year treatment period, savings of £119, £476, and £1094 were achieved with EHCF+LGG compared to SF, EHWF and AAF, respectively. Infant formula accounted for the largest proportion of resource consumption averaging 44% for all comparators, with a minimum of 31% for SF and a maximum of 53% for AAF over 3 years. General practitioners' visits constituted the second highest cost component, approximately 17% of total costs across comparators. The results were robust to deterministic and probabilistic sensitivity analyses. Conclusions: Compared to AAF, SF, and EHWF hypoallergenic formulas, EHCF+LGG was the most cost-effective, associated with lower total costs and contributing to a higher proportion of children being symptom-free and developing immune tolerance 3-years after diagnosis.

Precision medicine for cow's milk immunotherapy in clinical practice

PURPOSE OF REVIEW

Several novel immunotherapies have recently been reported for the treatment of cow's milk allergy (CMA). However, systematic methods for the selection of immunotherapy in clinical practice have not been investigated. In this review, we have provided suggestions for safe and effective immunotherapy for patients with CMA.

RECENT FINDINGS

Recent studies on cow's milk immunotherapy, using lower target doses, heated or baked cow's milk, combination treatment with adjuvants, or various routes of immunotherapy, included school-aged children with severe allergies, infants, and patients with mild CMA. These patients were administered various maintenance doses for various time periods. In the selection of immunotherapy, it would be useful to consider the patient's age and CMA severity at baseline: threshold dose, history of cow's milk anaphylaxis, and cow's milk-specific IgE levels.

SUMMARY

Considering the risks and benefits for patients with CMA, appropriate treatment should be selected based on the current evidence. Low-dose oral immunotherapy may be useful in clinical practice for school-aged children with severe CMA. Additional studies are needed to assess the indications for immunotherapy to select appropriate treatments in real-life settings.

Long-term follow-up of fixed low-dose oral immunotherapy for children with severe cow's milk allergy

BACKGROUND

The efficacy and safety of cow's milk (CM) low-dose oral immunotherapy (LOIT) at one-year follow-up have been previously reported. We investigated the outcome of fixed long-term LOIT in children with severe CM allergy.

METHODS

Children with positive reactions to oral food challenge (OFC) with 3 mL CM were included. The LOIT group (n = 33) ingested up to 3 mL CM for 1 year. After a two-week CM avoidance, 3 and 25 mL OFCs were performed. Children with positive reactions continued with 3 mL ingestion, with OFCs repeated yearly. Regular home consumption of 25 mL CM after passing the OFCs was defined as 25 mL short-term unresponsiveness (25 mL STU). The historical control group (n = 16) with reactions to 3 mL OFC eliminated daily CM ingestion.

RESULTS

The proportion of 25 mL STU in the LOIT group was 27%, 52%, and 61% after 1, 2, and 3 years, respectively, and the 3-year percentage was significantly higher than that in the historical control group (13%, P = .002). In the LOIT group, only one child developed severe symptoms. Furthermore, in this group, CM- and casein-specific immunoglobulin E (sIgE) levels decreased significantly and casein-specific IgG and IgG₄ levels increased significantly after 3 years, whereas the historical control group presented no significant change in these parameters. Baseline sIgE levels were significantly low in children achieving 25 mL STU.

CONCLUSION

Continued fixed LOIT yields immunologic improvement and may be effective and safe for severe CM allergy.

Epidemiology of non-IgE-mediated food allergies: what can we learn from that?

PURPOSE OF REVIEW

To underline the main characteristics of the non-Immunoglobulin E (IgE)-mediated food allergies (food protein-induced allergic proctocolitis food protein-induced enteropathy and food protein-induced enterocolitis syndrome ), which are common diseases in primary care and in allergy and gastroenterology specialty practices evaluating children.

RECENT FINDINGS

Non-IgE-mediated food allergies comprise a spectrum of diseases with peculiar features affecting infants and young children. The most prominent features of these diseases are symptoms that affect mainly the gastrointestinal tract.

