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Marques-Mejias A, Radulovic S, Foong RX, Bartha I, Krawiec M, Kwok M, Jama Z, Harrison F, Ricci C, Lack G, Du Toit G, Santos AF. Partial Egg Consumption Modifies the Diagnostic Performance of Allergy Tests to Predict Outcome of Double-Blind Placebo-Controlled Food Challenges to Egg. J Allergy Clin Immunol Pract 2024; 12:660-669.e5. [PMID: 38157981 DOI: 10.1016/j.jaip.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/17/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Many children are consuming some egg when they are diagnosed with egg allergy. We hypothesized that egg consumption could modify the diagnostic performance of allergy tests. OBJECTIVE To stratify diagnostic performance of tests according to egg consumption status. METHODS The BAT2 study (NCT03309488) participants underwent oral food challenge (OFC), food-frequency questionnaires, skin prick test (SPT), specific immunoglobulin E (sIgE) and specific immunoglobulin G4 (sIgG4) and basophil activation test (BAT). RESULTS At study entry, 45% of participants reported partial egg consumption ("consumers") and 55% were avoiding egg strictly ("avoiders"). Avoiders had larger SPT (P < .001), higher BAT to egg (P < .001), sIgE to egg white (EW; P = .001) and to ovalbumin (OVA; P = .001), but not to ovomucoid (P = .231). Consumers had higher levels of sIgG4 to all egg allergens (P < .001) than avoiders. In consumers, the test with the best diagnostic performance was BAT (area under the curve [AUC] = .912) followed by SPT to raw egg (AUC = 0.805), EW-sIgE (AUC = 0.738), and OVA-sIgE (AUC = 0.732). In avoiders, the best tests were BAT (AUC = 0.834) and EW-sIgE (AUC = 0.833) followed by OVA-sIgE (AUC = 0.793) and SPT to EW (AUC=0.789). Using 100% sensitivity and 100% specificity cut-offs, the proportion of patients requiring OFC were 33% for BAT, 53% for SPT to raw egg, 61% for OVA-sIgE, and 73% for EW-sIgE for consumers; and 73% for BAT, 79% for EW-sIgE, and 93% for SPT to EW for avoiders. CONCLUSIONS The diagnostic performance of tests is influenced by the immunomodulatory effect of egg consumption. BAT is the most reliable test and reduced the need for OFC, particularly in partial egg consumers.
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Affiliation(s)
- Andreina Marques-Mejias
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
| | - Ru-Xin Foong
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Irene Bartha
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
| | - Marta Krawiec
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
| | - Matthew Kwok
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Zainab Jama
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Faye Harrison
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Cristian Ricci
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - George Du Toit
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital, London, UK; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.
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Krawiec M, Radulovic S, Foong RX, Marques-Mejias A, Bartha I, Kwok M, Jama Z, Harrison F, Ricci C, Lack G, Du Toit G, Santos AF. Diagnostic utility of allergy tests to predict baked egg and lightly cooked egg allergies compared to double-blind placebo-controlled food challenges. Allergy 2023; 78:2510-2522. [PMID: 37417650 PMCID: PMC10790315 DOI: 10.1111/all.15797] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/17/2023] [Accepted: 05/14/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Double-blind placebo-controlled food challenges (DBPCFC) are the gold-standard to diagnose food allergy. However, they can cause allergic reactions of unpredictable severity. We assessed accuracy of current and new diagnostic tests compared to DBPCFC to baked egg (BE) and to lightly cooked egg (LCE). METHODS Children aged 6 months to 15 years were assessed for possible egg allergy as part of the BAT2 study (NCT03309488). They underwent clinical assessment, skin prick test (SPT), specific IgE (sIgE) and basophil activation test (BAT). The results of the tests were compared with DBPCFC outcomes to both BE and LCE. RESULTS A total of 150 children underwent DBPCFC to BE, 60 (40%) reacted to and 85 (57%) tolerated BE and 5 (3%) had inconclusive oral food challenges (OFC). Seventy-seven children tolerant to BE had DBPCFC to LCE and 16 reacted. The test within each modality with the best diagnostic performance for BE allergy was as follows: SPT to egg white (EW) (AUC = 0.726), sIgE to EW (AUC = 0.776) and BAT to egg (AUC = 0.783). BAT (AUC = 0.867) was the best test in the younger than 2 years age group. Applying 100% sensitivity and 100% specificity cut-offs, followed by OFC, resulted in 100% diagnostic accuracy. BAT enabled the greatest reduction in OFC (41%). Using sIgE followed by BAT allowed to reduce the number of BATs performed by about 30% without significantly increasing the number of OFC. CONCLUSIONS The best diagnostic test was BAT to egg in terms of diagnostic accuracy and reduction in number of OFC. Using sIgE to EW followed by BAT required fewer BATs with sustained OFC reduction and diagnostic accuracy.
