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Cela L, Gravina A, Semeraro A, Pastore F, Morelli R, Marchetti L, Brindisi G, Olivero F, Piccioni MG, Zicari AM, Anania C. Oral Food Challenge in Children with Tree Nut and Peanut Allergy: The Predictive Value of Diagnostic Tests. Diagnostics (Basel) 2024; 14:2069. [PMID: 39335748 PMCID: PMC11431423 DOI: 10.3390/diagnostics14182069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 09/13/2024] [Accepted: 09/17/2024] [Indexed: 09/30/2024] Open
Abstract
Food allergy (FA) affects approximately 6-8% of young children, with a peak prevalence at approximately one year of age. Tree nut and peanut allergies are among the main causes of anaphylaxis in the world. The gold standard for the diagnosis of FAs is the oral food challenge (OFC). Other diagnostic tests used in the clinical practice are skin prick tests (SPTs) and laboratory tests to measure out the presence of serum specific IgE (sIgE). In this narrative review, we collect the current evidence of the predictive value (PV) of SPTs and sIgE for the outcome of the OFCs. In literature, data are conflicting as to whether increasing sIgE concentration and wheal size in SPTs correlate with OFC outcomes. Most studies included in our review have shown that in vivo and in vitro tests may predict OFC outcomes with variable PV, but data are not conclusive; therefore, the OFC currently remains the gold standard for FA diagnosis.
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Affiliation(s)
- Ludovica Cela
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Alessandro Gravina
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Antonio Semeraro
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Francesca Pastore
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Rebecca Morelli
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Lavinia Marchetti
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Giulia Brindisi
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | | | - Maria Grazia Piccioni
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Anna Maria Zicari
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
| | - Caterina Anania
- Department of Maternal Infantile and Urological Science, Sapienza University of Rome, 00161 Rome, Italy; (L.C.); (A.G.); (A.S.); (F.P.); (R.M.); (L.M.) (G.B.); (M.G.P.); (A.M.Z.)
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Rowland AF, Nguyen TH, Cunha PP, Ezhuthachan I, Orenstein E, Kandaswamy S, Lee T. Implementing a clinical decision support tool to increase early peanut introduction guidance. J Allergy Clin Immunol 2024:S0091-6749(24)00712-7. [PMID: 38996876 DOI: 10.1016/j.jaci.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/15/2024] [Accepted: 07/09/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND General pediatric providers are the front line for early peanut introduction discussions, but many providers believe that they are ill-equipped to handle such discussions, as the guidelines have changed quickly. OBJECTIVE We hypothesized that a clinical decision support (CDS) tool could improve discussions of peanut introduction. METHODS CDS tools were designed by stakeholders, improved through usability testing, and integrated into the current note templates. On the basis of queries of electronic health records, we did a preperformance versus postperformance evaluation of conversations regarding peanut introduction, barriers to peanut introduction, and percentage of 12-month well-child checkups (WCCs) that resulted in successful introduction of peanut. Providers completed surveys before and after intervention to assess their awareness of early peanut introduction and comfort using the CDS tools. RESULTS Providers' awareness of early peanut introduction guidelines increased from 17.8% to 66.7% after the CDS tool was implemented; 79.1% of the providers were comfortable using the tool. The CDS tool improved peanut introduction conversations at the 4-month WCC from 2.4% to 81.2%, at the 6-month WCC from 3.0% to 84.2%, and at the 12-month WCC from 2.7% to 82.9%. In all, 56.6% of families had a plan to introduce peanut at the 4-month WCC. Of those who did not have a plan, the most common barrier was the family's unawareness of the benefits of early peanut introduction. At the 12-month WCC, 62.8% of families had introduced peanut without concerns. CONCLUSION A point-of-care CDS tool encouraged more discussions of early peanut introduction between general pediatric providers and all patients. CDS tools should be considered in quality improvement projects as an implementation method for the most up-to-date guidelines.
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Affiliation(s)
| | - Thinh H Nguyen
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Priscila P Cunha
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Idil Ezhuthachan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Evan Orenstein
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga; Division of Hospital Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Tricia Lee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
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Del Duca F, Manetti AC, Maiese A, Napoletano G, Ghamlouch A, Pascale N, Giorgio B, Paola F, Russa RL. Death Due to Anaphylactic Reaction: The Role of the Forensic Pathologist in an Accurate Postmortem Diagnosis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2184. [PMID: 38138287 PMCID: PMC10744436 DOI: 10.3390/medicina59122184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: The diagnosis of anaphylaxis comprehensively depends on both situational information and laboratory investigations. For this purpose, serum tryptase concentration is examined as an indicator of systemic mast cell mediator release, linked to an underlying anaphylactic process. Increased levels of tryptase may occur in some events different from anaphylaxis, but usually information from crime scene investigations is lacking and autoptic findings are not specific. For legal reasons, it is required to achieve a definite diagnosis of mast cell degranulation that can lead to a certain diagnosis of death from anaphylaxis. Immunohistochemistry seems to be a relatively simple, reliable, and easily repeatable method that can assist the forensic pathologist in the differential diagnosis of death from anaphylaxis. Materials and Methods: This work provides an overview of the current literature on immunohistochemical methods useful in the determination process of anaphylactic-related deaths. A systematic search, according to the PRISMA statement, was performed in databases to identify studies investigating immunohistochemical targets related to anaphylaxis death. Results: This work underscores the importance of anaphylaxis mediators such as tryptase, CD117, and chymase in the immunohistochemical analysis of anaphylactic deaths. Conclusions: According to the reviewed literature, the diagnosis of death due to anaphylaxis should depend not just on the suspicion of an anaphylactic reaction but also on confirming mast cell degranulation through the identification of IHC positivity for inflammatory mediators, particularly in the respiratory tract.
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Affiliation(s)
- Fabio Del Duca
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Alice Chiara Manetti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
| | - Gabriele Napoletano
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Alessandro Ghamlouch
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Natascha Pascale
- Department of Forensic Medicine, Hospital ‘San Carlo’, 85100 Potenza, Italy;
| | - Bolino Giorgio
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Frati Paola
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (F.D.D.); (A.C.M.); (G.N.); (A.G.); (B.G.); (F.P.)
| | - Raffaele La Russa
- Department of Clinical Medicine, Public Health, Life Sciences, and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
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Morinaga T, Yamamoto T, Sugimoto Y. A mouse model of food allergy permitting skin and nasal symptoms. Adv Med Sci 2023; 68:372-378. [PMID: 37797366 DOI: 10.1016/j.advms.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/26/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE Developing experimental animal models that show clinical symptoms and methods for quantitative and objective evaluation are important for understanding food allergies. Therefore, this study aimed to develop an ovalbumin (OVA)-induced mouse model of food allergy and a useful method to evaluate the symptoms of food allergy. MATERIAL/METHODS Mice were sensitized via intraperitoneal injection of OVA. Subsequently, local sensitization was performed once weekly by oral administration of OVA. Itching and nasal symptoms were observed after oral administration of the antigen. First, we examined the dose-dependency of the antigen. Symptoms were checked weekly. In order to confirm food allergy symptoms, the effect of histamine H1 receptor antagonist was examined. Finally, we measured antigen-specific IgE antibody levels in the serum. RESULTS Scratching behavior, sneezing and nasal rubbing were increased. Both itching and rhinitis symptoms increased steadily, after which, the number of symptoms remained almost constant. No difference was observed between the results of 3- and 5-week-old mice. Cetirizine inhibited these symptoms in a dose-dependent manner. In addition, antigen-specific IgE antibodies were produced in both 3- and 5-week-old mice. CONCLUSIONS This method may be useful for evaluating the symptoms of skin and rhinitis that could not be assessed in the conventional food allergy model and could be induced with a low dose of antigen. In particular, the developed method, which measures the number of itching and nasal symptoms, may enable quantitative, objective, and noninvasive evaluation of food allergy severity.
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Affiliation(s)
- Takafumi Morinaga
- Laboratory of Inflammatory Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Takuya Yamamoto
- Laboratory of Inflammatory Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan
| | - Yukio Sugimoto
- Laboratory of Inflammatory Pharmacology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Kita-ku, Okayama, Japan.
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Lopes JF, Carvalho MDA, Machado NC. Labeling food allergens in the packaged food pyramid groups in Brazil: analysis of descriptions, ambiguities, and risks. REVISTA PAULISTA DE PEDIATRIA 2022; 40:e2021079. [PMID: 35703721 PMCID: PMC9190470 DOI: 10.1590/1984-0462/2022/40/2021079in] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/24/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate allergenic labeling components of packaged foods for "What is the quality of food labels?" and "What is the group of Brazilian Food Pyramid that 'May contain' is predominant?." METHODS The photographs of 916 products were obtained, of which 518 were analyzed. Data from each label were evaluated according to Brazilian Food Pyramid Groups (i.e., Cereals, Fruits, & Vegetables; Soybean & products; Milk & dairy products; Meat & eggs; Fats & oils; and Sugars & sweets). Ten items were analyzed in each label, namely, the presence of a list of ingredients, alert phrase for allergy sufferers, grouping of the alert phrase, phrase location, uppercase phrase, the phrase in bold, the color of alert phrase contrasting to the background, adequate font size, do not claim the absence for any allergen with the ingredients, and others factors that make it difficult to read. For the second question, a structured questionnaire was completed, and products were classified into two categories, namely, "Contain" and "May contain." RESULTS The quality of the label was appropriate, and 69% of packaged foods had at least one allergen. The information "May contain" were higher in cow's milk (Cereals and Meat & eggs), soy (Soybean & products), and egg protein (Cereals). Soybean & products were the highest insecurity group. CONCLUSIONS Brazilian health professionals can count on good-quality labeling of packaged products. Consequently, they could promote patients' and parents/caregivers' education to consult the labels and manage the risks in processed foods about precautionary allergen labeling. Soybean & products were the most significant insecurity for food choices between Brazilian Pyramid Groups.
