An apple a day ... chronic glossitis in a 4-year-old boy

We report a case of chronic glossitis in a 4-year-old boy due to scurvy. The boy showed up in our department with a patchy depapillated tongue. A detailed dietary history revealed an unbalanced diet without any fruit or vegetable. The biological investigations showed a low serum ascorbic acid. The boy was treated by oral ascorbic acid during 15 days. The glossitis improved within one week and serum levels of vitamin C returned to the normal range. In industrial countries, scurvy became a rare disease in healthy children. However, since a few years, cases are reported in children and teenagers with unbalanced diet coming from economically favoured families. These extreme cases are one of the signs of a more general deterioration of dietary habits in paediatric populations in our societies. This emphasizes the importance of effective nutritional education programs aimed towards both parents and children.

Oral desensitization in children with milk and egg allergies obtains recovery in a significant proportion of cases. A randomized study in 60 children with cow's milk allergy and 90 children with egg allergy

BACKGROUND

Food allergy is treated by avoidance diets in order to prevent anaphylactic reactions and to cure chronic associated symptoms. However, the natural history is left unchanged.

OBJECTIVE

To search for a beneficial effect of an oral desensitization protocol to allergenic foods in IgE-dependent milk or egg allergies in children.

METHODS

60 children with documented cow's milk allergy (13 months-6.5 years), and 90 children with egg allergy (12 months-8 years), were consecutively included after 6-12 months of avoidance diet, if a SBPCFC to 60 ml milk (60 ml) or to 965 mg of raw egg white was negative. They were randomized for uninterrupted avoidance or oral desensitization (group A or OD). Six months later, a new SBPCFC was performed with, up to 200 ml of milk or 7g of raw egg white. Prick tests and specific IgE levels were carried out simultaneously.

RESULTS

Data were obtained for 57 children with CMA (30 A and 27 OD), and 84 children with EA (35 A and 49 OD). The two groups (AD or OD group) were similar with regard to means of ages, the size of PT wheals and the level of IgEs at baseline. MILK ALLERGY: A SBPCFC to milk was positive in 11.1% of those following OD vs. 40% after A (p < .025). The size of PT decreased after OD and increased after A (-3.4 mm vs. +0.84 mm; p < .002). EGG ALLERGY: The SBPCFC to egg was positive in 30.6% after OD vs. 48.6% after A (p < .1). After 6 months, in the OD group, the mean size of the PT and the level of specific IgE were significantly reduced compared to the A group. In the A group, the threshold of reactivity was often lower, or more serious symptoms were observed.

CONCLUSION

Oral desensitization helps the egg and milk allergic children to overcome their allergies. Since the avoidance of these foods is likely to increase sensitization as well as to lower the threshold of reactivity, an active treatment is required. Further attempts to standardize the procedures of oral desensitization are expected.

Thresholds of clinical reactivity to milk, egg, peanut and sesame in immunoglobulin E-dependent allergies: evaluation by double-blind or single-blind placebo-controlled oral challenges

BACKGROUND

The prevalence of food anaphylaxis due to masked allergens has increased within the last 10 years. Contamination of manufactured products by food allergens is a key concern for food industries.

OBJECTIVE

To determine quantities eliciting reactions in patients who have an IgE-dependent food allergy, thanks to standardized oral provocation tests. To evaluate the subsequent levels of sensitivity required for the detection tests of allergens for egg, peanut, milk and sesame.

METHODS

Prick-in-prick tests, Cap system RAST, and single or double-blind placebo-controlled food challenges (SBPCFC or DBPCFC) were performed. The doses of natural food were gradually increased from 5 to 5000 mg for solid food and from 1 to 30 mL for peanut oil, sunflower oil, soy oil and sesame oil.

RESULTS

Data from 125 positive oral challenges to egg, 103 to peanut, 59 to milk and 12 to sesame seeds were analysed. Haemodynamic modifications were observed in 2%, 3%, 1.7%, and 8% of the oral challenges (OCs) to egg, peanut, milk and sesame, respectively. Respiratory symptoms were observed in 12%, 20%, 10% and 42% of egg, peanut milk and sesame allergies, respectively. A cumulative reactive dose inferior or equal to 65 mg of solid food or 0.8 mL of milk characterized 16%, 18%, 5% and 8% of egg, peanut, milk and sesame allergies, respectively. 0.8% of egg allergies, 3.9% of peanut allergies, and 1.7% of milk allergies reacted to 10 mg or less of solid food or to 0.1 mL for milk. The lowest reactive threshold has been observed at less than 2 mg of egg; 5 mg of peanut, 0.1 mL of milk and 30 mg of sesame seed. Ten out of 29 OC with peanut oil, two out of two OC with soy oil and three out of six OC with sunflower oil were positive. Five out six OC with sesame oil were positive: 1 and 5 mL induced an anaphylactic shock.