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Affiliation(s)
- Marta Krawiec
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Ru-Xin Foong
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Andreina Marques-Mejias
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Irene Bartha
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Matthew Kwok
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Zainab Jama
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Faye Harrison
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Cristian Ricci
- Africa Unit for Transdisciplinary Health Research (AUTHeR), North-West University, Potchefstroom, South Africa
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - George Du Toit
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
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3
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Abstract
Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.
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Affiliation(s)
- Ru-Xin Foong
- Paediatric Allergy Department, Evelina London Children's Hospital, London, UK
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Paul Turner
- Section of Paediatrics, Imperial College London, London, UK
- Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Graham C Roberts
- University Child Health, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Adam T Fox
- Paediatric Allergy Department, Evelina London Children's Hospital, London, UK
- Department of Women and Children's Health, King's College London, London, UK
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Giovannini M, Foong RX, Greenhawt M, du Toit G. "Playing possum": The potential importance of neurological clinical manifestations occurring during anaphylaxis in infants and toddlers. Pediatr Allergy Immunol 2023; 34:e13989. [PMID: 37492906 DOI: 10.1111/pai.13989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/15/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Ru-Xin Foong
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - George du Toit
- Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Foong RX, Santos AF. Oral Tolerance Induction-Opportunities and Mechanisms. Foods 2022; 11:3386. [PMID: 36360000 PMCID: PMC9654436 DOI: 10.3390/foods11213386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
Oral tolerance is the active absence of response to food allergens, which involves complex mechanisms in the gut-associated lymphoid tissue. Food allergy results from the disruption of such tolerance or the absence of its establishment in the first place. It follows allergic sensitization with the production of allergen-specific IgE and results from the degranulation of basophils and mast cells on subsequent exposure to the allergen. Oral tolerance induction has been explored in the contexts of prevention and treatment of food allergy. Early introduction of allergenic foods (i.e., egg and peanut) in the diet of infants, before allergic sensitization occurs (i.e., via inflamed skin affected with eczema) has shown to be beneficial. Guidelines have changed to recommend the introduction of these allergenic foods by 6 months of age. For food allergic individuals, oral tolerance induction has been attempted using allergen-specific immunotherapy, which involves the administration of an allergen, modified or not, through various possible routes, including oral, sublingual, epicutaneous, and subcutaneous, with or without concomitant administration of antibody-based biologics. Further research into the immune mechanisms of food allergy and oral tolerance can lead to the identification of novel targets to suppress the food allergic response and reverse the current food allergy epidemic.
