Diese Präsentation wurde erfolgreich gemeldet.
Die SlideShare-Präsentation wird heruntergeladen. ×

Format 2015: what is new in pediatric allergic diseases

Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Anzeige
Wird geladen in …3
×

Hier ansehen

1 von 361 Anzeige

Weitere Verwandte Inhalte

Diashows für Sie (20)

Ähnlich wie Format 2015: what is new in pediatric allergic diseases (20)

Anzeige

Weitere von Envicon Medical Srl (20)

Aktuellste (20)

Anzeige

Format 2015: what is new in pediatric allergic diseases

  1. 1. What is New in Pediatric Allergic Diseases 2015 Attilio Boner University of Verona, Italy attilio.boner@univr.it Diagnosis Food Allergy Atopic Dermatitis Allergic Asthma Allergic Rhinitis Anaphylaxis Urticaria & Angioedema Risk & Protective factors Burden
  2. 2. The predictive value of allergen skin prick tests and IgE tests at pre-school age: The PACT study Dorthea RA, PAI 2014;25:691–698 Background •Sensitization toward allergens, as determined by SPTs or sIgE, is a predictor for the later presence of allergy-related disease (atopic eczema, allergic rhinoconjuctivitis and asthma). •However, it is not known whether SPT or sIgE should be the preferred test. •The aim of this study was to compare the predictive ability of SPT and sIgE when performed in a general population of 2-yr-old children.
  3. 3.  longitudinal population-based study of children aged 2–6 yr  SPTs and sIgE for 9 common allergens performed at 2 yr  allergy related disease evaluated by clinical examination and questionnaire at 2 and 6 yr of age (n = 199) 40 – 30 – 20 – 10 – .0 10.6% 21.1% % children aging 2 yrs with (+) SPTs (+) sIgE The predictive value of allergen skin prick tests and IgE tests at pre-school age: The PACT study Dorthea RA, PAI 2014;25:691–698
  4. 4. OR for subsequent allergic disease by age 6 yrs 7.0 – 6.0 – 5.0 – 4.0 – 3.0 – 2.0 – 1.0 – 0.0 6.5 4.1 (+) SPTs (+) sIgE The predictive value of allergen skin prick tests and IgE tests at pre-school age: The PACT study Dorthea RA, PAI 2014;25:691–698  longitudinal population-based study of children aged 2–6 yr  SPTs and sIgE for 9 common allergens performed at 2 yr  allergy related disease evaluated by clinical examination and questionnaire at 2 and 6 yr of age (n = 199)
  5. 5. OR for subsequent allergic disease by age 6 yrs 7.0 – 6.0 – 5.0 – 4.0 – 3.0 – 2.0 – 1.0 – 0.0 6.5 4.1 (+) SPTs (+) sIgE The predictive value of allergen skin prick tests and IgE tests at pre-school age: The PACT study Dorthea RA, PAI 2014;25:691–698  longitudinal population-based study of children aged 2–6 yr  SPTs and sIgE for 9 common allergens performed at 2 yr  allergy related disease evaluated by clinical examination and questionnaire at 2 and 6 yr of age (n = 199) Sensitization at 2 yr may be useful predictors of allergy-related disease later in childhood
  6. 6. OR for subsequent allergic disease by age 6 yrs 7.0 – 6.0 – 5.0 – 4.0 – 3.0 – 2.0 – 1.0 – 0.0 6.5 4.1 (+) SPTs (+) sIgE The predictive value of allergen skin prick tests and IgE tests at pre-school age: The PACT study Dorthea RA, PAI 2014;25:691–698  longitudinal population-based study of children aged 2–6 yr  SPTs and sIgE for 9 common allergens performed at 2 yr  allergy related disease evaluated by clinical examination and questionnaire at 2 and 6 yr of age (n = 199) Receiver operating characteristic analysis showed that SPT and sIgE had comparable predictive ability for atopic eczema, asthma or any allergy-related disease, but sIgE had better ability to predict later allergic rhinoconjunctivitis. ns
  7. 7. Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41  389 children from the Copenhagen Prospective Study on Asthma in Childhood  SPTs and sIgE levels assessed simultaneously for 16 common inhalant and food allergens at age ½, 1½, 4, and 6 years Inhalant allergens: changes in prevalence over time
  8. 8. Inhalant allergens: changes in prevalence over time Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41 The prevalence of inhalant allergen sensitization increased during childhood diagnosed by both sIgE levels (p<0.0001) and SPT results (p<0.0001)
  9. 9. Inhalant allergens, agreement between SPT and sIgE. The numbers in the figure are absolute numbers Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41  389 children from the Copenhagen Prospective Study on Asthma in Childhood  SPTs and sIgE levels assessed simultaneously for 16 common inhalant and food allergens at age ½, 1½, 4, and 6 years
