Food allergy and atopic dermatitis: Prediction, progression, and prevention

Development of a predictive model for pediatric atopic dermatitis: A retrospective cross-sectional nationwide database study

BACKGROUND

The rise in prevalence of atopic dermatitis (AD) has been correlated with numerous elements of the exposome, modern-day lifestyle, and familial history. The combined analysis of familial history and other risk elements may allow us to understand the driving factors behind the development of AD.

OBJECTIVE

To develop prediction models to assess the risk of developing AD using a large and diverse cohort (N = 77,525) and easily assessed risk factors.

METHODS

We analyzed electronic medical record data from Leumit Health System. Documented predictive factors include sex, season of birth, environment (urban/rural), socioeconomic status, household smoking, diagnosed skin conditions, number of siblings, a paternal, maternal, or sibling history of an atopic condition, and antibiotic prescriptions during pregnancy or after birth. Predictive models were trained and validated on the data set.

RESULTS

Medium (odds ratio [OR] 2.04, CI 1.92-2.17, P < .001) and high (OR 2.13, CI 1.95-2.34, P < .001) socioeconomic status, a previous diagnosis of contact dermatitis (OR 2.57, CI 2.37-2.78, P < .001), presence of siblings with an AD diagnosis (OR 2.21, CI 2.04-2.40, P < .001), and the percentage of siblings with any atopic condition (OR 2.58, CI 2.09-3.17, P < .001) drove risk for AD in a logistic regression model. A random forest prediction model with a sensitivity of 61% and a specificity of 84% was developed. Generalized mixed models accounting for the random effect of familial relationships boasted an area under the curve of 0.98.

CONCLUSION

Predictive modeling using noninvasive and accessible inputs is a powerful tool to stratify risk for developing AD.

Infant Formulas With Partially or Extensively Hydrolyzed Milk Proteins for the Prevention of Allergic Diseases: A Systematic Review and Meta-Analysis of Clinical Trials

Despite the widely recommended usage of partially hydrolyzed formula (PHF) or extensively hydrolyzed formula (EHF) of milk protein for preventing allergic diseases (ADs), clinical studies have been inconclusive regarding their efficacy compared with that of cow's milk formula (CMF) or breast milk (BM). We aimed to systematically evaluate the effects of PHF or EHF compared with those of CMF or BM on risk of ADs (cow's milk allergy, allergic rhinitis, eczema, asthma, wheeze, food allergy, and sensitization) in children. We searched PubMed, Embase, Cochrane Library, and Web of Science for clinical trials published from inception to 21 October, 2022. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to grade the strength of evidence. Overall, 24 trials (10,950 infants) were included, 17 of which specifically included high-risk infants. GRADE was low for the evidence that, compared with CMF, infants early fed with EHF had lower risk of cow's milk allergy at age 0-2 y [relative risk (RR): 0.62; 95% CI: 0.39, 0.99]. Moderate evidence supported that PHF and EHF reduced risk of eczema in children aged younger or older than 2 y, respectively (RR: 0.71; 95% CI: 0.52, 0.96; and RR: 0.79; 95% CI: 0.67, 0.94, respectively). We also identified moderate systematic evidence indicating that PHF reduced risk of wheeze at age 0-2 y compared with CMF (RR: 0.50; 95% CI: 0.29, 0.85), but PHF and EHF increased the risk compared with BM (RR: 1.61; 95% CI: 1.11, 2.31; and RR: 1.64; 95% CI: 1.26, 2.14). Neither PHF nor EHF had significant effects on other ADs in children of any age. In conclusion, compared with CMF, PHF, or EHF had different preventive effect on cow's milk allergy, eczema, and wheeze. Compared with BM, both PHF and EHF may increase risk of wheeze but not other ADs. Given that most trials included only high-risk infants, more research on non-high-risk infants is warranted before any generalization is attempted. This protocol was registered at PROSPERO as CRD42022320787.

Effects of Pollution on Pregnancy and Infants

The fetus is particularly susceptible to environmental contaminants as it is developing at the time of pregnancy and is, therefore, more susceptible to their effects. Pregnancy loss, which includes stillbirth and spontaneous abortion (miscarriage), preterm labor and delivery, and neonatal death, is the worst pregnancy outcome. Stunting and its related health and developmental effects are particularly common in populations living in underdeveloped countries or those exposed to high levels of particle pollution. Several environmental toxins can affect an embryo, fetus, or infant as they are developing. This study explores the following questions: What part do pesticides, heavy metals, dioxin derivatives, and polychlorinated diphenyl compounds play as macroenvironmental pollutants in mutagenesis and teratogenesis? What effects do substances that exposed persons have considerable control over, such as alcohol, narcotics, and tobacco smoke, have on the microenvironment? What consequences should practitioners be aware of these toxins in terms of ethics and the law? This study seeks to assess pertinent primary scientific studies on how pollution affects the health of the fetus and newborn during pregnancy.

Knowledge mapping of the links between the microbiota and allergic diseases: A bibliometric analysis (2002-2021)

BACKGROUND

In recent decades, dramatic changes in modern environmental exposures and lifestyles have resulted in a steep rise in the prevalence of allergic diseases such as asthma, allergic rhinitis, atopic dermatitis and food allergies. Evidence is mounting that the microbiota plays a crucial role in allergic disorder development and evolution. Therefore, a better understanding of allergic diseases within the context of the microbiota is urgently needed. This work aimed to comprehensively outline general characteristics, research hotspots, evolution routes, and emerging trends in this area.

METHODS

Relevant publications from January 2002 to December 2021 were obtained from the Web of Science Core Collection on 5 August 2022. Bibliometric and visual analyses were performed using CiteSpace; VOSviewer; an online bibliometric platform; and Microsoft Excel 2019.