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Elghoudi A, Narchi H. Food allergy in children—the current status and the way forward. World J Clin Pediatr 2022; 11:253-269. [PMID: 35663006 PMCID: PMC9134150 DOI: 10.5409/wjcp.v11.i3.253] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/16/2021] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Food allergy in children is a major health concern, and its prevalence is rising. It is often over-diagnosed by parents, resulting occasionally in unnecessary exclusion of some important food. It also causes stress, anxiety, and even depression in parents and affects the family’s quality of life. Current diagnostic tests are useful when interpreted in the context of the clinical history, although cross-sensitivity and inability to predict the severity of the allergic reactions remain major limitations. Although the oral food challenge is the current gold standard for making the diagnosis, it is only available to a small number of patients because of its requirement in time and medical personnel. New diagnostic methods have recently emerged, such as the Component Resolved Diagnostics and the Basophil Activation Test, but their use is still limited, and the latter lacks standardisation. Currently, there is no definite treatment available to induce life-long natural tolerance and cure for food allergy. Presently available treatments only aim to decrease the occurrence of anaphylaxis by enabling the child to tolerate small amounts of the offending food, usually taken by accident. New evidence supports the early introduction of the allergenic food to infants to decrease the incidence of food allergy. If standardised and widely implemented, this may result in decreasing the prevalence of food allergy.
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Affiliation(s)
- Ahmed Elghoudi
- Paediatric Department, Sheikh Khalifa Medical City, Abu Dhabi NA, Abu Dhabi, United Arab Emirates
- College of Medicine and Health Sciences, United Arab Emirates University, Alain, Abu Dhabi, United Arab Emirates
| | - Hassib Narchi
- College of Medicine and Health Sciences, United Arab Emirates University, Alain, Abu Dhabi, United Arab Emirates
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Gaffney LK, Porter J, Gerling M, Schneider LC, Stack AM, Shah D, Michelson KA. Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline. Pediatrics 2022; 149:184527. [PMID: 35059724 PMCID: PMC9250079 DOI: 10.1542/peds.2020-045831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019. METHODS A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System. RESULTS Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time. CONCLUSIONS We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.
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Affiliation(s)
- Lukas K. Gaffney
- Departments of Pediatrics,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Address correspondence to Lukas Gaffney, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston MA, 02115. E-mail:
| | | | | | | | | | - Dhara Shah
- Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
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Lopes JF, Carvalho MDA, Machado NC. Rotulagem de alérgenos alimentares em alimentos embalados segundo grupos alimentares da pirâmide brasileira: análise da descrição, riscos e ambiguidades. REVISTA PAULISTA DE PEDIATRIA 2022. [DOI: 10.1590/1984-0462/2022/40/2021079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RESUMO Objetivo: Avaliar os componentes alergênicos da rotulagem de alimentos embalados e responder “Qual é a qualidade da rotulagem?” e “Qual é o grupo de alimentos em que a expressão ‘Pode conter’ é predominante?”. Métodos: Foram obtidas fotografias de 916 produtos, dos quais 518 foram analisados. Os dados dos rótulos foram avaliados de acordo com os grupos da pirâmide alimentar brasileira (Cereais, Frutas & Vegetais; Soja & Derivados; Leite & Laticínios; Carne & Ovos; Gorduras & Óleos; Açúcares & Doces). Dez itens foram analisados nos rótulos: presença de lista de ingredientes; frase de alerta para alérgicos; frase de alerta; local da frase; frase em letras maiúsculas; frase em negrito; a cor da frase de alerta contrastando com o fundo; tamanho de fonte adequado; não alegar ausência de qualquer alérgeno; outros fatores de difícil leitura. Para a segunda questão, foi respondido questionário estruturado, e os produtos classificados em categorias: “Contém” e “Pode conter”. Resultados: A qualidade do rótulo foi adequada e 69% dos alimentos embalados continham pelo menos um alérgeno. A informação “Pode conter” foi mais identificada em: proteína do leite (Cereais e Carnes e ovos), soja (Soja & derivados) e proteína do ovo (Cereais). Soja e derivados foi o grupo alimentar de maior insegurança. Conclusões: Profissionais de saúde podem contar com rotulagem de boa qualidade dos produtos embalados e, consequentemente, promover a educação de pais/cuidadores para consultar os rótulos e gerenciar os riscos em alimentos processados. Soja e produtos são os alimentos com maior insegurança entre os Grupos da Pirâmide Brasileira.
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Bulsa K, Standowicz M, Baryła-Pankiewicz E, Czaja-Bulsa G. Chronic Milk-Dependent Food Protein-Induced Enterocolitis Syndrome in Children from West Pomerania Region. Nutrients 2021; 13:nu13114137. [PMID: 34836392 PMCID: PMC8617799 DOI: 10.3390/nu13114137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022] Open
Abstract
Characteristics of chronic milk-dependent food protein-induced enterocolitis syndrome (FPIES) in children from the region of Western Pomerania were studied. Prospectively, 55 children were diagnosed at a median of 2.2 months. The open food challenges (OFC), morphologies, milk-specific IgE (sIgE) (FEIA method, CAP system), and skin prick tests (SPTs) were examined. Vomiting and diarrhea escalated gradually but quickly led to growth retardation. Of the infants, 49% had BMI < 10 c, 20% BMI < 3 c; 25% had anemia, and 15% had hypoalbuminemia. During the OFCs we observed acute symptoms that appeared after 2-3 h: vomiting diarrhea and pallor. A total of 42% children required intravenous hydration. Casein hydrolysates or amino acids formulae (20%) were used in treatment. In 25% of children, SPT and milk sIgE were found, in 18%-other food SPTs, and in 14% allergy to other foods. A transition to IgE-dependent milk allergy was seen in 3 children. In the twelfth month of life, 62% of children had tolerance to milk, and in the twenty-fifth month-87%. Conclusions. Chronic milk-dependent FPIES resolves in most children. By the age of 2 children are at risk of multiple food sensitization, and those who have milk sIgE are at risk to transition to IgE-mediated milk allergy. Every OFC needs to be supervised due to possible severe reactions.
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Affiliation(s)
| | | | | | - Grażyna Czaja-Bulsa
- Chair and Department of Paediatrics and Paediatric Nursing, Pomeranian Medical University, 70-204 Szczecin, Poland
- Correspondence: ; Tel.: +48-91-480-09-51; Fax: +48-91-880-61-46
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Rangkakulnuwat P, Lao-Araya M. The prevalence and temporal trends of food allergy among preschool children in Northern Thailand between 2010 and 2019. World Allergy Organ J 2021; 14:100593. [PMID: 34721755 PMCID: PMC8521453 DOI: 10.1016/j.waojou.2021.100593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/01/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Although recent studies suggest that the prevalence of food allergy (FA) has not changed, the data from developing countries are limited. This study aimed to investigate time trends in the prevalence of FA among preschool children in 2010 and 2019 in Northern Thailand. Methods Two cross-sectional studies were performed, 9 years apart (2010 and 2019), using the same methods, in children aged 3–7 years living in Chiang Mai, Thailand. Parent-reporting questionnaire surveys were conducted. Families with children reporting FA were invited to undergo further investigations with skin prick testing, serum specific IgE, and oral food challenge (OFC). The prevalence of parent-reported FA, food sensitization, and OFC-confirmed FA were compared between the 2 periods. Results A total of 1013 out of 1146 questionnaires (452/546 in 2010 and 561/600 in 2019) were returned. The response rate was 88.4%. The prevalence of parent-reported food allergy in 2019 was significantly lower than that in 2010 (5.5% vs 9.3%; p = 0.02). However, there was no significant change in the prevalence of OFC-confirmed FA (0.9% vs 1.1%; p = 0.75). Three leading causative foods of parent-reported FA were cow's milk, shrimp, and eggs. Shrimp was still the most common OFC-confirmed food allergen. Atopic dermatitis was the most significantly parent reported factor associated with FA. Conclusion The overall prevalence of FA among preschool children in Northern Thailand had not increased during the past decade. There was no significant difference in the prevalence of OFC-confirmed FA between 2010 and 2019.
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Affiliation(s)
- Pisuttikan Rangkakulnuwat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,School of Medicine, Mae Fah Luang University, Chiang Rai, Thailand
| | - Mongkol Lao-Araya
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Sicherer SH, Abrams EM, Nowak-Wegrzyn A, Hourihane JO. Managing Food Allergy When the Patient Is Not Highly Allergic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:46-55. [PMID: 34098164 DOI: 10.1016/j.jaip.2021.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/12/2021] [Accepted: 05/26/2021] [Indexed: 11/30/2022]
Abstract
Few patients with food allergy are "highly allergic," meaning they always have severe reactions and always react to very small amounts of allergen. Standard medical approaches for allergy management have focused on the safety and lifestyle modifications this group truly needs, but consequently families with food allergy are typically advised to strictly avoid any exposure to their implicated allergens. Most food-allergic subjects are actually not reactive to very low doses, and many never experience severe reactions. There are also notable conditions where a different care plan is already commonly offered: patients with pollen-related food allergy syndrome, with food-associated exercise-induced anaphylaxis, and with resolving or mild milk or egg allergy might be advised to ingest the allergens in specific circumstances with detailed instructions. Because oral immunotherapy and allergy prevention by early exposure have emphasized alternatives to strict avoidance, there is increasing interest in prospects to forego strict avoidance in those with food allergy. For patients with a high threshold of reactivity (low-dose tolerant, high-dose mildly reactive), there may be options such as allowing the ingestion of products with precautionary allergen labels, allowing dietary indiscretions with small amounts of the allergen, or even encouraging ingestion of subthreshold amounts with therapeutic intent. These practices have not been extensively studied and could be considered controversial. If these approaches are considered, shared decision making is needed in discussing them with patients and families. This review considers the potential approaches to those who are "not highly allergic": the risks, benefits, shared decision making, and research needs.
