Bronchial challenges with aerosolized food in asthmatic, food-allergic children

Flying with nut and other food allergies: unravelling fact from fiction

There is a common perception that peanut/tree nut particles can be transmitted through aircraft ventilation systems and pose a significant risk to passengers with food allergies. In fact, food-induced allergic reactions are around 10-100 times less common during flights than 'on the ground', perhaps because of the multiple precautions food-allergic passengers take when flying. We review the evidence for strategies to help prevent accidental allergic reactions while travelling on commercial flights (review registered at PROSPERO, ref CRD42022384341). Research studies (including aircraft simulations) show no evidence to support airborne transmission of nut allergens as a likely phenomenon. Announcements requesting 'nut bans' are not therefore supported, and may instal a false sense of security. The most effective measure is for passengers to wipe down their seat area (including tray table and seat-back entertainment system). Food proteins are often 'sticky' and adhere to these surfaces, from where they are easily transferred to a person's hands and onto food that might be consumed. Airline companies can help to facilitate this through pre-boarding. Passengers at risk of anaphylaxis should be prescribed two adrenaline [epinephrine] autoinjector devices, to carry on their person at all times-including when flying. Airlines should consider including a separate supply of 'general use' adrenaline autoinjectors in the onboard medical kit for use in an emergency. All airlines should have clear policies relating to food allergies which are easily available from their websites or on request. These policies should be applied consistently by both ground staff and cabin crew, in order to provide reassurance to food-allergic passengers and their caregivers.

Anaphylaxis in Practice: A Guide to the 2023 Practice Parameter Update

This review summarizes new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters 2023 Anaphylaxis practice parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision-making are essential to support patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services after home epinephrine administration may not be required in all cases, and patients should be engaged in shared decision-making to determine when home management may be appropriate.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Childhood food allergy and food allergen sensitisation are associated with adult airways disease: A birth cohort study

BACKGROUND

Childhood food allergy (FA) and food allergen sensitization (FAS) are associated with allergic airway disease(s) [AAD] (asthma and rhinitis) in childhood. However, the associations between childhood FA/FAS and AAD in adulthood are not well described.

METHODS

We investigated the longitudinal relationship between childhood FA/FAS to common food allergens and AAD at 18 and 26 years, in the Isle of Wight birth cohort. Study subjects (N = 1456) were followed up at fixed time points from ages 1-26 years for FA/FAS status. AAD were evaluated from 4 years onwards. The associations between FA/FAS and AAD were assessed with univariate analyses and then multivariable logistic regression, adjusting for clinically relevant co-variates.

RESULTS

Food allergy at 4 years was significantly associated with asthma at 18 years [adjusted odds ratio (aOR): 2.75, 95% CI: 1.53-4.92, p = .001] and 26 years (aOR: 2.62, 95% CI: 1.32-5.20, p = .006). Conversely, childhood FA was not associated with adulthood rhinitis whatsoever. While FAS at ages 4 and 10 were associated with both AAD, the associations between FAS and rhinitis were less robust relative to asthma.

CONCLUSION

Childhood FA increased the odds of asthma during adulthood by nearly threefold. Additionally, childhood FAS was also associated with increased odds of asthma in adulthood. Conversely, FAS but not FA in childhood was associated with rhinitis in adulthood. We suggest that children with FA/FAS should be followed up to facilitate early detection and intervention of subsequent AAD, particularly asthma.

Relationship between longitudinal changes in type-2 inflammation, immunoglobulin E sensitization, and clinical outcomes in young asthmatics

BACKGROUND

Asthma is a heterogeneous condition where biomarkers may be of considerable advantage in diagnosis and therapy monitoring. However, the changes in asthma biomarkers and immunoglobulin E (IgE) over the course of life has not been extensively investigated.

OBJECTIVE

To study longitudinal changes in type-2 inflammatory biomarkers, IgE, and clinical outcomes, and the association between these changes, in young asthmatics.

METHODS

Asthmatics (age 10-35 years, n = 253) were examined at baseline and at a follow-up visit, 43 [23-65] (median [range]) months later. Subjects were analyzed using the multi-allergen tests Phadiatop and fx5 (ImmunoCAP) and grouped based on the baseline allergen-specific IgE antibody (sIgE) concentration: <0.10, 0.10-0.34, and ≥0.35 kU_A /L. The relationship between changes (Δ values) in type-2 biomarkers (individualized fraction of exhaled nitric oxide [FeNO%], blood eosinophil [B-Eos] count, total IgE [tIgE] and sIgE, lung function [% predicted forced expiratory volume in 1 second (FEV₁ ) and FEV₁ /forced vital capacity (FVC)], and Asthma Control Test [ACT]) score were determined.

