Exercise-induced bronchoconstriction, allergy and sports in children

Exercise-induced bronchoconstriction (EIB) is characterized by the narrowing of airways during or after physical activity, leading to symptoms such as wheezing, coughing, and shortness of breath. Distinguishing between EIB and exercise-induced asthma (EIA) is essential, given their divergent therapeutic and prognostic considerations. EIB has been increasingly recognized as a significant concern in pediatric athletes. Moreover, studies indicate a noteworthy prevalence of EIB in children with atopic predispositions, unveiling a potential link between allergic sensitivities and exercise-induced respiratory symptoms, underpinned by an inflammatory reaction caused by mechanical, environmental, and genetic factors. Holistic management of EIB in children necessitates a correct diagnosis and a combination of pharmacological and non-pharmacological interventions. This review delves into the latest evidence concerning EIB in the pediatric population, exploring its associations with atopy and sports, and emphasizing the appropriate diagnostic and therapeutic approaches by highlighting various clinical scenarios.

Fatal food anaphylaxis in adults and children

Anaphylaxis is a life-threatening reaction characterized by the acute onset of symptoms involving different organ systems and requiring immediate medical intervention. The incidence of fatal food anaphylaxis is 0.03 to 0.3 million/people/year. Most fatal food-induced anaphylaxis occurs in the second and third decades of life. The identified risk factors include the delayed use of epinephrine, the presence of asthma, the use of recreational drugs (alcohol, nicotine, cannabis, etc.), and an upright position. In the United Kingdom (UK) and Canada, the reported leading causal foods are peanuts and tree nuts. In Italy, milk seems to be the most common cause of fatal anaphylaxis in children < 18 years. Fatal food anaphylaxis in Italian children and adolescents almost always occurs outside and is characterized by cardiorespiratory arrest; auto-injectable adrenaline intramuscular was available in few cases. Mortality from food anaphylaxis, especially in children, is a very rare event with stable incidence, but its risk deeply impacts the quality of life of patients with food allergy and their families. Prevention of fatal food anaphylaxis must involve patients and their families, as well as the general public, public authorities, and patients' associations.

Imported allergens in Italy: an emerging issue

Imported allergens are involved in many allergic reactions, with unexpected and unusual implications. They can be involved in developing asthma, allergic rhinoconjunctivitis, Hymenoptera venom allergies and food allergies. Imported allergens can be implied in respiratory allergies attributable to commercial practices and accidental diffusion through air currents that have introduced non-native species in new geographical contexts. Ambrosia artemisiifolia L., a plant native to North America and currently in the western part of Lombardy, represents an example. Moreover, a variation in the pollen concentration in the Northwest Tuscany area and Trentino Alto-Adige was observed. Cannabis sativa is another imported allergen used frequently by adolescents. Regarding potential imported food allergens, there is no validated list. Imported food allergens derive from ethnic foods, referring to Mexican/Latin American, Chinese/Japanese, Southeast Asian, Arab/Middle Eastern and African cuisine. Four insect flours were recently introduced to the European and Italian markets (Acheta domesticus, Alphitobius diaperinus, Tenebrio molitor and Locusta migratoria). The association between the accidental introduction through commercial traffic, climate change, and the absence of natural enemies in the destination ecosystem is related to the introduction of a specific Hymenoptera, Vespa velutina, in Italy and Europe. External events attributable to human activities, such as climate change and the introduction of non-native plants, foods and Hymenoptera through trade, have contributed to the issue of imported allergens. Making the correct diagnosis and guiding the diagnostic and therapeutic path in this particular context represent the concerns of the pediatric allergist.

Why do some Children Get Sick with Recurrent Respiratory Infections?

Respiratory tract infections (RTI) represent a frequent condition, particularly among preschool children, with an important burden on the affected children and their families. It has been estimated that recurrent RTIs affect up to 25% of children during the first 4 years of life. These infections are mainly caused by viruses and are generally self-limiting. Social and environmental factors have been studied in determining the incidence of recurrent RTIs and the mostly recognized are precocious day care attendance, tobacco exposure and pollution. Primary immune defects, local anatomical factors, and genetic disorders such as primary ciliary dyskinesia or cystic fibrosis, may be also involved in recurrent RTIs of a subgroup of children, typically characterized by more severe and chronic symptoms. However, there is increasing awareness that RTIs have a complex pathophysiology and that some underrecognized factors, including genetic susceptibility to infections, low levels of some micronutrients, and respiratory microbiota might shape the probability for the child to develop RTIs. The sum (i.e. the number) of these factors may help in explaining why some children get sick for RTIs whilst other not. In some children iatrogenic factors, including improper use of antibiotics and NSAIDS or glucocorticoids might also aggravate this condition, further weakening the host's immune response and the possibly of establishing a "vicious circle". The present review aims to focus on several possible factors involved in influencing RTIs and to propose a unifying hypothesis on pathophysiological mechanisms of unexplained recurrent RTIs in children.

Latex Allergy in Children

Notwithstanding the efforts made in the last decades to mitigate the consequences of natural rubber latex allergy, this disease continues to be a major health problem, especially in developing countries. The categories of patients with greater and frequent exposure to latex (such as health care professionals and, in the pediatric field, subjects who undergo repeated surgery, e.g., those suffering from spina bifida and urogenital malformations) have an increased risk of developing sensitization and allergy to latex. Herein we provide an overview of the current knowledge and practical recommendations with a focus on epidemiology, diagnostics, and management (including both prevention and therapy) in order to guide a correct recognition and containment of this potentially fatal condition.

IgE-Mediated and Non-IgE-Mediated Fish Allergy in Pediatric Age: A Holistic Approach-A Consensus by Diagnostic Commission of the Italian Society of Pediatric Allergy and Immunology

Fish is one of the "big nine" foods triggering allergic reactions. For this reason, fish allergens must be accurately specified on food labels. Fish allergy affects less than 1% of the world population, but a higher prevalence is observed in pediatric cohorts, up to 7%. Parvalbumin is the main fish allergen found in the muscles. In childhood, sensitization to fish allergens occurs most frequently through the ingestion of fish, rarely transcutaneously or by inhalation. Fish allergy symptoms usually appear within two hours of the allergen contact. The diagnosis begins with the collection of the history. If it is suggestive of fish allergy, prick tests or the measurement of serum-specific IgE should be performed to confirm the suspicion. The oral food challenge is the gold standard for the diagnosis. It is not recommended in case of a severe allergic reaction. It is important to make a differential diagnosis with anisakiasis or scombroid poisoning, which have overlapping clinical features but differ in pathogenesis. Traditionally, managing fish allergy involves avoiding the triggering species (sometimes all bony fish species) and requires an action plan for accidental exposures. The present review will analyze IgE- and non-IgE-mediated fish allergy in children from epidemiology, pathogenesis to clinical features. Moreover, clinical management will be addressed with a particular focus on potential nutritional deficiencies.

