Atopy patch testing in children with asthma and rhinitis symptoms allergic to house dust mite

The atopy patch test (APT) is generally used to assess immunoglobulin E (IgE) mediated sensitization to allergens in patients with atopic dermatitis, but its diagnostic role in children with respiratory allergy is still controversial. The aim of the study was to evaluate APT with house dust mite (HDM) in children with asthma and rhinitis symptoms allergic to HDM and its relevance to skin prick test (SPT) diameters and specific IgE levels. The study population consisted of 33 children, aged 8-16 yr (median: 12 yr) with asthma and 30 children with allergic rhinitis in the same age range (median: 11 yr). All patients had positive SPT results and high serum specific IgE levels for Dermatophagoides pteronyssinus APT was performed on back skin of all patients with 200 index of reactivity (IR)/ml of D. pteronyssinus allergen extracts in petrolatum (Stallerpatch) and evaluated at 72 h. Of 63 patients, 16 (25%) showed a positive patch test result. APT with HDM showed 30% (10/33) positivity among the patients with asthma and 20% (6/30) positivity among the patients with allergic rhinitis. APT presented no significant correlation with age, SPT diameter, serum total and specific IgE levels for D. pteronyssinus, nasal provocation test or pulmonary function test results. Patch testing with HDM may partly identify mite sensitive children with respiratory allergy. Positive APT results may imply that delayed hypersensitivity reactions play a role in children with asthma and rhinitis allergic to HDM.     

ACE gene polymorphism might disclose why some Taiwanese children with allergic rhinitis develop asthma symptoms but others do not

Although allergic asthma and allergic rhinitis have recently been considered to be a single disease, many questions remain unanswered. Why do some atopic patients develop asthma symptoms and others develop allergic rhinitis symptoms? Which factors play a role in the development of different allergic phenotypes? We hypothesized that angiotensin‐converting enzyme (ACE) gene polymorphism might play a role in the development of asthma phenotypes in children with allergic rhinitis. The study sample included 106 children with allergic rhinitis, but no asthma, and 105 age‐ and gender‐matched children with allergic rhinitis and asthma. Subjects of both groups exhibited the same systemic immunologic changes and allergen sensitivities. Controls consisted of 102 healthy children. The ACE genotype was determined by polymerase chain reaction. The serum total immunoglobulin E (IgE) level, allergen‐specific IgE sensitivity, and eosinophil count were also measured. The frequencies of the DD genotype were significantly higher in the children with both allergic rhinitis and asthma than in the children with allergic rhinitis but no asthma [p = 0.018; odds ratio (OR) = 3.257; (1.222–8.680)]. Results of this study suggest that ACE gene polymorphism DD genotype might play a role in the development of the asthma phenotype in children with allergic rhinitis.     

Exhaled nitric oxide, total serum IgE and allergic sensitization in childhood asthma and allergic rhinitis

Exhaled nitric oxide (eNO) levels are correlated with several markers of atopy and inflammatory activity in the airways, but the relationship between eNO and total serum IgE has not been fully elucidated in the context of allergic sensitization. The aim of this study was to investigate the relationship between eNO, total serum IgE and allergic sensitization in childhood asthma and allergic rhinitis. eNO levels, lung function, skin prick tests and total serum IgE were determined in 109 children (mean age, 10.4 yr) with mild intermittent asthma and in 41 children (mean age, 10.1 yr) with allergic rhinitis; 25 healthy non-atopic children were recruited as controls. eNO levels (median) were significantly higher in patients with asthma (22.7 p.p.b.) and in those with allergic rhinitis (15.3 p.p.b.) than in healthy controls (5.9 p.p.b.). Children with allergic asthma had higher eNO levels than children with allergic rhinitis. A significant positive correlation was found between eNO and total serum IgE (asthma, r = 0.42, p < 0.0001; allergic rhinitis, r = 0.31, p < 0.01), and between eNO and the number of positive skin prick tests (asthma, r = 0.31, p < 0.0001; allergic rhinitis, r = 0.39, p < 0.01). eNO levels were better correlated with total IgE than with the number of positive skin prick tests. This correlation was independent of allergic sensitization. High total serum IgE represents a specific and predictive marker of eNO increase in children with asthma or allergic rhinitis. This finding adds further support to the hypothesis that increased serum IgE could be a marker itself of airway inflammation in patients with allergic disease.     

