EAACI Food Allergy and Anaphylaxis Guidelines. Food allergy health-related quality of life measures

Quality Appraisal of Quality of Life Research in Children and Adolescents with Food Allergy: A Systematic Review

INTRODUCTION

Quality of life (QOL) and health-related quality of life (HRQOL) in children and adolescents with food allergies have been an important and steadily growing field of research for the past 20 years. There seem to be conceptual and methodological challenges that might influence the face validity of QOL and HRQOL research in general health research, but this has not been investigated in pediatric and adolescent food allergy research up until now. The aim of this study was to perform a systematic review of the QOL and HRQOL studies on food allergy in children and adolescents under the age of 18.

METHODS

The systematic review was conducted on studies purporting to measure QOL or HRQOL in children and adolescents with food allergies. The literature search was developed in Ovid MEDLINE and databases used in the review were Embase, Cochrane Database of Systematic Reviews, CINAHL, and Scopus. Studies were evaluated based on a set of face validity criteria developed by Gill and Feinstein in 1994 and refined by Moons et al. in 2004.

RESULTS

Out of 61 studies eligible for the review, 11 (18%) defined QOL or HRQOL and two distinguished QOL from HRQOL. The Food Allergy Quality of Life (FAQLQ) instrument series is the most frequently used HRQOL measurement among the studies included. QOL and HRQOL were employed interchangeably in half of the studies, some of them also using a third term in addition.

CONCLUSION

Our findings lead to the conclusion that the research field investigated contains methodological and conceptual shortcomings regarding QOL and HRQOL. An increased awareness toward the terminology as well as consideration of points to reflect upon will be beneficial, as this will also improve the validity of future studies.

Higher Potential Sensitization of Cow αS1-Casein over Goat αS1-Casein in a Mouse Model due to Enhanced Dendritic Cell Uptake and Activation

Cow's milk allergy is a common food allergy, with the milk protein αS1-casein being a major allergen. This study aimed to investigate differences in sensitization between cow and goat αS1-CN. Cow and goat αS1-CN were labeled with fluorescent dyes and given to mice sensitized with cholera toxin adjuvant. Both proteins reached immune organs, suggesting no major difference in digestion. However, compared with goat αS1-CN, cow αS1-CN is more readily taken up by dendritic cells, inducing dendritic cell maturation. Furthermore, cow αS1-CN can more effectively induce the generation of Th2 cells, leading to a higher production of specific IgE. In a Caco-2/RBL-2H3 cell model, cow αS1-CN caused more mast cell degranulation and loss of epithelial barrier integrity than goat αS1-CN. In summary, this study found differences in immune responses between cow and goat milk αS1-CN. Cow αS1-CN elicited stronger dendritic cell and Th2 responses, leading to increased mast cell degranulation.

The Finnish versions of food allergy quality of life questionnaires including parent form 10

AIM

Examining health-related quality of life (HRQoL) is important to improve patient care. In this study, we translate and evaluate the Finnish versions of the Food Allergy Specific Quality of Life Questionnaires (FAQLQs) from a Finnish perspective and undertake a detailed evaluation of the 10-question Parent Form Questionnaire (FAQLQ-PF10).

METHODS

This validation study was performed to evaluate the Finnish versions of the FAQLQs. Validation was performed by analysing clinical characteristics, factor loadings and Cronbach's α reliability estimates. The inclusion criteria for participants in this study were having a doctor-diagnosed food allergy or being a parent of a child with a doctor-diagnosed food allergy and being able to answer the questionnaire in Finnish.

RESULTS

Altogether, 247 questionnaires were completed in this study. Most of the respondents had multiple food allergies (77%, 189/247). Spearman's correlations related to the 10-question parent form (FAQLQ-PF10), the 30-question parent form (FAQLQ-PF) and the Food Allergy Severity Measurement-Parent Form (FAIM-PF) were statistically significant (p value = 0.000-0.007). The reliability of the Finnish versions of the FAQLQs measured by Cronbach's α was overall good (0.75-0.981).

CONCLUSION

The Finnish versions of the FAQLQs are reliable and suitable to use, and the FAQLQ-PF10 has good usability.

Quality of life and psychological issues associated with food allergy

Food allergies (FA) pose risks beyond just the physical harm caused by anaphylaxis. The psychological consequences associated with an FA diagnosis can arguably be more detrimental for long-term health and quality of life than the consequences of an actual reaction. This can be seen in the hypervigilance of patients and caregivers surrounding mealtime, limited social interactions with peers, strained familial relationships, and increased reluctance to travel.1 More than 40% of children with FA have experienced at least one severe food-induced reaction. Given the need for daily nourishment, the potential for a very small amount leading to a life-threatening reaction is real, so it is not surprising that fear and anxiety can overwhelm patients with this condition.1 , 2 Allergists have a responsibility to recognize the difference between adaptive versus maladaptive anxiety. Whereas the demands of a busy office can often dissuade prolonged in-depth conversations about mental health, there are several validated tools that can be used to quickly and efficiently identify patients at risk. Allergists can play an important role in how an FA diagnosis is conceptualized and whether families leave the office with confidence or with excessive amounts of fear. Instilling a healthy respect for foods without crippling families with anxiety should be the goal of any clinic visit. To provide optimal support and treatment for patients with increased stress and anxiety, there needs to be a more substantial and easily accessible network of mental health professionals integrated within FA treatment centers so that patients and their families have the resources to address their mental health needs.

Association of Reaction Symptoms and Eliciting Dose With Health-Related Quality of Life in Children With Peanut Allergy

BACKGROUND

Food allergy adversely affects the health-related quality of life (HRQoL) of patients. It is unclear whether factors such as the reaction eliciting dose (ED) and the nature of allergic reaction symptoms affect HRQoL.

OBJECTIVE

To explore associations between reaction ED or the nature of allergic symptoms and HRQoL among children with peanut allergy.

METHODS

This study was a secondary analysis of baseline data from the PPOIT-003 randomized trial in 212 children aged 1 to 10 years with challenge-confirmed peanut allergy. Children's past reaction symptoms were collected by clinicians during screening. Associations between variables of interest and parent-reported child-proxy HRQoL were examined by univariable and multivariable linear regression.

RESULTS

Mean age of study participants was 5.9 years; 63.2% were male. Children with a low reaction ED of 80 mg peanut protein had significantly poorer HRQoL (β = -0.81; 95% CI, -1.61 to -0.00; P = .049) compared with children with a high ED of 2,500 mg peanut protein. Gastrointestinal symptoms (β = 0.45; 95% CI, 0.03-0.87; P = .037), lower airway symptoms (β = 0.46; 95% CI, 0.05-0.87; P = .030), multisystem involvement (β = 0.71; 95% CI, 0.25-1.16; P = .003), or anaphylaxis (β = 0.46; 95% CI, 0.04-0.87; P = .031) during a previous reaction were associated with worse HRQoL.

CONCLUSIONS

Peanut-allergic children with a lower allergen reaction threshold experienced a greater negative HRQoL impact compared with children with higher reaction thresholds. In addition, specific past allergic reaction symptoms were associated with comparatively worse HRQoL. Children experiencing these symptoms and those with lower reaction ED require increased clinical support to manage the food allergy and are likely to benefit from interventions that can improve HRQoL.