SUMMARY

It is of paramount importance to provide the clinicians with the tools for non-IgE-mediated food allergy recognition in clinical practice to avoid the misdiagnosis with unnecessary laboratory tests and detrimental treatments.

Genetics of Food Allergy

The risk factors for food allergy (FA) include both genetic variants and environmental factors. Advances using both candidate-gene association studies and genome-wide approaches have led to the identification of FA-associated genes involved in immune responses and skin barrier functions. Epigenetic changes have also been associated with the risk of FA. In this chapter, we outline current understanding of the genetics, epigenetics and the interplay with environmental risk factors associated with FA. Future studies of gene-environment interactions, gene-gene interactions, and multi-omics integration may help shed light on the mechanisms of FA, and lead to improved diagnostic and treatment strategies.

Rickets and gross motor delay in a child with atopic dermatitis

We report a case of a 14-month-old boy with atopic dermatitis (AD) who presented to our hospital with hypocalcemic tetany and gross motor delay. Further laboratory and imaging confirmed the diagnosis of vitamin D deficiency and rickets. He was breastfeeding and on a restricted diet due to presumed multiple food allergies. He received calcium and vitamin D supplementation which corrected his hypocalcemia. The patient developed Staphylococcus aureus bacteremia and superficial septic thrombophlebitis for which he was treated with antibiotics and anticoagulation. An elimination diet should be avoided in AD patients as true food-induced AD is rare and management should focus on optimal skincare. AD patients have a higher rate of S. aureus skin colonization, which increases their risk for infectious complications. This case also highlights the importance of maintaining a high index of suspicion for rickets in children with isolated gross motor delay, especially in those with risk factors.

Successful sublingual immunotherapy for severe egg allergy in children: a case report

Background

Egg allergy is one of the most common food allergies in children. To date, oral immunotherapy (OIT) has been considered as a promising treatment option for egg allergy. However, safety issues remain concerning severe adverse events requiring epinephrine injection. Hence, establishing a safer method to treat egg allergy would be beneficial. We report here two children with egg allergy who were safely treated with sublingual immunotherapy (SLIT) before transitioning to OIT.

Case presentation

Patient 1 was a 7-year-old girl and Patient 2 was a 5-year-old girl. Although OIT for egg had been attempted in both patients, severe anaphylactic symptoms were induced by ingesting only 0.1 g of heated whole egg. Therefore, SLIT was conducted with aqueous suspensions consisting of water and heated whole egg powder. Suspensions were administered sublingually, kept in the mouth for 2 min, and spat out immediately thereafter. SLIT was continued for 7 months for Patient 1 and 8 months for Patient 2 due to the exploratory character of the study. Afterwards, the patients successfully transferred to low-dose OIT with 1 g of heated whole egg (≒170 mg of egg protein) daily, and are continuing the therapy as of June 2020. As for adverse reactions, Patient 1 expressed oral cavity itchiness once at the beginning of SLIT. Patient 2 had no adverse reaction. The levels of antigen-specific IgE decreased in both patients after SLIT, and further decreased after switching to OIT.

Conclusions

Few clinical studies have evaluated the efficacy and safety of SLIT for egg allergy. Although the treatment was conducted in only two patients, our results have shown that SLIT is a promising treatment procedure for egg allergy. Further clinical trials will be needed to additionally assess the efficacy and safety of SLIT in children with food allergy.

Advances in Food Allergy Treatment

Food allergies represent life-threatening diseases which are increasing in prevalence with no definitive treatments currently in place. Current treatments are no more than preventative avoidance and symptom management. Research within the field has focused on therapeutic developments to modify the immune response in allergen-specific and non-specific methods. This review of the advances made in treatments intends to cover methods such as oral immunotherapy, modified food protein vaccines as well as the use of alternative medicine. Thus, this review aims to inform and further extend discussion surrounding the potential clinical applications as well as novel routes for further research into an, as of yet, unsolved question.