Mite component–specific IgE repertoire and phenotypes of allergic disease in childhood: The tropical perspective

To cite this article: Kidon MI, Chin CW, Kang LW, Ching OT, Seng TY, Ning WK, Angus AC, Theng OS, Feng GY, Reginald K, Zhi BX, Shen SH & Tim CF. Mite component–specific IgE repertoire and phenotypes of allergic disease in childhood: The tropical perspective. Pediatr Allergy and Immunol 2011; 22 : 202–210. Sensitization to perennial aeroallergens correlates with the risk of persistent asthma (AS) in children. In tropical Singapore, multiple codominant species of mites abound in the indoor environment, and preferential species‐specific sensitization has been associated with different phenotypes of allergic disease. We investigated the pattern of mite component–specific IgE (mcsIgE) in children with different phenotypes of clinical allergic disease in an environment with multiple mite species exposure. A prospective evaluation of newly diagnosed patients with clinical diagnosis of allergic rhinitis (AR), atopic dermatitis (AD), or AS and sensitization to one or more aeroallergens were performed. Sera were tested for specific IgE against an extensive panel of Dermatophagoides pteronyssinus and Blomia tropicalis allergens. A total of 253 children were included, mean age 7.3 yr, 79% fulfilled criteria for AR, 46% AS, 71% AD, and 31% for all three. Sensitization to one or both mites was observed in 91% of children, 89% were sensitized to D. pteronyssinus, and 70% to B. tropicalis. The most common mite allergens recognized by these atopic children were Der p 1 (64%), Der p 2 (71%), Blo t 5 (45%), Blo t 7 (44%), and Blo t 21 (56%). Specific IgE responses to an increased number of distinct mite allergens correlated with the complexity of the allergic phenotype. In multivariate analysis, an increased risk for the multi‐systemic phenotype (AR + AS + AD) was associated with sensitization to an increased repertoire of mite components (three or more) (OR 4.3, 95% CI 2.1–8.8, p = 0.001) and a positive parental history of AS (OR 2.4, 95% CI 1.2–2.9, p = 0.013). A highly pleiomorphic IgE response to the prevalent indoor mites is associated with the presence of a multi‐systemic allergic phenotype in childhood in a tropical environment.     

过敏性鼻炎的诊断与治疗新进展

介绍过敏性鼻炎（AR）的诊治新进展。遗传和环境因素被认为是AR的病因学因素,AR与哮喘常相伴发生。1999年世界卫生组织出台的“过敏性鼻炎及其对哮喘的影响”指南（ARIA）及过敏症报告,提供了规范的诊断方法及治疗指南,强调了AR对哮喘的影响,并对AR进行了新的分类。最常用的诊断试验包括皮肤试验及检测特异性血清lgE抗体（放射性过敏原吸附试验）。而标准化的鼻部激发试验（nasal provocation testing,NPT）在鉴别AR与非AR应用中,是一个十分有效且安全的方法。AR的治疗一般包括避免接触变庙原、药物治疔、侍疫疗法及手术疗法等。     

The effects of grass pollen allergoid immunotherapy on clinical and immunological parameters in children with allergic rhinitis

Allergoid immunotherapy is a new form of allergen immunotherapy allowing safe administration of high allergen doses. There is limited information on the effects of allergoid immunotherapy in children with allergic rhinitis. To investigate the immunological and clinical effects of allergoid immunotherapy in children with allergic rhinitis due to grass pollen allergy. Children with allergic rhinitis were assigned to allergoid immunotherapy (n = 27) or control (n = 26, no immunotherapy) groups. Children in the immunotherapy group received seven injections of grass pollen allergoid immunotherapy before grass pollen season and continued to receive maintenance immunotherapy for 27 months. All patients were offered a pharmacotherapy regimen to be used on demand during the pollen seasons. Clinical and laboratory parameters were compared between the immunotherapy and control groups. The rhinoconjunctivitis symptom-medication score and asthma symptom score were lower in the immunotherapy group after 1 yr of maintenance immunotherapy (p < 0.01 for both). Skin test reactivity and nasal reactivity as determined by nasal provocation testing for grass pollen were significantly decreased after 1 yr of immunotherapy (p < 0.001 for both). The seasonal increase in bronchial reactivity and nasal lavage eosinophil cationic protein levels were prevented after the first year of immunotherapy (p < 0.05 for both). The seasonal increase in immunoglobulin (Ig)E decreased (p < 0.05) and grass-specific IgG, IgG(1) and IgG(4) increased significantly already at the end of the seven-injection build-up therapy (p < 0.001, for all). Interleukin (IL)-4 levels in the culture supernatants showed a steady decline from baseline at first and second year of immunotherapy (p < 0.001) but remained unchanged in the control group. Allergoid immunotherapy is an effective method in the treatment of grass pollen-induced allergic rhinitis in children and prevents the seasonal increase in bronchial hyper-reactivity. Changes in specific IgE and IgG levels and decreased IL-4 production in peripheral blood mononuclear cell culture supernatants may account for the observed clinical effects.     