Immunonutrition: Diet Diversity, Gut Microbiome and Prevention of Allergic Diseases

Allergic diseases are increasing both in morbidity and mortality. Genetic, environmental, and dietary factors may all be involved in this increase. Nutrition during pregnancy, breastfeeding, and early life may play a particularly important role in preventing allergic diseases. Based on current systematic reviews, the intake of specific nutrients has failed to prevent allergic disease. Prevention strategies have shifted their focus to the overall diet which can be described using diet diversity. Infant and maternal diet diversity in pregnancy has been associated with reduced allergy outcomes in childhood. Overall, diet also seems to have a marked effect on the microbiome compared to single foods. Factors that may negate the allergy-preventative effect of overall diet diversity include the addition of emulsifiers, advanced glycation end-product content, and overuse of commercial baby foods. There is a need to perform randomized controlled trials using overall dietary intake to support international food allergy guidelines. These studies should ideally be conducted by multi-professional teams.

Health-related quality of life in food and venom induced anaphylaxis and role of influencing factors

The impact on health-related quality of life (HRQL) plays a key role for patients suffering from allergies and anaphylaxis. In this narrative review we review the HRQL in allergic patients suffering from food and venom allergy, both being the most frequent elicitors of severe allergic, potential life-threatening reactions and provide an overview on the current knowledge and identified gaps. The data show that for food and venom allergy standardized assessment tools to measure HRQL are available and have been successfully applied. Our analysis shows that multiple factors can modulate HRQL in these patient groups. These include sociodemographic data like patients' age and sex, fear of accidental reactions but also external factors like the social environment and the appreciation of the seriousness of the condition by others. External factors may have a significant impact on HRQL and should be considered in patient-related outcome assessments to avoid biased measurements possibly affecting the results. The assessment of the quality of life in the context of specific immunotherapy should consider lifestyle factors and ideally, the individual change in HRQL should be measured. Although there are many data indicating a negative impact on HRQL in food allergic children and their caregivers, limited data are existing from adults with food allergy and venom allergic patients from all age groups. Also, the use of standardized questionnaires should be extended to allow for a better comparability of results between studies. Therefore, translation to additional languages is necessary. Taken together, the eliciting allergen, the severity of the allergic disease but moreover multiple external factors impact the outcome in HRQL and should be considered in HRQL assessment.

Intestinal protein uptake and IgE-mediated food allergy

Food allergy is affecting 5-8% of young children and 2-4% of adults and seems to be increasing in prevalence. The cause of the increase in food allergy is largely unknown but proposed to be influenced by both environmental and lifestyle factors. Changes in intestinal barrier functions and increased uptake of dietary proteins have been suggested to have a great impact on food allergy. In this review, we aim to give an overview of the gastrointestinal digestion and intestinal barrier function and provide a more detailed description of intestinal protein uptake, including the various routes of epithelial transport, how it may be affected by both intrinsic and extrinsic factors, and the relation to food allergy. Further, we give an overview of in vitro, ex vivo and in vivo techniques available for evaluation of intestinal protein uptake and gut permeability in general. Proteins are digested by gastric, pancreatic and integral brush border enzymes in order to allow for sufficient nutritional uptake. Absorption and transport of dietary proteins across the epithelial layer is known to be dependent on the physicochemical properties of the proteins and their digestion fragments themselves, such as size, solubility and aggregation status. It is believed, that the greater an amount of intact protein or larger peptide fragments that is transported through the epithelial layer, and thus encountered by the mucosal immune system in the gut, the greater is the risk of inducing an adverse allergic response. Proteins may be absorbed across the epithelial barrier by means of various mechanisms, and studies have shown that a transcellular facilitated transport route unique for food allergic individuals are at play for transport of allergens, and that upon mediator release from mast cells an enhanced allergen transport via the paracellular route occurs. This is in contrast to healthy individuals where transcytosis through the enterocytes is the main route of protein uptake. Thus, knowledge on factors affecting intestinal barrier functions and methods for the determination of their impact on protein uptake may be useful in future allergenicity assessments and for development of future preventive and treatment strategies.

Food Allergy and Eosinophilic Gastrointestinal Diseases-The Next 10 Years

The first report of food allergy desensitization was in 1908, at least a few years before the first published description of a diagnostic test for food allergy. It has taken almost 100 years for food allergy to move from passive management of avoidance to a more proactive approach including prevention and treatment. In parallel, this has been matched by recognition of eosinophil gastrointestinal diseases, which were first described in the 1980s (although eosinophilic esophagitis was itself described in 1978). As we celebrate 10 years of The Journal of Allergy and Clinical Immunology: In Practice, we take the opportunity to look into the future and speculate how our practice may develop over the next decade.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

BACKGROUND

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).

OBJECTIVE

We sought to investigate the setting, management, and severity of pediatric FIA.

METHODS

We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.

RESULTS

We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.

CONCLUSIONS

Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Children and caregiver proxy quality of life from peanut oral immunotherapy trials

BACKGROUND

Health-related quality of life (HRQoL) is significantly and substantially reduced in individuals with peanut allergy due to many factors associated with unanticipated or potentially fatal reactions. Further insight on the impact of peanut oral immunotherapy in managing peanut allergy on HRQoL is needed. The aim of this analysis was to assess effects of peanut (Arachis hypogaea) allergen powder-dnfp (PTAH), a biologic drug for peanut oral immunotherapy, on HRQoL from three phase 3 and two follow-on trials of PTAH.

METHODS

HRQoL assessments from participants aged 4-17 in the PALISADE (ARC003), ARC004 (PALISADE follow-on), ARTEMIS (ARC010), RAMSES (ARC007), and ARC011 (RAMSES follow-on) trials were included in this analysis. Responses on the Food Allergy Quality of Life Questionnaire (FAQLQ) and Food Allergy Independent Measure (FAIM) were evaluated by age group and respondent (self or caregiver proxy). Data were analyzed with descriptive statistics and Student t tests.

RESULTS

Baseline FAQLQ and FAIM total scores appeared comparable between PTAH- and placebo-treated participants. Self and caregiver proxy-reported total scores on the FAQLQ for PTAH-treated participants generally improved at trial exit versus baseline; FAIM total scores improved throughout all trials. The tendency for improvement in FAQLQ total scores from baseline for PTAH appeared larger in self versus caregiver proxy-reports. Between treatment groups, PTAH was generally favored in the PALISADE and ARTEMIS trials; differences varied in the RAMSES trial based on age and respondent types.

CONCLUSIONS

PTAH for the management of peanut allergy in children appeared to have a beneficial effect on HRQoL in trials. Improvements were seen despite rigors of trial participation.

Psychometric parameters of food allergy quality of life during an allergen immunotherapy trial

BACKGROUND

The Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF) is a commonly used patient-reported outcome measure in food allergy (FA) research. It was developed before FA treatment clinical trials were commonplace and is used as a secondary outcome measure in pivotal FA treatment trials. We examined the psychometric properties of the FAQLQ-PF and its relevance to children with peanut allergy engaged in an epicutaneous immunotherapy (EPIT) clinical trial.

METHODS

Analysis was performed on 26 universally answered items of the FAQLQ-PF, from assessments undertaken during the phase 3 PEPITES study (baseline, Month 12), which examined the safety and efficacy of EPIT for children with peanut allergy aged 4-11 years. Item response theory (IRT) was used to assess psychometric parameters of the FAQLQ-PF (i.e., discrimination, difficulty, and information). Confirmatory factor analysis was also employed; reliability was assessed using McDonald's omega (ω) and Cronbach's alpha (α).

RESULTS

A total of 23 of 26 items presented very high discrimination levels (>1.7), and all 26 fell within the recommended difficulty threshold (between -1.5 and 1.5). The items contributed a reasonable information level for their respective factors/subdomains. The measure also presented a marginally acceptable model fit for the 3-factor structure (e.g., comparative fit index = 0.88, Tucker-Lewis index = 0.87) and good reliability levels across time points (ω and α > 0.90).