Cow's Milk Protein Allergy in Term and Preterm Infants: Clinical Manifestations, Immunologic Pathophysiology, and Management Strategies

Cow's milk allergy is a common food allergy among infants. Symptoms of cow's milk allergy are wide-ranging and depend on the mechanism involved. There are immunoglobulin E (IgE)-mediated, non-IgE-mediated, and mixed mechanisms of food allergy. Symptoms of IgE-mediated cow's milk allergy may be mild or may progress to anaphylaxis, which can be life-threatening. Non-IgE-mediated allergy includes food protein-induced allergic proctocolitis (FPIAP), food protein-induced enterocolitis syndrome, food protein-induced enteropathy, and Heiner syndrome (pulmonary hemosiderosis). These diagnoses comprise about half of all cow's milk allergies. The most common manifestation of cow's milk allergy in infants is FPIAP. FPIAP is commonly seen in healthy, full-term infants who present with rectal bleeding and are otherwise well-appearing. This can occur in both formula-fed and exclusively breastfed infants. Food proteins secreted in maternal breast milk can contribute to the development of these symptoms. Maternal cow's milk elimination diet is often successful in helping resolve symptoms. A period of reintroduction of cow's milk resulting in re-emergence of symptoms in stable asymptomatic infants is an excellent diagnostic tool to confirm a cow's milk allergy. Preterm infants are susceptible to food allergy, as demonstrated from several case reports of necrotizing enterocolitis-like illnesses that responded clinically to cow's milk elimination. Further study is needed about food allergy in the preterm infant population.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Immunological Outcomes of Allergen-Specific Immunotherapy in Food Allergy

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

Food Allergies

Food allergy is 1 of the 4 manifestations of the "atopic march," along with eczema, allergic rhinitis, and asthma. Depending on the pathophysiologic immune mechanisms behind a food allergy, it can be classified as immunoglobulin E-mediated, non-immunoglobulin E-mediated, or mixed. The prevalence of food allergies has risen worldwide during the past few decades, becoming a significant global health concern. Patients experiencing food allergies and their caregivers are heavily burdened personally, socially, emotionally, and financially. The health-care system is also considerably affected. Pediatricians, as primary health-care providers, are often challenged with these patients, becoming the first-line for the recognition and management of food allergies. The purpose of this review is to provide a comprehensive summary of food allergies, including the most up-to-date information, recent guidelines, and recommendations.

Applied kinesiology and dentistry - A narrative review

OBJECTIVE

To investigate the use of applied kinesiology in the field of dentistry.

METHODS

A review of the literature was carried out looking for all articles written on the topic. PubMed, Ovid Medline, and The Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched.

RESULTS

Only one study was retrieved on the use of applied kinesiology in temporomandibular disorder patients, and only one study was published on dental material testing. A change in muscle strength associated with changes in dental occlusion has been observed in many of the articles selected.

DISCUSSION

The use of applied kinesiology for the diagnosis and treatment of pathologies in the field of dentistry is not supported by scientific evidence. However, a relationship between dental occlusion or maxillo-mandibular relationship and isometric muscle strength has been noted.

Health Beliefs, Health Anxiety, and Diagnostic Type in Food Hypersensitivity in Adults

Abstract. Background: Food hypersensitivity is often self-diagnosed, and research into barriers to help-seeking is scarce. Aims: This study in the United Kingdom sought to establish the relationship between health beliefs, health anxiety, and diagnostic type (medically diagnosed vs. self-diagnosed) in individuals with food hypersensitivity, and qualitatively explored attitudes of self-diagnosed individuals and their barriers to attaining a medical diagnosis. Method: A mixed-methods design involving 107 participants with food hypersensitivity (64 medically diagnosed and 43 self-diagnosed). Participants completed an adapted version of the health belief model questionnaire and a health anxiety questionnaire. A subset of six self-diagnosed participants took part in semi-structured interviews. Results: Binary logistic regression showed that health anxiety, perceived susceptibility, and perceived severity were significantly associated with diagnostic type. Qualitative thematic analysis of interviews yielded three themes: control over food, diagnosis, and treatment; judgment regarding feeling judged negatively on one’s choice of food, and being compared to fad-dieters; and the public’s and participants’ own lack of perceived severity of food hypersensitivity. Limitation: The sample was self-selected and therefore not necessarily representative of the population; however, an adult population was examined in an area that has so far largely studied children. Conclusion: Health psychologists should become involved in developing and testing interventions to help those with food hypersensitivity to control and reduce distress. Further researching the issues of control, judgment, and perceived severity could help tackle barriers to help-seeking behavior.