吸入变应原sIgE在不同气道过敏性疾病儿童中的分布特征

目的了解不同气道过敏性疾病患儿吸入变应原血清特异性Ig E(slg E)的分布特征。方法应用Uni CAP250变应原定量Ig E检测系统的荧光酶联免疫法,对256例3~14岁气道过敏疾病患儿测定9种常见吸入变应原的血清slg E。256例患儿按临床诊断分为:变应性鼻炎组(简称"鼻炎组",37例)、支气管哮喘组(简称"哮喘组",82例)和变应性鼻炎合并支气管哮喘组(简称"鼻炎并哮喘组",137例)。比较3组患儿9种吸入变应原阳性检出率的分布差异,并比较3组患儿变应原致敏级别和致敏种类数的差异。结果哮喘组、鼻炎组和鼻炎并哮喘组患儿吸入变应原血清s Ig E的阳性检出率分别为57.3%(47/82)、86.5%(32/37)、82.5%(113/137),3组间比较差异有统计学意义(P0.05)。哮喘组、鼻炎组、鼻炎并哮喘组患儿常见变应原均依次为霉菌类(32.9%、54.1%、48.9%)、尘螨类(30.5%、45.9%、46.0%)、花粉类(26.8%、35.1%、32.8%)、宠物类(12.2%、27.0%、18.2%)、蟑螂(9.8%、5.4%、5.8%)。鼻炎组和鼻炎并哮喘组患儿霉菌混合的阳性检出率均高于哮喘组,差异有统计学意义(均P0.0166)。3组患儿9种变应原的致敏级别和致敏种类数比较差异无统计学意义。结论支气管哮喘、变应性鼻炎或二者合并患儿前3位吸入变应原均依次是霉菌类、尘螨类、花粉类;与支气管哮喘相比,霉菌致敏可能与变应性鼻炎关系更密切;这3种常见气道过敏性疾病吸入变应原的致敏分布具有相似性。     

Three-year follow-up of clinical and inflammation parameters in children monosensitized to mites undergoing sub-lingual immunotherapy

Parallel follow-up of clinical and inflammatory markers during sub-lingual immunotherapy (SLIT) is highly beneficial. Twenty-four children (age 4-16) monosensitized to house dust mite were randomized to receive either active or placebo SLIT for 1 yr in a double-blind placebo controlled design (Marcucci et al., Allergy 2003: 58: 657-62). Thereafter, for 2 yr they all received active treatment. Symptom scores for rhinitis, asthma, and drug usage were daily recorded. Eosinophil cationic protein (ECP) and tryptase in sputum and nasal secretions, serum and nasal mite-specific immunoglobulin E (IgE) were recorded before treatment and at 10-12 months intervals. Nasal ECP and nasal tryptase after specific nasal provocation tests were significantly reduced as compared to baseline values (p = 0.0043 and 0.0195, respectively) in the third year of active treatment. None of the other inflammatory parameters was increased. In placebo treated patients all these parameters tended to decrease only after switching to active treatment. Clinical scores did not improve in treated vs. placebo patients in the double-blind placebo-controlled phase of the study. In both cohorts a clinical benefit was observed as intra-group score reduction as compared to baseline. A significant difference was reached in patients treated for 2 yr for rhinitis and asthma (p = 0.0009 and 0.0019, respectively) but not for drug usage and in patients treated for 3 yr for rhinitis, asthma, and drug usage (p = 0.0105, 0.0048, and 0.02, respectively). SLIT in children monosensitized to mites reverted the spontaneous increase in nasal IgE and in local parameters of allergic inflammation. These outcomes were followed by a consolidated clinical improvement in the second and third year of treatment.     