RESULTS

At follow up, FEV₁ and FEV₁ /FVC had decreased (93.6% vs. 95.8%, and 93.4% vs. 94.7% of predicted, respectively [p < 0.001 both]), whereas ACT score had increased (21.6 vs. 20.6, p = 0.001). A significant decline in lung function was seen in subjects with sIgE ≥ 0.10 kUA/L, but not in those with undetectable sIgE (<0.10 kU_A /L). Furthermore, tIgE and sIgE declined over time (p < 0.001 all) whereas FeNO% and B-Eos count were not significantly changed. In univariate analysis, significant negative correlations between ∆B-Eos count and ∆FeNO%, on one hand, and changes in lung function, on the other hand, were seen, and multivariate analysis showed an independent relationship between ΔFeNO%, and ΔFEV₁ (p < 0.05) and ΔFEV₁ /FVC% (p < 0.01). Sex-specific analysis showed that the independent association between ΔFeNO%, and ΔFEV₁ remained only in females (p = 0.005), and there was a significant interaction with sex (p = 0.02).

CONCLUSION

In young asthmatics, IgE levels declined over 43 months, whereas FeNO and B-Eos remained unchanged. In spite of improved asthma control, an accelerated lung function decline was seen in patients with detectable sIgE at baseline, and the decline correlated with changes in type-2 biomarkers. Particularly, the increase in individualized FeNO associated independently with decline in FEV₁ in females.

Allergic diseases attributable to atopy in a population sample of Asian children

The proportion of allergic diseases attributable to atopy remains a subject of controversy. This study aimed to estimate the population risk of physician-diagnosed asthma, rhinitis and eczema attributed to atopy among a population sample of Asian school-age children. Asian children aged 5–18 years (n = 1321) in the Prediction of Allergies in Taiwanese CHildren (PATCH) study were tested for serum allergen-specific immunoglobulin E. Physician-diagnosed asthma, rhinitis and eczema were assessed by a modified International Study of Asthma and Allergies in Childhood questionnaire. Atopy was defined as the presence of serum allergen-specific immunoglobulin E. In this population-based study, 50.4% of the subjects with asthma, 46.3% with rhinitis, and 46.7% with eczema were attributable to atopy. The population attributable risk (PAR) of atopy for three allergic diseases was higher in adolescents (asthma, 54.4%; rhinitis, 59.6%; eczema, 49.5%) than younger children aged less than 10 years (asthma, 46.9%; rhinitis, 39.5%; eczema, 41.9%). Among the seven allergen categories, sensitization to mites had the highest PARs for all three allergic diseases (51.3 to 64.1%), followed by sensitization to foods (asthma, 7.1%; rhinitis, 10.4%; eczema 27.7%). In conclusion, approximately half (46.3 to 50.4%) of Asian children in Taiwan with allergic diseases are attributable to atopy.

Food Hypersensitivity Reactions to Seafish in Atopic Dermatitis Patients Older than 14 Year of Age - The Evaluation of Association with Other Allergic Diseases and Parameters

Background

Seafood allergy is among one of the common food allergies. Decrease in consumption of omega-3 polyunsaturated fatty acids (PUFAs), prevalent especially in oily fish, has been proposed to contribute to the increased prevalence of allergic diseases.

Aim

The aim of this study was to evaluate, in atopic dermatitis (AD) patients, the relation between the occurrence of food hypersensitivity reaction (FHR) to seafish and the occurrence of other atopic diseases and parameters.

Methods

Complete dermatological and allergological examination was performed in patients included in the study; 332 patients were examined, with the average age 26.8 years (SD 9.2 years).

Results

The FHR to seafish was confirmed in 11% of patients. Patients suffering from FHR to seafish suffered significantly more from sensitization to fungi (in 46%), from reactions to celery (in 34%), and from persistent eczematic lesions (in 82%).

Conclusion

FHRs to seafish in AD patients are associated with persistent eczematic lesions and with the higher occurrence of sensitization to fungi and reactions to celery. The occurrence of bronchial asthma, rhinitis, positive family history, and onset of AD under 5 years of age is higher in patients with reactions to seafish, but the difference is not statistically significant.

Asthma and Food Allergy: Which Risks?

Over the past few decades, an increase in the prevalence of asthma and food allergy has been observed in the pediatric population. In infants, food sensitization, particularly to egg, has increased the risk of developing allergic asthma. This is even more likely if sensitization to food allergens occurs early within the first few years of life. It is indeed known that both diseases may be present simultaneously in the pediatric population, but coexistence may negatively influence the severity of both conditions by increasing the risk of life-threatening asthmatic episodes as well as food-related anaphylaxis. Therefore, an accurate clinical and phenotype characterization of this high-risk group of children with both asthma and food allergy and a more aggressive management might lead to reducing related morbidity and mortality. The aim of this review is to provide an updated overview on the close link between food allergy and asthma and their negative mutual influence.