Allergic Proctocolitis: Literature Review and Proposal of a Diagnostic-Therapeutic Algorithm

Allergic proctocolitis (AP) is a benign condition, frequent in childhood, that is classified as a non-IgE-mediated food allergy. The prevalence is unknown; however, its frequency appears to be increasing, especially in exclusively breastfed infants. Clinical manifestations typically begin in the first few months of life with the appearance of bright red blood (hematochezia), with or without mucus, in the stool of apparently healthy, thriving infants. Most cases of AP are caused by cow's milk proteins; however, other allergens, such as soy, egg, corn, and wheat, may be potential triggers. Diagnosis is based on the patient's clinical history and on the resolution of signs and symptoms with the elimination of the suspected food antigen from the diet and their reappearance when the food is reintroduced into the diet. The treatment of AP is based on an elimination diet of the trigger food, with resolution of the symptoms within 72-96 h from the beginning of the diet. The prognosis of AP is good; it is a self-limiting condition, because most children can tolerate the trigger food within one year of life, with an excellent long-term prognosis. The purpose of this review is to provide an update on the current knowledge and recommendations in epidemiological, diagnostic, and therapeutic terms to the pediatricians, allergists, and gastroenterologists who may find themselves managing a patient with AP.

Pediatric Angioedema without Wheals: How to Guide the Diagnosis

Angioedema (AE) is a vascular reaction of subcutaneous and submucosal tissues that identifies various clinical pictures and often is associated with wheals. AE without wheals (AEwW) is infrequent. The ability to distinguish between AEwW mediated by mast cells and bradykinin-mediated or leukotriene-mediated pathways is often crucial for a correct diagnostic-therapeutic and follow-up approach. AEwW can be hereditary or acquired. Factors typically correlated with hereditary angioedema (HAE) are a recurrence of episodes, familiarity, association with abdominal pain, onset after trauma or invasive procedures, refractoriness to antiallergic therapy, and lack of pruritus. The acquired forms of AE can present a definite cause based on the anamnesis and diagnostic tests. Still, they can also have an undetermined cause (idiopathic AE), distinguished according to the response to antihistamine in histamine-mediated and non-histamine-mediated forms. Usually, in childhood, AE responds to antihistamines. If AEwW is not responsive to commonly used treatments, it is necessary to consider alternative diagnoses, even for pediatric patients. In general, a correct diagnostic classification allows, in most cases, optimal management of the patient with the prescription of appropriate therapy and the planning of an adequate follow-up.

Linear Immunoglobulin a Bullous Dermatosis in Children

Linear Immunoglobulin A Bullous Disease (LABD) is a rare dermatosis whose pathomechanisms are not yet completely understood. LABD has different features characterizing adults and children in terms of potential triggers, clinical manifestations, and prognosis. The aim of the present study is to review all neonatal and pediatric cases of LABD and summarize the major characteristics. Childhood LABD is mainly idiopathic with a benign prognosis. Neonatal cases are difficult to differentiate from infectious diseases and usually have a poor prognosis. Drugs are one of the possible triggers that can activate autoimmune responses through antigen mimicry and epitope spreading as well as different stimuli (e.g., infections, inflammatory diseases, trauma). The gold standard for the diagnosis is based on direct immunofluorescence. Prognosis is generally favorable but often depends on the prompt dermatological diagnosis, treatment and follow-up guaranteed by a multidisciplinary team, including pediatricians for this group of age.

The history of the drug-induced enterocolitis syndrome

The diagnosis of drug-induced enterocolitis syndrome (DIES), resembling the typical findings of a well-known disease, the food protein-induced enterocolitis syndrome (FPIES), was acknowledged in the first publication on the topic in 2014. Ten cases of DIES have been described so far. Unanswered questions concerning DIES include its pathogenetic mechanism, natural history, the possible presence of predisposing genetic factors, and the potential existence of its atypical forms. DIES is a recently defined and intriguing clinical entity, similar to FPIES but triggered by drugs. It seems well-defined from the clinical point of view, but its pathogenetic mechanisms are not known. DIES deserves more attention among allergists, especially among the professionals who work with children, and all efforts should be conceived to improve its correct recognition and accurate management.

Efficacy of sildenafil and high-dose anakinra in an MIS-C patient with pulmonary vasculitis: A case report

Multisystem inflammatory syndrome in children (MIS-C) is a newly identified clinical entity still not very well known in terms of epidemiology, pathogenesis, and long-term outcome. Pulmonary involvement with acute respiratory failure is an unusual life-threatening complication of MIS-C, often a reason for admission to the pediatric intensive care unit (PICU) and the use of mechanical ventilation. We present a case of a 7-year-old male patient, previously healthy, hospitalized for MIS-C, treated with intravenous immunoglobulins (IVIG), high dose methylprednisolone, and anakinra. After 2 days of the aforementioned therapy, the patient presented with hypoxia (SatO₂: 85% in ambient air room) and breathing difficulties. A chest computed tomography (CT) scan showed the presence of multiple bilateral basal parenchymal thickening and small basal pleural effusion and an arterial blood gas analysis revealed severe hypoxia (PaO₂/FiO₂ ratio, 170 mmHg). Because of a worsening of respiratory distress, the patient was transferred to the PICU, where invasive mechanical ventilation and a continuous infusion of anakinra (12 mg/kg/day) were started. An echocardiogram was performed, which showed an increase in pulmonary pressure (40 mmHg) with normal heart ejection fraction (55%), and the hypothesis of pulmonary vasculitis involving the pulmonary arterioles was made. Therefore, therapy with sildenafil (0.15 mg/kg/day) was promptly set up, with an immediate improvement of the clinical picture of respiratory failure, reduction of pulmonary pressure (23 mmHg), and subsequent extubation at 36 h with a regular clinical course until discharge. As far as we know, our case represents the first report of pulmonary vasculitis in an MIS-C patient. The use of sildenafil and high-dose continuous anakinra may represent a rescue therapy in cases of MIS-C with pulmonary vasculitis or with difficulty in extubation, allowing a short-term hospitalization in intensive care and improving the long-term outcome in these patients.