Immunoglobulin E-Mediated Food Allergies Differ in East Mediterranean Children Aged 0-2 Years

OBJECTIVE

Precise diagnosis of allergy requires knowledge of the population's food allergy (FA) spectrum and predictors.

METHODS

Medical charts of Turkish children aged 0-2 years with FA and/or atopic dermatitis (AD) were reviewed.

RESULTS

A total of 1,389 patients, 912 with FA and 1,140 with AD, were included. In the FA group, the most frequently diagnosed FAs were egg white (75.9%), cow's milk (55.7%), tree nuts (31.5%) and sesame (20.6%). The detection of FA in 99% of children with any kind of FA necessitate testing with egg white, cow's milk, hazelnut, sesame, walnut, cashew, and pistachio. In the FA group, 72.7 and 56.8% had AD and multiple FA respectively. Multiple FA (56.8 vs. 49.8%) and hen's egg allergy (85.5 vs. 50.2%, p < 0.005) were more common and cow's milk allergy (51.4 vs. 67.1%, p < 0.005) less common in the AD subgroup of the FA group than in the non-AD subgroup. Multiple FA likelihood increases parallel to the severity of AD (p < 0.05). In the AD group, 58.2% had an immunoglobulin E-mediated FA. The risk of concomitant FA increased as the age at symptom onset of AD decreased (OR 0.800 [95% CI 0.731-0.875]; p < 0.001) and the severity of AD increased (OR 2.350 [95% CI 1.898-2.911]; p < 0.001).

CONCLUSION

Although severe and early-onset AD is a predictor of the presence and magnitude of FA in infancy, the spectrum of FA is a reflection of cultural characteristics. The clinical presentations of both AD and FA may in fact be an expression of the extent of the immune dysregulation underlying atopy and allergy.

Likely questionnaire-diagnosed food allergy in 78, 890 adults from the northern Netherlands

BACKGROUND

It is challenging to define likely food allergy (FA) in large populations which limited the number of large studies regarding risk factors for FA.

OBJECTIVE

We studied the prevalence and characteristics of self-reported FA (s-rFA) in the large, population-based Dutch Lifelines cohort and identified associated risk factors.

METHODS

Likely food allergic cases (LikelyFA) were classified based on questionnaire reported characteristics consistent with FA. Subjects with atypical characteristics were classified as Indeterminate. We investigated 13 potential risk factors for LikelyFA such as birth mode and living on a farm and addressed health-related quality of life (H-RQOL).

RESULTS

Of the 78, 890 subjects, 12.1% had s-rFA of which 4.0% and 8.1% were classified as LikelyFA and Indeterminate, respectively. Younger age, female sex, asthma, eczema and nasal allergy increased the risk of LikelyFA (p-value range <1.00*10-250-1.29*10-7). Living in a small city/large village or suburb during childhood was associated with a higher risk of LikelyFA than living on a farm (p-value = 7.81*10-4 and p = 4.84*10-4, respectively). Subjects classified as Indeterminate more often reported depression and burn-out compared to those without FA (p-value = 1.46*10-4 and p = 8.39*10-13, respectively). No association was found with ethnicity, (duration of) breastfeeding, birth mode and reported eating disorder. Mental and physical component scores measuring H-RQOL were lower in both those classified as LikelyFA and Indeterminate compared to those without FA.

CONCLUSION

The prevalence of s-rFA among adults is considerable and one-third reports characteristics consistent with LikelyFA. Living on a farm decreased the risk of LikelyFA. The association of poorer H-RQOL as well as depression and burn-out with questionable self-perceived FA is striking and a priority for future study.