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Affiliation(s)
- Scott H Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Anna Nowak-Wegrzyn
- New York University Grossman School of Medicine, Allergy and Immunology, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, Royal College of Surgeons in Irerland, Dublin, Ireland; Childrens Health Ireland Temple St, Dublin, Ireland
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Okubo Y, Michihata N, Morisaki N, Yoshida K, Matsui H, Fushimi K, Yasunaga H. Effects of Glucocorticoids on Hospitalized Children With Anaphylaxis. Pediatr Emerg Care 2021; 37:255-259. [PMID: 29912092 DOI: 10.1097/pec.0000000000001544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The benefits of glucocorticoid treatment and recent trends of adjunctive treatments during episodes of anaphylaxis remain unclear. OBJECTIVES The aims of this study were to investigate the recent practice patterns and compare the effects of glucocorticoid for children hospitalized with anaphylaxis. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database, we compared the length of hospital stay, risk of 10-day readmission, and total hospitalization cost between the steroid and nonsteroid groups. We also evaluated recent trends of adjunctive treatments for anaphylaxis. RESULTS From 2010 to 2014, the proportions of H1-receptor antagonist use increased from 65.1% to 71.8% (Ptrend = 0.02). The proportions of H2-receptor antagonist use showed an upward trend, ranging from 12.8% to 16.7% (Ptrend = 0.01). No significant change in glucocorticoid use was observed (from 86.7% to 82.6%; Ptrend = 0.08). Stabilized inverse probability-weighting analyses showed that the total length of hospital stay was 0.39 days longer in the steroid group than in the nonsteroid group (95% confidence interval, 0.29-0.49 days). Total hospitalization cost was greater in the steroid group than in the nonsteroid group (difference, ¥3896; 95% confidence interval, ¥2464-¥5562). No significant difference in risk of 10-day readmission was observed between the groups. Instrumental variable analyses showed similar results to stabilized inverse probability-weighting analyses. CONCLUSIONS We observed increasing trends of H1- and H2-receptor antagonist use. Length of hospital stay and total hospitalization cost were greater in the steroid group than in the nonsteroid group, whereas readmission risks were similar between the 2 groups.
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Affiliation(s)
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo
| | - Naho Morisaki
- Department of Social Medicine, National Research Institute for Child Health and Development
| | - Koichi Yoshida
- Division of Allergy, Tokyo Metropolitan Children's Medical Center
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | | | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health
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13
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Eapen AA, Kim H. The Phenotype of the Food-Allergic Patient. Immunol Allergy Clin North Am 2021; 41:165-175. [PMID: 33863477 DOI: 10.1016/j.iac.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Food allergy's increasing prevalence across the globe has initiated research into risk factors associated with the disease and coexistence with other allergic diseases. Longitudinal birth cohorts have identified food allergy phenotypes of patients based on genetic background, racial diversity, and environmental factors. Identifying food sensitization patterns and coexistence of other allergic diseases allows physicians to provide appropriate care for food allergy and personalized anticipatory guidance for the appearance of other allergic diseases. The authors seek to detail key findings of 4 longitudinal allergy birth cohorts that investigate food allergy and other allergic diseases to further characterize food allergy phenotypes.
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Affiliation(s)
- Amy A Eapen
- Division of Allergy and Clinical Immunology, Henry Ford Health System, 1 Ford Place, Detroit, MI 48202, USA.
| | - Haejin Kim
- Division of Allergy and Clinical Immunology, Henry Ford Health System, 1 Ford Place, Detroit, MI 48202, USA
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Midun E, Radulovic S, Brough H, Caubet JC. Recent advances in the management of nut allergy. World Allergy Organ J 2021; 14:100491. [PMID: 33510829 PMCID: PMC7811165 DOI: 10.1016/j.waojou.2020.100491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022] Open
Abstract
Peanut/tree nut allergy is common and has been associated with particularly severe reactions. Epidemiological data have shown that the prevalence ranges between 0.05% and 4.9% for tree nut and between 0.5% and 3% for peanut. These large variations can be explained by differences in the age of included patients and the geographical region. In addition, the food consumption modality (ie, raw versus roasted) plays a major role, as heat treatment has the capacity to modify the allergenicity of nuts and legumes. Nut allergies tend to persist into adulthood and consequently have a high impact on quality of life. Recently, it has been demonstrated that a significant proportion of nut allergic patients are able to tolerate other nuts. As opposed to the avoidance of all nuts, this approach is currently proposed in several tertiary allergy centers. However, diagnosis of nut allergy is particularly difficult due to co-sensitization leading to high rate of false positive skin prick tests and/or specific IgE to whole allergen extracts. The use of component resolved diagnosis leads to major improvement of diagnosis, particularly to distinguish between primary and secondary nut allergies. The basophil activation test has been suggested to be useful but is still used mainly as a research tool. Thus, diagnosis remains mainly based on the oral food challenge, which is considered as the gold standard. Regarding treatment, avoidance remains the cornerstone of management of nut allergy. Oral immunotherapy is increasingly proposed as an alternative management strategy.
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Key Words
- Component-resolved diagnostic, CRD
- Cross reactivity
- Double-blind, placebo-controlled, food challenge, DBPCFC
- Food allergy
- Lipid transfer protein, LTP
- Oral allergy syndrome, OAS
- Oral food challenge, OFC
- Oral immunotherapy
- Oral induction tolerance, OIT
- Pathogenesis related protein type 10, PR-10
- Peanut
- Platelet-activating factor, PAF
- Pollen-food syndrome, PFS
- Precautionary Allergen Labels, (PAL)
- Skin prick test, SPT
- Tree nut
- Tree nut, TN
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Affiliation(s)
- Elise Midun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205 Geneva, Switzerland, University Lyon 1 Claude Bernard, 43 Boulevard Du 11-Novembre-1918, 69100, Villeurbanne, France
- Corresponding author.
| | - Suzana Radulovic
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen Brough
- Paediatric Allergy Group, Department of Women and Children's Health, King's College London, London, United Kingdom, Paediatric Allergy Group, Peter Gorer Dept of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guys' Hospital, London, United Kingdom, Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Rue Willy Donzé 6, 1205, Geneva, Switzerland
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Pistiner M, Mendez-Reyes JE, Eftekhari S, Carver M, Lieberman J, Wang J, Camargo CA. Caregiver-Reported Presentation of Severe Food-Induced Allergic Reactions in Infants and Toddlers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:311-320.e2. [PMID: 33217612 DOI: 10.1016/j.jaip.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recognizing anaphylaxis in infants and toddlers can be challenging for health care providers and caregivers, and current diagnostic criteria and anaphylaxis action plans do not specifically address this younger population. OBJECTIVE To describe symptoms and signs observed by primary caregivers of infants and toddlers during severe food-induced allergic reactions. METHODS We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when less than 36 months of age. Respondents who were present during the child's most severe reaction were asked to report symptoms and signs observed. The survey asked about infant- and toddler-specific symptoms and signs in lay language for caregivers. Data were compared with patient-reported data from past studies to identify distinct patterns among the younger population. RESULTS The survey was completed for 374 children (193 infants, 181 toddlers). The most common symptoms and signs reported were skin reactions (90%), facial and extremity swelling (59%), gastrointestinal issues (51%), and coughing/wheezing (45%). Infants (aged <12 months) more frequently experienced skin reactions, skin mottling, and ear pulling/scratching or putting fingers in ears, as compared with toddlers (aged 12-35 months). Toddlers experienced throat itching and coughing/wheezing more frequently than infants. CONCLUSIONS Anaphylaxis presentation demonstrates similarities and differences in infants and toddlers. Modifying the terminology used in the current criteria allowed for reporting of symptoms and signs of anaphylaxis that are more common in infants and toddlers. Diagnostic criteria, clinical guidelines, and anaphylaxis action plans may be enhanced to address this young, often nonverbal, population.
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Affiliation(s)
- Michael Pistiner
- Mass General Hospital for Children, Harvard Medical School, Boston, Mass.
| | | | | | | | - Jay Lieberman
- The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tenn
| | - Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Wang W, Lyu SC, Ji X, Gupta S, Manohar M, Dhondalay GKR, Chinthrajah S, Andorf S, Boyd SD, Tibshirani R, Galli SJ, Nadeau KC, Maecker HT. Transcriptional changes in peanut-specific CD4+ T cells over the course of oral immunotherapy. Clin Immunol 2020; 219:108568. [PMID: 32783912 DOI: 10.1016/j.clim.2020.108568] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/12/2023]
Abstract
Oral immunotherapy (OIT) can successfully desensitize allergic individuals to offending foods such as peanut. Our recent clinical trial (NCT02103270) of peanut OIT allowed us to monitor peanut-specific CD4+ T cells, using MHC-peptide Dextramers, over the course of OIT. We used a single-cell targeted RNAseq assay to analyze these cells at 0, 12, 24, 52, and 104 weeks of OIT. We found a transient increase in TGFβ-producing cells at 52 weeks in those with successful desensitization, which lasted until 117 weeks. We also performed clustering and identified 5 major clusters of Dextramer+ cells, which we tracked over time. One of these clusters appeared to be anergic, while another was consistent with recently described TFH13 cells. The other 3 clusters appeared to be Th2 cells by their coordinated production of IL-4 and IL-13, but they varied in their expression of STAT signaling proteins and other markers. A cluster with high expression of STAT family members also showed a possible transient increase at week 24 in those with successful desensitization. Single cell TCRαβ repertoire sequences were too diverse to track clones over time. Together with increased TGFβ production, these changes may be mechanistic predictors of successful OIT that should be further investigated.