Alpha-Gal Syndrome in Children: Peculiarities of a "Tick-Borne" Allergic Disease

The alpha-gal syndrome is an allergic syndrome that comprises two clinical pictures: an immediate hypersensitivity to drugs containing alpha-gal and a delayed hypersensitivity to the ingestion of red mammalian meat. This allergic syndrome is often under-recognized, and patients are mislabeled with diagnosis as spontaneous urticaria or idiopathic anaphylaxis. Even though less frequently, children could also be of interest, especially in tick-endemic areas. In most cases, a positive anamnesis for tick bites months before the onset of symptoms is recorded. The clinical manifestations could range from asymptomatic cases to severe anaphylaxis. The most frequently used diagnostic test is the determination of specific IgE for alpha-gal. Oral provocation test is usually reserved to unclear cases or to verify tolerance after diet. No long-term follow-up studies have been published, although an elimination diet could lead to a decrease of specific IgE for alpha-gal and a possible reintroduction of some avoided foods. This paper provides a literature review, focused on pediatric age, and an evaluation of available diagnostic tests. We analyze the correlation between tick bites and symptom onset and unfold the different clinical pictures to help clinicians to promptly recognized this syndrome. Lastly, we address unmet needs in this specific allergy.

Unusual Reactions to Hymenoptera Stings: Current Knowledge and Unmet Needs in the Pediatric Population

Hymenoptera stings are generally well-tolerated and usually cause limited local reactions, characterized by self-resolving erythema and edema associated with pain. However, Hymenoptera stings can induce immediate and delayed hypersensitivity reactions. In addition to these manifestations, unusual reactions to Hymenoptera stings have been reported. The latter are defined as unusual because of their atypical characteristics. They may differ from classical hypersensitivity reactions due to the stings' particular localization and the unusual involvement of one or more specific organs. Although unusual reactions to Hymenoptera stings are infrequent, it is essential for clinicians to know the possible related clinical manifestations. Here, we review the available literature and propose a diagnostic and management algorithm. At present, there are no defined guidelines for most of the unusual reactions to Hymenoptera stings, which should be managed in a tailored way according to the specifical clinical manifestations presented by the patients. Further studies are needed to better define these conditions and the underlying pathogenetic mechanisms to improve the diagnostic and therapeutic approach.

Pediatric eosinophilic esophagitis: a review for the clinician

Eosinophilic esophagitis (EoE) is a chronic clinical-pathologic disease characterized by eosinophilic infiltration of the esophageal epithelium with esophageal dysfunction symptoms.EoE can occur at any age and has different clinical manifestations depending on the age onset.To date, esophago-gastroduodenal endoscopy (EGD) with biopsy is the gold-standard for EoE diagnosis.According to the recent consensus guidelines, proton pump inhibitors, corticosteroids and elimination diets could be a first-line therapy option. The aim of the treatment is clinical and histological remission for preventing long-lasting untreatable fibrosis.A multidisciplinary approach (allergist, gastroenterology, dietitian, and pathologist) is recommended for managing patients affected by EoE, given the complexity of its treatment.This review will provide a practical guide to assist pediatricians treating children with EoE.Moreover, it highlights the unmet needs in diagnosis and treatment that require urgent attention from the scientific community in the aim of improving the management of patients with EoE.

The Role of Gut and Lung Microbiota in Susceptibility to Tuberculosis

Tuberculosis is one of the most common infectious diseases and infectious causes of death worldwide. Over the last decades, significant research effort has been directed towards defining the understanding of the pathogenesis of tuberculosis to improve diagnosis and therapeutic options. Emerging scientific evidence indicates a possible role of the human microbiota in the pathophysiology of tuberculosis, response to therapy, clinical outcomes, and post-treatment outcomes. Although human studies on the role of the microbiota in tuberculosis are limited, published data in recent years, both from experimental and clinical studies, suggest that a better understanding of the gut-lung microbiome axis and microbiome-immune crosstalk could shed light on the specific pathogenetic mechanisms of Mycobacterium tuberculosis infection and identify new therapeutic targets. In this review, we address the current knowledge of the host immune responses against Mycobacterium tuberculosis infection, the emerging evidence on how gut and lung microbiota can modulate susceptibility to tuberculosis, the available studies on the possible use of probiotic-antibiotic combination therapy for the treatment of tuberculosis, and the knowledge gaps and future research priorities in this field.

Heiner Syndrome and Milk Hypersensitivity: An Updated Overview on the Current Evidence

Infants affected by Heiner syndrome (HS) display chronic upper or lower respiratory tract infections, including otitis media or pneumonia. Clinically, gastrointestinal signs and symptoms, anemia, recurrent fever and failure to thrive can be also present. Chest X-rays can show patchy infiltrates miming pneumonia. Clinical manifestations usually disappear after a milk-free diet. The pathogenetic mechanism underlying HS remains unexplained, but the formation of immune complexes and the cell-mediated reaction have been proposed. Patients usually outgrow this hypersensitivity within a few years. The aim of this review is to provide an updated overview on the current evidence on HS in children, with a critical approach on the still undefined points of this interesting disease. Finally, we propose the first structured diagnostic approach for HS.

Component-Resolved Diagnosis of Hazelnut Allergy in Children

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

Hymenoptera venom allergy among children in Italy: time for pediatricians to take action

Hymenoptera venom allergy (HVA) is one of the most frequent causes of anaphylaxis following a bee, vespid or ant sting. Real-life data regarding the management of HVA in children are lacking. To address this unmet need, we carried out a survey defining the current management of HVA in children among pediatric allergists in Italy. Educational investments on the improvement of the management of pediatric patients with HVA are urgently needed, and our analysis represents a relevant instrument in targeting a roadmap with this aim. The time for pediatric allergists to take action has come, and a task force from the Rare Allergic Diseases Commission of the Italian Society of Pediatric Allergy and Immunology is working on the topic to improve pediatricians' knowledge and optimize the care of these patients.