Lipophilic Allergens, Different Modes of Allergen-Lipid Interaction and Their Impact on Asthma and Allergy

Molecular allergology research has provided valuable information on the structure and function of single allergenic molecules. There are several allergens in food and inhalant allergen sources that are able to interact with lipid ligands via different structural features: hydrophobic pockets, hydrophobic cavities, or specialized domains. For only a few of these allergens information on their associated ligands is already available. Several of the allergens are clinically relevant, so that it is highly probable that the individual structural features with which they interact with lipids have a direct effect on their allergenic potential, and thus on allergy development. There is some evidence for a protective effect of lipids delaying the enzymatic digestion of the peanut (Arachis hypogaea) allergen Ara h 8 (hydrophobic pocket), probably allowing this molecule to get to the intestinal immune system intact (sensitization). Oleosins from different food allergen sources are part of lipid storage organelles and potential marker allergens for the severity of the allergic reaction. House dust mite (HDM), is more often associated with allergic asthma than other sources of inhalant allergens. In particular, lipid-associated allergens from Dermatophagoides pteronyssinus which are Der p 2, Der p 5, Der p 7, Der p 13, Der p 14, and Der p 21 have been reported to be associated with severe allergic reactions and respiratory symptoms such as asthma. The exact mechanism of interaction of these allergens with lipids still has to be elucidated. Apart from single allergens glycolipids have been shown to directly induce allergic inflammation. Several-in parts conflicting-data exist on the lipid (and allergen) and toll-like receptor interactions. For only few single allergens mechanistic studies were performed on their interaction with the air-liquid interface of the lungs, in particular with the surfactant components SP-A and SP-D. The increasing knowledge on protein-lipid-interaction for lipophilic and hydrophobic food and inhalant allergens on the basis of their particular structure, of their capacity to be integral part of membranes (like the oleosins), and their ability to interact with membranes, surfactant components, and transport lipids (like the lipid transfer proteins) are essential to eventually clarify allergy and asthma development.

Association of food allergy and decreased lung function in children and young adults with asthma

BACKGROUND

Food allergy (FA) appears early in the atopic march, a progression that may lead to the development of asthma. The association between FA and pulmonary function in children with and without asthma remains unknown.

OBJECTIVE

To investigate the association between FA and lung function in children with and without asthma.

METHODS

We enrolled 1,068 children as a part of a family-based FA cohort. We then categorized children as having FA by physician diagnosis, evidence of specific IgE, and typical symptoms within 2 hours of food ingestion. We categorized asthma by physician diagnosis. We used American Thoracic Society criteria for spirometry measurements. We assessed the effects of asthma classification and FA number on lung function using mixed-effect models.

RESULTS

We enrolled 1,068 children: 417 (39%) had asthma, 402 (38%) had at least 1 FA, and 162 (15%) had 2 or more FAs. Unstratified analyses found no significant association between FA number and lung function. In children with asthma, we detected statistically significant differences in predicted forced expiratory flow at 25% to 75% between children with 2 or more FAs compared with those with none (mean [SE] β = -7.5 [3.6]; P = .04). This effect lost significance after adjusting for aeroallergen sensitization. We detected no significant associations between FA number and predicted forced expiratory volume in 1 second, forced vital capacity, and ratio of forced expiratory volume in 1 second to forced vital capacity.

CONCLUSION

Having 2 or more FAs is a potential risk factor for greater small airway airflow obstruction among children with asthma, highlighting the need for close clinical follow-up and improved intervention strategies for these patients.

Environmental Food Exposure: What Is the Risk of Clinical Reactivity From Cross-Contact and What Is the Risk of Sensitization

For food-allergic individuals, the typical exposure to food proteins happens during ingestion; however, individuals may be exposed to foods in other ways. In addition to ingestion reactions, allergic patients may have reactions from cutaneous or mucosal exposures to food proteins, with the classic example being a peanut-allergic child touching a counter with peanut butter and then rubbing their eyes. Similar to hands, saliva can also act as a carrier for food proteins. Finally, there is a wealth of new research regarding the presence of food proteins in the environment, for example, within household floor dust. This review will focus on (1) cross-contact of food proteins and (2) environmental food protein exposures. Cross-contact occurs when one type of food comes into contact with another type of food resulting in the mixture of proteins. For food allergies, cross-contact is important when an allergen is inadvertently transferred to a food/meal that is thought to not contain that specific allergen. We will discuss the current literature regarding the presence of detectable food proteins in different locations, how and if these proteins are transferred or eliminated, and the clinical implications of exposures to food proteins under these different scenarios.

Food Allergy and Asthma: Is There a Link?

Purpose of review

To describe and understand the links and interactions between food allergy and asthma.

Recent findings

Food allergy and asthma are characterized by an increasing prevalence. Moreover, food allergy and asthma often coexist. Both conditions are associated with each other in different ways. It has been shown that food allergy is a risk factor of developing asthma. Atopic dermatitis appears to be the common denominator in this interaction. Loss-of-function variants of the filaggrin mutation result in an impaired epidermal barrier function and have been shown to be a risk factor for the development of atopic dermatitis, allergies, and asthma. Early introduction of food allergens and optimal treatment of the skin barrier are preventive interventions for the development of food allergy and asthma. Asthma is also a risk factor for the development of severe or even fatal anaphylaxis in patients with food allergy. Isolated asthma is not a feature of a food allergic reaction; however, respiratory symptoms may be part of anaphylactic reactions. In addition, during an allergic reaction to food, non-specific bronchial hyperreactivity may increase. Cross-reactive allergens may be responsible for asthma-associated food allergy. This is particularly true for severe asthma upon ingestion of snail in patients allergic to house-dust mites. Finally, airborne allergens from occupational sources such as wheat, fish, and seafood may induce asthmatic reactions. This phenomenon is sometimes seen in non-occupational settings.