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Affiliation(s)
- Weiqi Wang
- Institute for Immunity, Transplantation, Infection, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Shu-Chen Lyu
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Xuhuai Ji
- Institute for Immunity, Transplantation, Infection, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Sheena Gupta
- Institute for Immunity, Transplantation, Infection, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Monali Manohar
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Gopal K R Dhondalay
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Sharon Chinthrajah
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Sandra Andorf
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Scott D Boyd
- Departments of Pathology and of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Robert Tibshirani
- Department of Biomedical Data Science, Department of Statistics, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Stephen J Galli
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America; Departments of Pathology and of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Kari C Nadeau
- Sean Parker Center for Allergy and Asthma Research, Stanford University School of Medicine, Stanford, CA 94305, United States of America
| | - Holden T Maecker
- Institute for Immunity, Transplantation, Infection, Stanford University School of Medicine, Stanford, CA 94305, United States of America.
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Remington BC, Blom WM, Bassa B, Koppelman SJ. Risk of shared equipment in restaurants for consumers with peanut allergy: a simulation for preparing Asian foods: A simulation for preparing Asian foods. Ann Allergy Asthma Immunol 2020; 125:543-551.e6. [PMID: 32763340 DOI: 10.1016/j.anai.2020.07.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Allergic reactions to meals consumed outside the home are common and can be severe and sometimes fatal. OBJECTIVE To quantify the risk reduction potentially achieved by increasing an individual's threshold sensitivity to peanut (such as by means of immunotherapy) in scenarios of peanut exposure through shared kitchen materials in a restaurant setting. METHODS Three versions of popular peanut-containing sauces were selected to represent common ingredients used in Asian cooking. Different combinations of utensils, equipment, sauces, and test conditions were prepared by a professional chef, with or without common cleaning procedures, to represent normal daily practice. Residue amounts of peanut-containing material on kitchen equipment and utensils were measured and used for quantitative risk assessment to model the risk reduction associated with increasing an individual's threshold. RESULTS Shared utensils had mean residue amounts of 23 to 1519 mg peanut protein (no cleaning) and 3 to 82 mg peanut protein (after water rinse). Shared woks and pans had up to 20 mg peanut protein after rinsing. Individuals who reach a threshold of 300 mg peanut protein have a predicted relative risk reduction of 94.9% to greater than 99.99% with brief cleaning. With no cleaning, relative risk reductions were 63.5% to 91.1% for individuals with a baseline threshold of less than or equal to 100 mg peanut protein who reach a threshold of 300 mg peanut protein, increasing to 91% to 99.7% when reaching a threshold value of 1000 mg peanut protein. CONCLUSION In all shared kitchen material scenarios that we studied, achieving an eliciting dose of 300 or 1000 mg peanut protein seems clinically relevant for the peanut-allergic population.
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Affiliation(s)
- Benjamin C Remington
- Netherlands Organisation for Applied Scientific Research (TNO), Utrecht, The Netherlands; Food Allergy Research and Resource Program, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - W Marty Blom
- Netherlands Organisation for Applied Scientific Research (TNO), Utrecht, The Netherlands
| | | | - Stef J Koppelman
- Food Allergy Research and Resource Program, University of Nebraska-Lincoln, Lincoln, Nebraska.
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Physician instructions to inject epinephrine with mild or no symptoms on food allergy and anaphylaxis emergency plans. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1423-1425.e7. [DOI: 10.1016/j.jaip.2020.01.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 12/30/2022]
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De Martinis M, Sirufo MM, Viscido A, Ginaldi L. Food Allergy Insights: A Changing Landscape. Arch Immunol Ther Exp (Warsz) 2020; 68:8. [PMID: 32239297 DOI: 10.1007/s00005-020-00574-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
The panorama of food allergies (FA) has changed profoundly in recent years. In light of recent advances in knowledge of pathogenetic mechanisms and a greater attention to the multifaceted range of possible clinical manifestations, there is a need for a critical review of past classifications. Changes in nutrition, environment and lifestyles around the world are modifying the global FA epidemiology and new FA phenotypes are also emerging. Furthermore, both biotechnological advances in this field and recent personalized therapies have improved the diagnostic and therapeutic approach to FA. Consequently, both the prevention and clinical management of FA are rapidly changing and new therapeutic strategies are emerging, even revolutionizing the current medical practice. Given the significant increase in the prevalence of FA in recent years, the objective of this review is to provide an updated and complete overview of current knowledge in its etiopathogenesis, diagnostics and therapy, useful not only for a better understanding of this frequent and complex pathology but also for practical guidance in its clinical management.
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Affiliation(s)
- Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy. .,Allergy and Clinical Immunology Unit, AUSL 04, Teramo, Italy.
| | - Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.,Allergy and Clinical Immunology Unit, AUSL 04, Teramo, Italy
| | - Angelo Viscido
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy.,Allergy and Clinical Immunology Unit, AUSL 04, Teramo, Italy
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Fierro V, Valluzzi RL, Banzato C, Plaza MA, Bosque M, Íbero M, Echeverría LAZ, Mennini M, Dahdah L, de Castellar R, Tort G, Jiménez J. A well-tolerated new amino acid-based formula for cow's milk allergy. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:140-149. [PMID: 32109005 PMCID: PMC7212192 DOI: 10.1002/iid3.286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 11/25/2022]
Abstract
Objectives Infants with cow's milk allergy (CMA) are in need of a substitute formula up to 2 years. The are three requisites for a substitute of milk in CMA: tolerability, nutritional adequacy, and cost‐effectiveness. We evaluate here the tolerability of a new amino acid–based infant formula for the management of CMA. Methods In a phase III/IV prospective, multicentre, open‐label, international study, infants and children with immunoglobulin E‐mediated CMA were exposed to a diagnostic double‐blinded, placebo‐controlled food challenge with a new amino acid formula by Blemil Plus Elemental using Neocate as the placebo. If tolerant to it, the study formula was integrated into the patients’ usual daily diet for 7 days. Efficacy on day 7 was assessed in terms of symptoms associated with CMA, amount of formula consumed, nutritional and energy intake, and anthropometric data. Results Thirty children (17 M and 13 F; median age, 1.58; range, 0.08‐12.83 years) completed the open challenge and were able to consume the study formula for at least 7 days. No signs or symptoms of allergic reactions were recorded among children assuming either the test or the control formula, with a lower 95% one‐sided confidence interval for the proportion of subjects who did not experience allergic reactions above 90%. Sixteen patient under the age of two continued with the optional extension phase. Conclusions The study formula meets the American Academy of Pediatric criteria for hypoallergenicity and is well tolerated in short‐term use. During optional phase, growth of the patients was not hindered by the study formula.
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Affiliation(s)
| | | | | | - Ma A Plaza
- Hospital Sant Joan de Deu, Barcelona, Spain
| | | | | | | | | | - Lamia Dahdah
- Pediatric Allergy Unit, Bambino Gesù Hospital, Roma, Italy
| | | | - Gloria Tort
- Laboratorios Ordesa, Sant Boi de Llobregat, Spain
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Characteristics and Treatment of Anaphylaxis in Children Visiting a Pediatric Emergency Department in Korea. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2014104. [PMID: 32190654 PMCID: PMC7064841 DOI: 10.1155/2020/2014104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
Anaphylaxis is a serious life-threatening allergic disease in children. This study is aimed at determining the characteristics of pediatric patients who experienced anaphylaxis along with treatments administered in order to determine the usefulness of tryptase level assessment as a marker of anaphylaxis in Korean children. A total of 107 patients who were diagnosed with anaphylaxis in a single pediatric emergency center over a 3-year period were included in the study. Patient clinical characteristics, symptoms, signs, allergy history, trigger factors, treatments, and laboratory findings, including serum tryptase levels, were included in the analysis. Food allergies (39.3%) were the most commonly reported patient allergic history, and 58 patients (54.2%) were triggered by food. Among this group, nuts and milk exposure were the most common, affecting 15 patients (25.9%). History of anaphylaxis and asthma were more common in severe anaphylaxis compared to mild or moderate anaphylaxis cases. Epinephrine intramuscular injection was administrated to 76 patients (71.0%), and a self-injectable epinephrine was prescribed to 18 patients (16.8%). The median tryptase level was 4.80 ng/mL (range: 2.70-10.40) which was lower than the 11.4 ng/mL value commonly documented for standard evaluation in adults with anaphylaxis. The most common cause of pediatric anaphylaxis was food including nuts and milk. The rate of epinephrine injection was relatively high in our pediatric emergency department. The median tryptase level associated with anaphylaxis reactions in children was lower than 11.4 ng/mL. Further studies are needed to help improve diagnostic times and treatment accuracy in pediatric patients who develop anaphylaxis.
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Miłosz M, Demkow U, Wolańczyk T. Relation Between Attention-Deficit Hyperactivity Disorder and IgE-Dependent Allergy in Pediatric Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1096:105-109. [PMID: 29623610 DOI: 10.1007/5584_2018_196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Food allergy is a common condition in children and adolescent, remitting with time. Few clinical studies have emphasized the link between food allergies and psychosocial conditions, suggesting a profound impact of atopic diseases on the development of attention-deficit hyperactivity disorder (ADHD) in children. The objective of this study was to compile and assess available studies on the comorbidity or causality between ADHD and atopic food allergy in children. We discuss epidemiology, interrelated mechanisms, and potential dietary interventions in the management of children with ADHD.