Epidemiology of rare allergic diseases in children

Allergic diseases have different frequencies. In particular, allergic rhinitis and asthma have high frequencies of about 20% and 10%, respectively. Other allergic diseases have lower frequencies; for example, food allergy has a frequency of 1%-4%. There are also rare allergic diseases, with a prevalence of 5 cases per 10 000 people in the general population, and they are included in Orphanet. However, other extremely rare allergic diseases still need to be properly known in order to be possibly recognized as rare diseases and cataloged in Orphanet.

Role of in vitro testing in food allergy

Oral food challenges remain the gold standard for the diagnosis of food allergy. Nevertheless, the allergy workup is based on the presence of a clinical history, which is evocative of an immune-allergic reaction, and the first assessment is usually the performance of skin prick tests. Based on these results, allergists are used to evaluate the presence of serum-specific IgE, which are today the most commonly prescribed in vitro test for the evaluation of a possible food allergy. Other in vitro tests include the basophil activation test, that is becoming more and more employed by clinicians and not only by researchers, and the evaluation of serum IgG4, which is still an issue of debate in the allergy community. The present paper reviews the use of these in vitro tests for the diagnosis of food allergy.

Use of Sublingual Immunotherapy for Aeroallergens in Children with Asthma

Asthma is a heterogeneous disease that in children is often allergen-driven with a type 2 inflammation. Sublingual immunotherapy represents an important progress in the use of personalized medicine in children with allergic asthma. It is a viable option for house dust mite-driven asthma and in subjects with the asthma associated with allergic rhinitis. The use and indications for isolated asthma caused by other allergens are still controversial owing to heterogeneity of commercially available products and methodological limitations of studies in children. Nevertheless, most studies and meta-analyses found the efficacy of sublingual immunotherapy. Sublingual immunotherapy is safe but cannot be recommended in children with uncontrolled asthma.

New insights into food protein-induced enterocolitis in children

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

A two-week summer program promoting physical activity: quality of life assessment in Italian children

Physical activity (PA) can be associated with better health-related quality of life (HRQoL). This study aimed to assess HRQoL before and after a two-week summer program promoting PA in Italian school-aged children. Participants were recruited during the Giocampus summer2017 (Parma, Italy), from June to July. Before (T0) and after (T1) the program, children and one of their parents answered the Kindl questionnaire. For each domain, least-square mean changes (LSmc) at T1 were derived from linear regression models stratified by responder and adjusted for child gender, age group, time spent in PAs and HRQoL score of the responder at T0. 350 children (7-13 years, 52% males) and 342 parents answered the questionnaire at both T0 and T1. At T1, the HRQoL score of the children significantly improved in the emotional (LSmc 2.9, p<0.001), self-esteem (LSmc 3.3, p<0.001), family (LSmc 4.2, p<0.001) and friend (LSmc 3.1, p<0.001) domains. Parents reported significantly more improvement in self-esteem than children (LSmc 6.7 vs 3.3, p=0.012). Children spending more time in PA reported significantly more improvement in self-esteem than those doing less PA (LSmc 4.4 [p<0.001] vs 2.2 [p=0.181]). A short summer program promoting PA may improve HRQoL in the general population of school-aged children.

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

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

Allergen-specific Immunotherapy for Inhalant Allergens in Children

Allergen-specific immunotherapy (AIT) for aeroallergens consists of the administration of standardized allergen extracts to patients with respiratory IgE-mediated diseases to the same allergen in order to achieve immune tolerance to the allergen and prevent the onset of symptoms. AIT is usually delivered by sublingual (SLIT), subcutaneous (SCIT) route. AIT with one or multiple allergens currently represents the only causal treatment able to change the natural history of allergic airway diseases. Significant progresses have been made in terms of AIT efficacy and safety. In this paper, mechanisms of action, indication and side effects of allergen immunotherapy are reviewed. SLIT and SCIT have been found to be effective in the treatment of asthma and rhinoconjunctivitis due to inhalant allergens. The route of AIT administration should be selected on availability, cost (dependent from the local health system), tolerability (better for SLIT), patient's preference (injections are less accepted in young children), and adherence (higher for SCIT beyond pediatric age). However, it should be taken into account that metanalyses on AIT do not consider that effectiveness and safety depend upon the product chosen for treatment. Each product should be separately assessed to avoid generalization on administration routes or age group that may affect the decision.

Report on advances for pediatricians in 2018: allergy, cardiology, critical care, endocrinology, hereditary metabolic diseases, gastroenterology, infectious diseases, neonatology, nutrition, respiratory tract disorders and surgery

This review reported notable advances in pediatrics that have been published in 2018. We have highlighted progresses in allergy, cardiology, critical care, endocrinology, hereditary metabolic diseases, gastroenterology, infectious diseases, neonatology, nutrition, respiratory tract disorders and surgery. Many studies have informed on epidemiologic observations. Promising outcomes in prevention, diagnosis and treatment have been reported. We think that advances realized in 2018 can now be utilized to ameliorate patient care.

Pollen-Food Allergy Syndrome: A not so Rare Disease in Childhood

Seasonal allergic rhinoconjunctivitis (SAR) affects millions of people worldwide, particularly in childhood and adolescence. Pollen food allergy syndrome (PFAS) is a common adverse reaction occurring few minutes after the consumption of vegetable foods in patients with pollen-induced SAR. PFAS has rarely been investigated in the pediatric population, as it has been mainly examined as an adult disease. Recent studies suggested that PFAS might be more frequent in childhood than previously recognized. The present review aims to give an overview of the epidemiology, pathophysiology, diagnosis, management and prognosis of PFAS in children with SAR-induced by pollens.

Hazardous Medications in Children with Egg, Red Meat, Gelatin, Fish, and Cow's Milk Allergy

Childhood food allergies are a growing public health problem. Once the offending food allergens have been identified, a strict elimination diet is necessary in treatment or prevention of most of the allergic reactions. Accidental food ingestion can lead to severe anaphylaxis. Food- derived substances can be used in medications at various stages of the manufacturing process. In this review, the possible roles of medications which may contain egg, red meat, gelatin, and fish allergens on allergic reactions in children with food allergy were evaluated.