CONCLUSIONS

Herein, we present a novel reanalysis of the FAQLQ-PF items using IRT. The longitudinal performance of individual items and subscales was corroborated, and items with the highest discrimination were identified, showing that the tool is suitable for longitudinal measurements in FA treatment trials.

Measuring the Impact of Food Immunotherapy on Health-Related Quality of Life in Clinical Trials

Food allergy is a common, and often lifelong, disorder with considerable negative impact on the quality of life of those affected and their families. While several promising immunotherapies for food allergy have either been approved or are in late-phase clinical trials based on demonstrated effectiveness at inducing desensitization, evidence of benefit in terms of improving patient-centered outcomes is inconsistent. Historically, health-related quality of life has not been prioritized as an endpoint in food immunotherapy trials and, even when included, findings have been undermined by methodological limitations of the measurement instruments used and issues with data interpretation. This review highlights the importance of measuring health-related quality of life as an endpoint in food immunotherapy trials and discusses the strengths and limitations of available evidence in this regard, with a focus on the appropriate use of assessment instruments and interpretation of findings. There remains much to learn regarding the impact of food immunotherapies on patient wellbeing, both during treatment and over the longer term. Our aim is to assist clinicians, researchers, policy makers and consumers in their interpretation of the existing literature, and to promote greater scientific rigor in the design and selection of outcome measurement frameworks for future studies evaluating the efficacy of immunotherapy treatments for food allergy.

Accidental Reactions to Foods: Frequency, Causes, and Severity

Purpose of Review

In this review, we present the epidemiology of food allergy and allergic reactions to foods using studies that have been published over the past decade. We review these allergic reactions — how they differ by food trigger, geographic region, demographic distribution, setting, and severity.

Recent Findings

The rising prevalence of food allergy and persistent accidental allergic reactions to foods in various settings remains a worldwide concern. Differences in global prevalence, food triggers for reactions, and severity of accidental reactions may be explained by diversity in diets and food labeling legislation. A number of studies are highlighted that describe the unique challenges and risk factors that contribute to accidental reactions in restaurants and schools, as well as the efforts that have been made to improve safety and outcomes in these settings.

Summary

Food allergy prevalence has demonstrated significant variations between regions and age groups. Despite best efforts by individuals, physicians, and legislative bodies to improve safety for food allergic individuals, accidental reactions to foods still occur and can result in fatalities.

Development and Validation of the Anaphylaxis Quality of Life Scale for Adults

BACKGROUND

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can have a detrimental impact on quality of life (QoL). There are no validated scales to measure the impact of anaphylaxis on QoL of adults.

OBJECTIVE

The aim of this study was to develop and assess the reliability and validity of a QoL scale for adults with anaphylaxis (Anaphylaxis Quality of Life Scale for Adults [A-QoL-Adults]).

METHODS

All participants were recruited from a specialist allergy clinic and had a confirmed diagnosis of anaphylaxis (as per the World Allergy Organization diagnostic criteria) to food, drugs, venom, or latex or had spontaneous anaphylaxis. Interviews were conducted with 13 adults; data were analyzed using thematic analysis to extract items for a QoL scale. A prototype QoL scale was then completed by 115 participants alongside validated scales to measure generic QoL (World Health Organization Quality of Life Scale [Brief Version] [WHOQoL BREF]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), and stress (Perceived Stress Scale [PSS]).

RESULTS

The A-QoL-Adults scale has 21 items demonstrating excellent internal reliability (Cronbach α = 0.96). Factor analysis produced 3 subscales: Emotional Impact; Social Impact; and Limitations on Life. Each has excellent internal reliability (0.92, 0.92, and 0.91, respectively). Poorer anaphylaxis-related QoL (total A-QoL-Adults score and subscale scores) correlated significantly with poorer general QoL and greater anxiety, depression, and stress (all P < .01 with medium-to-large effect sizes).

CONCLUSIONS

The A-QoL-Adults scale is a reliable measure of QoL in adults with anaphylaxis and shows good construct validity. It will offer health care professionals a means to further understand the impact of anaphylaxis on adult patients and could help direct and monitor allergy management and the need for further psychological intervention.

Probiotic peanut oral immunotherapy versus oral immunotherapy and placebo in children with peanut allergy in Australia (PPOIT-003): a multicentre, randomised, phase 2b trial

BACKGROUND

Oral immunotherapy is effective at inducing desensitisation to allergens and induces sustained unresponsiveness (ie, clinical remission) in a subset of patients, but causes frequent reactions. We aimed to investigate whether addition of a probiotic adjuvant improved the efficacy or safety of peanut oral immunotherapy.

METHODS

PPOIT-003, a multicentre, randomised, phase 2b trial, was conducted in three tertiary hospitals in Australia (Adelaide [SA], Melbourne [VIC], and Perth [WA]) in children aged 1-10 years, weighing more than 7 kg, with peanut allergy confirmed by a double-blind placebo-controlled food challenge (cumulative 4950 mg dose of peanut protein) and positive peanut skin prick test (≥3 mm) or peanut-specific IgE (≥0·35 kU/L). Children were randomly assigned (2:2:1) to receive probiotic and peanut oral immunotherapy (PPOIT), placebo probiotic and peanut oral immunotherapy (OIT), or placebo probiotic and placebo OIT (placebo) for 18 months, and were followed up until 12 months after completion of treatment. Oral immunotherapy consisted of increasing doses of peanut protein (commercially available food-grade 12% defatted peanut flour [50% peanut protein]) until a 2000 mg daily maintenance dose was reached. The probiotic adjuvant was a daily dose of 2 × 10¹⁰ colony-forming units of the probiotic Lactobacillus rhamnosus ATCC 53103. Placebo immunotherapy comprised maltodextrin, brown food colouring, and peanut essence, and placebo probiotic was maltodextrin. Dual primary outcomes were 8-week sustained unresponsiveness, defined as no reaction to a cumulative dose of 4950 mg peanut protein at treatment completion and 8 weeks after treatment completion, in the PPOIT versus placebo groups and the PPOIT versus OIT groups, analysed by intention to treat. Safety endpoints were adverse events during the treatment phase, and peanut ingestion and reactions in the 12-month post-treatment period. This study is registered with the Australian New Zealand Clinical Trials Registry, 12616000322437.

FINDINGS

Between July 4, 2016, and Sept 21, 2020, 201 participants were enrolled and included in the intention-to-treat analysis. 36 (46%) of 79 children in the PPOIT group and 42 (51%) of 83 children in the OIT group achieved sustained unresponsiveness compared with two (5%) of 39 children in the placebo group (risk difference 40·44% [95% CI 27·46 to 53·42] for PPOIT vs placebo, p<0·0001), with no difference between PPOIT and OIT (-5·03% [-20·40 to 10·34], p=0·52). Treatment-related adverse events were reported in 72 (91%) of 79 children in the PPOIT group, 73 (88%) of 83 children in the OIT group, and 28 (72%) of 39 children in the placebo group. Exposure-adjusted incidence of adverse events was 10·58 in the PPOIT group, 11·36 in the OIT, and 2·09 in the placebo group (ratio 0·92 [95% CI 0·85 to 0·99] for PPOIT vs OIT, p=0·042; 4·98 [4·11-6·03] for PPOIT vs placebo, p<0·0001; 5·42 [4·48-6·56] for OIT vs placebo, p<0·0001), with differences seen primarily in gastrointestinal symptoms and in children aged 1-5 years. During the 12-month post-treatment period, 60 (85%) of 71 participants in the PPOIT group, 60 (86%) of 70 participants in the OIT group, and six (18%) of 34 participants in the placebo group were eating peanut; rescue epinephrine use was infrequent (two [3%] of 71 in the PPOIT group, four [6%] of 70 in the OIT group, and none in the placebo group).