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Affiliation(s)
- Mateusz Miłosz
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Warsaw Medical University, Warsaw, Poland.
| | - Urszula Demkow
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Warsaw Medical University, Warsaw, Poland
| | - Tomasz Wolańczyk
- Deaprtment of Children and Adolescent Psychiatry, Warsaw Medical University, Warsaw, Poland
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Greenhawt M, Gupta RS, Meadows JA, Pistiner M, Spergel JM, Camargo CA, Simons FER, Lieberman PL. Guiding Principles for the Recognition, Diagnosis, and Management of Infants with Anaphylaxis: An Expert Panel Consensus. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1148-1156.e5. [PMID: 30737191 DOI: 10.1016/j.jaip.2018.10.052] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/25/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022]
Abstract
Infant anaphylaxis is an emerging risk, with food allergy the most common cause. Although the presentation of anaphylaxis involves the same systems as in older children and adults, there are real-world challenges to identifying symptoms of an allergic emergency in nonverbal children, as well as implementing optimal treatment. Recognition of anaphylaxis in infants can be challenging because allergic symptoms and certain normal infant behaviors may overlap. Intramuscular epinephrine is the treatment of choice for infants, as it is for older children and adults, and an epinephrine autoinjector approved by the Food and Drug Administration is now available for infants weighing between 7.5 and 15 kg. A panel of experts sought to develop guiding principles for the recognition, diagnosis, and management of anaphylaxis in infants, and provide a framework for the development of new guidelines and future research. Accordingly, anaphylaxis emergency action planning for infants was addressed by the panel. In considering formation of future infant anaphylaxis guidelines, health care providers should be aware of the needs to improve the recognition, diagnosis, and management of infants with anaphylaxis. Future research should identify and validate clinical criteria for the diagnosis of anaphylaxis in infants, as well as risk factors for the most severe reactions.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Ruchi S Gupta
- Departments of Pediatrics and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | - Michael Pistiner
- Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Jonathan M Spergel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - F Estelle R Simons
- Department of Pediatrics & Child Health, Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philip L Lieberman
- Division of Allergy and Immunology, University of Tennessee Health Science Center, Memphis, Tenn
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McBride DL. Life-threatening Allergic Reactions Increasing Among Children. J Pediatr Nurs 2019; 44:127-129. [PMID: 29895450 DOI: 10.1016/j.pedn.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 05/30/2018] [Indexed: 11/19/2022]
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25
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Sinai T, Goldberg MR, Nachshon L, Amitzur-Levy R, Yichie T, Katz Y, Monsonego-Ornan E, Elizur A. Reduced Final Height and Inadequate Nutritional Intake in Cow's Milk-Allergic Young Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:509-515. [PMID: 30529059 DOI: 10.1016/j.jaip.2018.11.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Growth impairment was previously described in milk-allergic children but was not examined in adults on reaching final height. OBJECTIVES To investigate the dietary intake and final stature of young adults with IgE-mediated cow's milk allergy (IgE-CMA) as compared with nonallergic controls. METHODS Eighty-seven patients with IgE-CMA, median age 19.5 years (interquartile range [IQR], 17.3-22.7), and 36 control participants without food allergies, median age 22.7 years (IQR, 18.9-26.1), were studied. Anthropometric and nutritional data were collected. Age and gender z-scores were determined according to the Centers for Disease Control and Prevention growth charts. Nutrient intake assessment was based on dietary records. Individuals with conditions or treatments affecting bone metabolism or growth, other than asthma, were excluded. RESULTS Mean values of height z-scores were significantly reduced in CMA subjects compared with controls (-0.64 ± 0.9 vs -0.04 ± 0.7, P = .001). In contrast, no differences were found between the 2 groups in weight and body mass index z-scores. Patients with CMA had significantly lower intake of protein, and several essential vitamins (A, B12, and riboflavin) and minerals (calcium, potassium, phosphorus, magnesium, and zinc) compared with controls (P < .05), but the intakes of calories, carbohydrate, and fat were not significantly different between the 2 groups. Differences between actual and expected (based on midparental height) height z-scores were comparable in CMA subjects with or without asthma and between those with and without additional food allergies. CONCLUSIONS Young adults who have CMA from infancy are at risk of not reaching their growth potential. Growth and nutritional monitoring and appropriate dietary intervention are of particular importance in these at-risk individuals.
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Affiliation(s)
- Tali Sinai
- The School of Nutritional Sciences, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Michael R Goldberg
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Liat Nachshon
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Roni Amitzur-Levy
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Tamar Yichie
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Yitzhak Katz
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel
| | - Efrat Monsonego-Ornan
- The School of Nutritional Sciences, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Arnon Elizur
- Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Zerifin, Israel; Department of Pediatrics, Yitzhak Shamir Medical Center, Zerifin, Israel.
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Severely Altered-Consciousness Status and Profuse Vomiting in Infants: Food Protein-Induced Enterocolitis Syndrome (FPIES), a Challenging Diagnosis. Pediatr Emerg Care 2018; 34:e187-e189. [PMID: 27741073 DOI: 10.1097/pec.0000000000000921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In infants, the causes of acute repetitive vomiting and severely altered-consciousness status include a broad differential diagnosis, that is, primarly sepsis, infectious gastroenteritis, head injury, and intoxication, as well as neurologic, metabolic, and cardiologic condition diseases. In patients developing such symptoms, allergy as an etiological cause is often not considered by primary care physicians. With this case report, we aim to draw the attention of general pediatricians, emergency physicians, and intensivists to the fact that non-immunoglobulin E-mediated food allergic gastrointestinal disorders such as food protein-induced enterocolitis syndrome should be considered in patients with sepsis-like symptoms.
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27
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Management of anaphylaxis and allergies in patients with long QT syndrome: A review of the current evidence. Ann Allergy Asthma Immunol 2018; 121:545-551. [PMID: 30059791 DOI: 10.1016/j.anai.2018.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To develop a treatment algorithm for patients with long QT syndrome (LQTS) in case they need antiallergic medications for allergic reactions, including asthma and anaphylaxis. DATA SOURCES A literature review was performed to assess safety and to develop antiallergic treatment strategies for patients with LQTS. STUDY SELECTIONS LQTS is a heterogeneous group of myocardial repolarization disorders characterized by prolongation of the QT interval that potentially results in life-threatening torsades de pointes tachycardia. Data on pharmacologic treatment in case of anaphylaxis in LQTS are sparse. For this narrative review, all currently available articles on the use of antiallergic drugs for allergic reactions, anaphylaxis, and asthma in patients with LQTS were used. RESULTS Local allergic symptoms can be safely treated primarily with fexofenadine, levocetirizine, desloratadine, or cetirizine and, if needed, a short course of corticosteroids. In case of systemic symptoms, epinephrine should be administered. It may be less effective in patients with LQTS treated with β-blockers, necessitating the use of glucagon as add-on treatment. In case of lower airway obstruction, ipratropium bromide should be used, but if not effective, inhaled β2-adrenergic agents may be used. Continuous cardiac monitoring is indicated with the use of epinephrine and inhaled β2-adrenergic agents. The use of the latter also warrants intense monitoring of serum potassium levels. Clemastine and dimetindene should be avoided in patients with LQTS. CONCLUSION Patients with LQTS have a higher risk of life-threatening complications during the treatment of their allergic reactions because of the underlying disease and concomitant treatment with β-blockers. Treatment algorithms will certainly decrease these complications.
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Abstract
Tree nut (TN) allergy is common and often severe. It has become an important health concern as availability and consumption have increased. Prevalence varies by age and geographic region and appears to have increased in children. Accidental ingestion of TNs is common. Unfortunately, there is a lower likelihood of resolution of TN allergy, roughly 10%. TN-specific skin tests and serum immunoglobulin E levels can help aid in the diagnosis of TN allergy, but a careful medical history is important because a positive test in isolation is not typically diagnostic. Component-resolved diagnostic tests are being increasingly utilized and may improve accuracy. Management consists of strict avoidance of the causal nut(s) and prompt treatment of symptoms upon accidental exposure. A specific consideration with regard to the management of TN allergy is the decision to avoid all TNs or only the TNs to which a patient is clinically allergic. There are currently no data on the primary or secondary prevention of TN allergy. Treatment strategies are being evaluated.
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Affiliation(s)
- Tamar Weinberger
- The Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott Sicherer
- The Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Vetander M, Protudjer JLP, Lilja G, Kull I, Hedlin G, van Hage M, Östblom E, Bergström A, Wickman M. Anaphylaxis to foods in a population of adolescents: incidence, characteristics and associated risks. Clin Exp Allergy 2017; 46:1575-1587. [PMID: 27790764 DOI: 10.1111/cea.12842] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Information about severe reactions to foods in adolescence is limited. OBJECTIVE To describe reactions to foods, including anaphylaxis, with regard to incidence, characteristics and associated risks, among 16-year-olds (adolescents) in a large, population-based birth cohort. METHODS Parent-reported questionnaire data from ages 2-3 months, and 1, 2 and 16 years were used (N = 3153). Anaphylaxis at age 16 years was defined per NIAID/FAAN criteria. Immunoglobulin E (IgE) antibodies to 14 common food and inhalant allergens were analysed at ages 4 (n = 2283) and 16 years (n = 2510). Among adolescents with food-related symptoms (FRS) and for whom blood was available (n = 221), 25 additional food allergen extracts or allergen components were analysed. Associations between reactions to foods, and sensitization and allergic multimorbidity were investigated. RESULTS In the 12 months prior to the 16-year assessment, 8.5% of adolescents had FRS. This included 0.8% (n = 24) adolescents who were classified as having anaphylaxis, yielding an incidence rate of 761/100 000 person-years. One-third of adolescents accessed health care during anaphylaxis. Allergic multimorbidity in infancy, as well as sensitization to foods and airborne allergens at age 4 years, was associated with an increased risk for FRS in adolescence. Peanuts and tree nuts were the most common culprit foods for anaphylaxis, and fruits and vegetables for non-anaphylactic reactions. Adolescents with anaphylaxis were significantly more likely to be sensitized to storage proteins (Ara h 2, Cor a 9, Cor a 14) and to be polysensitized to foods (P < 0.001 vs. non-anaphylactic reactions). CONCLUSIONS AND CLINICAL RELEVANCE The incidence of food-induced anaphylaxis during adolescence in our population-based birth cohort is higher than previously reported. Adolescents with anaphylaxis differ from adolescents with non-anaphylactic FRS with regard to culprit foods and sensitization. Adolescents with previous anaphylaxis are likely to be polysensitized to foods, particularly tree nut and peanut storage proteins, and which warrants consideration at follow-up.