Management of chronic urticaria in children: a clinical guideline

The aim of this guidance is to provide recommendations to clinicians and other interested parties on chronic urticaria in children. The Italian Society for Pediatrics (SIP), the Italian Society for Allergy and Immunology (SIAIP), the Italian Society for Pediatric dermatology (SIDerP) convened a multidisciplinary panel that prepared clinical guidelines for diagnosis and management of chronic urticaria in childhood. Key questions on epidemiology, natural history, diagnosis, and management were developed. The literature was systematically searched and evaluated, recommendations were rated and algorithms for diagnosis and treatment were developed. The recommendations focus on identification of diseases and comorbidities, strategies to recognize triggering factors, improvement of treatment by individualized care.

Clinical utility of beta-hydroxybutyrate measurement in the management of physiological ketosis at home in children under 5

AIM

To verify the possible advantages of 3- β-hydroxybutyrate (3HB) measurement compared to urinary assay of ketones during an intercurrent disease managed at home.

METHODS

Twelve Pediatricians were asked to enroll at least 4 patients aged 3 to 5 years, affected by an intercurrent illness and showing at least one of symptoms reliable to ketosis. Recruited patients were submitted to the simultaneous assay of 3HB in capillary blood and ketones in urine at 3 (T3) and 6 hours (T6) from the first measurement (T0). For urinary and blood ketone detection commercial tests were used.

RESULTS

Thirty-eight children (4.36±2.60 years old; 25 boys) were enrolled into the study. At T0 all children showed 3HB levels (1.2-3.2 mmol/L), but only 10 of them (26.3%) associated also urinary ketone bodies (2 to 4+). In response to 3 hour treatment (T3) with a glucose solution, 3HB values decreased in 19 (0,8-1,8 mmol/L) and normalized in 13 children (<0.2 mmol/L); while ketonuria disappeared in only 2 patients, it was confirmed in 8 and appeared (4+) the first time in the remaining 28 children. At T6 3HB levels fell definitively within the normal range in all children, while ketonuria was still present (2+) in 9 patients (23%). The pediatricians reported two limitations about blood 3HB dosage compared to the urinary test: the invasiveness of capillary blood collection, and the cost of supplies for finger pricking, reagent strips and reflectance meter.

CONCLUSIONS

3HB monitor in capillary blood is more effective and clinically more useful in diagnosing and managing of an ongoing ketosis in children with a mild infective disease than ketones detection in the urine. These advantages are mitigated by the cost of 3HB measurement.

Early molecular biomarkers predicting the evolution of allergic rhinitis and its comorbidities: A longitudinal multicenter study of a patient cohort

BACKGROUND

Pollen-related seasonal allergic rhinoconjunctivitis (SAR) is a very frequent pediatric disease in Westernized countries. Risk factors and disease phenotypes have been thoroughly examined in several cross-sectional studies. By contrast, only a few studies have examined disease evolution in patient cohorts. We investigated predictive biomarkers of disease evolution in a large cohort of children with SAR.

METHODS

During 2015-2017 (follow-up), we re-examined 401 patients from those enrolled in 2009-2011 (baseline) by the "Panallergens in Pediatrics" study, a large multicenter survey of Italian children with SAR. Information on clinical history (standard questionnaire, AllergyCARD®; TPS, Italy) and skin prick tests for inhalant and foods extracts (ALK-Abelló, Hørsholm, Denmark) was acquired as at baseline visit. Evolution in clinical and sensitization data of patients was analyzed over time, as well as their association with the main baseline characteristics and atopy risk factors.

RESULTS

The average age of participants was 10.4 ± 3.4 years at baseline and 16.2 ± 3.6 years at follow-up. SAR persisted in 93.3% of patients at follow-up and became more frequently associated with asthma (from 36.7% at baseline to 48.6% at follow-up) and oral allergy syndrome (OAS, from 23.4% to 37.7%). Compared to baseline, the prevalence of skin sensitization to some pollens (Phleum pratense, Corylus avellana, Platanus acerifolia, Artemisia vulgaris) and vegetables (hazelnut, wheat, and apple) significantly decreased at follow-up. Earlier onset of SAR and polysensitization at baseline were associated with incident asthma at follow-up. The presence at baseline of serum IgE to the following allergen molecules was identified as biomarkers of clinical evolution: (a) Phl p 1, for persistence of SAR; (b) Phl p 5, for persistence of both rhinitis and asthma; (c) Pru p 3, for new onset of asthma; (d) Bet v 1, for persistence of OAS.

CONCLUSIONS

Seasonal allergic rhinoconjunctivitis is clinically heterogeneous in its evolution from childhood to adolescence. The detection of serum IgE to specific molecules (Phl p 1, Phl p 5, Bet v 1, Pru p 3) may be useful as biomarkers to predict SAR persistence and future onset of comorbidities, such as asthma and/or OAS.

Hypersensitivity reactions to food and drug additives: problem or myth?

BACKGROUND AND AIM OF THE WORK

The possibility of an allergic reaction or an intolerance to additives is frequently suspected by parents, especially for chronic illness with frequent exacerbations such as atopic dermatitis or chronic urticaria. For more than 50 years, potential adverse reactions to additives have been suggested, but to date data are conflicting. The purpose of this article is to provide the clinicians with general information about additives and adverse reactions to them and to suggest a practical approach to children suspected to have reactions to food additives.

METHODS

We performed an extensive research on all English-language Medline articles, case reports and reviews published online until December 2018. Used search terms were: food additives, food dye, adverse reactions, food allergy, food hypersensitivity, intolerance, drugs, children.

RESULTS

There are only few case reports of adverse reactions in childhood with a clear involvement of additives. In this review article we reported the associations between additives and adverse reactions described in literature, in order to inform the pediatrician about the potential clinical manifestations.

CONCLUSIONS

Prior to suspect an adverse reaction to additives, it is important to rule out other possible causes: the diagnostic process is complicated and rarely conclusive. The gold standard is the double-blind placebo controlled oral challenge after an exclusion diet.

Allergic reactions to cow's milk proteins in medications in childhood

INTRODUCTION

Cow's milk is a frequent trigger of allergic reactions in childhood. Cow's milk proteins can be present in pharmaceutical excipients.

