Allergie aux protéines du lait de vache dans les suites d'une chirurgie digestive néonatale

Aim of the study. – To measure the prevalence of cow's milk protein allergy (CMPA) following neonatal intestinal surgery.Patients and methods. – The files of all children who underwent intestinal surgery in the neonatal period over for a four-year-period were reviewed. The diagnosis of CMPA was made on the basis of the association of one or several symptoms suggesting food allergy after the introduction of cow's milk protein in the diet, the disappearance of the symptoms after exclusion of cow's milk protein from the diet and their reappearance after reintroduction of cow's milk protein.Results. – During the study period, 251 neonates underwent intestinal surgery. Among them, 11 babies (4.3%) developed CMPA. The five children of these 11 babies who had been fed a diet containing cow's milk protein before surgery did not have symptoms suggesting CMPA before surgery. The diagnostic signs of CMPA were primarily digestive. Casein-specific immunoglobulin E was present in 9 out of 10 cases, and α-lactalbumin –– and/or β-lactoglobulin –– specific immunoglobulin E was present in 6 out of 10 cases. Prick tests performed in three of the children were positive.Conclusion. – The relatively high prevalence of CMPA among this group of patients raises the question of the role of neonatal intestinal surgery in the development of food allergy. These data underline the importance of considering a diagnosis of CMPA when digestive symptoms occur after the introduction of cow's milk in the diet of children undergoing neonatal intestinal surgery.     

Cow's milk protein allergy. A multi-centre study: clinical and epidemiological aspects

BackgroundDue to the age when it becomes apparent and the treatment needed, cow's milk proteins (CMP) allergy requires an accurate diagnosis to avoid labelling infants falsely as allergic and subjecting them to unnecessary diets. The objective of this multi-centre study carried out at the Allergy Units of 14 Children's Hospitals was to discover the epidemiological, clinical and evolutionary characteristics of cow's milk protein allergy (CMPA).Methods and resultsInfants suspected of CMPA who attended allergy clinics at the hospitals taking part during the study period were studied and a detailed clinical history was collected on all of them. Prick tests were done with cow's milk and its proteins and specific IgE anti-bodies were determined by means of CAP with the same allergens as the Prick test. The challenge test with cow's milk was carried out unless contraindicated by the diagnostic protocol. Two different challenge regimens were used: one of them carried out in 3 days and the other in one day.409 infants with suspected CMPA were included and the diagnostic challenge test was performed on 286 patients (70 %) and not carried out on 123, as it was not indicated according to the protocol. IgE-mediated allergy was confirmed in 234 infants (58 %) and in 15 (4 %) non-IgE-mediated hypersensitivity was diagnosed. The two challenge regimens were equally secure. The average age when the reaction to cow's milk formula took place was 3.5 months (10 days-10 months). The symptoms appeared in the first week of introduction in 95 % of cases and appeared in 60 % with the first feeding with the formula. The most frequent clinical signs were cutaneous in 94 % of cases and the majority of cases appeared within 30 minutes of the feed. 99 % had been breast fed and 44 % had received some cow's milk supplement during the lactation period. Sensitization to egg not given in the feed was noted in 30 % and to beef in 29 %, being well tolerated in all of these.ConclusionsCarrying out an appropriate diagnostic protocol in infants attending for suspected CMPA allows allergy to be ruled out in a high percentage of cases.     

Is oral food challenge test useful for avoiding complete elimination of cow's milk in Japanese patients with or suspected of having IgE-dependent cow's milk allergy?

BackgroundCow's milk, along with hen's egg, are common causes of food allergies in children worldwide. Accidental ingestion of milk is common and often induces severe allergic reactions. Oral food challenge test (OFC) is usually performed in patients with or suspected of having a food allergy. However, the evidence of whether cow's milk OFC is useful in IgE-dependent cow's milk allergy patients to avoid total elimination is not known.MethodsAfter setting the clinical question and outcomes, we performed a systematic review for relevant articles published from January 1, 2000 to August 31, 2019 using PubMed® and Ichushi-Web databases. Each article was then evaluated for the level of evidence. All positive results of the OFC were defined as adverse events.ResultsForty articles were selected in this study. Our review revealed that cow's milk OFC was able to avoid the complete elimination of cow's milk in 66% of the patients with cow's milk allergy. We also found that adverse events occurred frequently (50.5%).ConclusionsThis analysis supports the recommendation of conducting cow's milk OFC to avoid complete elimination of cow's milk, however the test should be conducted with careful consideration of the patient's safety. As the methods of OFC and subjects varied among the articles selected in this study, further studies are needed to obtain higher quality evidence.     