Summary

Food allergy and asthma are interconnected with each other beyond the presence of simple comorbidity. Food allergy precedes and predisposes to asthma, and mutual interactions range from respiratory symptoms and bronchial hyperreactivity during food-induced anaphylaxis to severe asthma due to cross-reactive food allergens and to occupational asthma upon exposure to airborne allergens. Moreover, coexisting asthma in food allergies may result in severe and sometimes fatal anaphylactic reactions.

Managing anaphylaxis in the office setting

BACKGROUND

Although the definition of anaphylaxis for clinical use may vary by professional health care organizations and individuals, the definition consistently includes the concepts of a serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or even fatal.

METHODS

In this review, we presented the important topics in the treatment of anaphylaxis in the office setting. This review will discuss triggers and risk factors, clinical diagnosis, and management of anaphylaxis in the office setting.

RESULTS

Anaphylaxis in the office setting is a medical emergency. It, therefore, is important to prepare for it, to have a posted, written anaphylaxis emergency protocol, and to rehearse the plan regularly. In this review, we presented the important steps in managing anaphylaxis in the office. Treatment of anaphylaxis should start with epinephrine administered intramuscularly at the first sign of anaphylaxis. Oxygen and intravenous fluids may be needed for moderate-to-severe anaphylaxis or anaphylaxis that is quickly developing or if the patient is unresponsive to the first injection of epinephrine. Antihistamine therapy is considered adjunctive to epinephrine, which mainly relieves itching and urticaria. Corticosteroids, with an onset of action of 4-6 hours, have no immediate effect on anaphylaxis.

CONCLUSION

To prevent near-fatal and fatal reactions from anaphylaxis, the patient, the family, and the physician must remember to follow the necessary steps when treating anaphylaxis. In anaphylaxis, there is no absolute contraindication for epinephrine.

Asthma, Food Allergy, and How They Relate to Each Other

The association between atopic diseases is well known, and previous research has shown that having one atopic disease can predispose to having another. The link between asthma and food allergy has been well researched, but the exact relationship between the two atopic conditions is not fully understood. Food allergic infants are at increased risk for the development of asthma and are at risk of food-induced asthmatic episodes and also anaphylaxis. Having a diagnosis of both food allergy and asthma has also been shown to have an effect on the severity of a patient's disease including being at greater risk of severe asthmatic episodes. Therefore, understanding the relationship between these two conditions in order to treat and manage these children safely is crucial to clinicians.

Clinical management of food allergy

Food allergies are commonly seen by the practitioner, and managing these patients is often challenging. Recent epidemiologic studies report that as many as 1 in 13 children in the United States may have a food allergy, which makes this an important disease process to appropriately diagnose and manage for primary care physicians and specialists alike. Having a understanding of the basic immunologic processes that underlie varying presentations of food-induced allergic diseases will guide the clinician in the initial workup. This review will cover the basic approach to understanding the immune response of an individual with food allergy after ingestion and will guide the clinician in applying appropriate testing modalities when needed by conducting food challenges if indicated and by educating the patient and his or her guardian to minimize the risk of accidental ingestion.

Asthma and Food Allergy in Children: Is There a Connection or Interaction?

This review explores the relationship between food allergy and asthma. They can share the same risk factors, such as parental allergy, atopic eczema, and allergen sensitization, and they often coincide in the same child. Coexistence may negatively influence the severity of both conditions. However, it remains to be determined whether food allergy may directly affect asthma control. An early food sensitization in the first year of life can predict the onset of asthma. Furthermore, asthmatic symptoms could rarely be caused by ingestion or inhalation of the offending food. Asthma caused by food allergy is severe and may be associated with anaphylactic symptoms. Therefore, an accurate identification of the offending foods is necessary in order to avoid exposure. Patients should be instructed to treat asthmatic symptoms quickly and to use self-injectable epinephrine.

Clinical Management of Food Allergy

Food allergies have become a growing public health concern. At present the standard of care focuses on avoidance of trigger foods, education, and treatment of symptoms following accidental ingestions. This article provides a framework for primary care physicians and allergists for the diagnosis, management, and treatment of pediatric food allergy.

School Food Allergy and Anaphylaxis Management for the Pediatrician--Extending the Medical Home with Critical Collaborations

Community pediatricians, working in consultation with allergists, create a medical home that is the central focus of care for the child with life-threatening food allergies. They participate in coordinating mutual and critical collaborations within schools that support families and children. They can provide leadership and guidance to both families and schools to safeguard children and adolescents, thereby extending the medical home goals into the school setting.