Long-lasting sensitization to food during the first two years precedes allergic airway disease

The purpose of the study was to investigate whether the duration of sensitization to food allergens during early childhood is related to later development of IgE mediated hypersensitivity to inhalant allergens and of allergic rhinitis and asthma in 5-year-old children and whether long-lasting food-sensitization may be used to predict subsequent allergic airway diseases. Five hundred and eight children of a prospective birth cohort study with available serum samples at one and two years of age were included and followed up until five years of age. Specific sensitization to food and inhalant allergens and the occurrence of subsequent allergic airway diseases were determined. Children with a long-lasting sensitization to food allergens (persistently sensitized for more than one year) produced significantly higher total IgE and specific IgE levels than children who were only transiently food-sensitized by two years of age. Children persistently sensitized to food had a 3.4 fold higher risk of developing allergic rhinitis and a 5.5 fold higher risk of developing asthma than infants who were only transiently food sensitized. Persistent food sensitization in combination with a positive atopic family history was a strong predictor for the development of allergic rhinitis and asthma at five years of age. The risks for these children are up to 50%, and 67% respectively. Persistently detectable sensitization to food over more than one year in early childhood is a strong prognostic factor for subsequent allergic airway disease. Persistently food-sensitized children especially in atopic families have to be regarded as a high-risk group and should be considered for preventive measures against respiratory atopy.     

Diagnosing and managing allergic conjunctivitis in childhood: The allergist’s perspective

Allergic conjunctivitis in childhood often poses problems of diagnosis and management for the allergist. We present the salient points concerning the diagnosis and treatment of ocular allergy emerging from a large cohort survey conducted jointly in the departments of ophthalmology and paediatric allergy in a French teaching hospital. Seasonal acute conjunctivitis is a common disorder and not overly difficult to diagnose and treat when associated with rhinitis leading to allergic rhinoconjunctivitis. An ophthalmologist should be consulted when conjunctivitis occurs alone and if another form of conjunctivitis is suspected, such as perennial allergic conjunctivitis, vernal keratoconjunctivitis or atopic keratoconjunctivitis. When IgE‐mediated hypersensitivity assessment does not establish aetiological diagnosis, a conjunctival allergen provocation test can be performed. The principal non‐IgE‐mediated allergy is chronic blepharoconjunctivitis. The main problem for differential diagnosis is the presence of signs suggestive of dry eye. Management includes non‐pharmacological treatments, such as lacrimal substitutes, avoidance measures and protection of the ocular surface. Second‐line treatment consists of eye drops, preferably single dose or without additives and with dual local action, mast cell stabilizer action and antihistaminic action. Third‐line treatment is reserved for severe forms. Short‐lasting local steroid therapy can control flare‐ups of allergic keratoconjunctivitis, which should have specialized follow‐up. Cyclosporine is a disease‐modifying treatment, which is both effective and well tolerated.     

Paediatric allergy diagnosis in primary care is improved by in vitro allergen-specific IgE testing

Allergy testing is an important pre‐requisite for both early identification of infants at increased risk for later development of allergic diseases and for specific allergy treatment including specific allergen avoidance measures, pharmacotherapy and specific immunotherapy. The aim of this study was to investigate the influence of in vitro allergen‐specific immunoglobulin E (IgE) testing on the primary care physician’s diagnosis and clinical management of children with symptoms of eczema, wheezing/asthma and rhinitis. The trial was a prospective study performed at 14 paediatric primary care practices in Germany, covering 380 children below 6 yr of age. For one group of children the physician received the IgE test results as soon as possible and used them as an additional tool when diagnosing and giving clinical management advice. For the other group of children the IgE test results were not made available to the physician until the children were brought to a second visit, about 7 wk later. When diagnosis was made without access to allergen‐specific IgE results, 8% of the children were diagnosed as allergic, 6% as non‐allergic and in 86% of the cases the physician was uncertain. With access to allergen‐specific IgE results the figures were 13%, 65% and 22%, respectively. Concerning clinical management advice no statistically significant differences between the two study groups were observed. When comparing the first and second visits of the patients coming for a second visit advice to reduce aeroallergen exposure was given to 27% of the patients at visit 1 and to 36% of the patients at visit 2 (p = 0.002). The difference between the first and second visits of the other clinical management advice studied did not reach statistical significance. In this study the availability of IgE test results to the primary care physician had an impact on the decision‐making process of the diagnosis but not on the pharmaceutical or avoidance advice given. The reason why IgE test results were not fully exploited needs to be further scrutinized.     