Diagnosis of Sesame Allergy: Analysis of Current Practice and Exploration of Sesame Component Ses i 1

BACKGROUND

Sesame is an allergen of increasing importance.

OBJECTIVE

We sought to characterize the outcomes of oral food challenges (OFCs) to sesame and evaluate the diagnostic accuracy of skin prick testing (SPT), sesame, and Ses i 1-specific IgE (sIgE).

METHODS

We reviewed sesame OFCs performed at the Mount Sinai pediatric allergy clinic between January 2010 and April 2018. We assessed the accuracy of diagnostic tests by calculating the area under the curve (AUC) of the receiver operating characteristic curves. The association between OFC outcome and sesame sensitization was analyzed using a logistic regression, which was then used to estimate the 95% positive predictive value (PPV) of these tests.

RESULTS

We identified 341 patients (69% male, mean age 7.7 years) who underwent sesame OFC. Among 106 (31%) positive OFCs, the median cumulative eliciting dose was 500 mg sesame protein (1/2 teaspoon tahini). Sesame SPT wheal ≥6 mm had sensitivity 54.1% and specificity 87.8%; AUC 0.756 (95% confidence interval [CI], 0.699-0.814). SPT wheal size ≥14 mm had 95% PPV. Sesame-sIgE level did not correlate with OFC outcome. Ses i-sIgE levels were analyzed in 30 patients using the Immuno Solid-phase Allergen Chip (ISAC) microarray and were significantly associated with OFC outcome (AUC: 0.715 [95% CI, 0.541-0.890]). Ses i 1-sIgE ≥0.3 ISAC Standardized Units had sensitivity 58.3% and specificity 83.3%.

CONCLUSIONS

This is the largest study of sesame allergy to date. Sesame SPT is a more accurate predictor of sesame allergy compared with sesame sIgE. Ses i 1-sIgE appears promising but requires further study regarding diagnostic accuracy.

Identification of goals and barriers to treatment from 92 consecutive consultations with families considering peanut oral immunotherapy

BACKGROUND

Peanut allergy has become an important public health issue. It can be the cause of severe reactions and also the trigger of significant anxiety for the allergic individual, especially with regards to the risk of unintentional accidental exposures. Peanut oral immunotherapy (POIT) is a newly developed treatment approach that has been shown to be highly effective in multiple research studies and has been associated with an acceptable safety profile. This treatment modality is likely to become more mainstream in the next few years with new commercial entities pursuing United States Food and Drug Administration approval for relevant products and multiple providers offering various forms of immunotherapy in their practices.

METHODS

The aim of our study was to obtain an accurate assessment of goals of treatment as well as concerns and barriers from families considering POIT in either the research or clinical setting. A single clinician allergist met with all the families and conducted semi-structured interviews on POIT. Families were provided with standardized written information on POIT prior to the consultation, which was used as a formalized instrument to communicate treatment protocols. Conversations were not recorded, but collected information was scribed by a second clinician who did not actively participate in the consultation. Scribed information was coded by the investigators. Thematic analysis identified common topics emerging from the discussions.

RESULTS

We report on the results of 92 consecutive family consultations on POIT conducted over a period of 1 year. Approximately 50% of the families had already researched POIT online, with 25% of families reported being part of Facebook parent groups. Groups identified the following areas as the most important considerations: efficacy, practical information, safety, benefits and goals, eligibility criteria and support in making the right decision. For all families pursuing POIT for their child, the initial goal was achieving protection from accidental exposure and cross-contamination and for approximately one-quarter, consumption of high peanut doses was the ultimate goal.

CONCLUSION

Our research adds to the limited available data in this area and provides information that may be used as an initial platform for clinical consultations and shared decision-making in POIT. Obtaining a better understanding of patients' expectations and concerns will hopefully facilitate this process, enabling more fruitful and engaging interactions between families and healthcare providers in the field of food allergy.