  10. 10. Food allergens: changes in prevalence over time Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41  389 children from the Copenhagen Prospective Study on Asthma in Childhood  SPTs and sIgE levels assessed simultaneously for 16 common inhalant and food allergens at age ½, 1½, 4, and 6 years
  11. 11. The Prevalence of food sensitization increased during childhood when diagnosed from sIgE (p<0.0001), but decreased when diagnosed from SPT (p=0.05) Food allergens: changes in prevalence over time Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41
  12. 12. Food allerges, agreement between SPT and SIgE. The numbers in the figure are absolute numbers Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41  389 children from the Copenhagen Prospective Study on Asthma in Childhood  SPTs and sIgE levels assessed simultaneously for 16 common inhalant and food allergens at age ½, 1½, 4, and 6 years
  13. 13. Food allerges, agreement between SPT and SIgE. The numbers in the figure are absolute numbers Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41  389 children from the Copenhagen Prospective Study on Asthma in Childhood  SPTs and sIgE levels assessed simultaneously for 16 common inhalant and food allergens at age ½, 1½, 4, and 6 years Overall, the agreement between SPT and sIgE levels was poor to moderate (all κ-coefficients≤0.60) and decreased from moderate to slight for food allergens by increasing age (κ-coefficients: 0.46)
  14. 14. 1) We observed that the agreement between SPT and sIgE levels for diagnosing inhalant and food allergen sensitization during preschool age was at best moderate with a striking decrease in agreement with age for food sensitization 2) Increasing the cutoff level of sIgE to 1.0 kUA/l had no noteworthy effect on agreement 3) The pattern observed for sensitization to food allergens measured by sIgE, with increasing prevalence with age, suggests this does not reflect clinical food allergy 4) Some commercial SPT extracts do not contain all the components of the foods, which may result in a higher sensitization prevalence using sIgE levels compared to SPT Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41
  15. 15. 5) In addition, cross-reactivity between inhalant and food allergens could add to the disagreement, for example, cross-reactivity between Bet v 1 in birch and Ara h8 in peanut would result in a higher prevalence of positive sIgE measurements for peanut compared to SPT, if the SPT extract does not contain Ara h8 6) An alternative explanation for the disagreeing test results might be that the immune response is different in the skin and in the blood 7) The disagreement between SPT and sIgE results emphasizes the importance of careful interpretation of test results based on assessment method, clinical history, age of the child, and the type of allergen tested for. Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41
  16. 16. 5) In addition, cross-reactivity between inhalant and food allergens could add to the disagreement, for example, cross-reactivity between Bet v 1 in birch and Ara h8 in peanut would result in a higher prevalence of positive sIgE measurements for peanut compared to SPT, if the SPT extract does not contain Ara h8 6) An alternative explanation for the disagreeing test results might be that the immune response is different in the skin and in the blood 7) The disagreement between SPT and sIgE results emphasizes the importance of careful interpretation of test results based on assessment method, clinical history, age of the child, and the type of allergen tested for. Disagreement between skin prick test and specific IgE in young children Schoos A. M. M. Allergy 2015;70:41 SPTs may underestimate the prevalence of mite, dog, grass, and birch allergy.
  17. 17. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 Background:  Sensitization to profilins and other cross-reacting molecules might hinder proper specific immunotherapy (SIT) prescription in polysensitized patients with pollen-related allergic rhinitis (AR).  In these patients, component-resolved diagnosis (CRD) might modify SIT prescription by improving the identification of the disease-eliciting pollen sources.