RESULTS

In total, 2535 documents met the requirements. The annual number of publications has shown rapid growth in the last two decades. The USA, University of California System, and Isolauri E of the University of Turku were the most productive and influential country, institution, and author, respectively. The Journal of Allergy and Clinical Immunology was the most prolific and most cocited journal. High-frequency keywords included "gut microbiota", "asthma", "atopic dermatitis", "children", and "probiotics". Recent studies have focused on "atopic dermatitis", "skin", "asthma", and "probiotics", according to the cocitation analysis of references. Burst detection analysis of keywords showed that "community", "skin microbiome", "microbiome", "Staphylococcus aureus", and "chain fatty acid" were emerging research frontiers, which currently have ongoing bursts.

CONCLUSION

In the last 20 years, studies of the microbiota in allergic diseases have been flourishing, and the themes have been increasing in depth. These findings provide valuable references on the current research hotspots and gaps and development trends in the link between the microbiota and allergic diseases.

Prevalence of Food Allergy in France up to 5.5 Years of Age: Results from the ELFE Cohort

Background: In France, updated data on food allergies (FAs) are lacking, despite the need for efficient FA management and prevention. This study aimed to evaluate the prevalence of FAs in children in France, describe the most common allergens and determine the prevalence of atopic diseases in children with FAs. Methods: The ELFE study comprises a French nationwide birth cohort, including 18,329 children born in 2011. FAs were assessed by parental reports of food avoidance based on medical advice related to FAs, provided at 2 months and 2, 3.5 and 5.5 years of age. Data regarding FAs were available for 16,400 children. Data were weighted to account for selection and attrition bias. Results: From birth to 5.5 years of age, FAs were reported for 5.94% (95% CI: 5.54–6.34) children. Milk was the most common allergen, followed by egg, peanut, exotic fruits, tree nuts, gluten and fish. Among children with FAs, 20.5% had an allergy to at least two different groups of allergens; 71% reported eczema at least once before 5.5 years of age; 24.4% reported incidence of asthma; and 42.3% reported incidence of allergic rhinitis or conjunctivitis. Conclusion: In France, the prevalence of FAs in children up to 5.5 years of age is approximately 6%. It was demonstrated that 1 in 5 children with allergies had multiple FAs.

Targeting therapeutic approaches and highlighting the potential role of nanotechnology in atopic dermatitis

Atopic dermatitis is a chronic as well as widespread skin disease which has significant influence on the life attributes of affected people and their families. Systemic immunosuppressive drugs can be utilised for effective care of disease, although they are often prescribed for rigorous disruption or disease that is complicated to manage. Therefore, topical applications of corticosteroids are considered the primary pharmacologic therapies for atopic dermatitis, and research recommends that these medications might be helpful in preventing disease flare-ups. However, topical medicine administration to deeper layers of skin is challenging because of the skin anatomic barrier that restricts deeper drug permeation, and also due to barrier function abnormalities in atopic dermatitis skin, which might result in systemic drug absorption, provoking systemic consequences. Hence, effective management of atopic dermatitis needs new, effective, safe and targeted treatments. Therefore, nanotechnology-based topical therapeutics have attracted much interest nowadays because of their tendency to increase drug diffusion and bioavailability along with enormous drug targeting potential to affected cells, and, thereby, reducing the adverse effects of medications. In this review, we mention different symptoms of atopic dermatitis, and provide an overview of the different triggering factors causing atopic dermatitis, with emphasis on its epidemiology, pathophysiology, clinical features and diagnostic, and preventive measures. This review discusses existing therapeutics for treating atopic dermatitis, and the newer approaches as well as the current classical pharmacotherapy of atopic dermatitis against new nanoparticle skin delivery systems. This review has also briefly summarised the recent patents and clinical status of therapeutic modalities for atopic dermatitis.

Pro-inflammatory Diet Pictured in Children With Atopic Dermatitis or Food Allergy: Nutritional Data of the LiNA Cohort

Background

Lifestyle and environmental factors are known to contribute to allergic disease development, especially very early in life. However, the link between diet composition and allergic outcomes remains unclear.

Methods

In the present population-based cohort study we evaluated the dietary intake of 10-year-old children and analyses were performed with particular focus on atopic dermatitis or food allergy, allergic diseases known to be affected by dietary allergens. Dietary intake was assessed via semi-quantitative food frequency questionnaires. Based on these data, individual nutrient intake as well as children’s Dietary Inflammatory Index (C-DII™) scores were calculated. Information about atopic manifestations during the first 10 years of life and confounding factors were obtained from standardized questionnaires during pregnancy and annually thereafter.

Results

Analyses from confounder-adjusted logistic regression models (n = 211) revealed that having atopic outcomes was associated with having a pro-inflammatory pattern at the age of 10 years: OR = 2.22 (95% CI: 1.14–4.31) for children with atopic dermatitis and OR = 3.82 (95% CI: 1.47–9.93) for children with food allergy in the first 10 years of life.

Conclusion

A pro-inflammatory dietary pattern might worsen the atopic outcome and reduce the buffering capacity of the individual against harmful environmental exposures or triggers. For pediatricians it is recommended to test for the individual tolerance of allergenic foods and to increase the nutrient density of tolerable food items to avoid undesirable effects of eating a pro-inflammatory diet.

Consensus on the diagnosis and treatment of cow's milk protein allergy of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Cow's milk protein allergy (CMPA) is the most frequent cause of food allergy in the first months of life. Despite the fact that there are different guidelines and recommendations on the management of children with CMPA, there continues to be great variability in diagnostic and therapeutic criteria in Latin America. The Food Allergy Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition summoned a group of Latin American experts to reach a consensus and formulate a document to unify diagnostic and therapeutic criteria for CMPA. Three teams were formed, each with a coordinator, and the members of each team developed a series of statements for their corresponding module: a) clinical manifestations and diagnosis; b) diagnostic tools, and c) treatment. A search of the medical literature was carried out to support the information presented in each module and 28 statements were then selected. The statements were discussed, after which they were evaluated by all the experts, utilizing the Delphi method. Their opinions on statement agreement or disagreement were anonymously issued. The final statements selected were those with above 75% agreement and their corresponding recommendations were formulated, resulting in the document presented herein.