Fish allergy: in review

Globally, the rising consumption of fish and its derivatives, due to its nutritional value and divergence of international cuisines, has led to an increase in reports of adverse reactions to fish. Reactions to fish are not only mediated by the immune system causing allergies, but are often caused by various toxins and parasites including ciguatera and Anisakis. Allergic reactions to fish can be serious and life threatening and children usually do not outgrow this type of food allergy. The route of exposure is not only restricted to ingestion but include manual handling and inhalation of cooking vapors in the domestic and occupational environment. Prevalence rates of self-reported fish allergy range from 0.2 to 2.29 % in the general population, but can reach up to 8 % among fish processing workers. Fish allergy seems to vary with geographical eating habits, type of fish processing, and fish species exposure. The major fish allergen characterized is parvalbumin in addition to several less well-known allergens. This contemporary review discusses interesting and new findings in the area of fish allergy including demographics, novel allergens identified, immunological mechanisms of sensitization, and innovative approaches in diagnosing and managing this life-long disease.

Food allergens in mattress dust in Norwegian homes - a potentially important source of allergen exposure

BACKGROUND

Sensitization to food allergens and food allergic reactions are mostly caused by ingesting the allergen, but can also occur from exposure via the respiratory tract or the skin. Little is known about exposure to food allergens in the home environment.

OBJECTIVE

The objective of this study was firstly to describe the frequency of detection of allergens from fish, egg, milk, and peanut in mattress dust collected from homes of 13-year-old adolescents and secondly to identify home characteristics associated with the presence of food allergen contamination in dust.

METHODS

Food allergens were measured by dot blot analysis in mattress dust from 143 homes in Oslo, Norway. We analysed associations between home characteristics (collected by parental questionnaires and study technicians) and food allergens by multivariate regression models.

RESULTS

Fish allergen was detected in 46%, peanut in 41%, milk in 39%, and egg allergen in 22% of the mattress dust samples; only three samples contained none of these allergens. All four food allergens were more frequently detected in mattresses in small dwellings (< 100 m(2)) than larger dwellings (≥ 130 m(2)); 63-71% of the small dwellings (n = 24) had milk, peanut, and fish allergens in the samples compared with 33-44% of the larger dwellings (n = 95). Milk, peanut, and egg allergens were more frequently detected in homes with bedroom and kitchen on the same floor as compared with different floors, with odds ratios of 2.5 (95% confidence interval (CI): 1.1, 5.6) for milk, 2.4 (95% CI: 1.0, 6.1) for peanut, and 3.1 (95% CI: 1.3, 7.5) for egg allergens.

CONCLUSIONS AND CLINICAL RELEVANCE

Food allergens occurred frequently in beds in Norwegian homes, with dwelling size and proximity of kitchen and bedroom as the most important determinants. Due to the amount of time children spent in the bedroom, mattress dust may be an important source of exposure to food allergens.

Aeroallergen and food IgE sensitization and local and systemic inflammation in asthma

BACKGROUND

We recently reported an independent association between IgE sensitization to food allergens and increased airway inflammation, assessed by fraction of exhaled nitric oxide (FeNO), in a population-based study (J Allergy Clin Immunol, 130, 2012, 397). Similar studies have not been performed in populations with asthma. The aim of the present study was to investigate the allergic sensitization profile in asthmatics and examine FeNO, airway responsiveness and blood eosinophilia in relation to type and degree of IgE sensitization.

METHOD

FeNO, airway responsiveness, blood eosinophil count (B-Eos) and IgE sensitization to food allergens and aeroallergens were determined in 408 subjects with asthma, aged 10-34 years.

RESULTS

Asthmatics had higher prevalence of IgE sensitization against all allergens than controls (P < 0.001). Mite, pollen, furry animal, mould and food sensitizations were each associated with increased FeNO, airway responsiveness and B-Eos in asthmatics. IgE sensitization to mould, furry animals and food allergens was independently related to FeNO (all P < 0.05) after adjustment for age, sex, height, smoking history and medication. IgE sensitization to mould (P < 0.001) and furry animals (P = 0.02) was related to airway responsiveness in a similar model. Finally, IgE sensitization to mould (P = 0.001), furry animals (P < 0.001) and food allergens (P < 0.001) was independently related to B-Eos.

CONCLUSION

Independent effects of IgE sensitization to aeroallergens (furry animals and mould) and food allergens were found on both local and systemic markers of inflammation in asthma. The finding regarding food IgE sensitization is novel, and a clinical implication might be that even food sensitization must be assessed to fully understand inflammation patterns in asthma.

Eosinophilic airway inflammation is increased in children with asthma and food allergies

BACKGROUND

Asthma is associated with food allergies in a significant number of children, with evidence linking allergies to asthma severity and morbidity. In this study, we tested our hypothesis that the eosinophilic lower airway inflammation is higher in asthmatic children with food allergies.

AIMS

The aims of the study were to compare the eosinophilic inflammatory markers in asthmatic children with and without food allergies.

MATERIALS AND METHODS

Children with asthma, with (n = 22) and (n = 53) without food allergies were included. All subjects were classified according to the GINA guidelines (2009) and had received at least 3 months of anti-inflammatory therapy prior to testing. Fractional exhaled nitric oxide and sputum differential counts were performed using standard techniques.

RESULTS

  Children with asthma and food allergies had significantly higher fractional exhaled nitric oxide median (range) [(22.4 (6.1-86.9) vs. 10.3 (2.7-38.7) (p = 0.01)] and sputum eosinophil percentage [15.5 (5.0-53.0) vs. 2.0 (0-20) (p < 0.001)] compared with asthmatic children without allergies.