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Affiliation(s)
- M Vetander
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - J L P Protudjer
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - G Lilja
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - I Kull
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - G Hedlin
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - M van Hage
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Immunology and Allergy Unit, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - E Östblom
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - A Bergström
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - M Wickman
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
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Prostaglandin D 2 metabolite in urine is an index of food allergy. Sci Rep 2017; 7:17687. [PMID: 29247205 PMCID: PMC5732293 DOI: 10.1038/s41598-017-17798-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/30/2017] [Indexed: 12/21/2022] Open
Abstract
Food allergy is immediate hypersensitive reactions to ingested foods. Since early diagnosis is effective for disease control, development of an objective diagnostic index is required. Using mediator-lipidomics, we found that levels of the urinary prostaglandin D2 (PGD2) metabolite, tetranor-PGDM, reflected the severity of the allergic symptoms and intestinal mast cell hyperplasia in mice. Repeated oral challenges with ovalbumin promoted allergic symptoms in sensitized mice. Particularly, the allergic mice presented with increased numbers of intestinal mast cells, which strongly expressed hematopoietic PGD synthase (H-PGDS). The levels of urinary tetranor-PGDM increased as the disease progressed. Treatment with a mast cell inactivator or an anti-inflammatory steroid attenuated these symptoms and decreased the tetranor-PGDM urinary levels. The levels of urinary tetranor-PGDM did not correlate with the disease severity in murine models of colitis, asthma, or allergic dermatitis. Furthermore, we have shown that urinary levels of tetranor-PGDM were significantly higher in patients with food allergy than those in healthy volunteers and patients with other types of allergic diseases such as asthma, allergic rhinitis, and atopic dermatitis. These findings suggest that urinary tetranor-PGDM is a useful diagnostic index of food allergy in both mice and humans.
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31
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Kliewer KL, Cassin AM, Venter C. Dietary Therapy for Eosinophilic Esophagitis: Elimination and Reintroduction. Clin Rev Allergy Immunol 2017; 55:70-87. [DOI: 10.1007/s12016-017-8660-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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32
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Abstract
PURPOSE OF REVIEW We focus on recent advances regarding the epidemiology, physiopathology, diagnosis and managements of non-IgE-mediated gastrointestinal food allergies (non-IgE-GI-FAs), particularly food protein-induced enterocolitis syndrome (FPIES). RECENT FINDINGS The first international FPIES diagnostic and management guidelines have been recently published. Although FPIES largely remains a diagnosis of exclusion, it may be more prevalent than previously thought. Ondansetron has emerged as a major tool for the treatment of FPIES acute reactions. Recent data also suggest an important role for innate immune cells in FPIES pathogenesis. SUMMARY Despite major advances in the diagnosis and management of non-IgE-GI-FAs, particularly FPIES, the lack of specific diagnostic tests and biomarkers to guide clinical management remains challenging.
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Children Covered by Medicaid/State Children's Health Insurance Program More Likely to Use Emergency Departments for Food Allergies. Pediatr Emerg Care 2017; 33:e152-e159. [PMID: 27404464 DOI: 10.1097/pec.0000000000000794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Food allergies (FAs) occur in 4% to 8% of children in the United States, and emergency department (ED) visits account for up to 20% of their costs. In 2010, the National Institute of Allergy and Infectious Diseases established diagnostic criteria and management practices for FAs, and recognition and treatment of FAs for pediatric ED practitioners has been described. OBJECTIVE This study identified trends and factors related to ED visits for pediatric FAs in the United States from 2001 to 2010. It was hypothesized that FAs increased and that differences existed in ED utilization based on age, insurance status, and geography. Low concordance with treatment guidelines for FAs was expected. METHODS Multivariate logistic regression, using National Hospital Ambulatory Medical Care Survey data, estimated factors associated with ED visits and treatment of FAs and nonspecific allergic reactions. Trends and treatment patters used weighted frequencies to account for the complex 4-stage probability survey design. RESULTS An estimated 239,303 (95% confidence interval [CI], 180,322-298,284) children visited the ED for FAs, demonstrating a significant rate increase during the period (53.08, P < 0.001). Logistic regression showed that the odds of ED visits for FAs were significantly associated with Medicaid/State Children's Health Insurance Program insurance (OR, 1.65 [95% CI, 1.01-2.69], P = 0.04), adolescents (OR, 1.92 [95% CI, 1.10-3.35], P = 0.02), and boys (OR, 1.55 [95% CI, 1.03-2.35], P = 0.04). Treatment with epinephrine for anaphylaxis diagnoses occurred in 57.4% of visits (95% CI, 42.3%-66.8%). CONCLUSIONS Medicaid/State Children's Health Insurance Program-insured pediatric patients had higher odds of visiting ED for recognized FAs and nonspecific allergic reactions and higher odds of receiving epinephrine than privately insured children.
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Guiot A, Ambroggio L, Parker M, Goodman MA, Ramirez LP, Lierl M, Schuler CL. Variation in the Inpatient Management of Pediatric Anaphylaxis. Clin Pediatr (Phila) 2017; 56:1064-1067. [PMID: 28357878 PMCID: PMC8207478 DOI: 10.1177/0009922817701176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Amy Guiot
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | - Michelle Parker
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Michelle Lierl
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Abstract
Anaphylaxis is a systemic, life-threatening disorder triggered by mediators released by mast cells and basophils activated via allergic (IgE-mediated) or nonallergic (non-IgE-mediated) mechanisms. It is a rapidly evolving, multisystem process involving the integumentary, pulmonary, gastrointestinal, and cardiovascular systems. Anaphylaxis and angioedema are serious disorders that can lead to fatal airway obstruction and culminate in cardiorespiratory arrest, resulting in hypoxemia and/or shock. Often, these disorders can be appropriately managed in an outpatient setting; however, these conditions can be severe enough to warrant evaluation of the patient in the ED and in some cases, hospitalization, and management in an ICU. Reports suggest that underdiagnosis and undertreatment of anaphylaxis are common. Several new syndromes have been described recently including bird-egg, pork-cat, delayed allergy to mammalian meat and a diverse group of mast cell activation disorders. Conditions such as postural orthostatic tachycardia syndrome, carcinoid syndrome, Munchausen stridor, and factitious anaphylaxis can present similarly and need to be included in the differential diagnosis. Anaphylaxis is a clinical diagnosis, but plasma tryptase and urinary histamine levels are often elevated, allowing diagnostic confirmation; however, diagnostic testing should not delay treatment as results may not be immediately available. The sine qua non of treatment is avoidance of any known triggers and epinephrine, which should never be delayed if this disorder is suspected. Secondary treatments include fluids, bronchodilators, antihistamines, and glucocorticoids. Patients with cardiopulmonary arrest or airway or vascular compromise require mechanical ventilation, vasopressors, and other advanced life support in the ICU.
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36
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Sicherer SH, Allen K, Lack G, Taylor SL, Donovan SM, Oria M. Critical Issues in Food Allergy: A National Academies Consensus Report. Pediatrics 2017; 140:peds.2017-0194. [PMID: 28739655 PMCID: PMC9923536 DOI: 10.1542/peds.2017-0194] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2017] [Indexed: 11/24/2022] Open
Abstract
The National Academies of Sciences, Engineering, and Medicine convened an expert, ad hoc committee to examine critical issues related to food allergy. The authors of the resulting report, "Finding a Path to Safety in Food Allergy: Assessment of the Global Burden, Causes, Prevention, Management, and Public Policy," evaluated the scientific evidence on the prevalence, diagnosis, prevention, and management of food allergy and made recommendations to bring about a safe environment for those affected. The committee recommended approaches to monitor prevalence, explore risk factors, improve diagnosis, and provide evidence-based health care. Regarding diagnostics, emphasis was placed on utilizing allergy tests judiciously in the context of the medical history because positive test results are not, in isolation, diagnostic. Evidence-based prevention strategies were advised (for example, a strategy to prevent peanut allergy through early dietary introduction). The report encourages improved education of stakeholders for recognizing and managing as well as preventing allergic reactions, including an emphasis on using intramuscular epinephrine promptly to treat anaphylaxis. The report recommends improved food allergen labeling and evaluation of the need for epinephrine autoinjectors with a dosage appropriate for infants. The committee recommended policies and guidelines to prevent and treat food allergic reactions in a various settings and suggested research priorities to address key questions about diagnostics, mechanisms, risk determinants, and management. Identifying safe and effective therapies is the ultimate goal. This article summarizes the key findings from the report and emphasizes recommendations for actions that are applicable to pediatricians and to the American Academy of Pediatrics.