INTERPRETATION

Both PPOIT and OIT were effective at inducing sustained unresponsiveness. Addition of a probiotic did not improve efficacy of OIT, but might offer a safety benefit compared with OIT alone, particularly in preschool children.

FUNDING

National Health and Medical Research Council Australia and Prota Therapeutics.

The causal association of polyunsaturated fatty acids with allergic disease: A two-sample Mendelian randomization study

Objectives

Previous studies have reported a potential association of polyunsaturated fatty acids (PUFAs) levels with allergic disease risk and the possible benefit of PUFAs supplementation on allergic disease prevention. This study was performed to estimate the genetic association between PUFAs and allergic diseases using the method of both univariable and multivariable two-sample Mendelian randomization (MR).

Methods

As indicators of the PUFAs levels, we included the omega-3, omega-6, docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), linoleic acid (LA), and the ratio of omega-6 to omega-3 (omega-6:3). Summarized statistics of genome-wide association studies (GWASs) for these PUFAs were obtained from the United Kingdom Biobank and the Twins United Kingdom cohort. Genetic data relating to allergic diseases, including atopic dermatitis (AD), allergic rhinitis (AR), allergic conjunctivitis (AC), allergic urticaria (AU) and asthma, were accessed from the FinnGen biobank analysis. Odds ratios and 95% CIs were used to express the impact.

Results

The MR results denoted a genetic association between the genetically determined increase in omega-3 levels and the decreased risk of some allergic diseases including AD (OR: 0.863; 95% CI: 0.785 to 0.949; p = 3.86E-03), AC (OR:0.720; 95% CI: 0.547 to 0.947; p = 1.87E-02) and AU (OR:0.821; 95% CI: 0.684 to 0.985; p = 3.42E-02), while omega-6 and DHA level was only found to have negatively correlation with risk of AC with ORs of 0.655 (95% CI: 0.445 to 0.964; p = 3.18E-02) and 0.671 (95% CI 0.490 to 0.918; p = 1.25E-02), respectively. Omega-6:3 were causally significantly associated with the increased risk of AD (OR:1.171; 95% CI: 1.045 to 1.312; p = 6.46E-03) and AC (IVW: OR:1.341; 95% CI: 1.032 to 1.743; p = 2.83E-02). After adjustment of age, economic level, BMI, smoking and alcohol behaviors in the multivariable MR analysis, a direct causal protective effect of omega-3 on AD and AC, as well as a direct causal association between DHA and AD were observed. Omega-6:3 was also found to be directly associated with an increased risk of AD and AC. No association was found of EPA or LA with allergic diseases.

Conclusion

Higher PUFA concentrations (omega-3, omega-6, DHA) and lower omega-6:3 ratios were genetically associated with a lower risk of some allergic diseases.

Responses of consumers with food allergy to the new allergen-labelling legislation in Saudi Arabia: a preliminary survey

OBJECTIVE

Preventing a food allergy reaction depends primarily on eliminating allergens from the diet. In October 2019, the Saudi Food and Drug Authority (SFDA) introduced new legislation requiring food establishments providing and selling non-prepacked foods to state the presence of the top fourteen food allergens on their menus. The current study aimed to assess the allergen-labelling knowledge, practices, preferences and perceptions towards the new SFDA allergen-labelling legislation among consumers with food allergy in Saudi Arabia.

DESIGN

Observational cross-sectional study using an online questionnaire.

SETTING

Saudi Arabia; February - March 2020.

PARTICIPANTS

Residents of Saudi Arabia with food allergy (n 427), aged 18-70 years.

RESULTS

Among participants, only 28·1 % knew that there were governmental regulations in Saudi Arabia regarding food-allergen labelling and approximately two-thirds (67 %) check labels on prepacked food products for allergens. The majority of the participants preferred food products carrying safety statements (84·1 %) and symbols (80·1 %). A total of 47·1 % were aware that regulations in Saudi Arabia require allergens to be declared in ingredient lists, while 51·3 % were aware that advisory allergen labelling is not required by law. Only 26·2 % were aware of the new SFDA legislation regarding provision of allergen information by food establishments. However, the majority (94·4 %) were supportive of the new legislation, and most of them were more likely to eat at restaurants that reported allergen information for food items on the menu.

CONCLUSIONS

The new SFDA food allergen-labelling legislation needs to be more widely and effectively disseminated to increase the level of awareness among adults with food allergy in Saudi Arabia.

Subjects develop tolerance to Pru p 3 but respiratory allergy to Pru p 9: A large study group from a peach exposed population

Peach tree allergens are present in fruit, pollen, branches, and leaves, and can induce systemic, respiratory, cutaneous, and gastrointestinal symptoms. We studied the capacity of peach fruit/Pru p 1, Pru p 3, Pru p 4, Pru p 7 and peach pollen/Pru p 9 for inducing symptoms following oral or respiratory exposure in a large group of subjects. We included 716 adults (aged 21 to 83 y.o.) exposed to peach tree pollen and fruit intake in the study population. Participants completed a questionnaire and were skin tested with a panel of inhalant and food allergens, including peach tree pollen, Pru p 9 and peach fruit skin extract. Immunoglobulin E antibodies (SIgE) to Pru p 1, Pru p 3, Pru p 4 and Pru p 7 were quantified. Sensitised subjects underwent oral food challenge with peach fruit and nasal provocation test with peach tree pollen and Pru p 9. The prevalence of sensitisation to peach fruit was 5% and most of these had SIgE to Pru p 3, with a very low proportion to Pru p 4 SIgE and no SIgE to Pru p 1 and Pru p 7. In only 1.8%, anaphylaxis was the clinical entity induced. Cases with positive skin tests to peach and SIgE to Pru p 3 presented a good tolerance after oral challenge with peach fruit. The prevalence of skin sensitisation to peach tree pollen was 22%, with almost half recognising Pru p 9. This induced respiratory symptoms in those evaluated by nasal provocation. In a large population group exposed to peach fruit and peach tree pollen, most individuals were tolerant, even in those with SIgE to Pru p 3. A positive response to Pru p 9 was associated with respiratory allergy.

Does Informal Education Training Increase Awareness of Anaphylaxis among Students of Medicine? Before-After Survey Study

Allergies are among the most common chronic diseases in Europe. The most serious complication is anaphylactic shock. Most cases occur outside the hospital; thus, knowledge of symptoms and first aid is crucial. This study aimed to evaluate the awareness of anaphylaxis and the ability to use adrenaline auto-injectors among medical students, and to determine an improvement after training based on non-formal education. The research was conducted among 364 medicine students (years 1–5) from the Medical University of Gdańsk, with year-specific curriculum-based general medical knowledge. Training consisted of pre-test, practical training and post-test. Descriptive statistics were used to reveal the characteristics of students from different grades. A Mann–Whitney U test was used for statistical analysis. The tested students did not have sufficient knowledge to provide first aid in cases of anaphylaxis before training. There was an increase in knowledge (on average, 28.6%, p = 0.005) after training. Almost all (99.4%) of the respondents believed that they would be able to use an adrenaline auto-injector in case of emergency after the training. The training based on non-formal education was effective. The use of the subject-performed task method helped students to remember the stages of action in stressful situations.

Implementing information and communication technology education on food allergy and anaphylaxis in the school setting

Introduction

Every year, 1/10,000 children experiences a food‐anaphylactic reaction. Most of these events, including attack‐related deaths, may happen during the school hours. In the current study, we assessed the influence of information and communication technologies (ICT) in the school‐staff's education on food allergy and anaphylaxis (FAA).