Absence of clinical symptoms upon introduction of egg into the diet of milk-allergic infants not previously sensitised to egg

BackgroundIt is unclear how many children suffering from IgE mediated cow's milk allergy are sensitised to egg in early life and what the clinical implication of this sensitisation is. It is also unclear if those not sensitised to egg in early life, do later on develop sensitisation and clinical allergy to egg.MethodsThis study examines the prevalence of egg sensitisation among infants with allergy to cow's milk, prior to and following the introduction of egg and what this sensitisation clinically means.ResultsThe percentage of egg-sensitised children seen among the group of children with cow's milk allergy was 43.2%, and predictive factors for egg sensitisation are discussed. 81.8% of the sensitised patients presented with symptoms when exposed to egg in at least one of its forms, although up to 54.5% of patients tolerated boiled egg and egg-based products. Of the non-sensitised patients, the vast majority (92.5%) did not present with symptoms after the introduction of egg in their diet.ConclusionsCoexistence of allergy to egg and milk allergy is common, and it is recommended that these patients be monitored, since children who are sensitised to egg despite having never been exposed to it in their diet, may present with symptoms immediately following first ingestion. Most children who are initially non-sensitised to egg do not require special care, and it is not generally recommended to delay or monitor these children, although a small number may have subsequently reacted to egg.     

In vitro methods for specific IgE detection in cow's milk allergy

BackgroundA new method for determining serum specific IgE (IMMULITE^® 2000 3gAllergy) has recently become available.ObjectiveTo evaluate the clinical performance of IMMULITE 2000 in the diagnosis of cow's milk allergy compared with that of UniCAP^®. Additionally, we verified the behavior of both methods at two diagnostic decision points proposed by other authors.MethodsThe study population consisted of 31 children with cow's milk allergy (group A) and a control group of 19 atopic children without food allergy (group B). A blood sample from each child was tested using both methods and the results were compared.ResultsIn group A, the values for cow's milk IgE ranged from 0.35 kU/L (the lowest common detection limit) to above 100 kU/L. In group B, the values were less than 1.1 kU/L for IMMULITE 2000 and less than 1.6 kU/L for UniCAP. An agreement of 90 % in IgE classes was obtained. Both methods demonstrated exactly the same diagnostic performance (sensitivity: 100 %; specificity: 78.9 %; negative predictive value: 100 %; positive predictive value: 84.6%; efficiency: 90.2 %). The evaluation of the two methods at the two different decision points proposed in the literature showed a better positive predictive value with UniCAP, but we obtained equivalent performance with IMMULITE 2000 by choosing higher cutoff values.ConclusionsWe conclude that IMMULITE 2000 is as effective as UniCAP in the diagnosis of cow's milk allergy. Both methods can be used to obtain site-specific decision points that are population, age and disease dependent.     

Milk-induced wheezing in children with asthma

BackgroundFood allergy has been gaining increasing attention, mostly as causing gastrointestinal and cutaneous reactions. Its role in asthma seems to be under-recognised.ObjectivesThis study's aim is to explore the frequency of involvement of a common food, namely cow's milk, in childhood asthma.Methods32 children (5 months to 11 years; median 24 months; mean 34 months) with asthma and a suspected history of cow's milk allergy were studied. They underwent skin prick testing (SPT) and specific IgE (sIgE) testing to whole cow's milk (WCM), casein, α-lactalbumin, and β-lactoglobulin, followed by single-blind oral milk challenge.ResultsReactions to milk challenge occurred in 12 (37.5%) including wheezing in 5 (41.7%, or 15.6% of the whole group). Children who developed wheezing at the time of challenge were younger than those who had negative challenge (23.0 months vs. 34.8 months). Challenge was positive in 33.3% of subjects who had a positive SPT, and SPT was positive in 50% of challenge-positive subjects. Regarding sIgE, challenge was positive in 26.7% of sIgE-positive subjects, and sIgE was positive in 33.3% of challenge positive subjects. Skin or serum testing with individual protein fractions did not seem to add significant advantage over testing with WCM alone.ConclusionThis study shows that cow's milk can cause wheezing in children with asthma. Although SPT seemed to be more reliable than sIgE testing, both had suboptimal reliability. It is worth considering possible milk allergy in children with asthma, particularly when poorly controlled in spite of proper routine management.     