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Affiliation(s)
- Ru-Xin Foong
- Department of Women and Children’s Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE1 9RT, UK
- Children’s Allergy Service, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Alexandra F. Santos
- Department of Women and Children’s Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE1 9RT, UK
- Children’s Allergy Service, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London SE1 9RT, UK
- Asthma UK Centre for Allergic Mechanisms of Asthma, London E1 8AA, UK
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6
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Foong RX, Du Toit G, Bahnson H, Huffaker M, Baloh C, van Ree R, Roberts G, Lack G. The kinetics of peanut allergy development and resolution in the EAT, LEAP, and PAS cohorts. J Allergy Clin Immunol 2022. [DOI: 10.1016/j.jaci.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Meyer R, De Koker C, Dziubak R, Godwin H, Reeve K, Chebar-Lozinsky A, Foong RX, Skrapac AK, Ellmer M, Shah N. The Challenge of Home Allergen Re-introductions Using the Ladder Approach in Children With Non-IgE Mediated Gastrointestinal Food Allergy. Front Allergy 2021; 2:721686. [PMID: 35386976 PMCID: PMC8974734 DOI: 10.3389/falgy.2021.721686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Oral food challenges remain the most reliable method for allergy confirmation. Although consensus guidelines have been published to unify Immunoglobulin E (IgE)-mediated challenges, this does not exist for non-IgE mediated gastrointestinal allergies outside of Food Protein Induced Enterocolitis Syndrome. We therefore set out to establish the use of home introduction protocols (HIP) for confirmation of food allergy for milk, soya, egg and wheat using a ladder approach in children with non-IgE mediated allergy. Materials and Methods: Patients with suspected non-IgE mediated gastrointestinal allergies (0–16 years) were recruited following symptom improvement on an elimination diet. All children had skin prick or specific IgE tests to rule out IgE-mediated allergies prior to suggestion the HIP. Number of trials and outcome was documented. HIPs were developed using a published ladder approach for cow's milk as baseline and final dose was calculated based on guidelines for food protein induced enterocolitis syndrome and portions for age from the National Diet and Nutrition Survey. First foods were baked/highly processed and every 4th day patients moved to a more unprocessed/unheated food. Results: From 131 recruited patients, 117 (89.3%) followed the HIP for food allergens. No adverse events were documented. In more than 50% of cases one attempt at the HIP was sufficient to establish allergy status, but many required 2–5 attempts before the outcome was clear. About half of the children were fully tolerant to foods they initially eliminated: 36, 26 and 30% were partially tolerant to milk, soya, and egg and only 15% achieved partial tolerance to wheat. Wheat was the allergen introduced earliest, followed by soya, cow's milk and egg. Conclusions: This study indicates that home HIPs are safe in non-IgE mediated gastrointestinal food allergy and that the ladder approach may be useful in re-introducing allergens in children at home with non-IgE mediated gastrointestinal allergies. From this study we can also conclude that tolerance to processed/baked allergens was observed in many children. Further studies should be performed on the HIP and ideally reintroduction should occur pre-defined time intervals.
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Affiliation(s)
- Rosan Meyer
- Department of Paediatric, Imperial College, London, United Kingdom
- *Correspondence: Rosan Meyer
| | - Claire De Koker
- Brackengate Intermediate Care Facility, Cape Town, South Africa
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Heather Godwin
- Frimley Health NHS Foundation Trust, Camberley, United Kingdom
| | - Kate Reeve
- Royal Hospital for Sick Children and Young People, Edinburgh, United Kingdom
| | | | - Ru-Xin Foong
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ana-Kristina Skrapac
- Department Nutrition and Dietetics, Chelsea and Westminster Hospital NHS Foundation Trust, Department of Nutrition and Dietetics, London, United Kingdom
| | - Marlene Ellmer
- Department of Gastroenterology, Great Ormond Street Hospital NHS Trust, London, United Kingdom
| | - Neil Shah
- Department of Gastroenterology, University College London, UK and Reckitt, Slough, United Kingdom
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Foong RX, Dantzer JA, Wood RA, Santos AF. Improving Diagnostic Accuracy in Food Allergy. J Allergy Clin Immunol Pract 2021; 9:71-80. [PMID: 33429723 PMCID: PMC7794657 DOI: 10.1016/j.jaip.2020.09.037] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/08/2023]
Abstract
The diagnosis of food allergy can have a major impact on the lives of patients and families, imposing dietary restrictions and limitations on social activities. On the other hand, misdiagnosis can place the patient at risk of a potentially severe allergic reaction. Therefore, an accurate diagnosis of food allergy is of utmost importance. The diagnosis of food allergy is often established by the combination of the clinical history and allergen-specific IgE; however, without a clear history of an allergic reaction, the interpretation of IgE sensitization tests can be difficult. There are also rare cases of clinical food allergy in the absence of IgE sensitization. For that reason, testing for suspected food allergy ideally requires access to oral food challenges (OFCs), which are currently the gold standard tests to diagnose food allergy. As OFCs are time consuming and involve the risk of acute allergic reactions of unpredictable severity, the question remains: how can we improve the accuracy of diagnosis before referring the patient for an OFC? Herein, we review the predictive value of different tests used to support the diagnosis of food allergy, discuss implications for therapy and prognosis, and propose a diagnostic approach to be applied in clinical practice.