Methods

The target population of this intervention was non‐university teaching centers from the local Regional Education Council, including both state and private institutions. The digital intervention was supported by the free‐of‐charge and open‐source learning‐management Aulatic Educational Platform. Structured questionnaires were developed to evaluate the educators' knowledge, feelings, and self‐efficacy on FAA, in addition to a satisfaction and quality survey of the training program.

Results

A total of 1748 school‐educators were virtually enrolled from May 2016 to June 2020 in one of the 8‐week course editions, with 80.6% of attendees successfully completing the full training. All scores concerning school‐staff's basic knowledge and self‐efficacy on FAA significantly improved after the educational intervention, reaching a high level of satisfaction among participants (98.5%) over the 4‐year educational program.

Conclusion

Our results highlighted the effectiveness of a focused e‐learning activity to improve teachers and school caretakers in the management of food allergic scholars and anaphylactic reactions during the school hours. The use of ICTs tools should become an integrated part of curricular frameworks in non‐university education, leading to a better care of FAA school children.

Update on Type-1 Allergy Diagnostics

Diagnostics in type-1 allergy rely on medical history and clinical examination. Extent and severity of signs and symptoms can be documented by standardized scores and questionnaires. Both skin prick test and intradermal test are useful for search of immunoglobulin E-mediated sensitizations but the availability of commercially available diagnostic extracts has been markedly reduced during the last years. Investigation of total and of specific serum IgE is the most important in vitro diagnostic analyte in type-1 allergy. Identification of the individual molecules to which patients are sensitized, known as molecular or component-resolved diagnostics (CRD), has recently markedly improved management of type-1 allergy to pollen, food and hymenoptera venoms. Main features of CRD are increased analytic sensitivity, detection of cross-reactivity and determination of individual sensitization profiles which allow for risk assessment and facilitate decisions for or against allergen immunotherapy. Basophil activation test as well as determination of selected biomarkers (e.g. tryptase) may also be helpful in some cases. If any allergy test is positive, one will have to distinguish reactions, which are clinically relevant, from those, which are not. In vivo provocation tests (e.g. nasal provocation, oral drug or food challenge) may help to clarify the relevance of a sensitization.

Improvement in Health-Related Quality of Life in Food-Allergic Patients: A Meta-analysis

BACKGROUND

Food allergy (FA) is a growing global problem that can affect patients' health-related quality of life (HRQoL) owing to increased anxiety as well as social and economic restrictions. Interventions such as oral food challenges (OFCs) and oral immunotherapy (OIT) have been shown to improve HRQoL. However, meta-analyses and systematic synthesis of these data are lacking.

OBJECTIVE

To review and quantitatively synthesize potential benefits of interventions (OIT and OFC) systematically to address FA to a variety of foods.

METHODS

We conducted a systematic search through PubMed and Cochrane Medical Library databases and performed a meta-analysis focusing on studies assessing changes in HRQoL after OIT and/or OFCs in FA participants and caregivers from 2010 to July 2020. Random effects model and I² statistics were used to assess overall intervention effects and heterogeneity across studies.

RESULTS

We included 13 publications in this meta-analysis (OIT = 7; OFCs = 6). Mean change in HRQoL scores after OIT and OFCs was -1.25 (P < .001) and -0.78 (P = .052), with a significant I² of 87% (P < .001) and 90% (P < .001), respectively. Five OIT studies found significant improvements in HRQoL in the OIT group compared with the placebo group, with an overall standardized mean difference of -0.56 (P = .007; I² = 42%, P = .099).

CONCLUSIONS

This meta-analysis showed that in FA patients, both OIT and OFCs are associated with an improvement in HRQoL. Well-designed and long-term HRQoL studies are necessary to ascertain sustained benefits of OIT and OFCs.

Predicting health-related quality of life in Spanish adolescents with allergic rhinoconjunctivitis and bronchial asthma

This study analyzed the predictive power of sociodemographic (age, sex) and medical variables (months since diagnosis and in treatment, immunotherapy, number of environmental allergens, food allergies or atopic dermatitistypes) on the quality of life of patients with rhinoconjunctivitis and bronchial asthma, using models based on comparative qualitative fuzzy analysis to compare them according to the pathology(s).Retrospective cross-sectional design.Sixty-four adolescents (65.60% boys) diagnosed with rhinoconjunctivitis and/or bronchial asthma aged between 12 and 16 years old (M= 14.02; SD = 1.45).The data were collected between February 2019 and January 2020 using the Brief Disease Perception Questionnaire (B-IPQ), the Adolescent Rhinoconjunctivitis Quality of Life Questionnaire (AdolRQoLQ) and the Respiratory Disease Questionnaire Self-administered and Standardized Chronicle (CRQ-SAS). Qualitative comparative analysis models (QCA) were used.In the QCA models, the various combinations indicated that the variables that predicted a higher quality of life for both rhinocojuntivitis symptoms and respiratory symptoms were receiving longer-term immunotherapy and a perceived lower threat of the disease. The consistencies of the models vary between 23-29%. In conclusion, the patients' QoL was explained by the presence of longer-term immunotherapy and a less threatening perception of the disease.Therefore, early multidisciplinary diagnosis and treatment is important.

Economic considerations on the usage of biologics in the allergy clinic

The advent of biologic therapies has transformed care for severe atopic disorders but their high cost poses new challenges with regard to long-term sustainability and fair allocation of resources. This article covers the basic concepts of cost-utility analyses and reviews the available literature on cost utility of biologic drugs in atopic disorders. When used within their limits as part of a multi-dimensional assessment, economic analyses can be extremely useful to guide decision-making and prioritization of care. Despite the good quality of most cost-utility analyses conducted for the use of biologics in asthma and other atopic diseases, their conclusions regarding cost-effectiveness are extremely variable. This is mainly due to the use of inconsistent estimates of health utility benefit with therapy. Development of reliable and validated instruments to measure disutility in atopic disorders and measure of indirect costs in atopic disease are identified as a priority for future research.

SF-6Dv2 preference value set for health utility in food allergy

BACKGROUND

The lack of a value set allowing the calculation of QALY is an important limitation when establishing the value of emerging therapies to treat food allergy. The aim of this study was to develop a Short-Form Six-Dimension version 2 (SF-6Dv2) preference value set for the calculation of health utility from the Canadian food-allergic population.

METHODS

Two hundred ninety-five parents of patients aged 0-17 years old and 154 patients aged 12 years old and above with food allergy were recruited in clinic and online. Participants were asked to complete a self-administered online questionnaire including generic health-related quality of life questionnaires. Various health states described by the SF-6Dv2 were valued with time-trade-off and discrete choice experiments. Data from elicitation techniques were combined using the hybrid regression model.

RESULTS

A total of 241 parents and 125 patients performed 3904 time-trade-off and 5112 discrete choice experiments. Utility decrements were estimated for each level of each SF-6Dv2 dimension. Utility values calculated based on the validated preference set were in average 0.15 lower (95%CI: 0.12-0.18) and were poorly correlated (R²  = 0.46) with those derived from the EQ-5D-5L generic questionnaire in the same cohort.

CONCLUSION

A representative preference value set for patients with food allergy was determined using the SF-6Dv2 generic questionnaire. This adapted preference set will contribute to improve the validity of future utility estimates in this population for the appraisal of upcoming potentially impactful but sometimes costly therapies.

Prevention of food allergy: can we stop the rise of IgE mediated food allergies?