CONCLUSION

The risk of asthma and anaphylactic shock to sesame and peanut is confirmed. Minimal reactive quantities show that, in order to guarantee a 95% safety for patients who are allergic to egg, peanut and milk, and on the basis of consumption of 100 g of food, the detection tests should ensure a sensitivity of 10 p.p.m. for egg, 24 p.p.m. for peanut and 30 p.p.m. for milk proteins. Oil allergies being considered, the limit of sensitivity should fall to 5 p.p.m.

[The individual reception project (IRP) for anaphylactic emergencies. The situation in France and French overseas territories in 2002]

INTRODUCTION

The management in schools of children with life-threatening or chronic diseases has led to the development of Individual Reception Projects (IRP) since 1993, notified in the state education ministry's circular letter. The aim of this study was to assess the status of such IRPs in France and the French Overseas Territories in the management of food allergy risks.

METHOD

The regional departments of educational promotion were contacted and the survey was run between May and June, 2002. The items of the questionnaire were: the number of IRPs for anaphylactic emergencies, details on the allergies themselves, an overview of the eventual existence of dialogue structures among school physicians, heads of schools, allergists, treatment prescribers and emergency protocols.

RESULTS

The total survey revealed 7482 IRP for anaphylactic reactions to food (14% of the total IRPs). The frequency of IRPs varied greatly depending on the regions. The Paris area represented 36.3% of the total. The Lorraine area: 5.6%, the Haute-Garonne: 5%, and the Bouches-du-Rhône: 3.3%. The IRPs represented 0.002 (Ardèche) to 0.33% (Alpes-de-Haute-Provence) of the school attending population. The mean level was of 0.065%; 71.6% of the IRPs concerned the 1st grade (1 IRP for 1091 children). In decreasing frequency, the allergens concerned were: peanuts, eggs, dried nuts, fish, dried peas and milk. Dialogue structures were established in 38 regions.

DISCUSSION

The IRPs have increased 4-fold since the circular letter in 1999. The enhanced prevalence of numerous (new) allergies to dried nuts and leguminous plants has been emphasized, and peanut allergies have been confirmed. The complexity of managing the IRPs and need for information and training of state education and municipal staff requires the further development of dialogue structures, which are still clearly insufficient.

[Use of an amino-acid-based formula in the treatment of cow's milk protein allergy and multiple food allergy syndrome]

Food allergy to cow's milk proteins (APLV) is frequently found in young infants. Treatment is by starting an elimination diet. Different substitution products have been proposed: soya milk, partial hydrolysate of the proteins of lactoserum, powdered casein hydrolysate, hydrolysed soya and pork collagen. Allergic reactions to soya milk, hydrolysates of lactoserum proteins, powdered casein hydrolysates and hydrolysates of soya have been described. The study that we present evaluates the effect on the natural development of these allergies of a formula based on amino-acids (Neocate) in 26 patients who presented a syndrome of multiple allergies one of which was a food allergy to milk. Twenty-five of them had a severe atopic dermatitis, isolated (14 cases), or associated with gastro-intestinal troubles (6) break in the growth curve (5), anaphylactic reactions (2), one asthma (1). One child had a chronic diarrhoea associated with a weight plateau. Evaluation 2 or 3 months later showed a significant improvement of the atopic dermatitis. Return of the stature-weight growth was noted in 4 children from 5, the check in one was reported as due to a initially unrecognised allergy to gluten. The recovery of the APLV was shown by double-blind oral provocation test in 20/23 children between 11 and 37 months (22 +/- 9). Duration of administration of Neonate was between 6 to 19 months (12 + 5) months. This study confirmed the beneficial effect of the amino-acid formula on weight gain, gastro-intestinal troubles and development of atopic dermatitis. The level of recovery of APLV of 86% at the age of 2 years is better than that reported in the syndrome of multiple food allergies of 22%. The influence of this diet on the development of other food allergies remains to be evaluated.

[Protein hydrolysates: hypoallergenic milks and extensively hydrolyzed formulas. Immuno-allergic basis for their use in prevention and treatment of milk allergy]

Allergy to milk has an estimated incidence of 2.5%. Hypoallergenic milks are partial hydrolysates of proteins with lactose. Extensive hydrolysates of casein are mainly small peptides and do not include lactose in their formula. A primary allergenicity as well as a cross-sensitivity are shown for all partial hydrolysates. Even extensive hydrolysates have a weak potential of cross-allergy. The prevention of cow's milk allergy in infants at peculiar risk, born from atopic parents, is based on breast-feeding and/or partial or extensive hydrolysates. There is no conclusive evidence for the usefulness of eviction of dairy products during pregnancy or during the period of breast-feeding. The treatment needs exclusively extensive casein hydrolysates ensuring a 90% protection with 95% confidence intervals. Predictive prick tests in certain cases may help the choice of another hydrolysate. Severe cases with failure to thrive or multiple food intolerance require an amino-acid based formula (Neocate). A rational diversification of the diet is advised in order to prevent the onset of a multiple food intolerance syndrome which could avert from the recovery of cow milk allergy.