  18. 18. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81  It has been suggested that SIT to a pollen should be prescribed only when serum IgE antibodies to major allergenic molecular components of that pollen are detectable.  Hence component-resolved diagnosis (CRD) should make it possible to avoid either the isolated administration of irrelevant allergens or the “dilution” of the relevant ones in an SIT preparation.  For example, it was proposed that patients with SPT reactivity to grass pollen extracts should receive SIT for grass only in the presence of IgE antibodies to the major allergenic molecules Phl p 1, Phl p 5, or both.  Similarly, patients with SPT response positivity to the extract of parietaria, mugwort, Betulaceae, or olive should receive SIT only if they have IgE to Par j 2, Art v 1, Bet v 1, and Ole e 1, respectively.
  19. 19. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 No IgE to the respective major allergens was detected in significant proportions of patients with supposed clinically relevant sensitization to 69% 60% 30% Betulaceae Parietaria 70 – 60 – 50 – 40 – 30 – 20 – 10 – 00 Mugwort artemisia  Children (n = 651) with moderate-to-severe pollen- related AR recruited 16 Italian outpatient clinics.  SPT to grass, Betulaceae, cypress, mugwort, olive, parietaria.  IgE to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) by ImmunoCAP. (-) Art v 1 (-) Bet v 1 (-) Par j 2
  20. 20. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 28% 15% 10% Cypress Grass 30 – 20 – 10 – 00 Olive No IgE to the respective major allergens was detected in significant proportions of patients with supposed clinically relevant sensitization to (-) Ole e 1 (-) Cup a 1 (-) Phl p 1 (-) Phl p 5  Children (n = 651) with moderate-to-severe pollen- related AR recruited 16 Italian outpatient clinics.  SPT to grass, Betulaceae, cypress, mugwort, olive, parietaria.  IgE to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) by ImmunoCAP.
  21. 21.  Children (n = 651) with moderate-to-severe pollen- related AR recruited 16 Italian outpatient clinics.  SPT to grass, Betulaceae, cypress, mugwort, olive, parietaria.  IgE to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) by ImmunoCAP. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 28% 15% 10% Cypress Grass 30 – 20 – 10 – 00 Olive No IgE to the respective major allergens was detected in significant proportions of patients with supposed clinically relevant sensitization to (-) Ole e 1 (-) Cup a 1 (-) Phl p 1 (-) Phl p 5 IgE to panallergens: profilins (Phl p 12), polcalcins, or both could justify 173 (37%) of 464 of these SPT reactions.
  22. 22. European American The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 42% 48% 47% 50 – 40 – 30 – 20 – 10 – 00 % of SIT prescription that was changed after component resolved diagnosis according to Approach Opinion of the 14 local pediatric allergists  Children (n = 651) with moderate-to-severe pollen- related AR recruited 16 Italian outpatient clinics.  SPT to grass, Betulaceae, cypress, mugwort, olive, parietaria.  IgE to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) by ImmunoCAP.
  23. 23.  Children (n = 651) with moderate-to-severe pollen- related AR recruited 16 Italian outpatient clinics.  SPT to grass, Betulaceae, cypress, mugwort, olive, parietaria.  IgE to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) by ImmunoCAP. European American The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 42% 48% 47% 50 – 40 – 30 – 20 – 10 – 00 % of SIT prescription that was changed after component resolved diagnosis according to Approach Opinion of the 14 local pediatric allergists In children with pollen-related AR, applying CRD leads to changes in a large proportion of SIT prescriptions as opposed to relying on clinical history and SPT alone.
  24. 24. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81 Criteria for SIT prescription A. European Monosensitization or Not more than 3 polysensitization B. American Monosensitization or As many as the clinically polysensitization relevant sensitization C. Monoallergenic Monosensitization or Only 1 polysensitization D. Monosensitization Monosensitization Only 1 Model Patient's clinically relevant sensitization Number of allergenic extracts
