Oral desensitization as a useful treatment in 2-year-old children with cow's milk allergy

BACKGROUND

Limited published evidence shows oral desensitization to be a potential intervention option for cow's milk protein (CMPs) allergy.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of oral desensitization in 2-year-old children with cow's milk allergy, as a treatment alternative to elimination diet.

METHODS

A total of 60 children aged 24-36 months with IgE-mediated allergy to CMPs were included in this multi-center study and were randomized into two groups. Thirty children (group A: treatment group) began oral desensitization immediately, whereas the remaining 30 (group B: control group) were kept on a milk-free diet and followed-up for 1 year.

RESULTS

After 1-year follow-up period, 90% of the children in group A had become completely tolerant vs. 23% of the children in group B. In group A, cow's milk skin reactivity and serum-specific IgE to milk and casein decreased significantly from the initial assessment, whereas group B showed no significant change after 1 year of follow-up. Twenty-four patients (80%) developed some reaction during the treatment period: 14 children developed moderate reaction (47%) and 10 mild reaction (33%). The most common manifestations were urticaria-angioedema, followed by cough.

CONCLUSIONS AND CLINICAL RELEVANCE

In this study, oral desensitization was found to be effective in a significant percentage of 2-year-old children with cow's milk allergy. Oral desensitization appears to be efficacious as an alternative to elimination diet in the treatment of 2-year-old children with cow's milk allergy. The side-effect profile appears acceptable but requires further study.

Sensitization in early age to food allergens in children with atopic dermatitis

BACKGROUND

Clinical and laboratory evidence increasingly supports the notion that food allergy plays a role in the pathogenesis of atopic dermatitis (AD). However, the prevalence of clinically significant food hypersensitivity among children with AD remains an unanswered question.

OBJECTIVE

To prospectively determine the prevalence of IgE-mediated food hypersensitivity among patients referred to a dermatology department for evaluation of AD, and to analyze the clinical relevance of these sensitizations in AD.

METHODS

We studied 44 infants of both sexes, aged less than 12 months old, who attended the dermatology department with symptoms of AD. Compliance with Hanifin-Rajka criteria was confirmed and the severity of AD was evaluated using the SCORAD index. IgE-mediated sensitization to cow's milk, alpha-lactalbumin, beta-lactoglobulin, casein, egg-white, egg-albumin, ovomucoid and foods introduced into the diet was studied using the skin prick test (SPT) and measurement of specific serum IgE (sIgE) by CAP System fluorescein-enzyme immunoassay. Cow's milk, as well as suspected foods from the clinical history or those with a positive SPT and/or sIgE, were withdrawn from the diet to evaluate improvement in AD, and an open controlled challenge test was carried out.

RESULTS

Of the 44 patients studied, sensitization to foods was detected in 27 (61 %). No changes were observed in AD during the elimination diet or when the eliminated foods were subsequently reintroduced into the diet. The results of open controlled food challenges were positive in 12 patients (27 %).

CONCLUSIONS

A high prevalence of food sensitization was found in infants with AD. The most frequent sensitization observed was to egg, although with little clinical relevance since this food had not been introduced into the diet. In the sample studied, the clinical relevance of the observed food hypersensitivities was confirmed in relation to AD. Further studies are required to confirm these results.

Prevalence of dermographism in children

The prevalence of dermographism in our pediatric population was studied in 238 children of both sexes (128 boys and 110 girls) aged 2-14 years, randomly selected from a health care center. Skin reaction was evaluated after 5 min pressure (3,200 g/cm2) applied with a dermatographometer on a 5-cm length of dorsal skin. The reaction was considered positive when a wheal of more than 2 mm was observed. The prevalence of dermographism was found to be 24%, with a significant female predominance (33%) over males (16%). Forty-one percent of the children with dermographism reported exanthema in response to friction and pressure, which was compatible with symptomatic dermographism, compared with only 5% of those who yielded negative reactions. In order to assess the prevalence of dermographism in the atopic population, 100 patients in the 4-14 age range with respiratory disease (perennial allergic rhinitis and/or bronchial asthma) involving sensitization to aeroallergens (house dust mites and/or Alternaria) were studied. A positive response to the application of pressure (3,200 g/cm2) was observed in 47% of cases, this figure being significantly higher than in the general pediatric population.

Vocal cord dysfunction in a child

Vocal cord dysfunction (VCD) involves paradoxical adduction of the vocal cord during the respiratory cycle. This usually occurs during inspiration, but can also be seen in expiration. Vocal cord appositioning produces airflow obstruction sufficient to cause wheezing, shortness of breath, chest tightness, and coughing. These symptoms often imitate the respiratory alterations of asthma, thus leading to inappropriate treatment; intubation or tracheotomy may prove necessary. An 11-year-old girl was admitted with intractable dyspnea. She had been diagnosed with atopic asthma, although she failed to respond to an increase in antiasthma medication, including high-dose oral steroids. Flow-volume loops were abnormal, with evidence of variable extrathoracic airway obstruction, manifested as a flat inspiratory loop. No structural abnormalities were seen with either computed tomography (CT) or magnetic resonance imaging (MRI). Fibroscopy revealed paradoxical adduction of the vocal cords during the respiratory cycle, no obstructive disorder being observed. After the diagnosis of VCD, the clinical manifestations resolved with psychiatric treatment. Adduction was not demonstrable at repeat fibroscopy after treatment. VCD may simulate bronchial asthma; it may also be associated with that disorder, thus masking the diagnosis. It should be suspected in patients with recurrent wheezing who fail to respond to usual asthma treatment. An early diagnosis avoids unnecessary aggressive management. Treatment should consist of respiratory and phonatory exercises; psychotherapy may be useful.

Lepidoglyphus destructor acarus in the urban house environment

To assess the presence of Lepidoglyphus destructor in the household environment of sensitized children living in an urban environment, samples of house dust were collected at the homes where two groups of patients were living, as well as in two bakeries in the city of Valencia, which were taken as a reference. Patients were divided into two groups. Group A included atopic children suffering from rhinitis and/or asthma, who were sensitized to L. destructor, as proven by prick test and specific IgE (CAP). Group B included children with the same features as those included in Group A, who were sensitized to Dermatophagoides pteronyssinus, with prick and CAP tests showing no significant sensitization to L. destructor. The samples of dust were analyzed, and the amounts of Der p I, Der f I, Der II and Lep d I per gram of dust were assessed through a solid-phase ELISA with monoclonal antibodies. In Group A, all patients but two showed a sensitization to D. pteronyssinus by prick test and serum IgE. At the homes of the patients from both groups, significant levels of Dermatophagoides were found. In Group A, only three houses showed levels of L. destructor which were comparable to those found in bakeries. Lep d I was not found in the houses of Group B patients. This means that a sensitization to L. destructor, as assessed with full extracts, is not always an indicator of its presence at the patient's house environment; it may rather refer to cross-reactivity to Dermatophagoides. Thus, availability of the main antigen Lep d I seems necessary to increase the specificity of the allergologic study.