CONCLUSION

These results suggest that the children with asthma and food allergies have increased eosinophilic inflammation of the airways.

Buckwheat allergy: a potential problem in 21st century Britain

Buckwheat is commonly consumed in many parts of the world and has recently become more available in the UK. Buckwheat allergy is well recognised in parts of mainland Europe and Asia, typically associated with consumption of specific regional foods. No adult cases of buckwheat allergy in the UK have been reported in the literature. The authors present two cases of buckwheat allergy that presented to our UK allergy service recently. A 57-year-old man presented with anaphylaxis after eating home-baked bread prepared using buckwheat flour bought in France. In the second case, a 63-year-old lady presented with bronchospasm and urticaria after consuming health-food muesli. Sensitisation was confirmed in both cases by positive skin prick testing and specific IgE to buckwheat. Given the growing popularity of foods that may contain buckwheat, including ethnic and health-food ranges, buckwheat allergy is likely to become increasingly common in the UK.

Living with food allergy: allergen avoidance

The primary treatment of food allergy is to avoid the culprit foods. This is a complex undertaking that requires education about reading the labels of manufactured products, understanding how to avoid cross-contact with allergens during food preparation, and communicating effectively with persons who are providing allergen-safe meals including relatives and restaurant personnel. Successful avoidance also requires a knowledge of nuances such as appropriate cleaning practices, an understanding of the risks of ingestion compared to skin contact or inhalation, that exposure could occur through unanticipated means such as through sharing utensils or passionate kissing, and that food may be a component of substances that are not ingested such as cosmetics, bath products, vaccines and medications. The authors review the necessary tools of avoidance that physicians and medical practitioners can use to guide their patients through the complexities of food avoidance.

Shellfish allergy

Seafood plays an important role in human nutrition and health. The growing international trade in seafood species and products has added to the popularity and frequency of consumption of a variety of seafood products across many countries. This increased production and consumption of seafood has been accompanied by more frequent reports of adverse health problems among consumers as well as processors of seafood. Adverse reactions to seafood are often generated by contaminants but can also be mediated by the immune system and cause allergies. These reactions can result from exposure to the seafood itself or various non-seafood components in the product. Non-immunological reactions to seafood can be triggered by contaminants such as parasites, bacteria, viruses, marine toxins and biogenic amines. Ingredients added during processing and canning of seafood can also cause adverse reactions. Importantly all these substances are able to trigger symptoms which are similar to true allergic reactions, which are mediated by antibodies produced by the immune system against specific allergens. Allergic reactions to 'shellfish', which comprises the groups of crustaceans and molluscs, can generate clinical symptoms ranging from mild urticaria and oral allergy syndrome to life-threatening anaphylactic reactions. The prevalence of crustacean allergy seems to vary largely between geographical locations, most probably as a result of the availability of seafood. The major shellfish allergen is tropomyosin, although other allergens may play an important part in allergenicity such as arginine kinase and myosin light chain. Current observations regard tropomyosin to be the major allergen responsible for molecular and clinical cross-reactivity between crustaceans and molluscs, but also to other inhaled invertebrates such as house dust mites and insects. Future research on the molecular structure of tropomyosins with a focus on the immunological and particularly clinical cross-reactivity will improve diagnosis and management of this potentially life-threatening allergy and is essential for future immunotherapy.

Clinical features of legume allergy in children from a Mediterranean area

BACKGROUND

Lentils, chickpeas, beans, and peas are the most common consumed legumes in the Mediterranean area. However, there is little information about allergy to these legumes.

OBJECTIVES

To describe the clinical features of a Spanish pediatric population allergic to legumes (lentils, chickpeas, peas, white beans, and peanuts), to evaluate the clinical allergy to several legumes, and to determine which legume extract is most appropriate to use in the diagnosis of legume allergy by skin tests.

METHODS

Fifty-four children with allergic reactions after exposure to legumes were studied. The diagnosis of legume allergy was confirmed by positive skin prick test results with legume extracts and food challenges or a recent convincing history of severe reactions.

RESULTS

The onset of allergic reactions was at approximately the age of 2 years (median, 22 months). Skin prick test results were positive for at least 3 legumes in 38 children (70%). Positive results were more frequent to boiled extracts than to raw extracts in children with a positive oral challenge. Allergy to lentil was the most frequently diagnosed legume allergy (43 children [80%]), followed by allergy to chickpea (32 children [59%]). Oral challenges with more than 1 legume (median, 3 legumes) were positive in 37 children (69%). The most frequent induced symptoms on challenge were respiratory (rhinitis and/or asthma) and cutaneous.

CONCLUSION

In this population, lentils and chickpeas are the legumes that cause most allergic reactions, clinical allergy to more than 1 legume is common, and boiled legume extracts are most appropriate to discriminate between allergic and tolerant sensitized children.