[Food protein-induced enterocolitis syndrome (FPIES) - a rare disease with frequent symptoms - the practitioner's compendium]

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy with varying degrees of severity. The acute form of the disease is manifested by vomiting, lethargy and pallor, which usually appear within 1-4 hours after food ingestion, and can lead to shock. The most common trigger foods are: cow's milk, soy, rice and oats. Chronic FPIES is typical for infants fed with cow's milk or soy infant formula and is manifested by chronic vomiting, diarrhea and failure to thrive. In the vast majority of patients with FPIES, the analysis of the clinical history is sufficient to diagnose and identify trigger foods. If the history is unclear, use an oral food challenge to help confirm the diagnosis. Long-term management of patients with FPIES involves elimination of the trigger foods, monitoring for FPIES resolution and caregivers' education. The majority of children acquire food tolerance at the age of 3-5.

Primary Prevention of Food Allergy

PURPOSE OF REVIEW

The goal of this review is to present an updated summary of the various approaches to prevent childhood food allergies and report recent advances in potential prevention trials for food allergy.

RECENT FINDINGS

Several approaches related to maternal dietary supplementation as well as infant GI-based supplementation have been tried and are the subject of ongoing clinical investigation. The prevalence of food allergy appears to be increasing but several, varied approaches to prevention are being actively pursued such that an effective strategy may not be too far in the future.

Next-Generation Approaches for the Treatment of Food Allergy

PURPOSE OF REVIEW

IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance.

RECENT FINDINGS

Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options. This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.

Clinical Features and Culprit Food Allergens of Korean Adult Food Allergy Patients: A Cross-Sectional Single-Institute Study

Purpose

To investigate the causative allergens and clinical characteristics of Korean adult patients with food allergy (FA).

Methods

This retrospective, cross-sectional single-institutional study enrolled Korean adult patients (n = 812) suspected of having FA. For diagnosis, causality assessment history taking, ImmunoCAP specific immunoglobulin E measurement and/or skin prick test were performed.

Results

Among 812 patients, 415 were diagnosed as having FA. The most common causative allergen was fruit, with a diagnosis of pollen food allergy syndrome (PFAS: 155, 37.3%), followed by crustaceans (111, 26.7%), wheat (63, 15.1%), fruits in patients without PFAS(43, 10.3%), buckwheat (31, 7.4%), peanut (31, 7.4%), walnut (25, 6.0%), red meat due to reaction to galactose-α-1,3-galactose (α-Gal) (8, 1.9%), and silkworm pupa (13, 3.1%). Allergy to egg, milk, fish, or shellfish was rare in Korean adults. One-third of patients with FA exhibited multiple FAs (238/415, 57.3%); the average number of causative allergens was 2.39. About 129 patients (31.0%) were diagnosed as having anaphylaxis; in these patients, wheat was the most frequent causative food. Twenty patients were further diagnosed with food-dependent exercise-induced anaphylaxis (FDEIA); all were due to wheat. In particular, crustaceans, wheat, PFAS, buckwheat, and red meat (α-Gal) were also frequent causes of anaphylaxis.

Conclusions

Wheat, fruits with or without PFAS, and crustaceans are important and frequent causative allergens in Korean adult FA; these allergens differ from those found in childhood FA. It is notable that non-classic allergies, such as PFAS, FDEIA, and α-Gal allergy, are the important causes of anaphylaxis in Korean adult FA.

Expression and significance of molecular profiles on eosinophils of children with food allergy

Peripheral blood eosinophils may increase in food allergy (FA). However, the correlation between activation status of blood eosinophils and features of FA are unknown. We collected 25 cases of FA out-patients with increased number of eosinophils and 20 healthy children. Eosinophil surface markers were analyzed by flow cytometry. We found that CD23, CD44, CD54, and CRTH2 were positive on different eosinophils and that their expressions were increased in FA patients compared to the control individuals. There was a positive correlation with strong protein–protein interactions between the four eosinophil surface markers which were functionally involved in regulation of cell killing, interferon-gamma-mediated signaling pathway, and Epstein–Barr virus infection pathway. Thus, blood eosinophils change their phenotype during FA and induce significant gene regulation changes that may cause FA with eosinophilia. Detection of the expression of CD23, CD44, CD54, and CRTH2 on eosinophils can be used as indicators of FA with eosinophilia.