Specificity and sensitivity of respiratory impedance in assessing reversibility of airway obstruction in children

Flow in the upper airway wall induces significant error in estimating respiratory impedance by the standard forced oscillation technique in subjects with airway obstruction and may be minimized by oscillating pressure around the subject's head (head generator technique). The aim of this study was to determine whether the latter improves the power of forced oscillations in detecting airway response to bronchodilators in children. Seventy-five children with airway obstruction were studied (ages 5.5 to 15 years old). Fifty-three had asthma and 22, cystic fibrosis. A bronchodilator was administered, and the percent changes in respiratory resistance at 10 Hz (Rrs10), 20 Hz (Rrs20), respiratory compliance (Crs), and resonant frequency (fn) with standard and head generator were compared with the corresponding change in FEV1. The response was positive in 38 (delta % FEV1 > or = 15%) and negative in 37 patients. Data on Rrs10, Crs, and fn could not be obtained in 7, 8, and 4 subjects, respectively, for technical reasons. The delta % Rrs20 was not different between head and standard generator in nonresponders (mean +/- SEM: -19.0 +/- 4.5, vs -11.8 +/- 3.1%), but significantly larger with head than standard generator in responders (-54.1 +/- 3.0 vs -26.5 +/- 2.4%; p < 0.001). The optimal decision level determined by Receiver Operation Characteristic analysis showed that, compared with the standard method, the head generator improved the specificity of Rrs20 (78 vs 65%) with no change in sensitivity (76% for both). Resonant frequency had larger sensitivity with standard than with head generator (91 vs 53%) but slightly lower specificity (70 vs 78%). Finally, delta %Crs was more specific (72 vs 67%) and more sensitive (68 vs 52%) with standard than with head generator. The overall incidence of false results was lower with the head generator than with the standard generator for resistance and lower with the standard generator than with the head generator for fn and compliance. Thus, the head generator improves the diagnostic power of the forced oscillation resistance in establishing the reversibility of airway obstruction, but parameters derived from the reactance may have better diagnostic value with the standard method.

The use of two multitests fx5 and fx10 in the diagnosis of food allergy in children: regarding 42 cases

The multitests Cap RAST fx5 and fx10 (Pharmacia, Cap System) are used for a rapid biological diagnosis of food allergy. These tests were assessed in 29 children who presented 42 food allergies (FA) documented by prick tests, specific IgE and labial or oral provocation tests (single blind placebo controlled food challenges). When the multitests were positive, the search for specific IgE to the corresponding allergens was performed (Cap RAST, Pharmacia). The theoretical coverage of FA could be estimated according to the frequency of food allergens involved in the children. It reaches 85% for Cap RAST fx5 and 29% for Cap RAST fx10. The sensitivity of Cap RAST fx5 is 89% and 50% for Cap RAST fx10. Even in the case when the child had a single food allergy, the detail of specific IgE showed multiple positivities to several allergens included in the multitest. Consequently, the positive predictive value of Cap RAST was only 32%. Prick tests to the same allergens were more rarely positive, gaining thus a better positive predictive value. The authors propose the use of Cap RAST fx5, eventually completed by a Cap RAST to beef for the first approach of food allergy in children. They stress the point that prick tests have to be carried on subsequently, in order to select properly allergens responsible for food allergy.

Risks of milk formulas containing peanut oil contaminated with peanut allergens in infants with atopic dermatitis

Four cases of infants with atopic dermatitis are reported. In all cases, a sensitization to peanut is demonstrated. Any ingestion of peanuts can be excluded, with the exception of a daily consumption of peanut oil, contained in milk formulas. Oral challenges with peanut oil induce a rash, and elimination of these brands is followed by the disappearance of eczematous lesions. The presence of residual allergenic proteins in peanut oil is thus suspected. Owing to the growing incidence of peanut hypersensitivity, the elimination of peanut oil from all milk formulas, food for babies, and ointments, seems to be highly advisable.

Allergy and intolerance to flavouring agents in atopic dermatitis in young children

The role of flavouring was studied in eleven children under five years of age suffering from severe atopic dermatitis. In all cases, the dietary questionnaire showed the high daily intake of natural vanilla, vanillin, natural and artificial flavouring. Double-blind oral provocation tests were carried out with balsam of Peru (225 mg), natural vanilla (50 mg), artificial vanillin (12.5 mg). Nine children out of eleven presented eczematous reactions, one a Quincke's oedema. Two challenges remained negative. The eviction of food flavouring agents brought about a clear improvement in six children. The authors point out the risk of increasing consumption of flavouring agents, and bring into question the traditional attitude of considering food flavouring agents as innocuous.