Effect of oral immunotherapy in children with milk allergy: The ORIMA study

BackgroundThis study was aimed at evaluating the efficacy and safety of oral immunotherapy (OIT) in children with severe cow's milk allergy.MethodsThe subjects comprised 28 children (aged 3–12 years) with allergic symptoms that were induced by ≤ 10 mL of cow's milk in an oral food challenge test (OFC). The subjects were randomly allocated to the treatment group (n = 14) and control group (n = 14); the former received rush immunotherapy for 2 weeks, followed by a gradual increase of cow's milk volume to 100 mL for 1 year, and the latter completely eliminated cow's milk for 1 year. Both groups underwent an OFC with 100 mL of cow's milk after 1 year.ResultsThe treatment group had significantly higher rates of a negative OFC [7/14 (50%) vs. 0/14 (0%), p < 0.01] compared with the control group. The cow's milk-specific IgE level significantly decreased in the treatment group (p < 0.01) but not in the control group (p = 0.63). During the study period, adrenaline was required in 6/14 patients (43%) of the treatment group and in 0/14 patients (0%) of the control group. Long follow-up data were available at the 2-year point after the study for 8 in the treatment group and 7 (87.5%) of these continued to ingest milk (>100 mL).ConclusionsThe effect of immunotherapy was 50%, but the incidence of adverse events was not low. Further studies focusing on safety is necessary to standardize OIT for cow's milk allergy.     

Predicting outgrowth of IgE-mediated cow's milk allergy: Diagnostic tests in children under two years of age

BackgroundLimited studies conducted on children <2 years old and/or involving a skin prick test (SPT) for fresh milk (FM) have examined the predictive value of allergometric tests for outgrowth of cow's milk allergy (CMA). We investigated the optimal decision points for outgrowth (ODP^fo) with SPT for commercial cow's milk extract (CE) and FM and specific immunoglobulin E (sIgE) levels for milk proteins to predict outgrowing allergy in children <2 years old.MethodsSPTs for CE and FM, tests for sIgEs (cow's milk, casein, α-lactoalbumin, β-lactoglobulin) and oral food challenges (OFC) were performed in children referred for evaluation of suspected CMA, and 15 months after diagnosis.ResultsFifty-one children (median age, 7.5 months; range, 2–23 months) were enrolled. Five had a history of anaphylaxis and 26 of 48 children with a positive initial challenge underwent milk elimination. The last OFC was performed in 28 children of whom 13 reacted to milk. The initial SPT responses to CE and FM and milk sIgE levels of the patients with persistent CMA were higher at diagnosis, with ODP^fo of 7 mm, 9 mm, and 10.5 kU/L, respectively; these values remained higher with ODP^fo of 4 mm, 11 mm, and 10.5 kU/L at the last OFC.ConclusionHigher initial SPTs for FM and CE and higher initial sIgE levels for cow's milk proteins are associated with a reduced likelihood of outgrowth. Initial milk sIgE level <10.5 kU/L and initial SPT for fresh milk <9 mm are related to the acquisition of tolerance in the follow-up period.     

Cow's Milk Allergy among Children with Gastroesophageal Reflux Disease

Background/Aims

Gastroesophageal reflux disease (GERD) and cow''s milk allergy (CMA) are two common conditions that occur in infancy. This study was performed to investigate the frequency of CMA in a group of patients with GERD.

Methods

Eighty-one children with signs and symptoms of GERD were enrolled in this study. All subjects received omeprazole for 4 weeks after the initial evaluation. Empirical elimination of cow''s milk from the diet was started for the patients who did not respond to the omeprazole treatment.