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Affiliation(s)
- Ru-Xin Foong
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jennifer A Dantzer
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Robert A Wood
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alexandra F Santos
- Faculty of Life Sciences and Medicine, Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Asthma UK Centre for Allergic Mechanisms of Asthma, London, United Kingdom.
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9
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Foong RX, Santos AF. Biomarkers of diagnosis and resolution of food allergy. Pediatr Allergy Immunol 2021; 32:223-233. [PMID: 33020989 DOI: 10.1111/pai.13389] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/30/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022]
Abstract
Food allergy is increasing in prevalence, affecting up to 10% of children in developed countries. Food allergy can significantly affect the quality of life and well-being of patients and their families; therefore, an accurate diagnosis is of extreme importance. Some food allergies can spontaneously resolve in 50%-60% of cow's milk and egg-allergic, 20% of peanut-allergic and 9% of tree nut-allergic children by school age. For that reason, food-allergic status should be monitored over time to determine when to reintroduce the food back into the child's diet. The gold-standard to confirm the diagnosis and the resolution of food allergy is an oral food challenge; however, this involves the risk of causing an acute-allergic reaction and requires clinical experience and resources to treat allergic reactions of any degree of severity. In the clinical setting, biomarkers have been used and validated to enable an accurate diagnosis when combined with the clinical history, deferring the oral food challenge, whenever possible. In this review, we cover the tools available to support the diagnosis of food allergies and to predict food allergy resolution over time. We review the latest evidence on different testing modalities and how effective they are in guiding clinical decision making in practice. We also evaluate predictive test cut-offs for the more common food allergens to try and provide guidance on when challenges might be most successful in determining oral tolerance in children.
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Affiliation(s)
- Ru-Xin Foong
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Children's Allergy Service, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Alexandra F Santos
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Children's Allergy Service, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK.,Asthma UK Centre for Allergic Mechanisms of Asthma, London, UK
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10
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Foong RX, Turner PJ, Fox AT. Fatal anaphylaxis due to transcutaneous allergen exposure: An exceptional case. The Journal of Allergy and Clinical Immunology: In Practice 2020; 8:332-333. [DOI: 10.1016/j.jaip.2019.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
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Foong RX, Brough HA, Chan S, Fox AT. US guidelines for the prevention of peanut allergy 2017. Arch Dis Child Educ Pract Ed 2018; 103:249-252. [PMID: 29175880 DOI: 10.1136/archdischild-2017-313094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/18/2017] [Accepted: 10/07/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK
- University College of London and Institute of Child Health, London, UK
| | - Helen A Brough
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Susan Chan
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Adam T Fox
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK
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12
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Abstract
BACKGROUND It is well known that there is a common interplay between atopic conditions and that having one atopic condition can predispose to the development of others. The link between asthma and food allergy has been well researched over the years; although the exact interplay between the two atopic conditions is yet to be fully described. Research suggests that children who have both asthma and food allergy are at greater risk of more severe asthmatic episodes. CONCLUSION They are also at risk of food allergen triggered asthmatic episodes as well as foodallergen induced anaphylaxis. Therefore, it is important for clinicians to understand and recognise the association between these two atopic conditions to provide children and their families with the correct treatment and management to avoid potentially life-threatening events related to their disease.