PURPOSE OF REVIEW

Food allergy has become more prevalent in recent decades. Without a curative treatment for food allergy, prevention is key. Can we intervene and halt the food allergy epidemic?

RECENT FINDINGS

There are three main hypotheses to explain the rise in food allergy: the dual-allergen exposure hypothesis, the hygiene hypothesis and the vitamin D hypothesis. In a recent systematic review of randomized controlled trials, only introduction of allergenic foods, namely egg and peanut, in the diet at the time of weaning and avoidance of temporary supplementation with cow's milk formula in the first few days of life showed low to moderate evidence of a preventive effect.

SUMMARY

For primary prevention, introduction of allergenic foods at the time of weaning and avoidance of temporary supplementation with cow's milk formula in the first few days of life has been recommended. Introduction of foods once allergy has been excluded may be beneficial for sensitized subjects (secondary prevention). Once food allergy has been established, it is important to minimise complications (tertiary prevention) through allergen avoidance, timely treatment of allergic reactions, control of atopic co-morbidities and dietetic and psychological support, as appropriate. Immunomodulatory treatments can potentially be disease-modifying and require further research.

Dietary factors during pregnancy and atopic outcomes in childhood: A systematic review from the European Academy of Allergy and Clinical Immunology

RATIONALE

Allergic diseases are an increasing public health concern, and early life environment is critical to immune development. Maternal diet during pregnancy has been linked to offspring allergy risk. In turn, maternal diet is a potentially modifiable factor, which could be targeted as an allergy prevention strategy. In this systematic review, we focused on non-allergen-specific modifying factors of the maternal diet in pregnancy on allergy outcomes in their offspring.

METHODS

We undertook a systematic review of studies investigating the association between maternal diet during pregnancy and allergic outcomes (asthma/wheeze, hay fever/allergic rhinitis/seasonal allergies, eczema/atopic dermatitis (AD), food allergies, and allergic sensitization) in offspring. Studies evaluating the effect of food allergen intake were excluded. We searched three bibliographic databases (MEDLINE, EMBASE, and Web of Science) through February 26, 2019. Evidence was critically appraised using modified versions of the Cochrane Collaboration Risk of Bias tool for intervention trials and the National Institute for Clinical Excellence methodological checklist for cohort and case-control studies and meta-analysis performed from RCTs.

RESULTS

We identified 95 papers: 17 RCTs and 78 observational (case-control, cross-sectional, and cohort) studies. Observational studies varied in design and dietary intakes and often had contradictory findings. Based on our meta-analysis, RCTs showed that vitamin D supplementation (OR: 0.72; 95% CI: 0.56-0.92) is associated with a reduced risk of wheeze/asthma. A positive trend for omega-3 fatty acids was observed for asthma/wheeze, but this did not reach statistical significance (OR: 0.70; 95% CI: 0.45-1.08). Omega-3 supplementation was also associated with a non-significant decreased risk of allergic rhinitis (OR: 0.76; 95% CI: 0.56-1.04). Neither vitamin D nor omega-3 fatty acids were associated with an altered risk of AD or food allergy.

CONCLUSIONS

Prenatal supplementation with vitamin D may have beneficial effects for prevention of asthma. Additional nutritional factors seem to be required for modulating the risk of skin and gastrointestinal outcomes. We found no consistent evidence regarding other dietary factors, perhaps due to differences in study design and host features that were not considered. While confirmatory studies are required, there is also a need for performing RCTs beyond single nutrients/foods.

Impact of nickel oral hyposensitization on quality of life in systemic nickel allergy syndrome

Nickel (Ni) oral hyposensitization treatment (NiOHT) is an effective management approach for Ni allergy. No health-related quality of life (HRQoL) data exist for the pre- and post-treatment with NiOHT in systemic nickel allergy syndrome (SNAS). The aims of this study were (a) to explore HRQoL in SNAS patients, (b) to assess changes of HRQoL after 1 year of NiOHT; (c) to evaluate psychological status of patients. SNAS patients completed the Short-Form 36-Item Health Survey and Psychological General Well-Being Index before and 1 week after the end of NiOHT. Moreover, psychological state was assessed with the Minnesota Multiphasic Personality Inventory (MMPI-2). A total of 52 patients self-reported pre- and post-treatment questionnaires. HRQoL was poor at baseline. After 1 year of NiOHT, all outcome measure scores improved by about 20% with respect to baseline data (P < 0.01 for all indices, except depressed mood). Finally, 33 patients performed the MMPI-2. High rates for hypochondriasis and depression were noted. Furthermore, most of the patients had high scores for anxiety, depression, and health concerns. This is the first study showing that NiOHT improves HRQoL of SNAS patients, which can be considered a “personalized medicine” approach.

EAACI Allergen Immunotherapy User's Guide

Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.

Sleep disturbances and affecting factors in young children with food allergy and their mothers

OBJECTIVE

To examine sleep patterns and sleep disturbance of children with food allergy (FA) and their mothers.

METHODS

The food allergy group included 71 children with mean age, 2.97±1.52 years, and 58 control children were recruited the study. Mothers of children completed the Childhood Sleep Habits Questionnaire (CSHQ) and The Pittsburgh Sleep Quality Index (PSQI) in order to evaluate sleep disturbance in both children and themselves. Depressive symptomatology of mothers of children with or without food allergy was assessed with Beck-Depression Inventory II (BDI-II).

RESULTS

The mean total scores of CSHQ was 49.33±7.93 (range=31-68) in the FA and 42.39±6.43 (range=30-62) in controls. The total CSHQ scores were significantly higher in children with FA than in controls (p=0.002). The total PSQI score was significantly higher in mothers of children with FA than in mothers of children without FA (7.09±3.11 vs 5.15±2.59, p<0.001) indicating that the mothers of children with FA had worse sleep quality. The mothers of children with FA had more depressive symptoms than mothers of children without FA. The mean total scores of BDI-II were 10.10±6.95 in mothers of children with FA and 7.78±6.64 in mothers of children without FA (p=0.005).

CONCLUSION

The presence of a food allergy in a child may be associated with a deterioration in sleep quality in children and mothers as well as increased depressive symptoms in mothers.

Food insecurity and caregiver perceptions of food allergen risk by food purchase location in children with food allergies

Meeting nutritional needs of children with food allergy (FA) may be challenging without affordable, quality foods. Food purchase location may impact availability of FA-safe foods; however, no research examining food purchase location in families of children with FA exists. This study compared caregiver report of food insecurity (FIS; food insecure vs. food secure), FA risk, and history of food-induced anaphylaxis (FIA) in families of children with FA, who primarily purchase food items at grocery/supermarkets (n = 140) or convenience marts/bodegas (CB; n = 32). Caregivers (N = 172; 49% mothers, 49% fathers, 2% grandparent/other relative) of children with FA (57% male; Mage = 7.5 years; 66% White [22% Latinx and 44% non-Latinx] and 23% Black) completed an online survey. Variables included demographics, history of FIA, and caregiver perceptions of FIS and FA risk. Caregivers who purchased food items from CB versus supermarkets reported higher perceived risk of accidental ingestion (χ2 = 20.49, p < .001, 94% vs. 50%), severe reaction (χ2 = 15.05, p < .001, 97% vs. 61%), death (χ2 = 27.48, p < .001, 91% vs. 49%), FIS (χ2 = 21.69, p < .001, 94% vs. 49%), and FIA (χ2 = 11.96, p = .001, 94% vs. 32%). Effect sizes were small-moderate (Cramer's V = .26-.40). Families who purchased food at CB reported greater food allergen concerns and FIS than families who purchased food at supermarkets. Differences in FA-related perceived risks may reflect the health disparity and adversity these families face to meet basic nutritional needs, such as FA-related constraints. Point-of-care efforts are needed to provide early screening for families who may be at risk for experiencing FIS.