METHODS

We have analyzed paediatric literature on allergic reactions to cow's milk proteins in medication, focusing on the different routes of administration (inhaled, parental and oral).

RESULTS

Dry-powder inhalers may contain lactose as excipient. Lactose can be rarely contaminated with milk proteins and it may induce allergic reactions in patients with cow's milk allergy. Case reports have described immediate hypersensitivity reactions to methylprednisolone sodium succinate 40 mg injection, a formulation that contains lactose as excipient. Some cases of anaphylaxis after receiving diphteria-tetanus-pertussis vaccine injection in children allergic to milk have been reported. Cow's milk proteins can be detected also in oral polio vaccine, certain probiotics and lactulose syrup.

CONCLUSIONS

We suggest caution in administration of pharmaceuticals containing milk allergens in children allergic to milk.

Disturbed eating behavior in pre-teen and teenage girls and boys with type 1 diabetes

AIM

To investigate Disturbed Eating Behavior (DEB) and eating patterns in the context of a teenage population with T1D.

METHODS

DEB was investigated using Eating Disorder Examination (EDE) test by a psychologist. Questions regarding insulin dosage manipulation or omission to obtain decrease in weight were added. Specific behavioral items from the EDE were used to define DEB: Objective Binge-eating, Self-induced Vomiting for weight control; the use of Diuretics, Laxatives or Insulin Omission for weight loss. Some EDE items provided information about four composite subscales which assesse Restraint, Eating concern, Shape concern and Weight concern.

RESULTS

Shape and Weight concern showed significantly higher scores than those observed in the other two subscales (p=0.021). Average scores of each subscale resulted significantly higher in girls than in boys as well as in teen than in pre-teen participants. Objective binge eating (20%) and insulin dosage omission or reduction (17.6%) were the most common DEB (p<0.03). Forty-one percent of participants reported to consume three, 25% four and 34% five meals daily. A significantly lower proportion of females than males resulted to consume breakfast and mid-afternoon snacks.

CONCLUSIONS

Findings from this study suggest that caregivers working in pediatric diabetes units should be alert in order to discover some DEB such as medication omission and binge-eating, all indicative symptoms of dissatisfaction of the body and psychological distress in diabetes management.

SIAIP position paper: provocation challenge to antibiotics and non-steroidal anti-inflammatory drugs in children

Drug hypersensitivity reactions (DHRs) in childhood are mainly caused by betalactam or non-betalactam antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs). Laboratory tests for identifying children who are allergic to drugs have low diagnostic accuracy and predictive value. The gold standard to diagnose DHR is represented by the drug provocation test (DPT), that aims of ascertaining the causative role of an allergen and evaluating the tolerance to the suspected drug. Different protocols through the administration of divided increasing doses have been postulated according to the type of drug and the onset of the reaction (immediate or non immediate reactions). DPT protocols differ in doses and time interval between doses. In this position paper, the Italian Pediatric Society for Allergy and Immunology provides a practical guide for provocation test to antibiotics and NSAIDs in children and adolescents.

Solid Food Introduction and the Development of Food Allergies

The rise of food allergy in childhood, particularly among developed countries, has a significant weight on public health and involves serious implications for patients' quality of life. Even if the mechanisms of food tolerance and the complex interactions between the immune system and environmental factors are still mainly unknown, pediatricians have worldwide implemented preventive measures against allergic diseases. In the last few decades, the prevention of food allergy has tracked various strategies of complementary feeding with a modification of international guidelines from delayed introduction to early weaning. Current evidence shows that complementary foods, including allergenic ones, should be introduced into diet after four months, or even better, following World Health Organization advice, around six months irrespective of risk for allergy of the individual. The introduction of peanut is recommended before 12 months of age among infants affected by severe eczema and/or egg allergy to diminish the occurrence of peanut allergy in countries with high peanut consumption. The introduction of heated egg at 6⁻8 months of age may reduce egg allergy. Infants at high risk of allergy similarly to healthy children should introduce complementary foods taking into account family and cultural preferences.

Advances in pediatrics in 2017: current practices and challenges in allergy, endocrinology, gastroenterology, genetics, immunology, infectious diseases, neonatology, nephrology, neurology, pulmonology from the perspective of Italian Journal of Pediatrics

This review provides an overview of a remarkable number of significant studies in pediatrics that have been published over the past year in the Italian Journal of Pediatrics. We have selected information from papers presented in the Journal that deal with allergy, endocrinology, gastroenterology, genetics, immunology, infectious diseases, neonatology, nephrology, neurology, pulmonology. The relevant epidemiologic findings, and developments in prevention, diagnosis and treatment of the last year have been discussed and placed in context. We think that advances achieved in 2017 will help readers to make the future of patients better.

Could infantile interactive drawing technique be useful to promote the communication between children with Type-1 diabetes and pediatric team?

Aim: to finding what young patients with type-1 diabetes (T1D) knows about their body and also on their illness in perspective to tailor educational interventions to their real ability to understand. Methods: the present study involved 68 children with T1D , 5 to 14 years old with a duration of diabetes ranging from 2 to 6 years and a total HbA1c mean value of 7.96±0.87%. The sample was divided into two age Groups: 28 children 5 to 10 years old were gathered in the Group 1 and 40 teenagers aged from 11 to 14 years in the Group 2. These patients were invited to draw over a white paper using a black pencil “The human body as it is made inside”. Subsequently they were asked to explain: “what is diabetes?” and “where does insulin go?”. According to the methodology of the “interactive drawing”, the interviewer interacted with the children while drawing, forcing them to verbalize the reasons for their choices, to justify their proceeding, to explain their plan and then to explicit their theories. Drawings and replies were classified as Correct, Correct-but-Incomplete and Incorrect. Results: the overall production of correct/correct-but-incomplete drawings was 83.82% vs 16.20% of the incorrect ones. One-hundred of the children who have produced a correct drawing supplied also a correct verbal reply, whereas 100% of the children who have produced an incorrect drawing was unable to supply any information on diabetes or about insulin. Both younger and older subjects who produced a complete-but-incorrect drawing appeared to have misunderstood the action of insulin therapy (only 23% and 17% of correct replies). Children who produced incomplete drawings and provided incorrect replies to the questions about their disease showed also a HbA1c mean value higher (8.36±0.97%) compared to the children who drew and answered correctly (p=0.0023). Conclusions: the operative epistemic approach could represent a promising tool for a health professional team to verify the real understanding acquired by a child about T1D, and to provide pediatrician a guideline to directly communicate with his patient. (www.actabiomedica.it)

Evaluating children with suspected allergic reactions to vaccines for infectious diseases

BACKGROUND

Vaccines often contain potentially allergenic material in addition to pathogen-specific immunogens that may induce allergic reactions. Parents and physicians often suspect that adverse reactions to vaccines are allergic in etiology. The concern that some of the substances contained in vaccines may trigger an anaphylactic reaction may lead to a low vaccination adherence with emergence of infectious disease epidemics.