  25. 25. The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever. Stringari G, J Allergy Clin Immunol 2014;134:75-81  In the European model, when 4 or more clinically relevant sensitizations were detected, the 3 most relevant allergens were selected on the basis of the opinion of the locally recruiting doctor.  In the American model the number of allergenic sources to be mixed was unlimited.  In the monoallergenic model only the most important allergenic source was allowed.
  26. 26. Factors augmenting allergic reactions Niggemann B, Allergy 2014;69:1582  Augmenting factors may explain why certain conditions lead to anaphylaxis.  Augmenting factors may exhibit 3 effects: 1) lowering the threshold, 2) increasing the severity, and 3) reversing acquired clinical tolerance.  Common augmenting factors are •physical exercise, •menstruation, •NSAIDs, •alcohol, •body temperature, •acute infections, •antacids.
  27. 27. Therapeutic options may address causative, preventive, pragmatic, or symptomatic considerations: • avoid the eliciting food • take an antihistamine before any situation with a possible risk of augmentation • separate food and sport (at least for 2 h) • carry an adrenaline autoinjector at all times Factors augmenting allergic reactions Niggemann B, Allergy 2014;69:1582
  28. 28. Proposal for a new terminology of risk factors for anaphylactic reactions Factors augmenting allergic reactions Niggemann B, Allergy 2014;69:1582
  29. 29. Different effects of augmenting factors (A) Lowering the threshold (B) Increasing severity (C) Reversing acquired clinical tolerance Factors augmenting allergic reactions Niggemann B, Allergy 2014;69:1582
  30. 30. Possible interacting mechanisms of augmentation Factors augmenting allergic reactions Niggemann B, Allergy 2014;69:1582
  31. 31. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74 A. Asthma is likewise a critically important disease. B. Up to 92% of asthmatic patients incorrectly use inhalers. C. Even among medical personnel, rates of correct use are suboptimal. D. This misuse translates into reduced clinical efficacy of therapy.
  32. 32. % MDI users demonstrating perfect technique 7% The most commonly missed step was exhaling to functional residual capacity or residual volume before actuating the canister (66% of imperfect users failed to perform this step). 20 – 15 – 10 – 05 – 00 Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74  Factors associated with incorrect use of metered-dose inhalers (MDIs) and epinephrine autoinjectors.  102 patients using epinephrine and 44 patients using MDIs with spacers from adult and pediatric clinics.
  33. 33. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74 Device technique standards: MDI
  34. 34. Errors in metered-dose inhaler technique demonstration. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74 (C) Number of steps performed incorrectly by patients with a MDI (D) Frequency with which each step was performed incorrectly (MDI).
  35. 35. 1) Anaphylaxis is a concerning disorder because of its life-threatening potential and increasing incidence. 2) It is well established that intramuscular epinephrine is a life-saving therapy in anaphylaxis; however, patients frequently do not understand how to self-administer the medication. 3) The problem of incorrect epinephrine autoinjector use is documented in the literature with rates of correct use as low as 22%. 4) This misuse has been documented in cases of fatal anaphylaxis. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74
  36. 36.  Factors associated with incorrect use of metered-dose inhalers (MDIs) and epinephrine autoinjectors.  102 patients using epinephrine and 44 patients using MDIs with spacers from adult and pediatric clinics. % patients used the epinephrine autoinjector properly 20 – 15 – 10 – 05 – 00 16% The most common error was not holding the unit in place for ≥ 10 seconds after triggering. This error was done by 76% of patients. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74
  37. 37. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74 Device technique standards: EpiPen
  38. 38. Errors in technique demonstration. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease Bonds Ann Allergy 2015;114:74 (A) Number of steps performed incorrectly by patients with epinephrine autoinjector. (B) Frequency with which each step was performed incorrectly (epinephrine autoinjector).
