Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group

When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti‐inflammatory drug‐associated angioedema and serum sickness‐like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up‐to‐date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.     

EAACI IG Biologicals task force paper on the use of biologic agents in allergic disorders

Biologic agents (also termed biologicals or biologics) are therapeutics that are synthesized by living organisms and directed against a specific determinant, for example, a cytokine or receptor. In inflammatory and autoimmune diseases, biologicals have revolutionized the treatment of several immune‐mediated disorders. Biologicals have also been tested in allergic disorders. These include agents targeting IgE; T helper 2 (Th2)‐type and Th2‐promoting cytokines, including interleukin‐4 (IL‐4), IL‐5, IL‐9, IL‐13, IL‐31, and thymic stromal lymphopoietin (TSLP); pro‐inflammatory cytokines, such as IL‐1β, IL‐12, IL‐17A, IL‐17F, IL‐23, and tumor necrosis factor (TNF); chemokine receptor CCR4; and lymphocyte surface and adhesion molecules, including CD2, CD11a, CD20, CD25, CD52, and OX40 ligand. In this task force paper of the Interest Group on Biologicals of the European Academy of Allergy and Clinical Immunology, we review biologicals that are currently available or tested for the use in various allergic and urticarial pathologies, by providing an overview on their state of development, area of use, adverse events, and future research directions.     

Occupational anaphylaxis – an EAACI task force consensus statement

Anaphylaxis is a systemic allergic reaction, potentially life‐threatening that can be due to nonoccupational or, less commonly, to occupational triggers. Occupational anaphylaxis (OcAn) could be defined as anaphylaxis arising out of triggers and conditions attributable to a particular work environment. Hymenoptera stings and natural rubber latex are the commonest triggers of OcAn. Other triggers include food, medications, insect/mammal/snake bites, and chemicals. The underlying mechanisms of anaphylactic reactions due to occupational exposure are usually IgE‐mediated and less frequently non‐IgE‐mediated allergy or nonallergic. Some aspects of work‐related allergen exposure, such as route and frequency of exposure, type of allergens, and cofactors may explain the variability of symptoms in contrast to the nonoccupational setting. When assessing OcAn, both confirmation of the diagnosis of anaphylactic reaction and identification of the trigger are required. Prevention of further episodes is important and is based on removal from further exposure. Workers with a history of OcAn should immediately be provided with a written emergency management plan and an adrenaline auto‐injector and educated to its use. Immunotherapy is recommended only for OcAn due to Hymenoptera stings.     

EAACI position paper: Influence of dietary fatty acids on asthma,food allergy,and atopic dermatitis

The prevalence of allergic diseases such as allergic rhinitis, asthma, food allergy, and atopic dermatitis has increased dramatically during the last decades, which is associated with altered environmental exposures and lifestyle practices. The purpose of this review was to highlight the potential role for dietary fatty acids, in the prevention and management of these disorders. In addition to their nutritive value, fatty acids have important immunoregulatory effects. Fatty acid‐associated biological mechanisms, human epidemiology, and intervention studies are summarized in this review. The influence of genetics and the microbiome on fatty acid metabolism is also discussed. Despite critical gaps in our current knowledge, it is increasingly apparent that dietary intake of fatty acids may influence the development of inflammatory and tolerogenic immune responses. However, the lack of standardized formats (ie, food versus supplement) and standardized doses, and frequently a lack of prestudy serum fatty acid level assessments in clinical studies significantly limit our ability to compare allergy outcomes across studies and to provide clear recommendations at this time. Future studies must address these limitations and individualized medical approaches should consider the inclusion of specific dietary factors for the prevention and management of asthma, food allergy, and atopic dermatitis.     