Are avoidance diets still warranted in children with atopic dermatitis?

Nearly 40% of children with moderate-to-severe atopic dermatitis (AD) have IgE-mediated food allergy (FA). This clinical observation has been extensively documented by experimental data linking skin inflammation in AD to FA, as well as by food challenges reproducing symptoms and avoidance diets improving AD. Although food avoidance may improve AD, avoidance diets do not cure AD, may even have detrimental effects such as progression to immediate-type allergy including anaphylactic reactions, and may significantly reduce the quality of life of the patient and the family. AD care should focus upon optimal medical management, rather than dietary elimination. Food allergy testing is primarily indicated when immediate-type allergic reactions are a concern. In recalcitrant AD, if food is being considered a possible chronic trigger, a limited panel of foods may be tested. An avoidance diet is only indicated in patients clearly identified as food allergic by an appropriate diagnostic food challenge, and after adequately informing the family of the limited benefits, and possible harms of an elimination diet.

Prostaglandin E2 signal inhibits T regulatory cell differentiation during allergic rhinitis inflammation through EP4 receptor

Objective

Allergic rhinitis (AR) is a common disease seriously affecting quality of life, and until now the effect of medical therapy is not satisfactory. It is essential to explore in depth the pathologic mechanism of AR to offer new ideas for developing novel treatment strategies. The defect of T regulatory (Treg) cells plays a critical role in the pathogenesis of AR, but the underlying mechanism remains to be elucidated. This study aims to determine the effect of Prostaglandin E2 (PGE2) on the differentiation of Treg cells in AR patients and the involvement of E prostanoid (EP) receptor signaling pathway.

Methods

The proportion of Treg cells and the level of PGE2 in the peripheral blood of AR patients and healthy controls were compared. Differentiation rate of Treg cells under the influence of various concentrations of PGE2 with or without diverse EP receptor agonists and antagonists were investigated through cell culture and flow cytometry in vitro. The cyclic AMP (cAMP) mimic or protein kinase B (Akt) inhibitor was also added to the culture to evaluate the downstream pathway of EP receptor signaling.

Results

The proportion of Treg cells decreased and PGE2 concentration increased in the peripheral blood of AR patients compared to healthy controls. PGE2 dose-dependently suppressed the differentiation of Treg cells from both human and mice naïve CD4⁺ T cells in vitro. This inhibitory effect was mediated through EP4 via a mechanism involving activation of cAMP-dependent proteinkinase A (PKA) signaling pathway.

Conclusion

PGE2-EP4-cAMP signaling might mediate the development of AR by inhibiting the differentiation of Treg cells.

Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study

BACKGROUND

Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported.

OBJECTIVE

To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors.

METHODS

A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.

RESULTS

Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid.

CONCLUSIONS

A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.

How to manage food allergy in nursery or school

PURPOSE OF REVIEW

The aim of this review is to describe effective management strategies in nursery or school based upon research findings.

RECENT FINDINGS

The prevalence of food allergy and number of emergency department visits for food-related anaphylaxis are increasing in children and adolescents. As there is currently no cure, the most effective strategy to decrease allergic reactions is food allergen avoidance. However, allergic reactions are inevitable in both food allergic children as well as in first-time reactors. Misconceptions exist on the safety of products with advisory labels and questions remain on whether school-wide bans decrease the risk of allergic reactions in school. Recent legislation has prompted schools to consider requiring unassigned epinephrine autoinjectors to better manage those who have allergic reactions in nursery or school.

SUMMARY

A collective effort is required to keep children with food allergies safe at school. Families, healthcare providers, and school personnel should be informed on food allergen avoidance strategies, symptoms consistent with allergic reactions and anaphylaxis, how to respond to allergic reactions, and the impact the diagnosis of food allergy may have on quality of life for affected children and their families.

Psychosocial Mediators of Change and Patient Selection Factors in Oral Immunotherapy Trials

Health-related quality of life (HRQL) is influenced by physiological, psychological, and environmental variables and can be best understood by considering the interactions of factors that cut across multiple levels. One of the most important issues relating to treatment in food allergy is to identify, describe, and define predictors that may contribute to modify HRQL outcomes. The research presented demonstrates that measures of HRQL are able to distinguish key features of known groups (e.g. relating to reaction severity, treatment, allergen type/number, expectation of outcome) and delineate impact on hitherto unknown groups (e.g. relating to personality types and coping styles). This heterogeneity may explain why HRQL or other patient-related outcomes may differ in individuals during, or following any treatment or intervention. Patient-reported outcomes are relatively poorly defined to date. Since HRQL has only been studied in relatively few oral immunotherapy trials to date, primarily looking at caregiver HRQL, it is unclear which factors, measures, or subscales are most predictive of short- and/or long-term treatment outcomes for which type of patient, and which time points for measurement are most informative. A standardised protocol that incorporates HRQL and other relevant patient-related outcome measures and agreed definitions of outcomes would allow for the comparison of efficacy of food allergy treatments between centres, trials, or countries. Further evidence-based research aimed at exploring the effects of interventions on outcomes in food allergy is needed, including the influence of patient and parent factors on protocol design. To this end, it is vital that patient-related outcomes such as improved HRQL are seen as a primary outcome and are measured at multiple intervals during the trial duration and beyond. The creative use of methods and designs (both qualitative and quantitative) to better understand the role of HRQL in immunotherapy treatment trials will enable improved modelling of the costs, risks, and benefits of any treatment. Systematic analysis and modelling of antecedent factors, mediators, and outcomes will be important to boost intervention effects and to maximise the overall benefits of treatment.

Comparing the eating out experiences of consumers seeking to avoid different food allergens

Background

Eating outside the home is challenging for consumers with food allergy (FA) and intolerance (FI) and lack of allergen information provision in eating out venues can lead to unnecessary restrictions. Following European legislation (2014) designed to improve allergen information provision, little is known about differences in information provision experienced by consumers seeking to avoid particular allergens, or how this impacts on their eating out experiences. This study compared the information provision that consumers with FA/FI to different allergens experience when eating out.

Methods

Using mixed methods, participants were recruited from across the UK and took part in self-report surveys or in-depth interviews. Surveys were completed by 232 participants avoiding either gluten (n = 66), nuts (peanuts/tree nuts) (n = 94), or milk (n = 74), and responses were subject to quantitative analyses. Interviews were carried out with 49 participants avoiding either gluten (n = 13), nuts (n = 14), milk (n = 13) or a combination of these allergens (n = 9), and analysed using the framework approach.

Results

Although general improvements in information provision following the legislation were reported, variations in provision between allergen groups led participants seeking to avoid milk to conclude that their dietary needs were less well-understood and seen as less important. These perceptions were reflected in a reluctance to involve eating out venue staff in deliberations about the potential for milk-free meal options.

Conclusions

The provision of visual indicators of the presence of milk and of staff trained in allergen-awareness would improve the eating out experiences of consumers seeking to avoid milk. Medical professions can play a key role in encouraging these patients to pursue their right to make enquiries about allergens in order to avoid accidental milk ingestion when eating out.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6117-y) contains supplementary material, which is available to authorized users.

The impact of oral food challenges for food allergy on quality of life: A systematic review

BACKGROUND

Food allergy significantly impairs health-related quality of life (HRQL). Currently, it is still unknown whether diagnostic interventions for food allergy improve HRQL. We aim to assess the impact of diagnostic interventions for food allergy on HRQL.