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Affiliation(s)
- Scott H. Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York;,Address correspondence to Scott H. Sicherer, MD, Mount Sinai Hospital, Box 1198, 1 Gustave L Levy Place, New York, NY 10029. E-mail:
| | - Katrina Allen
- Centre for Food and Allergy Research, Murdoch Children’s Research Institute, The University of Melbourne, Victoria, Australia;,Institute of Inflammation and Repair, University of Manchester, Manchester, United Kingdom
| | - Gideon Lack
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King’s College London, London, United Kingdom;,Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steve L. Taylor
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska
| | - Sharon M. Donovan
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, Illinois; and
| | - Maria Oria
- National Academies of Sciences, Engineering and Medicine, Washington, DC
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37
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Farbman KS, Michelson KA, Neuman MI, Dribin TE, Schneider LC, Stack AM. Reducing Hospitalization Rates for Children With Anaphylaxis. Pediatrics 2017; 139:peds.2016-4114. [PMID: 28562277 PMCID: PMC5470504 DOI: 10.1542/peds.2016-4114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most children with anaphylaxis in the emergency department (ED) are hospitalized. Opportunities exist to safely reduce the hospitalization rate for children with anaphylaxis by decreasing unnecessary hospitalizations. A quality improvement (QI) intervention was conducted to improve care and reduce hospitalization rates for children with anaphylaxis. METHODS We used the Model for Improvement and began with development and implementation in 2011 of a locally developed evidence-based guideline based on national recommendations for the management of anaphylaxis. Guideline adoption and adherence were supported by interval reminders and feedback to providers. Patients from 2008 to 2014 diagnosed with anaphylaxis were identified, and statistical process control methods were used to evaluate change in hospitalization rates over time. The balancing measure was any return visit to the ED within 72 hours. To control for secular trends, hospitalization rates for anaphylaxis at 34 US children's hospitals over the same time period were analyzed. RESULTS Over the study period, there were 1169 visits for children with anaphylaxis, of which 731 (62%) occurred after the QI implementation. The proportion of children hospitalized decreased from 54% to 36%, with no increase in the 72-hour ED revisit rate. The hospitalization rate across 34 other US pediatric hospitals remained static at 52% over the study period. CONCLUSIONS We safely reduced unnecessary hospitalizations for children with anaphylaxis and sustained the change over 3 years by using a QI initiative that included evidence-based guideline development and implementation, reinforced by provider reminders and structured feedback.
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Affiliation(s)
| | | | | | | | - Lynda C. Schneider
- Allergy/Immunology, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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38
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Polloni L, Ferruzza E, Ronconi L, Toniolo A, Lazzarotto F, Bonaguro R, Celegato N, Muraro A. Assessment of children's nutritional attitudes before oral food challenges to identify patients at risk of food reintroduction failure: a prospective study. Allergy 2017; 72:731-736. [PMID: 27659406 DOI: 10.1111/all.13055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Inappropriate dietary eliminations may impair quality of life, affect children's growth and unnecessarily impact on healthcare costs. Previous retrospective studies reported that around 25% of children continue a food-avoidance diet despite a negative oral food challenge (OFC). A definite pattern has not been found yet for patients not reintroducing the food. This study aimed to examine the role of child's nutritional attitudes and maternal anxiety in reintroducing food after a negative OFC. METHODS A prospective study was conducted involving 81 mothers of children with IgE-mediated food allergy. They completed a survey on nutritional behaviour and attitudes and the State-Trait Anxiety Inventory on the day of OFC and 6 months later. RESULTS In total, 11.1% of children never or rarely ate the food after a negative OFC. Consumption of the reintroduced food is positively correlated to child's interest in tasting new foods before and after OFC and to changes in child's nutritional habits after OFC. It is negatively correlated to monotony of the diet after OFC. No correlations were found with other participants' characteristics or maternal anxiety. State anxiety significantly decreased after the OFC. A correlation was found between trait and state anxiety and the degree of change in nutritional habits after OFC. CONCLUSIONS Evaluating child's approach towards food before the OFC is a promising approach to identify patients at risk of food reintroduction failure. Furthermore, it underlined the importance of reassessing food consumption in all patients after a negative OFC and supporting patients in the reintroduction of food.
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Affiliation(s)
- L. Polloni
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
| | - E. Ferruzza
- Department of Developmental Psychology and Socialization; University of Padua; Padua Italy
| | - L. Ronconi
- Department of Philosophy, Sociology, Education and Applied Psychology; University of Padua; Padua Italy
| | - A. Toniolo
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
| | - F. Lazzarotto
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
| | - R. Bonaguro
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
| | - N. Celegato
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
| | - A. Muraro
- Food Allergy Referral Centre for Diagnosis and Treatment; Veneto Region; Department of Women and Child Health; Padua University Hospital; Padua Italy
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Yanagida N, Sato S, Asaumi T, Ogura K, Ebisawa M. Risk Factors for Severe Reactions during Double-Blind Placebo-Controlled Food Challenges. Int Arch Allergy Immunol 2017; 172:173-182. [PMID: 28380495 DOI: 10.1159/000458724] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 01/31/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Severe anaphylactic symptoms can occur during oral food challenges (OFCs). Thus, high-risk patients (e.g., patients with a history of anaphylaxis or high antigen-specific immunoglobulin E [IgE] levels) must carefully undergo OFCs in hospitals. We attempted to identify the risk factors for severe symptoms during OFC testing among high-risk patients. METHODS We retrospectively evaluated patients' characteristics and severe symptoms that were experienced during a double-blind placebo-controlled food challenge test performed before the patients underwent oral immunotherapy between June 2008 and June 2012. Patients were ≥5 years old and had an anaphylactic history or antigen-specific IgE (>30 kUA/L). Severe symptoms were defined using the grading of the Japanese Anaphylaxis Guidelines, which are modified from the European Academy of Allergology and Clinical Immunology Guidelines. RESULTS We evaluated 393 cases with positive test results, including 98 cases with severe symptoms. The most frequent severe symptoms were respiratory (77%), gastrointestinal (28%), cardiovascular (27%), and neurological (13%) symptoms. Multivariate analysis revealed that the significant factors for a severe reaction were a history of anaphylaxis to the causative food (adjusted odds ratio [OR]: 2.147, p = 0.003), older age (per 1 year increase, adjusted OR: 1.102, p = 0.044), and an egg OFC (adjusted OR: 0.433, p = 0.003). CONCLUSIONS The risk factors for a severe reaction to OFCs were a history of an anaphylactic reaction and older age. An egg OFC was associated with low risk of severe symptoms during OFC. Therefore, OFCs for patients with these risk factors should only be performed under specialist supervision with access to rapid treatment and full resuscitation equipment.
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Affiliation(s)
- Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Sagamihara, Japan
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International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2017; 139:1111-1126.e4. [PMID: 28167094 DOI: 10.1016/j.jaci.2016.12.966] [Citation(s) in RCA: 371] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/07/2016] [Accepted: 12/21/2016] [Indexed: 01/22/2023]
Abstract
Food protein-induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.
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Abstract
PURPOSE OF REVIEW Anaphylaxis is a serious allergic reaction that can be life threatening. We will review the most recent evidence regarding the diagnosis, treatment, monitoring, and prevention of anaphylaxis in children. RECENT FINDINGS Histamine and tryptase are not sufficiently accurate for the routine diagnosis of anaphylaxis, so providers should continue to rely on clinical signs. Platelet-activating factor shows some promise in the diagnosis of anaphylaxis. Intramuscular is the best route for epinephrine administration for children of all weights. Glucocorticoids may reduce prolonged hospitalizations for anaphylaxis. Children with anaphylaxis who have resolving symptoms and no history of asthma or previous biphasic reactions may be observed for as few as 3-4 h before emergency department discharge. Early peanut introduction reduces the risk of peanut allergy. SUMMARY Epinephrine remains the mainstay of anaphylaxis treatment, and adjuvant medications should not be used in its place. All patients with anaphylaxis should be prescribed and trained to use an epinephrine autoinjector. Clinically important biphasic reactions are rare. Observation in the emergency department for most anaphylaxis patients is recommended, with the duration determined by risk factors. Admission is reserved for patients with unimproved or worsening symptoms, or prior biphasic reaction.
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Affiliation(s)
- Karen S. Farbman
- Boston Children's Hospital, Division of Emergency Medicine, Boston, MA
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Hartman H, Dodd C, Rao M, DeBlasio D, Labowsky C, D'Souza S, Lenkauskas S, Roeser E, Heffernan A, Assa'ad A. Parental timing of allergenic food introduction in urban and suburban populations. Ann Allergy Asthma Immunol 2016; 117:56-60.e2. [PMID: 27184198 DOI: 10.1016/j.anai.2016.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/06/2016] [Accepted: 04/13/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recommendations on timing for introduction of allergenic foods in an infant diet have changed twice during the past decade. How families with different demographic characteristics implement the change has not been studied in the United States. OBJECTIVE To compare the age of introduction of allergenic foods between an urban Medicaid-based population and a suburban private insurance-based population in Cincinnati, Ohio. METHODS Two hundred parent surveys were distributed at well-child checkups between 4 and 36 months of age. Data were analyzed using distribution mapping to determine the difference in the age of introduction of infant formula, infant solids, whole cow's milk, eggs, peanut, and fish. Random forest analysis was used to determine the most important factors affecting the age of introduction for both populations. RESULTS There was no statistically significant difference in the age of infant solid introduction, but urban populations introduced allergenic foods earlier than suburban populations, with a statistically significant difference in the age of introduction of infant formula, whole cow's milk, eggs, peanut, and fish. The most important factor for the timing of all food introductions was the recommended age of introduction from health care professionals. CONCLUSION There is a difference between urban and suburban populations in the timing of introduction of allergenic foods but not in other infant solid foods. The reliance on physician recommendation for both populations supports the need for education and guidance to health care professionals on up-to-date guidance and recommendations.