  39. 39. What is New in Pediatric Allergic Diseases 2015 Attilio Boner University of Verona, Italy attilio.boner@univr.it Diagnosis Food Allergy Atopic Dermatitis Allergic Asthma Allergic Rhinitis Anaphylaxis Urticaria & Angioedema Risk & Protective factors Burden
  40. 40. Peanut allergens are rapidly transferred in human breast milk and can prevent sensitization in mice Bernard H., Allergy 2014; 69: 888 Ara h6 is detected as soon as 10 min after peanut ingestion, with peak values observed within the first hour after ingestion. The transfer is long-lasting, small quantities of peanut allergens being detected over a 24-h period  Human breast milk was collected from 2 non-atopic peanut-tolerant mothers before and at different time points after ingestion of 30 g of commercial roasted peanut  Ara h6, Ara h6 immune complexes, and the IgE binding capacity of breast milk samples were measured using specific immunoassays  Human breast milk obtained before or after peanut ingestion was administered intragastrically to BALB/c mice, and mice were further experimentally sensitized
  41. 41. Peanut allergens are rapidly transferred in human breast milk and can prevent sensitization in mice Bernard H., Allergy 2014; 69: 888  Human breast milk was collected from 2 non-atopic peanut-tolerant mothers before and at different time points after ingestion of 30 g of commercial roasted peanut  Ara h6, Ara h6 immune complexes, and the IgE binding capacity of breast milk samples were measured using specific immunoassays  Human breast milk obtained before or after peanut ingestion was administered intragastrically to BALB/c mice, and mice were further experimentally sensitized Peanut allergens transferred in milk are IgE reactive and can induce an allergic reaction in vitro Ara h6 is detected as soon as 10 min after peanut ingestion, with peak values observed within the first hour after ingestion. The transfer is long-lasting, small quantities of peanut allergens being detected over a 24-h period
  42. 42. Ara h6 is rapidly excreted in human breast milk Peanut allergens are rapidly transferred in human breast milk and can prevent sensitization in mice Bernard H., Allergy 2014; 69: 888  Human breast milk was collected from 2 non-atopic peanut-tolerant mothers before and at different time points after ingestion of 30 g of commercial roasted peanut  Ara h6, Ara h6 immune complexes, and the IgE binding capacity of breast milk samples were measured using specific immunoassays  Human breast milk obtained before or after peanut ingestion was administered intragastrically to BALB/c mice, and mice were further experimentally sensitized 24 hrs12 hrs10 min
  43. 43. However, administration of human breast milk to young mice, notably before weaning, does not lead to sensitization, but instead to partial oral tolerance Peanut allergens are rapidly transferred in human breast milk and can prevent sensitization in mice Bernard H., Allergy 2014; 69: 888  Human breast milk was collected from 2 non-atopic peanut-tolerant mothers before and at different time points after ingestion of 30 g of commercial roasted peanut  Ara h6, Ara h6 immune complexes, and the IgE binding capacity of breast milk samples were measured using specific immunoassays  Human breast milk obtained before or after peanut ingestion was administered intragastrically to BALB/c mice, and mice were further experimentally sensitized
  44. 44. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. 20 – 15 – 10 – 05 – 00 Avoidance Group Consumption Group p<0.001 17.2% 3.2% Prevalence of peanut allergy (+OFC) at 60 months of age in the whole cohort. ±
  45. 45. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. 20 – 15 – 10 – 05 – 00 Avoidance Group Consumption Group p<0.001 17.2% 3.2% Prevalence of peanut allergy (+OFC) at 60 months of age in the whole cohort. ±
  46. 46. ± Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. 20 – 15 – 10 – 05 – 00 Avoidance Group Consumption Group p<0.001 17.2% 3.2% Increases in levels of peanut-specific IgG4 antibody occurred predominantly in the consumption group. A greater percentage of participants in the avoidance group had elevated titres of peanut-sIgE. sIgE sIgG4 Prevalence of peanut allergy (+OFC) at 60 months of age in the whole cohort.