Allergic rhinitis in children

Allergic rhinitis affects up to 40% of children but is commonly undiagnosed. Careful assessment of nasal symptoms allows for the most appropriate therapeutic options to be chosen. Allergen avoidance is often difficult in practice. Antihistamines are of limited benefit in allergic rhinitis caused by house dust mite and other perennial allergens, where symptoms, predominantly nasal obstruction, are not histamine mediated. In contrast, symptoms triggered by pollen, such as nasal itch, rhinorrhoea and sneezing, are relieved by antihistamines. Intranasal steroids are the treatment of choice for persistent moderate–severe allergic rhinitis and are more effective than antihistamines for relief of nasal obstruction. Failure to respond to intranasal medications is often caused by poor compliance or inefficient use of nasal sprays. Immunotherapy may be a useful, if expensive, option, particularly where symptoms are because of a specific pollen. The benefits of immunotherapy in house dust mite‐induced rhinitis and asthma remain controversial.     

变应性疾病患儿皮肤变应原试验与血清尘螨特异性IgE及IgG4水平的关系

目的探讨变应性疾病(包括支气管哮喘和变应性鼻炎)患儿常见的变应原与血清尘螨特异性IgE(sIgE)和IgG4水平的关系。方法对310例4～13岁变应性疾病儿童进行12种常见变应原皮肤点刺试验,同期采用夹心ELISA方法检测血清尘螨sIgE和IgG4水平。采用SPSS13.0软件进行统计学分析。结果变应性疾病儿童皮肤变应原检测阳性100%(310/310例),≥3种变应原阳性者占35.8%(111/310例)。引起变应性疾病的变应原主要为吸入物,阳性率最高的变应原是粉尘螨。变应性疾病儿童血清尘螨sIgE和IgG4水平明显高于健康对照组(t=14.253、12.314,Pa<0.01)。血清尘螨sIgE水平与皮肤变应原试验阳性种类的多少无相关性(r=-0.004 3,P>0.05);粉尘螨变应原阳性强度与血清尘螨sIgE水平呈正相关(r=0.219 8,P<0.05);血清尘螨sIgE水平与IgG4水平呈一定正相关(r=0.173 0,P<0.05)。结论变应原皮肤点刺试验有助于发现变应性疾病儿童的变应原及了解机体免疫状态强度,提供应尽可能避免接触的变应原,有条件者可进行脱敏治疗。监测血清sIgE和IgG4水平对...     

Bet v 1-specific IgA increases during the pollen season but not after a single allergen challenge in children with birch pollen-induced intermittent allergic rhinitis

Allergen-specific immunoglobulins of the Immunoglobulin A (IgA) type have been found in the nasal fluid of patients with allergic rhinitis. IgA may play a protective role, but there are also data which show that allergen-specific IgA can induce eosinophil degranulation. The aim of this study was to quantitate Bet v 1-specific IgA in relation to total IgA in the nasal fluid of children with birch pollen-induced intermittent allergic rhinitis and healthy controls, after allergen challenge and during the natural pollen season. Eosinophil cationic protein (ECP), Bet v 1-specific IgA and total IgA were analyzed in nasal fluids from 30 children with birch pollen-induced intermittent allergic rhinitis and 30 healthy controls. Samples were taken before the pollen season, after challenge with birch pollen and during the pollen season, before and after treatment with nasal steroids. During the pollen season, but not after nasal allergen challenge, Bet v 1-specific IgA increased in relation to total IgA in children with allergic rhinitis. No change was found in the healthy controls. The ratio of Bet v 1-specific IgA to total IgA increased from 0.1 x 10(-3) (median) to 0.5 x 10(-3) in the allergic children, p < 0.001. No change was seen after treatment with nasal steroids, although symptoms, ECP and eosinophils were reduced. In conclusion, allergen-specific IgA in relation to total IgA increases in nasal fluids during the pollen season in allergic children but not in healthy controls. These findings are compatible with the hypothesis that allergen-specific IgA plays a role in the allergic inflammation and further studies are needed to clarify the functional role of these allergen-specific antibodies.     