Prevalence of legume sensitization in patients with naso-bronchial allergy

Prevalence of legume allergy and concomitant sensitization to different allergens was evaluated in patients of asthma and/ or rhinitis. Skin prick test with 27 common food allergens and 61 aeroallergens in 76 subjects was performed. Out of 76 subjects, 41 perceived allergenic problems with different food items as contributing factor. Only six patients showed prick test positivity compatible with their anamnesis. However, 35 subjects showed sensitization to different food items, out of which thirty were sensitive to legumes. The common foods in decreasing order of allergenicity were chickpea, followed by green gram, egg white, and bean fresh/red gram. Concomitant sensitization to different legume crops was found in patients.

New visions for food allergy: an iPAC summary and future trends

The spectrum of food allergy consists of a variety of different clinical pictures including immunoglobulin (Ig)E, and non-IgE food allergy as well as mixed, IgE and non-IgE disorders. In addition, eosinophilic diseases of the gastrointestinal (GI) tract with occasional IgE-type sensitization are increasingly recognized. As a consequence, the clinical picture of food allergy is pleomorphic and can range from chronic GI symptoms to severe anaphylaxis. The diagnosis of food allergy is mostly hampered by the lack of reliable in vitro tests for non-IgE-mediated diseases, and in most cases relies on a reoccurrence of symptoms upon re-exposure to the antigen; in general during a standardized food challenge. Currently, there is no safe and efficient treatment for food allergy and the treatment relies on avoidance diets. Priorities for research have been identified by iPAC (international Pediatric Allergy and Asthma Consortium) and outlined in this review. They include studies to better identify the pathogenesis of food allergy, including genetic aspects; studies to develop diagnostic and follow-up tests; studies for standardization of food challenges; as well as studies addressing a safe and efficient treatment of food allergy.

[Food hypersensibility: inhalation reactions are different from ingestion reactions]

Eight children, aged from 3 to 9 years, presented to inhaled peanut an immediate allergic reaction. All were sensitized to peanut but none had already ingested it overtly. A strict avoidance diet was prescribed concerning this food allergen. An oral provocation challenge was realized to determine the eliciting dose (ED) to ingestion. The ED was high enough to allow all the children a less restrictive diet. Inhaled allergic reaction to peanut does not always justify a strict avoidance diet.

Anaphylaxis to foods

Three crucial areas of the management of anaphylaxis due to food allergy are discussed: making a diagnosis, deciding who needs a self-injectable adrenaline device and spotting the novel allergen. Managing children and teenagers with anaphylaxis is challenging due to the lack of available evidence that specific addresses these issue. The available evidence is presented and discussed.

Food allergy as a risk factor for asthma morbidity in adults

BACKGROUND

The objective of this study was to evaluate the relationship between food allergy and asthma morbidity in adults.

METHODS

We interviewed a cohort of persistent asthmatics from an inner-city clinic. Allergies to food were assessed by patient report of convincing symptoms of acute allergic reactions. Outcome variables included health resource utilization and medication use.

RESULTS

The prevalence of allergy to fish, peanut, tree-nut, shellfish, and seed allergies were 3%, 3%, 3%, 13%, and 1%. Patients with allergies to > 1 food had increased asthma hospitalizations, ED visits, and use of oral steroids (p < 0.05 for all comparisons). Specifically, allergy to fish was associated with a greater risk of health resource utilization and increased frequency of oral steroid use (p < or = 0.03 for all comparisons).

CONCLUSIONS

Self-reported allergy to foods was associated with worse outcomes, suggesting that food allergy may be a risk factor for increased asthma morbidity in adults.

The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology

Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.

Food Intolerance and childhood asthma: what is the link?

Food allergies and asthma are increasing worldwide. It is estimated that approximately 8% of children aged <3 years have food allergies. Foods can induce a variety of IgE-mediated, cutaneous, gastrointestinal, and respiratory reactions. The most common foods responsible for allergic reactions in children are egg, milk, peanut, soy, fish, shellfish, and tree nuts. Asthma alone as a manifestation of a food allergy is rare and atypical. Less than 5% of patients experience wheezing without cutaneous or gastrointestinal symptoms during a food challenge. In addition to acute respiratory symptoms, a food allergy may also induce airway hyper-responsiveness beyond the initial reaction. This process can occur in patients who do not demonstrate a decrease in lung function during the reaction. Inhalation of aerosolized food particles can cause respiratory symptoms in selected food-allergic individuals, particularly with fish and shellfish during cooking and aerosolization. However, this has not been demonstrated with the smelling of, or casual contact with, peanut butter. Rarely, food additives such as sulfating agents can cause respiratory reactions. This reaction occurs primarily in patients with underlying asthma, particularly in patients with more severe asthma. In contrast, there is no convincing evidence that tartrazine or monosodium glutamate can induce asthma responses. Although food-induced asthma is rare, it is common for patients and clinicians to perceive that food can trigger asthma. Avoidance of specific foods or additives has not been shown to improve asthma, even in patients who may perceive that a particular food worsens their asthma.However, patients with underlying asthma are more likely to experience a fatal or near-fatal food reaction. Food reactions tend to be more severe or life threatening when they involve the respiratory tract. The presence of a food allergy is a risk factor for the future development of asthma, particularly for children with sensitization to egg protein. The diagnosis of a food allergy includes skin or in vitro testing as an initial study when the history suggests food allergy. While negative testing generally rules out a food allergy, positive testing should be followed by a food-challenge procedure for a definitive diagnosis. The CAP-RAST FEIA (CAP-radioallergosorbent test [RAST] fluoroenzyme immunoasssay system [FEIA]) is an improved in vitro measure that in some cases may decrease the need for food challenges. However, similar to skin testing and the RAST, there is good sensitivity but poor specificity, such that specific challenges are often warranted.