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Affiliation(s)
- Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, United Kingdom.,Institute of Child Health, University College of London, London, United Kingdom
| | - George du Toit
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adam T Fox
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
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13
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Foong RX, Brough H. The role of environmental exposure to peanut in the development of clinical allergy to peanut. Clin Exp Allergy 2017; 47:1232-1238. [PMID: 28779526 DOI: 10.1111/cea.12992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/27/2017] [Accepted: 07/27/2017] [Indexed: 01/17/2023]
Abstract
The prevalence of peanut allergy has increased over the years and still remains one of the most common causes of food-related anaphylaxis. The way in which peanut sensitization occurs has been explored, such as via maternal consumption in pregnancy, via breastmilk and through a disrupted skin barrier. It has previously been shown that environmental exposure to aeroallergens in household dust can be a risk factor for the development of allergic asthma. There is an increasing body of evidence that the combination of cutaneous sensitization via a disrupted skin barrier (ie children with eczema or with filaggrin mutations) and environmental peanut exposure influences the development of peanut allergy. This review aims to explore routes of peanut sensitization and the current evidence on how environmental exposure to peanut affects the development of peanut allergy.
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Affiliation(s)
- R X Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK.,Institute of Child Health, University College of London, London, UK
| | - H Brough
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
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14
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Turcanu V, Brough HA, Du Toit G, Foong RX, Marrs T, Santos AF, Lack G. Immune mechanisms of food allergy and its prevention by early intervention. Curr Opin Immunol 2017; 48:92-98. [PMID: 28892729 DOI: 10.1016/j.coi.2017.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 07/25/2017] [Accepted: 08/16/2017] [Indexed: 12/12/2022]
Abstract
The environmental factors driving the increase in food allergies are unclear and possibly involve dual exposure to allergens, microbiome-driven effects or other mechanisms. Until they can be better understood, early intervention aiming at establishing oral tolerance provides an effective way to decrease the window-of-risk when children may develop allergic sensitisation to foods due to the absence of a protective immune response. Thus, the recent LEAP (Learning Early About Peanut allergy) and LEAP-On studies achieved a high level of peanut allergy prevention by early introduction of peanuts in the infants diet and conveyed more information regarding the evolution of IgE and IgG4 antibody responses to food antigens over time.
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Affiliation(s)
- Victor Turcanu
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - Helen A Brough
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - George Du Toit
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - Ru-Xin Foong
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - Tom Marrs
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - Alexandra F Santos
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom
| | - Gideon Lack
- Department of Paediatric Allergy, King's College London, Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH United Kingdom.
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Du Toit G, Foong RX, Lack G. The role of dietary interventions in the prevention of IgE-mediated food allergy in children. Pediatr Allergy Immunol 2017; 28:222-229. [PMID: 28258631 DOI: 10.1111/pai.12711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2017] [Indexed: 02/06/2023]
Abstract
Over the last 30 years, the prevalence of food allergy has been on the rise and remains a disease that can have a significant impact on the quality of life of children and their families. There are several hypotheses that have been suggested to account for the increasing prevalence, but this review will focus on the impact that dietary factors have on food allergy development. In the past food allergy, prevalence has largely focused on allergen avoidance; however, there is increasing evidence from interventional studies that have shown that early introduction to potential food allergens may have a beneficial role in allergy prevention. This review aims to look at the evidence in support of early introduction of allergens into infant diets to prevent against the development of food allergy.