Results

Seventy-two cases presented with gastrointestinal signs and symptoms, whereas the remaining nine cases presented with respiratory complaints. After the initial treatment with omeprazole, two thirds of the cases (54 patients, 66.7%) responded well, and all of their symptoms were resolved. Cow''s milk was eliminated from the diets of the remaining 27 patients. All signs and symptoms of GERD were resolved in this group after a 4 week elimination of cow''s milk from the diet.

Conclusions

A diagnosis of CMA was considered in one third of the pediatric cases with signs and symptoms of GERD. This finding shows that CMA can mimic or aggravate all signs and symptoms of severe GERD during infancy.     

Tolerance to baked and fermented cow's milk in children with IgE-mediated and non-IgE-mediated cow's milk allergy in patients under two years of age

BackgroundIgE-mediated cow's milk allergy (CMA) has been shown consistent in milder heated-milk tolerant and severe heated-milk reactant groups in patients older than two years. Little is known whether fermentation of milk gives rise to similar clinical phenotypes.We aimed to determine the influence of extensively heated and fermented cow's milk on the IgE-mediated and non-IgE-mediated CMA in children younger than two years.MethodsSubjects followed with the diagnosis of IgE-mediated and non-IgE-mediated CMA for at least six months underwent unheated milk challenge. IgE-mediated and non-IgE-mediated groups were categorised as unheated milk-reactive and tolerant, separately. Unheated milk-reactive groups were further challenged sequentially with fermented milk (yoghurt) and baked milk, 15 days apart. Allergy evaluation with skin tests, prick-to-prick tests and atopy patch tests were performed.ResultsFifty-seven children (median age: 14 months; range: 7–24 months) underwent unheated milk challenge. Eleven of 27 children with IgE-mediated CMA and 14 of 30 children with non-IgE-mediated CMA tolerated unheated milk. Among subjects who reacted to unheated milk; 15 of 16 subjects (93%) with IgE-mediated CMA also reacted to yoghurt, whereas 11 of 16 subjects (68%) with non-IgE-mediated CMA tolerated fermented milk. Thirteen subjects (81%) of the unheated milk-reactive IgE-mediated group tolerated to heated milk. None of 16 subjects of unheated milk-reactive non-IgE-mediated group reacted to baked milk.ConclusionThe majority of children under the age of two years with both IgE-mediated and non-IgE-mediated CMA tolerated baked-milk products. Yoghurt was tolerated in two thirds of unheated milk reactive patients suffering from non-IgE-mediated CMA.     

Predictors of a positive oral food challenge to cow's milk in children sensitized to cow's milk

Introduction and objectivesThe diagnosis of IgE-mediated cow's milk allergy (CMA) is often based on clinical history and on specific IgE levels and/or skin-prick tests (SPT), both of which are sensitive but not specific. The gold standard, oral food challenge (OFC), is expensive and time-consuming and involves a risk of severe allergic reactions. This study aimed to determine the value of specific IgEs, ratios of specific IgEs for cow's milk and its components to total IgE, and wheal size on SPT for predicting a positive OFC for CMA.Material and methodsWe retrospectively studied 72 patients [median age, four years; age range 0.75–15 years] sensitized to cow's milk who underwent OFCs to milk. predictive variables between patients with positive and negative OFCs were compared. Receiver operator characteristic (ROC) curves were uses to assess variables’ discriminatory capacity and Youden's index to determine the best cut-offs for predicting CMA.ResultsThe OFC was positive in 39 (54%) patients. Wheal size on SPT and all specific IgEs and specific-to-total IgE ratios were significantly different between patients with positive OFCs and those with negative OFCs (p < 0.001). The variable with the greatest area under the ROC curve was casein-specific IgE (0.98), followed by β-lactoglobulin-specific IgE (0.923), casein-specific-to-total-IgE ratio (0.919), and α-lactalbumin-specific IgE (0.908). Casein-specific IgE ≥0.95 kU/L yielded 88.9% sensitivity and 90.9% specificity.ConclusionsIn our center, casein-specific IgE >0.95 kU/L can obviate an OFC to cow's milk for the diagnosis of CMA in patients sensitized to cow's milk with a compatible history.     