Viral Infection and Respiratory Exacerbation in Children: Results from a Local German Pediatric Exacerbation Cohort

Respiratory viruses play an important role in asthma exacerbation, and early exposure can be involved in recurrent bronchitis and the development of asthma. The exact mechanism is not fully clarified, and pathogen-to-host interaction studies are warranted to identify biomarkers of exacerbation in the early phase. Only a limited number of international exacerbation cohorts were studied. Here, we have established a local pediatric exacerbation study in Germany consisting of children with asthma or chronic, recurrent bronchitis and analyzed the viriome within the nasopharyngeal swab specimens derived from the entire cohort (n = 141). Interestingly, 41% of exacerbated children had a positive test result for human rhinovirus (HRV)/human enterovirus (HEV), and 14% were positive for respiratory syncytial virus (RSV). HRV was particularly prevalent in asthmatics (56%), wheezers (50%), and atopic (66%) patients. Lymphocytes were decreased in asthmatics and in HRV-infected subjects, and patients allergic to house dust mites were more susceptible to HRV infection. Our study thus confirms HRV infection as a strong ‘biomarker’ of exacerbated asthma. Further longitudinal studies will show the clinical progress of those children with a history of an RSV or HRV infection. Vaccination strategies and novel treatment guidelines against HRV are urgently needed to protect those high-risk children from a serious course of disease.

Associations between sensitisation to allergens and allergic diseases: a hospital-based case-control study in China

OBJECTIVES

To assess the associations of sensitisation to common allergens with atopic dermatitis, allergic rhinitis and allergic asthma in adults.

DESIGN

Case-control study.

SETTING

Data were collected from the First Affiliated Hospital of Harbin Medical University in Harbin, China.

PARTICIPANTS

Cases were 5111 patients with physician-diagnosed atopic dermatitis (n=2631), allergic asthma (n=1320) and allergic rhinitis (n=1160) recruited from the department of allergy from March 2009 to December 2017. Controls were 2576 healthy adults who underwent physical examination at the same hospital during the same period.

MAIN OUTCOME MEASURES

Specific IgE levels to 16 common food, indoor and outdoor allergens were assessed in all participants. Adjusted ORs and 95% CIs for the association between allergen sensitisation and allergic diseases were estimated using multivariate logistic regression.

RESULTS

The prevalence of allergen sensitisation was higher in patients with atopic dermatitis (indoor=17.14%, outdoor=12.85%, food=21.44%), allergic rhinitis (indoor=23.18%, outdoor=26.81%, food=8.94%) and allergic asthma (indoor=24.65%, outdoor=16.46%, food=14.31%) compared with controls (indoor=11.03%, outdoor=6.84%, food=5.83%). After adjustment for potential confounding variables, there was a dose-response relevance between the levels of allergen-specific IgE and allergic diseases (p trend <0.0001). The number of allergens to which a patient was sensitised increased the risk of allergic diseases (atopic dermatitis: highest adjusted OR=4.28, 95% CI 2.57 to 7.11; allergic rhinitis: highest adjusted OR=13.00, 95% CI 3.76 to 45.00; allergic asthma: OR=2.37, 95% CI 1.67 to 3.37).

CONCLUSION

There was a dose-response relevance between levels of allergen-specific IgE and allergic diseases' prevalence, and multiple sensitisations increased the risk of allergic diseases. This study provides evidence for the prophylaxis of allergic diseases.

Time Trends in the Prevalence of Atopic Dermatitis in Korean Children According to Age

This study aimed to explore time trends in the prevalence of atopic dermatitis (AD) according to age in Korean children. We observed changes in the estimated annual prevalence of AD using data from the Korean National Health Insurance Service (NHIS) and Statistics Korea between 2003 and 2018. In each year, the highest prevalence was evident among children aged 12 to 23 months, and then the prevalence decreased with age. The annual prevalence of AD in Korean children under the age of 18 slightly increased from 4.0% in 2003 to 4.5% in 2018. During this period, the prevalence in children aged 6 to 18 years increased from 1.9% in 2003 to 3.1% in 2018, while that of infants aged less than 24 months substantially decreased. Among children who were born in 1991, 1997, 2000, 2003 and 2006, the slopes of decreasing trend lines over age 6 were similar. Comparing children born in 2009 and 2012 with those born before 2006, the more recent the birth year, the higher the prevalence of AD over age 6. In conclusion, time trends of the annual prevalence of AD in Korean children from 2003 through 2018 were different according to age group. These results suggest that AD development during infancy is decreasing whereas either a late-onset AD or early-onset, persistent phenotype is likely to increase. Different strategies according to age are required for more effective prevention and treatment of AD in Korean children.

Developments in pediatrics in 2020: choices in allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, ortopedics, respiratory tract illnesses and rheumatology

In this article, we describe the advances in the field of pediatrics that have been published in the Italian Journal of Pediatrics in 2020. We report progresses in understanding allergy, autoinflammatory disorders, critical care, endocrinology, genetics, infectious diseases, microbiota, neonatology, neurology, nutrition, orthopedics, respiratory tract illnesses, rheumatology in childhood.

Metabolomic profiling revealed altered lipid metabolite levels in childhood food allergy

BACKGROUND

The pathophysiology of childhood food allergy (FA) and its natural history are poorly understood. Clarification of the underlying mechanism may help identify novel biomarkers and strategies for clinical intervention in children with FA.

OBJECTIVE

This study aimed to identify metabolites associated with the development and resolution of FA.

METHODS

The metabolomic profiles of 20 children with FA and 20 healthy controls were assessed by liquid chromatography-tandem mass spectrometry. Comparative analysis was performed to identify metabolites associated with FA and FA resolution. For subjects with FA, serum samples were collected at the time of diagnosis and after resolution to identify the changes in metabolite levels. The selected metabolites were then quantified in a quantification cohort to validate the results. Finally, genome-wide association analysis of the metabolite levels was performed.

RESULTS

The study demonstrated a significantly higher level of sphingolipid metabolites and a lower level of acylcarnitine metabolites in children with FA than those in healthy controls. At diagnosis, subjects with resolving FA had a significantly high level of omega-3 metabolites and a low level of platelet-activating factors compared to persistent FA. However, the level of omega-3 metabolites decreased in children with resolving FA but increased in children with persistent FA during the same time. The quantification data of omega-3-derived resolvins, platelet-activating factor, and platelet-activating factor acetylhydrolase activity further supported these results.