Food processing and occupational respiratory allergy‐ An EAACI position paper

Occupational exposure to foods is responsible for up to 25% of cases of occupational asthma and rhinitis. Animal and vegetable high‐molecular‐weight proteins present in aerosolized foods during food processing, additives, preservatives, antioxidants, and food contaminants are the main inhalant allergen sources. Most agents typically cause IgE‐mediated allergic reactions, causing a distinct form of food allergy (Class 3 food allergy). The allergenicity of a food protein, allergen exposure levels, and atopy are important risk factors. Diagnosis relies on a thorough medical and occupational history, functional assessment, assessment of sensitization, including component‐resolved diagnostics where appropriate, and in selected cases specific inhalation tests. Exposure assessment, including allergen determination, is a cornerstone for establishing preventive measures. Management includes allergen exposure avoidance or reduction (second best option), pharmacological treatment, assessment of impairment, and worker's compensation. Further studies are needed to identify and characterize major food allergens and define occupational exposure limits, evaluate the relative contribution of respiratory versus cutaneous sensitization to food antigens, evaluate the role of raw versus cooked food in influencing risk, and define the absolute or relative contraindication of patients with ingestion‐related food allergy, pollinosis, or oral allergy syndrome continuing to work with exposure to aerosolized food allergens.     

EAACI position paper on diet diversity in pregnancy,infancy and childhood: Novel concepts and implications for studies in allergy and asthma

To fully understand the role of diet diversity on allergy outcomes and to set standards for conducting research in this field, the European Academy of Allergy and Clinical Immunology Task Force on Diet and Immunomodulation has systematically explored the association between diet diversity and allergy outcomes. In addition, a detailed narrative review of information on diet quality and diet patterns as they pertain to allergic outcomes is presented. Overall, we recommend that infants of any risk category for allergic disease should have a diverse diet, given no evidence of harm and some potential association of benefit in the prevention of particular allergic outcomes. In order to harmonize methods for future data collection and reporting, the task force members propose relevant definitions and important factors for consideration, when measuring diet diversity in the context of allergy. Consensus was achieved on practice points through the Delphi method. It is hoped that the definitions and considerations described herein will also enable better comparison of future studies and improve mechanistic studies and pathway analysis to understand how diet diversity modulates allergic outcomes.     

An occupational respiratory allergy caused by Sinapis alba pollen in olive farmers

BACKGROUND: Sinapis alba (white mustard) is a entomophilic species included in the Brassicaceae family. To date it has not been related to allergic sensitization or clinical respiratory disease. METHODS: Twelve olive orchard workers had a history of rhinitis and/or bronchial asthma that occurred during control weed management and/or harvest, from January to March. They underwent skin prick tests (SPT) with S. alba pollen extract and a standard battery of aeroallergens. Sinapis alba pollen extract was prepared for performing quantitative skin tests, enzyme allergosorbent test and nasal challenge test (NCT). A portable monitoring station and an urban volumetric Hirst-type spore trap were used for the aerobiological study. RESULTS: Eleven patients suffered from rhinitis and bronchial asthma and one had only from rhinitis. All patients were sensitized to S. alba pollen extract, and they showed a positive NCT response. In the urban aerobiologic monitoring station the amount of S. alba pollen only exceptionally reached peaks of 21 grains/m(3), whereas in the work environment peaks of 1801 grains/m(3) were detected between 15 February and 7 April. CONCLUSIONS: We demonstrate the existence of a new occupational allergen for olive farmers: S. alba pollen. We point out the importance of perform aerobiological sampling within the occupational environment for the detection and quantification of the allergenic source.     

Occupational asthma and food allergy due to carmine

Carmine (E120), a natural red dye extracted from the dried females of the insect Dactylopius coccus var. Costa (eochineal), has been reported to cause hypersensitivity reactions. We report a case of occupational asthma and food allergy due to carmine in a worker not engaged in dye manufacturing. A 35-year-old nonatopic man, who had worked for 4 years in a spice warehouse, reported asthma and rhinoeonjunctivitis for 5 months, related to carmine handling in his work. Two weeks before the visit, he reported one similar episode after the ingestion of a red-colored sweet containing carmine. Peak flow showed drops higher than 25% related to carmine exposure. Prick tests with the cochineal insect and carmine were positive, but negative to common aeroallergens, several mites, foods, and spices. The methacholine test was positive. Specific bronchial challenge test with a cochineal extract was positive with a dual pattern (20% and 24% fall in FEV_i). Double-blind oral challenge with E120 was positive. The patient's sera contained specific IgE for various high-molecular-weight proteins from the cochineal extract, as shown by immunoblotting. Carmine proteins can induce IgE-mediated food allergy and occupational asthma in workers using products where its presence could be easily overlooked, as well as in dye manufacture workers.     