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Affiliation(s)
- Heather Hartman
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Caitlin Dodd
- Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marepalli Rao
- Center for Clinical and Translational Science and Training, Division of Biostatistics and Epidemiology, University of Cincinnati, Cincinnati, Ohio
| | - Dominick DeBlasio
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | | | - Amal Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. amal.assa'
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Michelson KA, Monuteaux MC, Neuman MI. Variation and Trends in Anaphylaxis Care in United States Children's Hospitals. Acad Emerg Med 2016; 23:623-7. [PMID: 26833535 DOI: 10.1111/acem.12922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/13/2015] [Accepted: 12/18/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to determine the extent of variation in treatment of children with anaphylaxis. METHODS We identified children 1 month to 18 years of age presenting with a primary diagnosis of anaphylaxis to one of the 35 pediatric hospitals included in the Pediatric Health Information System between January 1, 2009, and September 30, 2013. We evaluated the variation in use of β2 agonists, glucocorticoids, histamine-1 (H1) antagonists, histamine-2 (H2) antagonists, inhaled epinephrine, intravenous fluids, and oxygen. We assessed whether variation exists in the rates of hospitalization and 3-day emergency department (ED) revisits and whether a temporal trend exists in the ED visit rate for anaphylaxis. RESULTS Among 10,351 children with anaphylaxis, the hospital-level median use of common anaphylaxis therapies varied for β2 agonists (22%, interquartile range [IQR] = 16%-26%), glucocorticoids (71%, IQR = 65%-76%), H1 blockers (60%, IQR = 57%-65%), H2 blockers (53%, IQR = 36%-64%), inhaled epinephrine (2.2%, IQR = 1.3%-3.5%), intravenous fluids (26%, IQR = 13%-41%), and oxygen (2.6%, IQR = 0.8%-4.1%). Hospitalization rates ranged from 12% to 95%, with a median rate of 41%. Anaphylaxis diagnoses rose from 5.7 to 11.7 patients per 10,000 ED visits between 2009 and 2013 (p < 0.001 for trend). CONCLUSIONS There is substantial variability in the use of common therapies and hospitalization rates for children cared for in U.S. children's hospitals. Additionally, ED visits for children with anaphylaxis are increasing at U.S. children's hospitals. These findings highlight the need for research defining optimal care for anaphylaxis.
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Affiliation(s)
| | | | - Mark I. Neuman
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
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Grabenhenrich L, Lange L, Härtl M, Kalb B, Ziegert M, Finger A, Harandi N, Schlags R, Gappa M, Puzzo L, Stephan V, Heigele T, Büsing S, Ott H, Niggemann B, Beyer K. The component-specific to total IgE ratios do not improve peanut and hazelnut allergy diagnoses. J Allergy Clin Immunol 2016; 137:1751-1760.e8. [PMID: 27087317 DOI: 10.1016/j.jaci.2016.01.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 11/17/2015] [Accepted: 01/13/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Specific IgE measurement predicts the outcome of oral food challenges with considerable uncertainty when evaluating food allergy. OBJECTIVE Our aim was to assess whether accounting for the ratio of component- or allergen-specific to total IgE can improve this prediction. METHODS This multicenter study collected blood samples from children with suspected peanut or hazelnut allergy referred to allergy specialist clinics for food challenges. Specific IgE to peanuts, hazelnuts, and their components (Ara h 1, Ara h 2, Ara h 3, Ara h 8, Cor a 1, Cor a 8, Cor a 9, and Cor a 14) and total IgE levels were determined by using the ImmunoCAP-FEIA. Specific to total IgE ratios were compared with raw IgE levels in terms of discrimination and prediction. RESULTS Eighty-eight (43%) of 207 children with suspected peanut allergy and 44 (31%) of 142 children with suspected hazelnut allergy had symptoms during food challenge. Discrimination was similar for raw and ratio measures: areas under the curve of 0.93 for Ara h 2-specific IgE versus 0.92 for the Ara h 2-specific/total IgE ratio and 0.89 for Cor a 14-specific IgE versus 0.87 for the Cor a 14-specific/total IgE ratio. The probability for a positive peanut challenge with 0.35 kU/L Ara h 2-specific IgE was 16% when the total IgE level was greater than 500 kU/L compared with 51%/48% for low/medium total IgE levels (<100/100-500 kU/L). A positive hazelnut challenge with 0.35 kU/L Cor a 14-specific IgE was estimated in 7% when total IgE levels were high compared with 34%/32% with low/medium total IgE levels. CONCLUSIONS Raw Ara h 2- and Cor a 14-specific IgE levels were the best single predictors for pediatric peanut and hazelnut allergies, suggesting the omission of challenges at very high levels. Calculating ratio measures did not improve prediction in this population. However, estimation of individual probabilities for challenge outcomes could be supported by total IgE levels because high levels might indicate lower probabilities at a given component-specific IgE level.
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Affiliation(s)
- Linus Grabenhenrich
- Charité - Universitätsmedizin Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany.
| | - Lars Lange
- St Marien-Hospital, Department for Pediatrics, Bonn, Germany
| | - Magdalena Härtl
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Birgit Kalb
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany
| | - Mandy Ziegert
- German Red Cross Hospital, Department for Pediatrics, Berlin, Germany
| | - Antje Finger
- St Marien-Hospital, Department for Pediatrics, Bonn, Germany
| | | | | | - Monika Gappa
- Marien-Hospital, Children's Department, Wesel, Germany
| | - Letizia Puzzo
- Marien-Hospital, Children's Department, Wesel, Germany
| | | | | | - Susanne Büsing
- Children's Hospital Osnabrück, Department for Pediatrics, Osnabrück, Germany
| | - Hagen Ott
- Children's Hospital Auf der Bult, Hannover, Germany
| | - Bodo Niggemann
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany; German Red Cross Hospital, Department for Pediatrics, Berlin, Germany
| | - Kirsten Beyer
- Charité - Universitätsmedizin Berlin, Department of Pediatric Pneumology and Immunology, Berlin, Germany; Icahn School of Medicine at Mount Sinai, New York, NY
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Elizur A, Appel MY, Goldberg MR, Yichie T, Levy MB, Nachshon L, Katz Y. Clinical and laboratory 2-year outcome of oral immunotherapy in patients with cow's milk allergy. Allergy 2016; 71:275-8. [PMID: 26482941 DOI: 10.1111/all.12794] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/28/2022]
Abstract
Studies examining the long-term effect of oral immunotherapy in food-allergic patients are limited. We investigated cow's milk-allergic patients, >6 months after the completion of oral immunotherapy (n = 197). Questionnaires, skin prick tests, and basophil activation assays were performed. Of the 195 patients contacted, 180 (92.3%) were consuming milk protein regularly. Half experienced adverse reactions, mostly mild. Thirteen patients (6.7%) required injectable epinephrine. Higher reaction rate after immunotherapy was associated with more anaphylactic episodes before treatment and a lower starting dose (OR = 2.1, P = 0.035 and OR = 2.3, P = 0.035, respectively). Reaction rate in patients who were 6-15 months, 15-30 months, or >30 months post-treatment decreased from 0.28/month to 0.21/month to 0.15/month, respectively (P < 0.01). Milk-induced %CD63 and %CD203c expression was significantly lower in patients >24 months vs in patients <24 months post-treatment (P = 0.038 and P = 0.047, respectively). In conclusion, many patients experience mild adverse reactions after completing oral immunotherapy and some require injectable epinephrine. Progressive desensitization, both clinically and in basophil reactivity, occurs over time.
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Affiliation(s)
- A. Elizur
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
- Department of Pediatrics; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - M. Y. Appel
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
| | - M. R. Goldberg
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
| | - T. Yichie
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
| | - M. B. Levy
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
| | - L. Nachshon
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
| | - Y. Katz
- Allergy and Immunology Institute; Assaf-Harofeh Medical Center; Zerifin Israel
- Department of Pediatrics; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Successful immunotherapy induces previously unidentified allergen-specific CD4+ T-cell subsets. Proc Natl Acad Sci U S A 2016; 113:E1286-95. [PMID: 26811452 DOI: 10.1073/pnas.1520180113] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Allergen immunotherapy can desensitize even subjects with potentially lethal allergies, but the changes induced in T cells that underpin successful immunotherapy remain poorly understood. In a cohort of peanut-allergic participants, we used allergen-specific T-cell sorting and single-cell gene expression to trace the transcriptional "roadmap" of individual CD4+ T cells throughout immunotherapy. We found that successful immunotherapy induces allergen-specific CD4+ T cells to expand and shift toward an "anergic" Th2 T-cell phenotype largely absent in both pretreatment participants and healthy controls. These findings show that sustained success, even after immunotherapy is withdrawn, is associated with the induction, expansion, and maintenance of immunotherapy-specific memory and naive T-cell phenotypes as early as 3 mo into immunotherapy. These results suggest an approach for immune monitoring participants undergoing immunotherapy to predict the success of future treatment and could have implications for immunotherapy targets in other diseases like cancer, autoimmune disease, and transplantation.
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Abstract
The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.
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Affiliation(s)
- Smita Awasthi
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123.
| | - Marti Jill Rothe
- Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032
| | - Lawrence F Eichenfield
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123
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Childhood Food Allergy Update. Pediatr Clin North Am 2015; 62:xvii-xviii. [PMID: 26456451 DOI: 10.1016/j.pcl.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yanagida N, Imai T, Sato S, Ebisawa M. Do Longer Intervals between Challenges Reduce the Risk of Adverse Reactions in Oral Wheat Challenges? PLoS One 2015; 10:e0143717. [PMID: 26624006 PMCID: PMC4666606 DOI: 10.1371/journal.pone.0143717] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/09/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The use of oral food challenges (OFCs) in clinics is limited because they are complicated and associated with anaphylactic symptoms. To increase their use, it is necessary to develop novel, effective, and safe methods. However, the effectiveness of different OFCs has not been compared. OBJECTIVE To investigate the effect of ingestion methods on wheat allergy symptoms and treatment during OFCs. METHOD Without changing the total challenge dose, we changed the administration method from a 5-installment dose titration every 15 min (15-min interval method) to 3 installments every 30 min (30-min interval method). We retrospectively reviewed and compared the results of 65 positive 15-min interval wheat challenge tests conducted between July 2005 and February 2008 and 87 positive 30-min interval tests conducted between March 2008 and December 2009. RESULTS A history of immediate symptoms was more common for the 30-min interval method; however, no difference between methods was observed in other background parameters. Switching from the 15-min to the 30-min interval method did not increase symptoms or require treatment. The rate of cardiovascular symptoms (p = 0.032), and adrenaline use (p = 0.017) was significantly lower with the 30-min interval method. The results did not change after adjusting for the effects of immediate symptom history in multivariate analysis. CONCLUSION This study suggests that the 30-min interval method reduces the risk of adverse events, compared to the 15-min interval method.
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Affiliation(s)
- Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Takanori Imai
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
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