Allergic reactions to foods by inhalation

Although allergic reactions to foods occur most commonly after ingestion, inhalation of foods can also be an underlying cause of these reactions. For example, published reports have highlighted the inhalation of allergens from fish, shellfish, seeds, soybeans, cereal grains, hen's egg, cow's milk, and many other foods in allergic reactions. Symptoms have typically included respiratory manifestations such as rhinoconjunctivitis, coughing, wheezing, dyspnea, and asthma. In some cases, anaphylaxis has been observed. In addition, there have been many investigations of occupational asthma following the inhalation of relevant food allergens. This report reviews the current literature focusing on allergic reactions to foods by inhalation.

Rice (Oryza sativa) allergy in rhinitis and asthma patients: a clinico-immunological study

Sensitization to foods varies in different countries reflecting a possible interaction of genetic factors, cultural and dietary habits. Rice is a major food consumed world wide and needs evaluation for IgE mediated reactions. The present study was carried out to identify rice allergy in patients of rhinitis and asthma and identify the allergenic proteins in raw and cooked rice. Of 1200 patients screened using standard questionnaire, 165 presented with history of rice allergy. Of these, 20 (12.1%) patients demonstrated marked positive skin prick test (SPT) and 13 showed significantly raised specific IgE to rice compared to normal controls. Double blind placebo controlled food challenge (DBPCFC) confirmed rice allergy in 6/10 patients. Immunoblot with hypersensitive individual patients' sera showed 14-16, 33, 56 and 60 kDa proteins as major IgE-binding components in rice. Boiled rice retained four IgE reactive proteins of 16, 23, 33 and 53 kDa. In summary, IgE-mediated rice allergy affects 0.8% [(0.42-1.58) at 95% CI] of asthma and rhinitis cases. The subjects with severe SPT reactions (4 mm or above) and specific IgE, 6.9 ng/ml to rice demonstrated positive blinded food challenge with clinical symptoms.

Oral and nasal sensitization promote distinct immune responses and lung reactivity in a mouse model of peanut allergy

Despite structural and functional differences between the initial sites of contact with allergens in the gastrointestinal and nasal tracts, few animal models have examined the influence of the mucosal routes of sensitization on host reactivity to food or environmental antigens. We compared the oral and nasal routes of peanut sensitization for the development of a mouse model of allergy. Mice were sensitized by administration of peanut proteins in the presence of cholera toxin as adjuvant. Antibody and cytokine responses were characterized, as well as airway reactivity to nasal challenge with peanut or unrelated antigens. Oral sensitization promoted higher levels of IgE, but lower IgG responses, than nasal sensitization. Both orally and nasally sensitized mice experienced airway hyperreactivity on nasal peanut challenge. The peanut challenge also induced lung eosinophilia and type 2 helper T-cell-type cytokines in orally sensitized mice. In contrast, peanut challenge in nasally sensitized mice promoted neutrophilia and higher levels of lung MAC-1(+) I-A(b low) cells and inflammatory cytokines. In addition, nasal but not oral, sensitization promoted lung inflammatory responses to unrelated antigens. In summary, both oral and nasal peanut sensitization prime mice for airway hyperreactivity, but the initial mucosal route of sensitization influences the nature of lung inflammatory responses to peanut and unrelated allergens.

Adverse reactions to foods

Food allergy encompasses a variety of immune-mediated adverse reactions to foods. IgE-mediated, cell-mediated, and mixed-mechanism food allergy disorders are recognized. Over the past 2 decades, the prevalence of food allergy doubled and its phenotypic expression increased in Westernized societies. Major food allergens have been identified for many common foods. Laboratory diagnosis of food allergy relies heavily on the detection of food-specific IgE antibodies, but novel approaches include tests for T-cell-mediated disorders and tests for prediction of tolerance. OFC remains the diagnostic standard for food allergy. Management of food allergy focuses on avoidance of the offending foods, nutritional support, and prompt recognition and treatment of acute food allergic reactions. Anti-IgE monoclonal antibody is the first potential therapy for food allergy that is under-going testing in clinical trials.

Food allergy and additives: triggers in asthma

Exposure to food allergens can cause a varied pattern of respiratory symptoms, with allergic responses ranging from asthma symptoms to occupational asthma. Food allergy in a patient presenting as asthma tends to indicate a more severe disease constellation. Patients with underlying asthma experience more severe and life-threatening allergic food reactions. When a food reaction involves respiratory symptoms, it is almost always a more severe reaction compared with reactions that do not involve the respiratory tract. Susceptible patients may even react to a causative food on inhalation without ingestion. However, isolated asthma or rhinitis symptoms without concomitant cutaneous or gastrointestinal symptoms are rare events.