CONCLUSION

The lipid metabolite profile is closely related to childhood FA and FA resolution. This study suggests potential predictive biomarkers and provides insight into the mechanisms underlying childhood FA.

Allergic diseases in infancy: I - Epidemiology and current interpretation

Objective

Among non-communicable diseases, the prevalence of allergic diseases has increased significantly in the new millennium. The increase of allergic diseases is linked to the changing environment of infants.

Methods

This narrative review summarizes the discussions and conclusions from the 8^th Human Milk Workshop. Information from the fields of pediatrics, epidemiology, biology, microbiology, and immunology are summarized to establish a framework describing potential avenues for the prevention of allergic diseases in the future.

Results

Several environmental circumstances are linked to the development of allergic diseases. While cesarean section is increasing the risk of allergies, early childhood exposure to a farm environment has a protective effect. From their analysis, nutritive and non-nutritive factors influencing the allergy risk in later life have been identified. The effect of breastfeeding on food allergy development is non-univocal. Human milk components including immunoglobulins, cytokines, and prebiotics have been indicated as important for allergy prevention.

Conclusion

Many factors linked to the western lifestyle have been associated with the development of allergic diseases. This suggests several theories that may serve as a basis for new protective interventions. While it is indubitable that mother's milk protects from infectious diseases, its role in the prevention of allergic diseases is to be elucidated.

Association of exposure to hydrocarbon air pollution with the incidence of atopic dermatitis in children

Background

There is growing evidence suggesting that air pollution may act as an important environmental risk factor in the development and aggravation of childhood atopic dermatitis (AD).

Methods

We collected data from the Taiwan National Health Insurance (NHI) research database and linked the data to the Taiwan Air Quality-Monitoring Database. From January 1, 2000 to December 31, 2012; children aged below 18 years were selected from the database and followed longitudinally until the diagnosis of AD, withdrawal from the NHI, or December 31, 2012. Children with missing data or those diagnosed with AD before enrolment in this study were excluded. We measured the incidence rate and hazard ratios (HRs) for AD and stratified them by quartiles (Q1–Q4) of air pollutant concentration. Multivariable Cox proportional hazards models were also applied by adjusting for age, sex, monthly income, and level of urbanization.

Results

When compared with the concentrations of pollutants in the Q1 quartile, the adjusted HR for AD increased with an increase in the exposure concentrations of total hydrocarbons (THCs), non-methane hydrocarbons (NMHCs), and methane (CH₄) from 1.65 (95% confidence interval [CI]: 1.47–1.84) to 10.6 (95% CI: 5.85–7.07), from 1.14 (95% CI: 1.06–1.24) to 2.47 (95% CI: 2.29–2.66), and from 1.70 (95% CI: 1.52–1.89) to 11.9 (95% CI: 10.8–13.1), respectively. Patients exposed to higher levels of THCs, NMHCs, and CH₄ exhibited greater incidence rates of childhood AD.

Conclusions

The present study demonstrated that exposure to higher concentrations of THCs, NMHCs, and CH₄ were associated with an increased risk of childhood AD.

Atopic Dermatitis-Beyond the Skin

Atopic dermatitis is a chronic inflammatory disease that can arise during the first months of life or at maturity and have a significant negative impact on the quality of life. The main pathogenic mechanism is the breakdown of cutaneous barrier integrity, which is associated with systemic inflammatory immunologic disorders. Atopic dermatitis involves numerous immunologic, allergic, respiratory, and ophthalmologic comorbidities that develop through similar intricate pathogenic phenomena. The atopic march represents the evolution in time of various allergic diseases, of which food allergies often cause the first manifestations of atopy, even from a very young age. Chronic inflammation translated through specific markers, next to increased immunoglobulin E (IgE) serum levels and heterogenous clinical manifestations, argue for the inclusion of atopic dermatitis in the systemic disease category.

Is a strict cow's milk-free diet necessary to treat milk oral immunotherapy-related eosinophilic esophagitis?

We report the case of a 15-year-old boy who developed eosinophilic esophagitis (EoE) during cow’s milk oral immunotherapy (CM-OIT). In order to not completely invalidate OIT benefits, baked milk-containing foods were allowed instead of a strict CM-free diet. However, histological remission of EoE was reached only after a strict cow’s milk-free diet, not associated to pharmacological treatment. Nevertheless, given the limited data on real incidence of food OIT related EoE and potential beneficial treatment for this condition, we highlight the need of prospective studies aimed to evaluate if a strict CM free diet in OIT related EoE is always necessary to obtain remission of the disease or similarly to CM EoE, baked milk-containing foods” diet could be abeneficial treatment also in these patients. (www.actabiomedica.it)

Long-term oral administration of transgenic rice containing cedar pollen T-cell epitopes potentially improves medication- and allergy-related quality-of-life scores

Background: We previously developed a transgenic rice that contains seven linked human predominant T-cell epitopes (7Crp) derived from Japanese cedar (JC) pollen allergens Cry j 1 and Cry j 2. Oral administration of 80 g of transgenic rice for 20 weeks suppressed allergen-specific T-cell proliferation in participants with JC pollinosis, but their clinical symptoms did not improve. Objective: We examined the clinical efficacy of low-dose (5 g and 20 g) intake of the transgenic rice administered for two successive seasons. Methods: In this randomized, double-blind, placebo controlled study, transgenic rice seeds (5 g or 20 g) were orally administered to the participants for 24 weeks in each of two successive JC pollen seasons. We analyzed T-cell proliferation and cytokine expression, and monitored symptom and medication scores during the pollen season. Quality of life (QOL) was evaluated by using the Japanese Allergic Rhinitis Quality of Life Standard Questionnaire (JRQLQ). Results: Specific T-cell proliferation after stimulation with 7Crp, Cry j 1, and Cry j 2 was significantly suppressed in the second JC pollen season. No significant differences were found among the three groups (5 g, 20 g, and placebo) with regard to clinical symptoms or medication scores in the first season. However, the medication scores and face scale for overall condition of JRQLQ improved in the 5-g transgenic rice group in the second season, although careful re-examination with a large sample size is necessary to confirm the results. Conclusion: Low-dose oral administration of transgenic rice that contains 7Crp significantly reduced allergen-specific T-cell responses and improved medication scores during the second season of administration. Thus, oral intake of the transgenic rice has the potential to induce immune tolerance to JC pollen allergens when administered for at least two successive seasons.