METHODS

A systematic search was performed in MEDLINE, Embase, Cochrane Library, and CINAHL focused on patients with a (suspected) food allergy who underwent diagnostic interventions (ie, skin prick test, specific IgE, or oral food challenges [OFC]) and in whom HRQL was assessed. The mean difference between HRQL before and after the diagnostic intervention was calculated. A minimal clinically important difference of 0.5 was considered clinically relevant for the food allergy quality of life questionnaire.

RESULTS

Seven of 1465 original identified publications were included in which the impact of an OFC on HRQL was investigated (total patients n = 1370). No other diagnostic interventions were investigated. Food allergy-specific parent-reported HRQL improved significantly after an OFC irrespective of the outcome in children with a suspected food allergy in two publications. The change was considered clinically relevant in one of two publications. In addition, parent-reported HRQL improved after an OFC to assess the eliciting dose in children with a confirmed food allergy. The parental burden was significantly reduced after an OFC to assess resolution of food allergy. A meta-analysis could not be performed due to the limited numbers of, and considerable heterogeneity between, eligible publications.

CONCLUSION

An OFC is associated with an improved food allergy-specific HRQL and a reduced parental burden of food allergy.

The longitudinal impact of probiotic and peanut oral immunotherapy on health-related quality of life

BACKGROUND

We previously reported that probiotic and peanut oral immunotherapy (PPOIT) was effective at inducing sustained unresponsiveness compared with placebo in a double-blind, placebo-controlled randomized trial. This study evaluated the impact of PPOIT on health-related quality of life (HRQL).

METHOD

Fifty-one participants (PPOIT 24; placebo 27) from the PPOIT trial completed Food Allergy Quality of Life Questionnaire (FAQLQ-PF) and Food Allergy Independent Measure (FAIM) at pre-treatment, end-of-treatment and 3 months after end-of-treatment. A total of 42 participants (20 PPOIT; 22 placebo) completed measures at 12 months post-treatment. Changes over time in PPOIT and placebo groups were examined by repeated-measures analysis of variance and paired t tests.

RESULTS

Probiotic and peanut oral immunotherapy was associated with significant improvement in FAQLQ-PF (F = 3.63, P = .02), with mean difference 0.8 at 3 months post-treatment (P = .05) and 1.3 at 12 months post-treatment (P = .005), exceeding the 0.5 minimal clinically important difference for FAQLQ-PF. For FAIM, mean difference was 0.5 (P = .03) at 3 months and 0.4 (P = .04) at 12 months post-treatment. In placebo group, post-treatment FAQLQ and FAIM remained unchanged from pretreatment. Improvement in FAQLQ-PF and FAIM scores related specifically to acquisition of sustained unresponsiveness rather than to receiving PPOIT treatment or participation in the trial.

CONCLUSIONS

Probiotic and peanut oral immunotherapy has a sustained beneficial effect on psychosocial impact of food allergy at 3 and 12 months after end-of-treatment. Treatment was not associated with reduced HRQL relative to baseline in either PPOIT or placebo groups, indicating that PPOIT was well tolerated and psychological well-being was not negatively impacted. Improved HRQL was specifically associated with acquisition of sustained unresponsiveness.

Factors Affecting Food Allergy-Related Quality of Life From Parents' Perception in Turkish Children

Purpose

Food allergy (FA) affects the daily lives of children and parents in varying degrees. The Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF) is a valid and reliable instrument to assess the quality of life (QoL) of children from parents' perception. The aim of this study was to validate and determine the reliability of the Turkish FAQLQ-PF and to assess QoL in food-allergic children.

Methods

Children aged between 0 and 12 years and diagnosed with immunoglobulin E (IgE)-mediated FA for at least 1 month were enrolled. The English FAQLQ-PF was translated into Turkish according to the World Health Organization guidelines. The Food Allergy Independent Measure and the Turkish Child Health Questionnaire-Parent Form 50 were used for construct validity.

Results

One hundred and fifty-seven patients participated. The median age of patients and FA duration were 2.4 years (1.2–5.2 years, interquartile-ranges) and 2 years (0.8–5.1), respectively. Ninety-six (61.1%) patients had anaphylaxis. The Cronbach's alpha coefficient and intra-class correlation coefficient for test-retest reliability was good for all age groups of children (<4, 4–6, and 7–12 years). Patients with either asthma or anaphylaxis had worse scores than others. Total scores of FAQLQ-PF tended to increase with age. Patients aged 7–12 had the highest total scores among all patients (2.2±0.1, 3.0±0.2, and 3.3±0.3 for <4, 4–6, and 7–12 years, respectively, P<0.001, P for trend <0.001). Other factors causing the poor QoL were cow's milk allergy, sibling allergy, mother's age over 30 years, mother's high education level and lower number of persons in household.

Conclusions

The Turkish FAQLQ-PF is a valid and reliable scale. FA-related QoL was significantly worse with age. Coexistent asthma, anaphylaxis regardless of its severity, cow's milk allergy, sibling allergy and the older and educated mothers seem to poorly affect QoL.

EAACI guidelines on allergen immunotherapy: Prevention of allergy

Allergic diseases are common and frequently coexist. Allergen immunotherapy (AIT) is a disease-modifying treatment for IgE-mediated allergic disease with effects beyond cessation of AIT that may include important preventive effects. The European Academy of Allergy and Clinical Immunology (EAACI) has developed a clinical practice guideline to provide evidence-based recommendations for AIT for the prevention of (i) development of allergic comorbidities in those with established allergic diseases, (ii) development of first allergic condition, and (iii) allergic sensitization. This guideline has been developed using the Appraisal of Guidelines for Research & Evaluation (AGREE II) framework, which involved a multidisciplinary expert working group, a systematic review of the underpinning evidence, and external peer-review of draft recommendations. Our key recommendation is that a 3-year course of subcutaneous or sublingual AIT can be recommended for children and adolescents with moderate-to-severe allergic rhinitis (AR) triggered by grass/birch pollen allergy to prevent asthma for up to 2 years post-AIT in addition to its sustained effect on AR symptoms and medication. Some trial data even suggest a preventive effect on asthma symptoms and medication more than 2 years post-AIT. We need more evidence concerning AIT for prevention in individuals with AR triggered by house dust mites or other allergens and for the prevention of allergic sensitization, the first allergic disease, or for the prevention of allergic comorbidities in those with other allergic conditions. Evidence for the preventive potential of AIT as disease-modifying treatment exists but there is an urgent need for more high-quality clinical trials.

Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management

This review provides general information to serve as a primer for those embarking on understanding food allergy and also details advances and updates in epidemiology, pathogenesis, diagnosis, and treatment that have occurred over the 4 years since our last comprehensive review. Although firm prevalence data are lacking, there is a strong impression that food allergy has increased, and rates as high as approximately 10% have been documented. Genetic, epigenetic, and environmental risk factors are being elucidated increasingly, creating potential for improved prevention and treatment strategies targeted to those at risk. Insights on pathophysiology reveal a complex interplay of the epithelial barrier, mucosal and systemic immune response, route of exposure, and microbiome among other influences resulting in allergy or tolerance. The diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges, but emerging use of component-resolved diagnostics is improving diagnostic accuracy. Additional novel diagnostics, such as basophil activation tests, determination of epitope binding, DNA methylation signatures, and bioinformatics approaches, will further change the landscape. A number of prevention strategies are under investigation, but early introduction of peanut has been advised as a public health measure based on existing data. Management remains largely based on allergen avoidance, but a panoply of promising treatment strategies are in phase 2 and 3 studies, providing immense hope that better treatment will be imminently and widely available, whereas numerous additional promising treatments are in the preclinical and clinical pipeline.