OBJECTIVE

To provide practical suggestions for managing children suspected to have an allergic reaction to a vaccine.

METHODS

Information was obtained from a search of guidelines and relevant studies on allergic reactions to vaccines for infectious diseases.

RESULTS

True allergic reactions elicited by a vaccine are rare. Skin testing to the vaccine and to its components may identify the triggering agent. Graded dosing desensitization is helpful in children sensitized to the offending vaccine.

CONCLUSION

All children with a suspected allergic reaction to a vaccine should be carefully evaluated by routine allergy tests. When it is necessary, further immunization should be given under strict medical surveillance, which ensures that every child can safely complete the vaccination schedule.

Diagnostic relevance of IgE sensitization profiles to eight recombinant Phleum pratense molecules

BACKGROUND

Grass pollen-related seasonal allergic rhinoconjunctivitis (SARg) is clinically heterogeneous in severity, comorbidities, and response to treatment. The component-resolved diagnostics disclosed also a high heterogeneity at molecular level. Our study aimed at analyzing the characteristics of the IgE sensitization to Phleum pratense molecules and investigating the diagnostic relevance of such molecules in childhood.

METHODS

We examined 1120 children (age 4-18 years) with SARg. Standardized questionnaires on atopy were acquired through informatics platform (AllergyCARD™). Skin prick tests were performed with pollen extracts. Serum IgE to airborne allergens and eight P. pratense molecules (rPhl p 1, rPhl p 2, rPhl p 4, rPhl p 5b, rPhl p 6, rPhl p 7, rPhl p 11, rPhl p 12) were tested by ImmunoCAP FEIA.

RESULTS

The analysis of IgE responses against eight P. pratense molecules showed 87 profiles. According to the number of molecules recognized by IgE, the more complex profiles were characterized by higher serum total IgE, higher grass-specific serum IgE, and higher number and degree of sensitization to pollens. The most frequent IgE sensitization profile was the monomolecular Phl p 1. Sensitization to Phl p 7 was a reliable biomarker of asthma, whereas Phl p 12 of oral allergy syndrome. Sensitization to Phl p 7 was associated with a higher severity of SARg, and complex profiles were associated with longer disease duration.

CONCLUSIONS

In a large pediatric population, the complexity of IgE sensitization profiles against P. pratense molecules is related to high atopic features although useless for predicting the clinical severity. The detection of serum IgE to Phl p 1, Phl p 7, and Phl p 12 can be used as clinical biomarkers of SARg and comorbidities. Further studies in different areas are required to test the impact of different IgE molecular profiles on AIT response.

Effectiveness of a tailored medical support to overcome the barriers to education, treatment and good metabolic control in children with type-1 diabetes from ethnic minorities

Aim:

To analyze the effectiveness of a tailored medical support to help children from ethnic minorities to achieve the same good metabolic control of autochthonous peers with type-1 diabetes (T1D).

Methods:

Children <10 years of age belonging to ethnic minority (EM) families (Group 1) were compared with autochthonous peers (Group 2) who received the diagnosis of T1D in 2014-2016. The Protocol for minorities included other than the standard protocol: booklets translated in ethnic minority languages; weekly visits at home or at school; family-guides; clinic visits supported by professional interpreters. After twelve months of this approach, parents of ethnic minority children answered a short questionnaire concerning satisfaction about educational tools for diabetes management.

Results:

From 1^st January 2014 to December 31^st 2016, 72 children received the diagnosis of T1D at the University Children Hospital of Parma, Italy. Nineteen children belonged to an EM family (26.38%), and were included in the Group 1. Twenty-one autochthonous peers were randomly recruited for the Group 2. T1D was diagnosed at the same mean age in Group 1 (5.2±2.2) and in Group 2 patients (5.7±2.4). Metabolic derangements at diagnosis were more severe in Group 1 than in Group 2 patients. However, patients of both Groups showed a similar decrease in HbA1c levels during the first 3 and 6 months post diagnosis. Patients did not differ in mean insulin doses at discharge and at follow up. The calls to the emergency toll-free telephone number were more numerous from the parents from Group 1 than from the parents of Group 2. Total cost to implement the tailored protocol in Group 1 was higher of 87% compared with the standard protocol used for Group 2 patients. Great majority of parents reported to be satisfied with the provided diabetes education program.

Conclusions:

1The results of this study suggested that children from EM families can achieve the same good metabolic control of autochthonous peers with T1D, providing a cost-effective tailored support to their family members. (www.actabiomedica.it)

Diabetic ketoacidosis at the onset of Type 1 diabetes in young children Is it time to launch a tailored campaign for DKA prevention in children <5 years?

AIM

To analyze clinical characteristics associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes (T1D) in children aged <5 years in order to identify early signs or symptoms useful to prevent DKA appearance.

METHODS

Data of patients  with newly diagnosed TID aged <5 years (Group 1) and 6-10 years old  (Group 2) coming from the province of Parma were collected in the period 2012-2016.

RESULTS

Mild/moderate ketoacidosis at diabetes diagnosis occurred more frequently in Group 1 than in Group 2 patients (p<0.0015). Severe DKA incidence was higher in children below 5 (21.8%) than in those over 5 years of age (3.75%; p=0.021). Latent period before overt T1D diagnosis was longer in Group 1 than in Group 2 patients (p=0.0081). During this latent period similar indicators were recorded among parents of children <3 years old: frequent use of disposable baby diapers (87%), wet baby diapers because of a large amount of urine (86%), body weight loss (79%).  In children aged 3-4 years reported symptoms consisted of polyuria (89%), polydipsia (79%), fatigue (72%). In Group 2 patients predominant signs concern unusual episodes of  enuresis.