Clinical phenotypes of childhood food allergies based on immune mechanisms: A multicenter study

Background: Food allergies (FA) are an important public health concern that place a major burden on the lives of children and their families. The complex pathogenesis of FAs results in multisystemic and heterogenous clinical presentations. Objective: To evaluate, according to immune mechanisms, the characteristics and risk factors of childhood FA in Turkey. Methods: This descriptive multicenter study included 1248 children with FA, aged < 18 years,, who were evaluated by pediatric allergists in 26 different centers. Results: Immune mechanisms of FA were immunoglobulin E (IgE) mediated in 71.8%, non-IgE mediated in 15.5%, and mixed IgE/non-IgE mediated in 12.7% of the patients. An episode of anaphylaxis had occurred in 17.6% of IgE-mediated FA. The most common food allergens were classified into five categories (in order of decreasing frequency): cow's milk, egg, tree nuts and/or peanut, wheat, and seafood. Allergies to cow's milk and egg declined significantly with age, whereas tree nuts and/or peanut allergies increased with age. The 0-2 year age group accounted for 62.5% of the cases. The most frequent cause of FA and food anaphylaxis was cow's milk before age 13 years and tree nuts and/or peanut during adolescence (ages 13-18 years). Compared with other phenotypes, male sex (odds ratio [OR] 1.486; p = 0.032), sibling(s) (OR 1.581; p = 0.021), and maternal atopy (OR 1.531; p = 0.045) increased the likelihood of IgE-mediated FA, whereas high household income (OR 1.862; p = 0.026) increased the likelihood of non-IgE-mediated FA in multivariate regression analysis. Conclusion: This study showed that the clinical findings of FA were highly variable, depending on age and underlying immune mechanism. Knowing the population characteristics will enable better management of FA in children.

Characteristics associated with clinical response to Comano thermal spring water balneotherapy in pediatric patients with atopic dermatitis

BACKGROUND

Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients.

METHODS

An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated.

RESULTS

A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course.

CONCLUSIONS

Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.

Treatment with a Probiotic Mixture Containing Bifidobacterium animalis Subsp. Lactis BB12 and Enterococcus faecium L3 for the Prevention of Allergic Rhinitis Symptoms in Children: A Randomized Controlled Trial

Background: Probiotics may prevent the allergic response development due to their anti-inflammatory and immunomodulatory effects. The aim of this study is to determine if the prophylactic treatment with a mixture of Bifidobacterium animalis subsp. Lactis BB12 and Enterococcus faecium L3 would reduce symptoms and need for drug use in children with allergic rhinitis (AR). Methods: The study included 250 children aged from 6 to 17 years, affected by AR. Patients were randomly assigned to the intervention group (150) or to the placebo group (100). Patients in the intervention group, in addition to conventional therapy (local corticosteroids and/or oral antihistamines), were treated in the 3 months preceding the onset of symptoms related to the presence of the allergen to which the children were most sensitized, with a daily oral administration of a probiotic mixture containing the Bifidobacterium animalis subsp. Lactis BB12 DSM 15954 and the Enterococcus faecium L3 LMG P-27496 strain. We used Nasal Symptoms Score (NSS) to evaluate AR severity before and after the treatment with probiotics or placebo. Results: the patients in the intervention group had a significant reduction in their NSS after probiotic treatment (p-value = 2.2 × 10⁻¹⁰. Moreover, for the same group of patients, we obtained a significant reduction in the intake of pharmacological therapy. In particular, we obtained a reduction in the use of oral antihistamines (p-value = 2.2 × 10⁻¹⁶), local corticosteroids (p-value = 2.2 × 10⁻¹³), and of both drugs (p-value 1.5 × 10⁻¹⁵). Conclusions: When administered as a prophylactic treatment, a mixture of BB12 and L3 statistically decreased signs and symptoms of AR and reduced significantly the need of conventional therapy.

Component-Resolved Diagnosis of Hazelnut Allergy in Children

Hazelnuts commonly elicit allergic reactions starting from childhood and adolescence, with a rare resolution over time. The definite diagnosis of a hazelnut allergy relies on an oral food challenge. The role of component resolved diagnostics in reducing the need for oral food challenges in the diagnosis of hazelnut allergies is still debated. Therefore, three electronic databases were systematically searched for studies on the diagnostic accuracy of specific-IgE (sIgE) on hazelnut proteins for identifying children with a hazelnut allergy. Studies regarding IgE testing on at least one hazelnut allergen component in children whose final diagnosis was determined by oral food challenges or a suggestive history of serious symptoms due to a hazelnut allergy were included. Study quality was assessed by the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Eight studies enrolling 757 children, were identified. Overall, sensitivity, specificity, area under the curve and diagnostic odd ratio of Cor a 1 sIgE were lower than those of Cor a 9 and Cor a 14 sIge. When the test results were positive, the post-test probability of a hazelnut allergy was 34% for Cor a 1 sIgE, 60% for Cor a9 sIgE and 73% for Cor a 14 sIgE. When the test results were negative, the post-test probability of a hazelnut allergy was 55% for Cor a 1 sIgE, 16% for Cor a9 sIgE and 14% for Cor a 14 sIgE. Measurement of IgE levels to Cor a 9 and Cor a 14 might have the potential to improve specificity in detecting clinically tolerant children among hazelnut-sensitized ones, reducing the need to perform oral food challenges.