Spice allergy: results of skin prick tests and RAST with spice extracts

Skin prick tests (SPT) with freeze-dried spices and 5% (w/v) spice extracts were performed on 50 patients with 2+ or stronger SPT reactions to spices per se, and RAST were performed on 10 of them. Freeze-dried extracts produced mostly equal or stronger SPT reactions than corresponding whole spices, but 5% (w/v) extracts produced weaker reactions and also remained totally negative in some patients. Positive RAST results were seen in all 10 patients tested. The correlation between the RAST and SPT results was good for mustard and paprika, but poor for cayenne, coriander, caraway and white pepper. Five patients with positive SPT and RAST for spices contracted rhinitis from powdered spices in their working environments, and one patient suffered from gastrointestinal pains caused by spiced food. The others had noticed no clinical symptoms caused by spices. The present results thus indicate that both SPT and RAST should include purified spice extracts.     

EAACI Food Allergy and Anaphylaxis Guidelines: diagnosis and management of food allergy

Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence‐based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non‐life‐threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines.     

Occupational rhinoconjunctivitis and bronchial asthma due to Phoenix canariensis pollen allergy

We report a case of occupational bronchial asthma and rhinoconjunctivitis caused by Phoenix canariensis (PC) pollen. The canary palm is a type of palm tree, belonging to the Arecaceae family, which is widely distributed in frost-free regions as an ornamental tree. Our patient was referred because he suffered symptoms of bronchial asthma, rhinoconjunctivitis, and contact urticaria when pruning dried leaves from PC during the pollination months. The skin prick test (SPT) with a PC pollen extract was positive, as was the specific IgE to PC pollen determined by Phadezym RAST, indicating an IgE-mediated sensitization. The nonspecific bronchial provocation test (BPT) performed with methacholine disclosed a mild bronchial hyperreactivity, and specific BPT with PC pollen elicited an immediate fall of 25% in FEV₁ with respect to baseline. On RAST inhibition studies, a significant cross-reactivity was found between PC pollen and date palm ( P. dactylifera ) pollen. These results suggest that PC pollen could be a potential allergen in PC-growing areas.     

Identification and practical management of latex allergy in occupational settings

Allergy to natural rubber latex (NRL) from Hevea brasiliensis is a relevant occupational health hazard. The use of gloves and products manufactured with latex and environmental allergen exposure in the work environment are risks factors for the development of occupational allergy among different job categories. Healthcare workers have been the most commonly affected, but other professions with exposure to latex products such as hairdressers, cleaners, food handlers and those making natural rubber latex (NRL) products are also at risk of developing occupational allergy. Clinical manifestations of IgE-mediated latex allergy can range from troublesome skin disorders to life-threatening systemic reactions. It is very important to identify the occupational allergic diseases in their early stages in order to implement avoidance strategies. For this purpose, the interventions for prevention should emphasize the importance of latex allergy awareness and surveillance among exposed workforces.     

Occupational allergy in laboratory workers caused by the African migratory grasshopper Locusta migratoria

BACKGROUND: Recent reports of fatal asthma cases associated with swarms of locusts affecting African countries have highlighted the importance of this insect in causing asthma morbidity and mortality. However, only limited information is available about the allergic health outcomes such as asthma and its determinants in exposed individuals. In this study, workers exposed to the African migratory locust Locusta migratoria were evaluated for allergic health outcomes as well as the nature of the offending allergens. METHODS: Ten scientists and technicians exposed to locusts in a laboratory were investigated for locust-related allergy using questionnaires and immunological tests. The presence of allergy was determined by quantification of specific IgE and IgG to L. migratoria using the UniCAP system and via skin-prick testing (SPT). The allergens were characterized by Western blot and ImmunoCAP inhibition assays. RESULTS: Six of the 10 workers experienced symptoms ranging from urticaria and rhinoconjuctivitis to asthma. Seven individuals demonstrated sensitivity on SPT and five had specific IgE antibodies to L. migratoria. Significant cross-reactivity was demonstrated for allergens in the locust faeces, body and wings but not to cockroach allergens. Novel allergens with molecular weights of approximately 70 kDa were identified in locust wings, which are distinctly different from other known allergen sources from locusts. CONCLUSION: Exposure to L. migratoria allergens is a potential sensitizer in exposed individuals. Raised levels of locust-specific IgE can be readily quantified. The wings of this insect species have been identified as a novel allergen source.     

EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy

Food allergy can have significant effects on morbidity and quality of life and can be costly in terms of medical visits and treatments. There is therefore considerable interest in generating efficient approaches that may reduce the risk of developing food allergy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Prevention and is part of the EAACI Guidelines for Food Allergy and Anaphylaxis. It aims to provide evidence‐based recommendations for primary prevention of food allergy. A wide range of antenatal, perinatal, neonatal, and childhood strategies were identified and their effectiveness assessed and synthesized in a systematic review. Based on this evidence, families can be provided with evidence‐based advice about preventing food allergy, particularly for infants at high risk for development of allergic disease. The advice for all mothers includes a normal diet without restrictions during pregnancy and lactation. For all infants, exclusive breastfeeding is recommended for at least first 4–6 months of life. If breastfeeding is insufficient or not possible, infants at high‐risk can be recommended a hypoallergenic formula with a documented preventive effect for the first 4 months. There is no need to avoid introducing complementary foods beyond 4 months, and currently, the evidence does not justify recommendations about either withholding or encouraging exposure to potentially allergenic foods after 4 months once weaning has commenced, irrespective of atopic heredity. There is no evidence to support the use of prebiotics or probiotics for food allergy prevention.     

EAACI Food Allergy and Anaphylaxis Guidelines: managing patients with food allergy in the community

The European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines, managing patients with food allergy (FA) in the community, intend to provide guidance to reduce the risk of accidental allergic reactions to foods in the community. This document is intended to meet the needs of early‐childhood and school settings as well as providers of non‐prepackaged food (e.g., restaurants, bakeries, takeaway, deli counters, and fast‐food outlets) and targets the audience of individuals with FA, their families, patient organizations, the general public, policymakers, and allergists. Food allergy is the most common trigger of anaphylaxis in the community. Providing children and caregivers with comprehensive information on food allergen avoidance and prompt recognition and management of allergic reactions are of the utmost importance. Provision of adrenaline auto‐injector devices and education on how and when to use these are essential components of a comprehensive management plan. Managing patients at risk of anaphylaxis raises many challenges, which are specific to the community. This includes the need to interact with third parties providing food (e.g., school teachers and restaurant staff) to avoid accidental exposure and to help individuals with FA to make safe and appropriate food choices. Education of individuals at risk and their families, their peers, school nurses and teachers as well as restaurant and other food retail staff can reduce the risk of severe/fatal reactions. Increased awareness among policymakers may improve decision‐making on legislation at local and national level.     

EAACI Guidelines on the effective transition of adolescents and young adults with allergy and asthma

Adolescent and young adult (AYA) patients need additional support, while they experience the challenges associated with their age. They need specific training to learn the knowledge and skills required to confidently self-manage their allergies and/or asthma. Transitional care is a complex process, which should address the psychological, medical, educational and vocational needs of AYA in the developmentally appropriate way. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline to provide evidence-based recommendations for healthcare professionals to support the transitional care of AYA with allergy and/or asthma. This guideline was developed by a multidisciplinary working panel of experts and patient representatives based on two recent systematic reviews. It sets out a series of general recommendations on operating a clinical service for AYA, which include the following: (a) starting transition early (11-13 years), (b) using a structured, multidisciplinary approach, (c) ensuring AYA fully understand their condition and have resources they can access, (d) active monitoring of adherence and (e) discussing any implications for further education and work. Specific allergy and asthma transition recommendations include (a) simplifying medication regimes and using reminders; (b) focusing on areas where AYA are not confident and involving peers in training AYA patients; (c) identifying and managing psychological and socio-economic issues impacting disease control and quality of life; (d) enrolling the family in assisting AYA to undertake self-management; and (e) encouraging AYA to let their friends know about their allergies and asthma. These recommendations may need to be adapted to fit into national healthcare systems.