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目的比较3~14岁哮喘和变应性鼻炎患儿吸入性致敏原分布特征的异同。方法2004-10—2005-10,北京儿童医院对527例哮喘和620例变应性鼻炎患儿进行吸入性致敏原皮肤点刺试验(skin prick test,SPT),分析比较检出阳性的致敏原在两组病例中的分布特征。结果哮喘和变应性鼻炎患儿SPT阳性检出率分别为77·8%和78·9%(χ2=0·823,P>0·05)。户尘螨、粉尘螨、交链孢霉、猫上皮、艾蒿是两种疾病主要致敏原。哮喘患儿户尘螨、粉尘螨、混合霉菌的阳性率分别为64·6%、59·8%、8·8%,均高于变应性鼻炎患儿(49·5%、47·9%、3·9%,均P<0·05)。变应性鼻炎患儿杂草花粉和艾蒿的阳性率分别为25·6%、26·0%,均高于哮喘患儿(19·3%、19·3%,均P<0·05)。40·2%的哮喘和46·2%的变应性鼻炎为单致敏原阳性。尘螨霉菌混合致敏及尘螨宠物混合致敏在哮喘和变应性鼻炎中最为常见。结论尘螨、霉菌、夏秋季花粉和宠物是3~14岁哮喘和变应性鼻炎患儿主要吸入性致敏原,两病具有相似的致敏原分布特征,但尘螨及霉菌过敏多见于哮喘,夏秋季花粉过敏多见于变应性鼻炎。     

The association between early sensitization patterns and subsequent allergic disease. The DARC birth cohort study

Prevention of allergic diseases depends on early identification of clinical markers preceding such disorders. This study describes the natural course of sensitization as measured by skin prick test (SPT) and specific immunoglobulin E (S‐IgE) and analyses the association between early sensitization patterns and subsequent allergic disease at 6 yr of age. In an ongoing population‐based birth cohort study of 562 children, follow‐up visits were performed at 0, 3, 6, 9, 12, 18, 36, and 72 months. Visits included an interview, physical examination, SPTs, and S‐IgE measurements for 12 food and inhalant allergens. The frequency of S‐IgE sensitization to ≥1 inhalant allergen was constant from 0 to 6 months (9–10%), decreased at 12–18 months before increasing from 36 months onwards. S‐IgE sensitization to at least one food allergen remained constant from 0 to 6 yr. SPT sensitization to food and inhalant allergens appeared from 3 and 12 months, respectively. Early food sensitization (S‐IgE) between 3 and 18 months was found to be significantly (p < 0.05) associated with atopic dermatitis (OR: 4.0 [1.6–9.9]) and asthma (OR 4.0 [1.1–12.5]) at the age of 6 yr. Children with atopic dermatitis, asthma, or rhinoconjunctivitis, and sensitization at 6 yr, were sensitized to food allergens to a large extent (53%, 42%, and 47%, respectively) already at 6 months. Early inhalant sensitization (S‐IgE) did not increase the risk of later allergic disease. Early atopic dermatitis (0–18 months) was also highly associated with subsequent allergic disease. Children with early food sensitization and/or atopic dermatitis would be a proper target group for future interventional studies.     

High prevalence and young onset of allergic rhinitis in children with bronchial asthma

Bronchial asthma and allergic rhinitis often co-exist, and rhinitis is a major risk factor for the development of asthma. However, the reported incidence of allergic rhinitis in asthmatic children varies widely. The aim of this study was to elucidate the incidence of allergic rhinitis, the onset age of chronic upper and lower airway symptoms, and the correlation of these two symptoms in asthmatic children. A cohort of 130 consecutive children (ages 2–10) with asthma was evaluated. A questionnaire regarding upper and lower airway symptoms was filled out by the parents. Objective diagnosis of allergic rhinitis was also made on the basis of rhinoscopy, nasal cytology, nasal challenge, and specific serum IgE (CAP-RAST). Persistent nasal symptoms were present in 83.8% of the asthmatic children. The incidence of allergic rhinitis was 77.7% based on the objective findings. The mean onset age of asthma was 2.8 yr, and that of rhinitis was 2.9 yr. Nasal symptoms started as early as the first year of life in 8.9% of the children. In children with comorbid asthma and allergic rhinitis, rhinitis preceded in 33.7%, asthma preceded in 31.7%, and both started in the same year in 26.7%. In 7.9%, rhinitis was asymptomatic. Concomitant exacerbation of the upper and lower airways occurred in 34.6% of the total 130 children. These results demonstrate that allergic rhinitis manifested early in life in the majority of the asthmatic children. Persistent nasal symptoms in infancy may point to subsequent development of asthma and possible early intervention.     