  47. 47. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13 Prevalence of peanut allergy (+OFC) at 60 months of age in the (+) SPT cohort. 40 – 30 – 20 – 10 – 0 Avoidance Group Consumption Group p=0.00435.3% 10.6%  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. ±
  48. 48. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13 40 – 30 – 20 – 10 – 0 Avoidance Group Consumption Group p<0.001 13.7% 1.9% Prevalence of peanut allergy (+OFC) at 60 months of age in the (-) SPT cohort.  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. ±
  49. 49. ± Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy Du Toit G, N Engl J Med 2014;372:803-13 40 – 30 – 20 – 10 – 0 Avoidance Group Consumption Group p<0.001 13.7% 1.9%  640 infants, aged between 4 and 11 months, with severe eczema, egg allergy, or both.  Randomly assigned to:  dietary peanut consumption or  dietary peanut avoidance.  Randomly stratified into 2 study cohorts on the basis of the results of a skin prick test for peanut allergy:  no measurable wheal  a wheal measuring 1 to 4 mm in diameter. Early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts. Prevalence of peanut allergy (+OFC) at 60 months of age in the (-) SPT cohort.
  50. 50. Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350 Background: •Egg-sensitized infants who have never eaten egg may react at first ingestion. •We sought to determine the association between skin prick test (SPT) and sIgE to egg proteins (EP) and oral food challenge (OFC) outcomes to find cut-off points which can diagnose egg allergy. ±
  51. 51. Patient classification relating SPT and outcomes after OFC Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350  154 infants up to 18 months, with cow’s milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption  Skin prick test (SPT) to egg proteins (EP) were performed. If it was positive, sIgE was performed  If positive SPT and/or sIgE (n = 94), oral food challenge (OFC) performed between 12 and 18 months ±
  52. 52. ± Patient classification relating SPT and outcomes after OFC Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350  154 infants up to 18 months, with cow’s milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption  Skin prick test (SPT) to egg proteins (EP) were performed. If it was positive, sIgE was performed  If positive SPT and/or sIgE (n = 94), oral food challenge (OFC) performed between 12 and 18 months Egg white (EW) and ovalbumin (OVA) sIgE have the best area under the curve (AUC)
  53. 53. Sensitized infants but “cooked egg tolerant”  154 infants up to 18 months, with cow’s milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption  Skin prick test (SPT) to egg proteins (EP) were performed. If it was positive, sIgE was performed  If positive SPT and/or sIgE (n = 94), oral food challenge (OFC) performed between 12 and 18 months Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350 ±
  54. 54. ± Sensitized infants but “cooked egg tolerant”  154 infants up to 18 months, with cow’s milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption  Skin prick test (SPT) to egg proteins (EP) were performed. If it was positive, sIgE was performed  If positive SPT and/or sIgE (n = 94), oral food challenge (OFC) performed between 12 and 18 months Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350 In egg-sensitized infants with egg white (EW) SPT ≥8mm and/or EW sIgE ≥8.36 KU/l, egg diagnostic oral food challenge (OFC) can be avoided as there is 94% probability of resulting positive
  55. 55. ± Sensitized infants but “cooked egg tolerant”  154 infants up to 18 months, with cow’s milk allergy (CMA) and/or atopic dermatitis (AD) without previous egg consumption  Skin prick test (SPT) to egg proteins (EP) were performed. If it was positive, sIgE was performed  If positive SPT and/or sIgE (n = 94), oral food challenge (OFC) performed between 12 and 18 months Tolerance to egg proteins in egg-sensitized infants without previous consumption Alvaro M, Allergy 2014;69:1350 In the other patients, oral food challenge (OFC) should be performed safely and early to avoid unnecessary diets