Best practices, challenges and innovations in pediatrics in 2019

This paper runs through key progresses in epidemiology, pathomechanisms and therapy of various diseases in children that were issued in the Italian Journal of Pediatrics at the end of last year. Novel research and documents that explore areas such as allergy, critical care, endocrinology, gastroenterology, infectious diseases, neonatology, neurology, nutrition, and respiratory tract illnesses in children have been reported. These observations will help to control childhood illnesses.

Atopic dermatitis, inhalant allergy and food allergy: A paediatric approach

Food and inhalant allergens have also been identified as potential trigger factors of atopic dermatitis symptoms. Here we aimed to investigate relationships between atopic dermatitis and inhalant-food allergen sensitization in Turkish children with atopic dermatitis. We included 70 patients (42 male, 28 female) with atopic dermatitis and 45 controls (30 male, 15 female) with no atopy, no atopy familial history, no atopy clinical findings no atopic dermatitis. We noted patients' and controls' age, gender, passive smoking exposure, atopy, xerosis, bath water temperature, shower gel type, clothes detergent type, blood hemoglobin, blood eosinophil count, blood eosinophil percent, values of serum immunoglobulin E, serum immunoglobulin A, serum immunoglobulin G, serum immunoglobulin M, results of inhalant allergen, and food allergen testing. We found that nine cases had inhalant allergen sensitization and 21 cases had food allergen sensitization. There were significant relationships between cases and controls in terms of count of eosinophil and percent of eosinophil (P = .008, P = .009, respectively). Humoral and cellular allergen-specific immune responses to food and inhalant allergens can be detected in patients with atopic dermatitis. Accordingly, we believe that blood eosinophil count and percent are more valuable laboratory parameters than serum total IgE for following patients with atopic dermatitis.

Urticaria in childhood

Histaminergic urticaria-angiodema is a common complaint in children. According to clinical criteria, it is classified as acute and chronic urticaria. A further clinical classification relies on triggering factors. We focus on diagnosis and therapeutic strategies. We report the main progresses in the field and issues that remain to be understood.

What is new in anaphylaxis?

Available information suggests that anaphylaxis must be promptly recognized keeping in mind the airway patency, breathing (ventilation and respiration), circulation and mental status and treated. The first treatment is adrenaline. After successful treatment of an anaphylactic episode, attention must be paid to the prevention of early recurrences (biphasic anaphylaxis) and assessment of causes. Children should not be discharged before prescribing self-injectable adrenaline and explain how and under what circumstances it must be injected, An action plan must be communicated to their communities. Inform the school about potential reactions, how to prevent them and avoidance measures. (www.actabiomedica.it)

Atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease, clinically characterized by recurrent eczematous lesions and intense itching, leading to excoriations and susceptibility to cutaneous infections. Although it is considered a pediatric disorder, mainly starting in infancy, it is also very common in adults. Etiology of AD is complex and multifactorial: interaction between genetic susceptibility and environment, but also cutaneous barrier impairment, change in microbiome composition and innate and adaptive immune dysregulation are the main factors involved in the pathogenesis of the disease. Originally, the disorder was considered mediated by an imbalance towards a T-helper 2 response and excessive IgE production to allergens, but now it is recognized as a lifelong disposition with variable clinical expressivity, where dysfunctions of the epidermal barrier, immune system and microbiome play a central role. AD leads to a substantial psycho-social burden on patients and their relatives and increases the risk of other allergic and non allergic disorders. The real economic impact of AD is difficult to measure due to the broad spectrum of disease severity and the multiple direct and indirect costs, but the overall medical expenses seem to be very high and similar to those of other diseases such as diabetes. Currently, a multiple therapeutic approach is aimed only at improving the skin state, reducing itching and keeping a stable condition. New safety and curative treatments may be developed only after enhancing our understanding on the pathogenesis of AD and the heterogeneity of its clinical manifestations. (www.actabiomedica.it)

Food allergy: an updated review on pathogenesis, diagnosis, prevention and management

Food allergy (FA) is an adverse immunologic response triggered by normally innocuous food protein antigens.  FA can be broadly classified into those that are IgE mediated, those that are mediated by both IgE-dependent and IgE-independent pathways (mixed), and those that are not IgE mediated  Immunoglobulin E. (IgE)-mediated reaction is characterized by rapid onset of symptoms involving respiratory, gastrointestinal, dermatologic and cardiovascular systems; mixed and non-IgE-mediated has a longer onset and manifests primary in the gastrointestinal tract and skin. The diagnosis of food allergy is based on clinical history, diagnostic testing (skin prick test and allergen-specific IgE levels in the serum), elimination diet and, oral food challenge. In recent years the diagnosis and treatment of pediatric FA have notably improved. In the diagnostic pathway of FA an important recent innovation is the CRD introduction.  This resulted in the possibility of improving diagnostic accuracy through FA prediction severity and prognosis and thereby decreasing the OCF necessity. Recent studies emphasize the possibility of preventing FA through early introduction of food (peanuts and egg) to high-risk infants. FA management is based on avoidance of offending food and prompt treatment of allergic reaction. Currently under study are recently developed treatment approaches for FA management including specific OIT.

New insights into food protein-induced enterocolitis in children

Food protein-induced enterocolitis syndrome (FPIES) represents a non-IgE-mediated food allergic disorder with delayed gastrointestinal symptoms that may evolve in a medical emergency. Clinically, FPIES can be distinguished into acute and chronic phenotypes. FPIES is mainly diagnosed in infancy however the onset at older ages is being progressively described. The pathogenetic mechanism underlying FPIES remains mainly unexplained, but an alteration of food-specific T-cell response has been proposed. The diagnosis of FPIES is primarily clinical, since there are not available specific biomarkers. Oral food challenge (OFC) is the gold standard for diagnosing FPIES or excluding the onset of tolerance to the triggering food. Management of FPIES includes an acute phase treatment and a maintenance therapy with the strict food avoidance until challenge, in order to prevent new attacks and avoid nutritional alterations. Acute management requires hydration that can be performed orally or intravenously according to clinical status. Long-term management of FPIES is based on the avoidance of the culprit food(s) and supervised introduction of other high-risk foods if never taken before among infants before 12 months of age. There is a compelling need of future achievements in FPIES research for the definition of underlying disease pathogenesis and potential therapeutic point of care.