A Structured Gradual Exposure Protocol to Baked and Heated Milk in the Treatment of Milk Allergy

OBJECTIVE

To evaluate the efficacy and safety of a structured gradual exposure protocol (SGEP) with extensively heated and baked milk in promoting allergy resolution in children with cow milk allergy (CMA).

STUDY DESIGN

In a case control study, children with CMA aged 1-4 years who were treated with SGEP including extensively heated and baked milk, were compared with children treated with strict avoidance. Data were collected from medical records and from validated telephone questionnaires. Data analysis was performed using a nonparametric Kaplan-Meier and proportional hazard Cox regression model, after evaluation of the adequacy of the case control matching.

RESULTS

There were 43 children with milk allergy-26 (62%) males with a mean age at intervention of 21 months (range, 12-47 months)-who were treated with SGEP and followed to a mean age of 40 months (range, 20-82 months). The median age at resolution of CMA was compared with a matched group of 67 children treated with strict avoidance at least until 4 years of age or followed until earlier resolution, with a mean age at follow-up of 71 months (range, 11-176 months). The median estimated age at CMA resolution in the SGEP group was 36 months (95% CI, 34.5-49.7) compared with 98 months (95% CI, 82.4-114.1) in controls (P < .001). At last follow-up, 86% of treated children were tolerant to unheated milk proteins vs 52% of controls (P = .003).

CONCLUSION

A structured protocol with extensively heated and baked milk seems to promote faster resolution of CMA.

Probiotics as treatment for food allergies among pediatric patients: a meta-analysis

Background

The burden of disease of food allergy is increasing worldwide. The standard of management is allergen avoidance and symptomatic treatment. Probiotics have been proposed to be beneficial for treatment and prevention of food allergy.

Objective

To determine the effectiveness of probiotic administration in treating food allergies among pediatric patients.

Methods

A systematic search of electronic medical literature databases was conducted. Manual search of the reference lists and search for unpublished articles were also done. All randomized controlled trials available from inception until February 19, 2018 were retrieved. The primary outcome of interest was relief of allergic symptoms, while the secondary outcome of interest was inducement of tolerance. Two independent authors did the search, screening, appraisal, and data abstraction. Data analysis and synthesis were done using RevMan 5.3 software. Subgroup analysis was done based on the probiotic strains and time periods in measuring the outcome. Exclusion sensitivity analysis was also done.

Results

Nine trials involving 895 pediatric patients with cow’s milk allergy (CMA) were included in the review. The primary outcome of interest, relief of symptoms, was measured using the scoring index for eczema. Pooled results from two studies showed larger reduction in the scoring index among patients given probiotics, but this effect was imprecise (MD -1.30, 95% CI -3.88, 1.28). For the secondary outcome of interest, pooled results from four studies showed benefit of probiotics in inducing tolerance, but again this result is imprecise with significant heterogeneity (RR 0.58, 95% CI 0.34, 1.00). Subgroup analysis per probiotic strain showed benefit of Lactobacillus rhamnosus GG in inducing tolerance based on two studies involving infants with suspected cow’s milk allergy (RR = 0.41, 95% CI 0.28 to 0.62). Another subgroup analysis showed a duration-dependent effect associated with probiotic usage, with inducement of tolerance noted after at least 2 years (RR = 0.44, 95% CI 0.29 to 0.67).

Conclusion

Analysis of available evidence shows moderate certainty that the use of probiotics can relieve symptoms of children with cow’s milk allergy. The reduction in certainty is due to imprecise results. Moreover, there is low certainty that probiotics can induce tolerance among children with cow’s milk allergy, due to problems of imprecision and attrition bias. In the subgroup analysis, Lactobacillus rhamnosus GG administration likely results in inducing tolerance among infants with suspected cow’s milk allergy. Only studies on CMA were analyzed since no studies were found on probiotics as treatment for other types of food allergy among children.

Electronic supplementary material

The online version of this article (10.1186/s40413-018-0204-5) contains supplementary material, which is available to authorized users.