Adaptación transcultural y validación de la versión en español del Cow&#x27;s Milk-related Symptom Score (CoMiSS) para alergia a la proteína de leche de vaca

Introduction and aimsThe prevalence of cow's milk protein allergy in the first year of life varies from 1.8 to 7.5%. The Cow's Milk-related Symptom Score (CoMiSS) was published in 2014 and facilitates the diagnosis of cow's milk protein allergy. It is not meant to replace the clinical diagnosis, but rather to guide the treating team in the diagnostic process and reduce unnecessary diets. The aim was to translate the CoMiSS from English to Spanish and culturally adapt and validate the resulting Spanish version.Materials and methodsAn adaptation and validation study on the CoMiSS questionnaire was carried out in two phases: First, the CoMiSS was translated from English to Spanish, after which interrater reliability of the translated score was assessed. Second, interrater reliability tests were carried out on 32 pediatric patients under 7 years of age that were treated for the first time at the Food Allergy Clinic of the Hospital Italiano de Buenos Aires, were suspected of having cow's milk protein allergy, and had not received any treatment, within the time frame of May 2018 and May 2019.ResultsThirty-two patients were evaluated, 14 of whom were females (45%), and the median patient age was 3 months (IQR 2-4). The median result of the first measurement of the scale was 7.0 (IQR 4.5-9.0) and the median of the second measurement was 5.0 (IQR 4.0-8.0). The final intraclass correlation coefficient was 0.80 (95% CI 0.63-0.9).ConclusionThe Spanish translation of the CoMiSS was comparable to the original English version, with excellent interrater reliability. This simple and little-known tool has the benefit of being a noninvasive, rapid, reliable, and easy-to-use strategy.     

Cow's Milk and Type 1 Childhood Diabetes: No Increase in Risk

A retrospective case-control study was undertaken to investigate the relationship between the early introduction of cow's milk and the subsequent risk of developing Type 1 diabetes (< 15 years at diagnosis). A total of 268 children who developed diabetes during the period 1980–1990 (11 years inclusive) in Leicestershire were identified. Age-, sex-, and race-matched controls were identified using the Leicestershire population register. Parents of children with diabetes and their controls completed a structured questionnaire on infant feeding habits from birth. A total of 184 questionnaires (67%) were analysed. There was no difference between the diabetic and control children with respect to the introduction of cow's milk at an early age and the risk of developing diabetes (odds ratio: 0.98 (0.65–1.47)). In addition, short duration of breast-feeding (< 3 months) had no influence on the incidence of diabetes (1.05 (0.64–1.75)). This study does not support the hypothesis that the early introduction of cow's milk or a short duration of breast-feeding increases the risk of developing Type 1 diabetes.     

Quoi de neuf en allergologie pédiatrique en 2004 ? Partie 3 : allergie cutanée,alimentaire, médicamenteuse et aux venins d'insectes (Une revue de la littérature internationale d'octobre 2003 à septembre 2004)

Severity and risk of persistence/relapse of atopic dermatitis are correlated with total IgE levels and food sensitization. Weaning to hypoallergenic formula improves SCORAD and gut barrier function in breastfed infants with persistent atopic dermatitis. Risk of anaphylaxis is high in children with cold-induced urticaria, and these children should be provided with an epinephrine autoinjector. Occult sensitizations are important risk factors for food allergy. The predictive values of serum egg-specific IgE levels are debated. The diagnostic value of atopy patch-tests with foods is confirmed in children with non-immediate food hypersensitivity reactions. Risk of persistence of food allergy is high in children with high specific IgE levels and/or with a low rate of decrease in food-specific IgE levels. Oral desensitization induces tolerance in children with persistent cow's milk allergy, except for children with very high levels of specific IgE. However, tolerance to anaphylactogenic food may be temporary, with the occurence of severe relapses after a few months. Ten per cent of children treated with penicillins are sensitized to these antibiotics. However, only a few of these children are at risk of developing allergy to penicillins. Non allergic hypersensitivity to non steroidal anti-inflammatory drugs is frequent in children. Sublingual immunotherapy may be efficient in children with latex hypersensitivity. A clinically important number of non-hyposensitized children do not outgrow hymenoptera venom allergy. In contrast, venom immunotherapy leads to a significantly lower risk of systemic reaction to stings. Thus, children with moderate to severe allergic reactions to hymenoptera stings should receive specific immunotherapy.     