Advances in paediatrics in 2019: current practices and challenges in allergy, endocrinology, gastroenterology, public health, neonatology, nutrition, nephrology, neurology, respiratory diseases and rheumatic diseases

We highlight the main developments that have been published during the first semester of the last year in the Italian Journal of Pediatrics. We have carefully chosen information from numerous exciting progresses issued in the Journal in the field of allergy, endocrinology, gastroenterology, neonatology, nutrition, nephrology, neurology, public health, respiratory diseases and rheumatic diseases. The impact on the care of patients has been placed in the broader context of studies that appeared in other journals. We think that many observations can be used directly to upgrade management of patients.

Allergic symptoms and sensitisation in adolescents with cows' milk allergy and atopic eczema in infancy

Background

The association between atopic sensitisation, atopic eczema (AE) and asthma is known, but distinct roles of allergies on long‐term health are unestablished.

Objective

Evaluation of allergic symptoms and sensitisation in adolescents who in infancy had AE and verified cows' milk allergy (CMA) or AE and a negative CMA challenge, and controls.

Methods

Children with AE, with and without CMA, from a randomised controlled study in 1999‐2001 examining the effect of probiotics on AE severity at older than 12 months of age, attended a follow‐up visit at age 16 to 18, with age‐matched controls. Data came from a questionnaire (ISAAC questionnaire), analysis of serum antigen‐specific immunoglobulin Es (IgEs), and clinical evaluation. Group comparisons were carried out (χ² tests and logistic regression).

Results

Fifty‐two patients with AE and CMA (AE/CMA+ group), 52 with AE and suspicion of CMA (AE/CMA− group), and 57 controls attended a study visit. IgE‐mediated sensitisation was significantly more prevalent in the AE/CMA+ group vs the controls, for horse, cat, dog, egg white and wheat (P < .024 for all). For birch, timothy and mugwort (P < .008 for all), sensitisation was more prevalent in both the AE/CMA+ group and the AE/CMA− group vs controls. On the basis of questionnaire data the AE/CMA + group reported a significantly higher lifetime prevalence of wheezing (64% vs 35% and 32%; P = .001), noninfectious rhinitis (85% vs 62% and 56%; P = .004), and hay fever (77% vs 52% and 33%; P < .001) vs the AE/CMA− group and the control group, respectively.

Conclusion and Clinical Relevance

Patients with AE and CMA in infancy, as opposed to patients with AE only, or controls, report more allergic symptoms and exhibit more allergic sensitisation in adolescence. This indicates that CMA in infancy is an independent risk factor of allergic disease in adolescence.

Soluble CD83 suppresses experimental food allergy via regulating aberrant T helper 2 responses

Aberrant T helper-2 (Th2) responses play a critical role in the pathogenesis of allergic diseases. The underlying mechanism is to be further investigated. It is reported that soluble CD83 (sCD83) has immune-regulatory effects. This study aims to investigate the role of sCD83 in the regulation of Th2 polarization. Blood samples were collected from pediatric patients with food allergy (FA). The Th2 response was analyzed by pertinent immunological approaches. An FA murine model was developed to test the role of sCD83 in the regulation of FA response. We found that the serum sCD83 levels were lower in FA patients. A negative correlation was detected between serum sCD83 levels and serum Th2 cytokine levels. The presence of sCD83 suppressed Th2 cell differentiation and antigen-specific Th2 cell activation. sCD83 upregulated the T-bet expression and suppressed the GATA3 expression in CD4+ T cells. Administration of sCD83 suppressed experimental FA. Pediatric FA patients have low serum sCD83 levels. Administration of sCD83 can alleviate experimental FA via suppression of aberrant Th2 polarization.

COVID-19 and food allergy in children

In children with food allergy the visits should be limited to those that are unequivocally needed on clinical basis. Food challenge can be performed in selected situations, taking a more detailed history to make sure that patients provide whatever information we need. The maintenance of a safe diet can be hampered by several factors. Nutritional supplementation may be necessary. (www.actabiomedica.it)

Clinical relevance of eosinophils, basophils, serum total IgE level, allergen-specific IgE, and clinical features in atopic dermatitis

Background

Atopic dermatitis (AD) is an inflammatory disease with diverse clinical features. Although AD is diagnosed mainly by clinical features, the laboratory abnormalities can be found in most patients and may be of diagnostic value. However, few studies have been performed on the clinical significance of laboratory abnormalities in adult and adolescent AD.

Methods

Adult and adolescent patients with AD were included in this study. The questionnaire and dermatological examination were completed by investigators. Laboratory tests included complete blood count, serum total IgE, and allergen‐specific IgE.

Results

A total of 473 patients were recruited and 396 of them were diagnosed as AD. Increased serum total IgE level, peripheral eosinophils, and basophils were seen more frequently in AD patients than in non‐AD patients (P < .05). Positive aeroallergens were seen more in AD patients than in non‐AD patients (P < .05). Both total serum IgE level (R = .286, P < .001) and peripheral eosinophils (R = .444, P < .001) significantly correlated with EASI score. Serum total IgE level and extrinsic type AD decreased with age. Patients with elevated serum total IgE are more likely to have a personal history of atopic diseases (P = .014). AD‐associated symptoms (such as flexural dermatitis, white dermographism, and anterior neck folds) are more frequently observed in AD patients with high serum IgE or eosinophilia (P < .05).

Conclusion

The serum total IgE level, allergen‐specific IgE, peripheral eosinophils, and basophils are important for the diagnosis of AD. And they are associated with the severity, age groups, and clinical manifestations.