  56. 56. Predicting Outcomes of Oral Food Challenges by Using the Allergen-Specific IgE–Total IgE Ratio Gupta RS, J Allergy Clin Immunol Pract 2014;2:300-5 Background  Although allergists typically use allergen-specific IgE (sIgE) levels or skin prick test wheal sizes to identify food allergens that may provoke IgE-mediated food-induced allergic reactions, both tests have high rates of false positivity and mislabel patients who are tolerant as allergic to the food allergen. Objective  To examine the accuracy of the ratio of sIgE to total IgE (“Ratio”) in predicting the outcome of challenges performed to confirm the development of tolerance. Ratio = (sIgE/tIgE) × 100
  57. 57. Predicting Outcomes of Oral Food Challenges by Using the Allergen-Specific IgE–Total IgE Ratio Gupta RS, J Allergy Clin Immunol Pract 2014;2:300-5  Children diagnosed with food allergy.  Oral food challenge.  The Ratio was calculated by using the following formula: Ratio = (sIgE/tIgE) × 100. sIgE to total IgE (“Ratio”) % 0.49% 1.5 – 1.0 – 0.5 – 00 1.48% (-) (+) FOOD CHALLENGE
  58. 58. Predicting Outcomes of Oral Food Challenges by Using the Allergen-Specific IgE–Total IgE Ratio Gupta RS, J Allergy Clin Immunol Pract 2014;2:300-5  Children diagnosed with food allergy.  Oral food challenge.  The Ratio was calculated by using the following formula: Ratio = (sIgE/tIgE) × 100. sIgE to total IgE (“Ratio”) % 0.49% 1.5 – 1.0 – 0.5 – 00 1.48% FOOD CHALLENGE The Ratio was significantly more accurate than sIgE alone in predicting challenge outcome (Ratio 0.69 vs sIgE alone 0.55; P =0.03 ). (-) (+)
  59. 59. Predicting Outcomes of Oral Food Challenges by Using the Allergen-Specific IgE–Total IgE Ratio Gupta RS, J Allergy Clin Immunol Pract 2014;2:300-5 Median Ratio (sIgE/tIgE) stratified by outcome of oral food challenge “Less persistent FA” refers to milk, egg, wheat, and soy as a group (red); “more persistent FA” refers to peanut, tree nuts, shellfish, and seeds as a group (blue). Ratio = (sIgE/tIgE) × 100
  60. 60. Ratio = (sIgE/tIgE) × 100 Predicting Outcomes of Oral Food Challenges by Using the Allergen-Specific IgE–Total IgE Ratio Gupta RS, J Allergy Clin Immunol Pract 2014;2:300-5 Median Ratio (sIgE/tIgE) stratified by outcome of oral food challenge “Less persistent FA” refers to milk, egg, wheat, and soy as a group (red); “more persistent FA” refers to peanut, tree nuts, shellfish, and seeds as a group (blue). The Ratio for participants who failed their OFC was higher than the Ratio for those who passed, especially for more persistent allergens (eg, peanut and tree nuts).
  61. 61. Differences in empowerment and quality of life among parents of children with food allergy Warren C, Ann Allergy Asthma Immunol, 2015;114:117-25 Psychological empowerment has been defined as “a process through which people gain greater control over decisions and actions affecting their health.” Psychological empowerment is believed to facilitate the appropriation of medical knowledge and reinforce psychosocial skills, thus increasing self-efficacy with regard to disease and treatment-related behaviors.  876 families of children with food allergy.  Food allergy defined by stringent criteria.  Parental empowerment and Food Allergy-Related Quality Of Life (FAQOL) assessed by the adapted Family Empowerment and FAQOL-Parental Burden scales.
  62. 62. Differences in empowerment and quality of life among parents of children with food allergy Warren C, Ann Allergy Asthma Immunol, 2015;114:117-25  876 families of children with food allergy.  Food allergy defined by stringent criteria.  Parental empowerment and Food Allergy-Related Quality Of Life (FAQOL) assessed by the adapted Family Empowerment and FAQOL-Parental Burden scales.  Mothers reported greater empowerment (p < .001) and lower FAQOL (p < .001) compared with fathers.  Greater effects on FAQOL were seen for milk and egg compared with other food allergies.
  63. 63. Differences in empowerment and quality of life among parents of children with food allergy Warren C, Ann Allergy Asthma Immunol, 2015;114:117-25  876 families of children with food allergy.  Food allergy defined by stringent criteria.  Parental empowerment and Food Allergy-Related Quality Of Life (FAQOL) assessed by the adapted Family Empowerment and FAQOL-Parental Burden scales. Although parents of children with food allergy might be empowered to care for their child, they continue to experience impaired FAQOL owing to fears of allergen exposure beyond their control.  Mothers reported greater empowerment (p < .001) and lower FAQOL (p < .001) compared with fathers.  Greater effects on FAQOL were seen for milk and egg compared with other food allergies.