CONCLUSIONS

We believe that it is time to launch a DKA prevention campaign tailored for children under 5 years old and focused just on the above-mentioned three warning signs. Information program must involves pediatricians, pediatric nurses, new moms and nursery school teachers.

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

The rising burden of allergic diseases in childhood requires a compelling need to identify individuals at risk for atopy very early in life or even predict the onset of food allergy and atopic dermatitis since pregnancy. The development and clinical phenotypes of atopic diseases in childhood depend on a complex interaction between genetic and environmental factors, such as allergen exposure, air pollution, and infections. Preventive strategies may include avoidance measures, diet supplements, and early complementary food introduction. Overall, the management of allergic diseases has been improving to date toward a patient's tailored approach. This review will cover the current understanding of risk factors, prediction, and management of food allergy and atopic dermatitis in childhood and discuss how these may contribute to the modification of the natural history of food allergy and atopic dermatitis.

Advances in paediatrics in 2016: current practices and challenges in allergy, autoimmune diseases, cardiology, endocrinology, gastroenterology, infectious diseases, neonatology, nephrology, neurology, nutrition, pulmonology

This review reports main progresses in various pediatric issues published in Italian Journal of Pediatrics and in international journals in 2016. New insights in clinical features or complications of several disorders may be useful for our better understanding. They comprise severe asthma, changing features of lupus erythematosus from birth to adolescence, celiac disease, functional gastrointestinal disorders, Moebius syndrome, recurrent pneumonia. Risk factors for congenital heart defects, Kawasaki disease have been widely investigated. New diagnostic tools are available for ascertaining brucellosis, celiac disease and viral infections. The usefulness of aCGH as first-tier test is confirmed in patients with neurodevelopmental disorders. Novel information have been provided on the safety of milk for infants. Recent advances in the treatment of common disorders, including neonatal respiratory distress syndrome, hypo-glycemia in newborns, atopic dermatitis, constipation, cyclic vomiting syndrome, nephrotic syndrome, diabetes mellitus, regurgitation, short stature, secretions in children with cerebral palsy have been reported. Antipyretics treatment has been updated by national guidelines and studies have excluded side effects (e.g. asthma risk during acetaminophen therapy). Vaccinations are a painful event and several options are reported to prevent this pain. Adverse effects due to metabolic abnormalities are reported for second generation antipsychotic drugs.

Spontaneous Dissemination in Neighboring Provinces of DKA Prevention Campaign Successfully Launched in Nineties in Parma's Province

Aim: to investigate how much effectiveness of the historical campaign of DKA prevention at T1D diagnosis has survived in Parma’s province where this was launched in Nineties, and how much it has spontaneously spread in the neighboring provinces. Method: children aged 6-14 years with newly diagnosed TID coming from province of Parma (Group 1) and from two other nearby provinces (Group 2) were investigated. Clinical and laboratory data were retrospectively collected from medical files of each patient and included age, gender, capillary pH, serum bicarbonate, 3-beta-hydroxybutyrate (3HB), glycated hemoglobin (HbAlc) at the time of admittance from 1st January 2012 and 31 December 2016. Results: no DKA condition was globally found in 25/36 patients (69.4%): 16/17 and 9/19 patients belonged to Group 1 and 2 respectively (p=0.002). Mild or moderate DKA was reported in 5.9% patients of Group 1 and in 47.31% (p=0.005) patients from Group 2. Severe DKA was observed in only 1 child from Group 2. Normal 3-beta-hydroxybutyrate (3HB) serum levels was reported in the 25 patients without DKA at diabetes diagnosis. Duration of hyperglycemia-related symptoms before overt T1D diagnosis was shorter (4.6±2.5 days) in patients with 3HB levels <1 mmol/dl than in those with 3HB levels exceeding 1 mmol/dl (9.6±4.2 days, p<0.0001). HbA1c values were on overage lower in patients without DKA (9.9±1.2%) than in patients with DKA at diabetes diagnosis (13.60±1.3%; p<0,001). Conclusion: 1) the campaign for DKA prevention, launched in Nineties and renewed at beginning of Twenties in Parma’s province, continues to be effective in the same province after several years; 2) in the two control provinces despite no information campaign being officially promoted in loco, an unexpected decrease in severe DKA incidence as well a shorter latency before overt T1D diagnosis were observed in the same period. (www.actabiomedica.it)

Long-acting insulin allergy in a diabetic child

Insulin allergy has been uncommon since the introduction of human recombinant insulin preparations; the prevalence is 2.4%. Insulin injection could elicit immediate reactions, which are usually induced by an IgE-mediated mechanism, within the first hour after drug administration. In the present study, we describe the case of a child who experienced immediate urticaria after long-acting insulin injection. A 9-year-old girl affected by type I diabetes mellitus referred a history of three episodes of urticaria 30 min after insulin subcutaneous injection. During the first week of insulin therapy, she developed generalized immediate urticaria twice after long-acting insulin glargine first and then once after insulin degludec administration. Symptoms resolved within a few hours after treatment with oral antihistamine. She tolerated rapid insulin lispro. Her personal allergological history was negative. Skin prick tests with degludec, glargine and detemir were performed, showing negative results. Intradermal 1:100000-diluted tests were immediately positive for both degludec and glargine but not for detemir. In light of these findings, detemir was administered without any reaction. Our results show that detemir is tolerated by patients with clinical hypersensitivity reactions to degludec and glargine. Although reactions could be attributable to additives allergy, such as zinc or metacresol, this was excluded since all three preparations contain the same components. So, insulin itself acted as offending allergen. Detemir differs from degludec and glargine in a few aminoacids. Therefore, it is possible that the conformational rather than the linear epitope may be responsible for the reaction. This result suggests integrating intradermal tests in the diagnostic flowchart for insulin allergy. Insulin allergy should always be suspected in patients with immediate symptoms after drug injection. As allergologic work-up, prick by prick test and intradermal test to insulin preparations should be performed. In case of negative results of cutaneous tests, insulin analogs may be administered.