Primary Prevention of Allergic Diseases: The Role of Early Exposure to Cow's Milk Formula

The burden of atopic disorders is continuously worsening worldwide, especially in childhood. Therefore, risk factors and preventive measures have been called into question. The age when infants introduce complementary foods, varies greatly according to traditional habits, clinical practice recommendations, and breastfeeding duration. It is still debated the impact of early exposure to cow's milk on the increase of allergic diseases, mainly food allergy, and atopic dermatitis. Many factors may play a role in this potential link, such as genetic variation, parental atopy, infant feeding regimens. Recent evidences suggest that the early introduction of complementary foods (up to 6 months of age), including cow's milk, could prevent the development of food allergies. So, several countries included this new approach into feeding guidelines. Our review will focus on the influence of early exposure to cow's milk formula on the development of allergic diseases. Some trials found that cow's milk supplementation in the first days of life could even increase the development of IgE sensitization and food allergies. Other trials did not show any efficacy on prevention of allergic disorders. Further studies are needed to understand the prospective for allergy prevention related to optimal timing of cow's milk formula introduction.

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.

Hydrolyzed Protein Formula for Allergy Prevention in Preterm Infants: Follow-Up Analysis of a Randomized, Triple-Blind, Placebo-Controlled Study

Background: Allergic diseases are a major public health burden worldwide. Evidence suggests that early nutrition might play a key role in the future development of allergies and the use of hydrolyzed protein formulas have been proposed to prevent allergic disease, mainly in term infants with risk factors. Aim: To evaluate the preventive effect of a hydrolyzed protein formula vs. an intact protein formula on allergy development in preterm infants with or without risk factors. Methods: We performed a 3-year follow-up study of a previous triple-blind, placebo-controlled randomized trial. Evidence of atopic dermatitis, asthma and IgE-mediated food allergies were evaluated according to a validated parental questionnaire (Comprehensive Early Childhood Allergy Questionnaire). Food sensitization was also investigated by skin prick test at 3 years of chronological age. Results: Of the 30 subjects in the intact protein formula group and 30 in the extensively hydrolyzed formula group, respectively 18 and 16 completed the 3-year follow-up and entered the final analysis. No group differences in the incidence of atopic dermatitis, asthma, IgE-mediated food allergies, and food sensitization were found. Conclusion: Despite the small number of cases, extensively hydrolyzed protein formula seems to be ineffective in allergic diseases prevention in preterm neonates. Further adequately powered, randomized controlled trials evaluating hydrolyzed protein formula administration to prevent allergic diseases in preterm neonates are needed.

Mouse Models for Food Allergies: Where Do We Stand?

Food allergies are a steadily increasing health and economic problem. Immunologically, food allergic reactions are caused by pathological, allergen-specific Th2 responses resulting in IgE-mediated mast cell degranulation and associated inflammatory reactions. Clinically, food allergies are characterized by local inflammation of the mouth mucosa, the face, the throat, the gastrointestinal tract, are frequently paralleled by skin reactions, and can result in life-threatening anaphylactic reactions. To better understand food allergies and establish novel treatment options, mouse models are indispensable. This review discusses the available mouse food allergy models, dividing them into four categories: (1) adjuvant-free mouse models, (2) mouse models relying on adjuvants to establish allergen-specific Th2 responses, (3) mouse models using genetically-modified mouse strains to allow for easier sensitization, and (4) humanized mouse models in which different immunodeficient mouse strains are reconstituted with human immune or stem cells to investigate humanized immune responses. While most of the available mouse models can reproducibly portray the immunological parameters of food allergy (Th2 immune responses, IgE production and mast cell activation/expansion), so far, the recreation of the clinical parameters has proven more difficult. Therefore, up to now none of the available mouse models can reproduce the complete human pathology.

Analysis of the Association of Polymorphisms rs5743708 in TLR2 and rs4986790 in TLR4 with Atopic Dermatitis Risk

BACKGROUND

We carried out a meta-analysis to assess whether Toll-like receptor 2 (TLR2) rs5743708 and Toll-like receptor 4 (TLR4) rs4986790 polymorphisms are associated with the risk of atopic dermatitis.

METHODS

A systematic search of PubMed, Embase, and Web of Science was performed to identify eligible case-control studies on the association of rs5743708 and rs4986790 with the risk of atopic dermatitis. Statistical analyses of the odds ratio (OR), 95% confidence interval (CI), and p value were performed using STATA software.

RESULTS

Our meta-analysis included a total of nine case-control studies, all involving Caucasian populations. With respect to the TLR2 rs5743708 G/A polymorphism, there was a statistically significant difference in the overall risk of atopic dermatitis between the case and control groups [OR = 2.07, p value of association test, p_{(association)} = 0.001 in allele (A vs. G) model; OR = 1.93, p_{(association)} = 0.004 in carrier (A vs. G) model; OR = 2.07, p_{(association)} = 0.001 in heterozygote (GA vs. GG) model; OR = 1.99, p_{(association)} = 0.001 in dominant (GA+ AA vs. GG) model]. Similar positive results were observed in the subgroup analysis of "population-based control." For the TLR4 rs4986790 A/G polymorphism, an increased atopic dermatitis risk was detected in the case group under the allele [OR = 1.78, p_{(association)} = 0.013], carrier [OR = 1.69, p_{(association)} = 0.027] and heterozygote [OR = 1.74, p_{(association)} = 0.020] models, but not the dominant [OR = 1.44, p_{(association)} = 0.070] model, in comparison to the population-based control group.

CONCLUSION

Our meta-analysis revealed a novel finding that the heterogeneous "GA" genotype of the TLR2 rs5743708 and "AG" genotype of the TLR4 rs4986790 may be associated with increased susceptibility to atopic dermatitis in Caucasians.

Do we still need oral food challenges for the diagnosis of food allergy?

Food challenges are standard in the diagnosis in patients suspected of being allergic to food. However, their role is regularly questioned due to the time required to perform them, and to their cost and the inherent risk of severe reactions. Food challenges have been challenged by recent advances defining threshold values for food-specific IgE helping to predict the probability of having symptoms to the suspected food. Also, identification of major allergens to various highly allergenic foods such as peanuts or tree nuts has contributed to an increased accuracy of IgE testing. Altogether, these new data have contributed to a better definition of the role of oral food challenges in the diagnosis of food allergy. Oral food challenges are not outdated and remain the gold standard in the diagnosis of food allergy.