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Affiliation(s)
- George Du Toit
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Institute of Child Health, University College of London, London, UK
| | - Gideon Lack
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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16
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Foong RX, Meyer R, Godwin H, Dziubak R, Lozinsky AC, Reeve K, Knibb R, Shah N. Parental perception of their child's quality of life in children with non-immunoglobulin-E-mediated gastrointestinal allergies. Pediatr Allergy Immunol 2017; 28:251-256. [PMID: 27992662 DOI: 10.1111/pai.12689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Food allergy can have a significant impact on health-related quality of life (HRQoL). Parental proxy questionnaires are commonly used when children are too young to complete questionnaires themselves. Little data are available on HRQoL in children with non-IgE-mediated gastrointestinal food allergy (GIFA). The aim of this study was to evaluate HRQoL in these children by parent proxy. METHODS A cross-sectional questionnaire study was conducted with children aged 2-16 years with confirmed GIFA. Parents of these children completed the Pediatric Quality of Life Inventory (PedsQL™ ) and the family impact module of the PedsQL. The PedsQL scores were compared to two published cohorts: functional abdominal pain (FAP) and IgE-mediated food allergy. RESULTS Fifty-two parents of children with GIFA completed the PedsQL™ parent proxy. The GIFA cohort had significantly better overall HRQoL compared with the FAP cohort, but lower emotional functioning scores. The GIFA cohort also had poorer physical QoL compared with the IgE cohort (all p < 0.05). The more foods excluded, comorbidity of nasal congestion, abdominal pain, back arching, the persistence of flatus and gastrointestinal symptom severity after elimination diet were related to poorer QoL in this non-IgE cohort. Regression analyses showed that number of foods and nasal congestion significantly predicted total QoL score as perceived by parents. CONCLUSIONS This study has shown that different areas of HRQoL of children with GIFA are affected compared with children with FAP or IgE-mediated food allergy, highlighting the need for a specific GIFA HRQoL questionnaire to better understand the impact on these children.
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Affiliation(s)
- R X Foong
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R Meyer
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - H Godwin
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R Dziubak
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - A C Lozinsky
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - K Reeve
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R Knibb
- Psychology, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - N Shah
- Institute of Child Health, University College, London, UK
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17
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Foong RX, Meyer R, Dziubak R, Lozinsky AC, Godwin H, Reeve K, Hussain ST, Nourzaie R, Shah N. Establishing the prevalence of low vitamin D in non-immunoglobulin-E mediated gastrointestinal food allergic children in a tertiary centre. World Allergy Organ J 2017; 10:4. [PMID: 28101293 PMCID: PMC5225666 DOI: 10.1186/s40413-016-0135-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 02/02/2023] Open
Abstract
Background There is no data on the prevalence of vitamin D deficiency in children with non-immunoglobulin-E (IgE) mediated gastrointestinal food allergy. The aims of our study were to understand the prevalence of vitamin D insufficiency and deficiency in children with non-IgE mediated gastrointestinal food allergy and identify predisposing factors. Methods This was a retrospective study which looked at data from Great Ormond Street Hospital from January 2002 to September 2015. Children 0–18 years old with a confirmed diagnosis of non-IgE mediated gastrointestinal food allergy who had a vitamin D level measured during the course of their disease were included. Low vitamin D levels were defined as <50 nmol/L; insufficient levels were defined as 25–50 nmol/L and deficient levels as <25 nmol/L. Patient characteristics and clinical factors were also recorded. Results Ninety-two patients met the study criteria; 49% were female and median age was 10 years 2 months [IQR: 4 years 8 months to 13 years 7 months]. Of the cohort, 26% (24/92) had low vitamin D levels; 16% had insufficient vitamin D levels and 10% had vitamin D deficiency. Gender (p = 0.043) and age (p = 0.035) were significantly associated with low vitamin D levels. Twelve percent of children who were on an amino acid formula (AAF) had low vitamin D compared to 31% of children who were not (p = 0.06). No other clinical factors were found to be significantly associated with low vitamin D levels. Conclusions Children with non-IgE mediated gastrointestinal food allergy are at risk of vitamin D insufficiency and deficiency. Further prospective studies need to be performed in all children with non-IgE mediated gastrointestinal food allergies. Trial registration The study was registered with the GOSH Research & Development department as a retrospective case note review. The Health Research Authority confirmed that NHS Research and Ethics Committee approval was not required; thus there is no trial registration number.