Conocimiento sobre el diagnóstico y el tratamiento de la alergia a las proteínas de la leche de vaca por un grupo de gastroenterólogos pediatras en Iberolatinoamérica: resultado de la encuesta del Grupo de Trabajo de Alergia Alimentaria de la Sociedad Latinoamericana de Gastroenterología,Hepatología y Nutrición Pediátrica

IntroductionThere are discrepancies in the diagnosis and management of cow's milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA.Material and methodsPediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively.ResultsThe survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57, 83 and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing.ConclusionCMPA management is diverse and there is poor adherence to the clinical practice guidelines.     

Cow's Milk Exposure and Asthma in a Newborn Cohort: Repeated Ascertainment Indicates Reverse Causation

The effect of cow's milk consumption on childhood asthma has been debated for several years. This study attempts to provide further insight into this association through the use of a longitudinal study design. Newborns from parents with atopic history were recruited from Germany, Austria, and England (n = 696). For five repeated ascertainments, information was collected on cow's milk exposure, incidence of doctor-diagnosed asthma, and confounders. Generalized estimation equations, incorporating different models (concurrent, delayed, combined, and reverse causation), were used to determine this association. No association between cow's milk consumption and childhood asthma was found for the concurrent effects model (OR = 0.81, 95% confidence interval [CI]: 0.55, 1.20). In the delayed effects model, the direction of the association varied with time of follow-up. Thus, we stratified by period, which resulted in a significant protective delayed effect at 36 months (OR = 0.18, 95% CI = 0.06, 0.49). However, reverse causation negated this finding since the presence of asthma in prior months led to a reduction in further exposure to cow's milk (OR = 0.40, 95% CI = 0.16, 0.99). Hence, cow's milk consumption does not protect against childhood asthma. The apparent protection of cow's milk against asthma may result from parents of asthmatic children avoiding cow's milk, rather than actual prophylaxis.     

Position document: IgE-mediated allergy to egg protein

Egg is the food that most often causes allergy in young Spanish children, with an incidence of 2.4–2.6% in the first 2 years of life. The prevalence of sensitisation and allergy to egg is greater in children with allergy to cow's milk and in those suffering atopic dermatitis. The protein component from egg white is the cause of the allergic response in child. The major allergens in egg white are ovomucoid and ovalbumin. Most of the allergic reactions affect the skin, followed by gastrointestinal and respiratory systems. Egg allergy is one of the most common causes of severe anaphylaxis. The diagnosis of egg allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which represents the gold standard for confirming the diagnosis.The treatment of egg allergy is based on the avoidance of egg protein intake. A subgroup of egg-allergic patients are tolerant to cooked egg. In these cases, only uncooked egg must necessarily be avoided. Maintaining a diet with strict egg avoidance is difficult, and transgressions are relatively common. The patient, family, and school environment should receive education and training in the avoidance of egg and in the management of possible allergic reactions. With an avoidance diet, up to 15–20% of children will remain allergic and the severity of the reactions will increase over the years. In these more severe cases of egg-allergy, it becomes more difficult to adhere to the avoidance diet over the years, with a significant decrease in patient quality of life.Oral tolerance induction can be regarded as a therapeutic option for IgE-mediated egg allergy. The anti-IgE, omalizumab, might become another genuine therapeutic option for food allergy, not only to prevent allergic reactions after a contact with egg, but also as a complementary treatment to oral tolerance induction for egg allergy, with the purpose of reducing adverse reactions.The administration of influenza vaccine to children with egg allergy is safe in children that do not manifest severe reactions after egg intake, and in children who tolerate cooked egg. The triple viral vaccine (MMR) can be given to egg-allergic children in their usual vaccination centre, with no added risk. Different medicinal products can be formulated with egg proteins, and therefore should be avoided in children with egg allergy.     