Practical aspects of allergy-testing

Allergy-testing is a prerequisite for specific allergy treatment, including specific allergen avoidance measures, relevant pharmacotherapy and specific allergy vaccination. All children with persisting, recurrent or severe possible "allergic symptoms" or those with a need for continuous treatment should be tested, irrespective of the child's age. Allergy-testing includes a careful case history and a determination of IgE sensitisation by skin prick test or the measurement of allergen-specific IgE in serum by standardised and validated methods. The diagnosis of food allergy cannot usually be based solely on the case history and IgE sensitisation; the diagnosis has to be confirmed by controlled food elimination and food challenge procedures. The diagnosis of inhalant allergic disease requires only confirmatory nasal, conjunctival or bronchial challenges in equivocal cases or before specific allergy treatment such as extensive allergen avoidance measures or allergy vaccination.     

Discrepancy between sensitization to inhaled allergens and respiratory symptoms in pediatric patients with type 1 diabetes mellitus

According to the ‘Th₁/Th₂ paradigm’, children with type 1 diabetes mellitus (T1DM) should have a lower risk of developing allergic sensitization and, because of the involvement of insulin in modulating airway inflammation, different frequency or severity in allergy‐related respiratory manifestations. This article aims at evaluating the frequency and type of allergic sensitization and its respiratory manifestation, asthma and/or rhinitis, in a group of pediatric patients with T1DM. Patients (112) with T1DM, 7.8–16.9 yr of age (63 males and 49 females) were evaluated. Skin prick test (SPT) reactivity to the most common classes of aeroallergens were performed and compared with data obtained in 709 school‐aged children. The frequency of sensitization was not different in the T1DM and in the control subjects (43.7% and 40.8%, respectively; p = 0.55), with similar proportions of individuals sensitized to one allergen (32.7% and 38.1%, respectively; p = 0.47). In both groups, sensitization to house dust mite allergens was the most frequently detected (69.4% and 65.4%, respectively; p = 0.59), with a higher proportions of individuals sensitized to Graminae (+Cynodon dactylon; p < 0.0001) and a lower, but weakly significant, proportion sensitized to Parietaria (p = 0.03) in the T1DM group, as compared with controls. No differences were found between T1DM and control groups in the proportion of individuals reporting rhinitis (26.8% and 29.2%; p = 0.60). However, comparing separately sensitized and non‐sensitized subjects, a lower proportion of rhinitis subjects was detected in the non‐sensitized T1DM patients, when compared with the non‐sensitized control subjects (p = 0.01). In addition, no differences were detected between T1DM and control groups in frequency of symptoms related to ‘lifetime asthma’, i.e., asthma episodes during life (14.3% and 16.5%, respectively: p = 0.55), also when sensitized and non‐sensitized subjects were evaluated separately (p = 0.12 and p = 1.00, respectively). However, no T1DM patient had ‘actual asthma’, i.e., asthma episodes in the last year, vs. 5.8% of the individuals in the control group (p = 0.009), the difference being mostly ascribed to sensitized subjects (p = 0.012). Finally, out of the 16 T1DM patients with ‘lifetime asthma’, 15 had mild intermittent disease and only one mild persistent disease. T1DM does not seem to play a downregulating role on the development of allergic sensitization to aeroallergens, but may lower the frequency or the severity of its clinical manifestations at respiratory level.     

Hyposensitization: indications and expectations

Allergy is the most frequent immunologic disorder in childhood. The prevalence of allergic complaints among children is estimated as about 10%. The diagnosis of an allergy takes the following factors into account: The patient's history, skin test, determination of total and specific IgE antibodies and a provocation test to a diseased organ. Hyposensitization is recommended for allergic patients without any significant improvement in spite of avoidance of allergen and in spite of pharmacologic therapy. Modified allergens/allergoids demonstrate a comparable efficacy as a conventional subcutaneous allergen immunotherapy. Measurement of specific IgE- and IgG-antibodies permits an evaluation of degree of sensitization and/or immune response to hyposensitization treatment.