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Affiliation(s)
- Ru-Xin Foong
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK ; Institute of Child Health, University College, London, UK
| | | | - Robert Dziubak
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Adriana Chebar Lozinsky
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Heather Godwin
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kate Reeve
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Syeda Tahmida Hussain
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Romman Nourzaie
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Neil Shah
- Paediatric Gastroenterology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK ; Institute of Child Health, University College, London, UK
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Abstract
The association between atopic diseases is well known, and previous research has shown that having one atopic disease can predispose to having another. The link between asthma and food allergy has been well researched, but the exact relationship between the two atopic conditions is not fully understood. Food allergic infants are at increased risk for the development of asthma and are at risk of food-induced asthmatic episodes and also anaphylaxis. Having a diagnosis of both food allergy and asthma has also been shown to have an effect on the severity of a patient's disease including being at greater risk of severe asthmatic episodes. Therefore, understanding the relationship between these two conditions in order to treat and manage these children safely is crucial to clinicians.
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Affiliation(s)
- Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK.,Institute of Child Health, University College of London, London, UK
| | - George du Toit
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Adam T Fox
- Division of Asthma, Allergy and Lung Biology, Department of Paediatric Allergy, King's College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, London, UK
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Du Toit G, Foong RX, Lack G. Corrigendum to "Prevention of food allergy - Early dietary interventions" [Allergol Int 65 (2016) 370-377]. Allergol Int 2017; 66:159. [PMID: 28081842 DOI: 10.1016/j.alit.2016.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- George Du Toit
- Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Ru-Xin Foong
- Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK; Institute of Child Health, University College of London, London, UK
| | - Gideon Lack
- Department of Paediatric Allergy, King's College London and Guy's and St. Thomas' NHS Foundation Trust, London, UK.
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Foong RX, Roberts G, Fox AT, du Toit G. Pilot study: assessing the clinical diagnosis of allergy in atopic children using a microarray assay in addition to skin prick testing and serum specific IgE. Clin Mol Allergy 2016; 14:8. [PMID: 27547124 PMCID: PMC4991090 DOI: 10.1186/s12948-016-0046-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 08/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Children with atopic dermatitis (AD) are at risk of developing allergy. Alongside clinical history, testing modalities include skin prick tests (SPT), specific immunoglobulin-E (sp-IgE) and recently, microarray assays. The aim of this pilot study was to assess current tests and the ISAC sIgE-112 system in the diagnosis of food and aeroallergen allergy. Methods Children aged 0–11 years with moderate to severe AD were included. An initial allergy assessment including clinical history, SPT and sp-IgE was performed to determine food and aeroallergen sensitization. A second independent clinical assessment using the same information given to the first assessor and ISAC test results for food and aeroallergen sensitization was also made for each participant. The results from both were compared. Results 30 children [mean age 3.91 years (SD 3.3)] were included; 53.3 and 46.7 % had moderate and severe AD, respectively. Sp-IgE tests had a higher percentage of positive results compared to SPT and ISAC tests for common allergens. There was a significant difference between the three tests in detecting aeroallergen sensitization (p = 0.038), especially between sp-IgE and ISAC tests, but no significant difference between the tests for food allergen sensitization. There was good agreement between the two assessors; 70 % of the children had a change in diagnosis, with 60 % having at least one diagnosis added and 40 % having at least one diagnosis removed. Conclusions There is a role for the use of ISAC testing in diagnosing sensitization and allergy in children with AD as it leads to a change in diagnosis for many patients. Further work is required to assess its clinical and cost effectiveness. Electronic supplementary material The online version of this article (doi:10.1186/s12948-016-0046-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ru-Xin Foong
- Division of Asthma, Allergy and Lung Biology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH UK ; Institute of Child Health, University College of London, London, UK
| | - Graham Roberts
- University of Southampton and National Institute for Health Research Respiratory Biomedical Research Unit, Southampton and David Hide Centre, Southampton, UK
| | - Adam Tobias Fox
- Division of Asthma, Allergy and Lung Biology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH UK
| | - George du Toit
- Division of Asthma, Allergy and Lung Biology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 7EH UK
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