Diagnostic accuracy of atopy patch tests for food allergy in children with atopic dermatitis aged less than two years

BackgroundAtopy patch tests (APT) have been introduced as a valuable tool for the diagnosis of food allergy. However, interpretation of the readout of APT requires further clarification.ObjectiveTo investigate the accuracy of APT in identifying atopic sensitisation to hen's eggs (HE), cow's milk (CM), soybean and wheat in Chinese children with atopic dermatitis (AD) aged less than two years and to evaluate skin signs of APT for accurate diagnosis of food allergy.MethodsAPT was performed and food allergy confirmed by open oral food challenges with HE, CM, soybean and wheat in 150 Chinese AD children aged less than two years. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative likelihood ratio (LR−) of APT were calculated.ResultsErythema and infiltration were not sufficiently indicative of a positive APT. The PPV increased with the appearance of indurations and the number of papules. The true positive APT rate increased from scores of + to +++. The PPV and specificity were 100% while APT scores of +++ were obtained with HE, CM and wheat. The sensitivity of APT with HE, CM, soybean and wheat allergy ranged from 59.6% to 90.5%, while the specificity ranged from 82.1% to 92.4%.ConclusionThe APT is a suitable method for the diagnosis of AD in Chinese children aged less than two years with food allergies. Erythema and infiltration are not sufficient indicators of APT positivity. The PPV increases with indurations and the number of papules.     

Prospective,comparative effectiveness trial of cow's milk elimination and swallowed fluticasone for pediatric eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune‐mediated disease in which food antigens play a key role. Current therapeutic options are limited to long‐term steroid medication and dietary elimination of multiple foods, each of which is challenging. Our objective was to compare single food elimination of cow's milk to swallowed fluticasone in pediatric EoE patients. This is a prospective, comparative effectiveness trial of newly diagnosed EoE patients (ages 2–18 years) treated with swallowed fluticasone (n = 24) or elimination of cow's milk (n = 20). The dual outcome measures of repeat esophageal biopsy (6–8 weeks) and change in Pediatric Quality of Life Inventor (PedsQL) EoE Module and Symptoms Scales were used to assess response to treatment. After 6–8 weeks of treatment, peak esophageal eosinophil counts decreased to below the threshold of 15 eosinophils/high‐power field in 64% of patients treated with cow's milk elimination and 80% of patients treated with swallowed fluticasone (P = 0.4). Mean PedsQL EoE Module total scores (69 vs. 82; P < 0.005) and Total Symptoms scores (58 vs. 75; P = 0.001) showed significant improvement with cow's milk elimination. Among children treated with swallowed fluticasone, mean PedsQL EoE Module total scores (64 vs. 75; P < 0.05) and Total Symptoms scores (58 vs. 69; P < 0.01) were also significantly improved after 6–8 weeks of therapy. Removal of cow's milk from the diet is an effective single food elimination treatment for pediatric patients with EoE as assessed by statistically significant histologic and symptomatic improvement. Cow's milk elimination may be more desirable for EoE patients who do not want to take chronic, long‐term steroid medications.     

Food Protein-Induced Gastrointestinal Syndromes in Identical and Fraternal Twins

BackgroundIt has been suggested that gene-environmental interactions play crucial roles in the development of allergy, especially in early life. Analysis of twin cases may provide novel insights into the pathogenesis and pathophysiology of allergy. Though several studies have indicated the importance of a genetic contribution to the expression of allergic diseases based on twin analyses, very few data are available regarding twins with Food Protein-Induced Gastrointestinal Syndrome (FPIGS). Two pairs of identical and fraternal twins with FPIGS are presented.Case SummaryThe twins were born with no abnormalities and fed breast milk and supplemental formula. The identical twins developed vomiting and bloody stool simultaneously. The fraternal twins developed prolonged vomiting and loose stools at different times. Since their symptoms disappeared with when formula feeding was stopped, the symptoms were thought to indicate the presence of an allergy to cow's milk. The clinical symptoms and laboratory findings of the four patients were highly suggestive of FPIGS. The identical and fraternal twins showed very similar symptoms, including their onset and clinical courses. However, a substantial clinical disparity existed in the clinical features of the two pairs of twins.DiscussionComparisons of the twins' similarities and disparities suggest a profound genetic effect on the patients' clinical features, along with individual environmental factors. The prevalence of FPIGS is increasing, and it is now a major topic of public concern in Japan. Further accumulation of data on twins with FPIGS is needed to clarify the genetic contributions to this disease.