Can we determine a threshold level for allergenic foods by statistical analysis of published data in the literature?

A comparison of double-blind, placebo-controlled food challenge and open food challenge

BACKGROUND

Double-blind, placebo-controlled food challenge (DBPCFC) remains the gold standard for diagnosing food allergy, despite sparse comparisons to open food challenges (OpenFCs). The objective of this retrospective study was to compare severity of symptoms and threshold values (cumulative dose of food allergen eliciting a clinical reaction) in children and adults with peanut allergy, challenged in an open and/or double-blind, placebo-controlled protocol.

METHODS

This study included patients from the Allergy Centre, Odense University Hospital with a positive oral food challenge, defined as strict objective signs, with peanut during the period 2001-2022. Severity of symptoms was graded using the Sampson's severity score. Distribution models of threshold values were calculated using log-normal interval-censored survival analysis, and the number of placebo reactions was evaluated.

RESULTS

In total, 318 positive OpenFCs and 86 DBPCFCs were included. There was no difference in severity of symptoms nor threshold values comparing the two challenge types, neither when stratified for age groups. However, a higher proportion of children experienced Grade 3 symptoms in the double-blind group. Only one patient had a positive reaction to a placebo challenge.

CONCLUSION

Our findings do not advocate for DBPCFC being superior to OpenFC, if the latter is performed with strict objective stop criteria by trained staff.

Quantification of Soy-Derived Ingredients in Model Bread and Frankfurter Matrices with an Optimized Liquid Chromatography-Tandem Mass Spectrometry External Standard Calibration Workflow

ABSTRACT

The detection and quantification of soy protein is important for food allergen management and identifying the presence of undeclared soy proteins. Heat processing and matrix interactions can affect the accuracy of allergen detection methods. The sensitivity of enzyme-linked immunosorbent assay methods can be compromised if protein epitopes are modified during processing. Therefore, a mass spectrometry (MS)-based method was evaluated for the recovery of total soy protein in incurred matrices. MS-based quantification of total soy protein was assessed by using a combination of external and internal standards. The reproducibility of the standard curves was investigated by comparing within-day and among-day variation. Incurred samples were prepared using bread and frankfurters as model food matrices. Several soy-derived ingredients were used to prepare the matrices with varying levels of soy protein (1, 10, 50, or 100 ppm of total soy protein). A pooled standard curve was used to estimate the total soy protein concentration of the incurred food matrices and the percent total protein recovery. The variation of replicate standard curves between days and among all days was not significant. The differences in slopes obtained from replicate standards run on different days were minimal. The most influential factor on the quantitative protein recovery in incurred samples was the effect of the physical matrix structure on protein extraction. The lowest percent protein recoveries, less than 50%, were calculated for uncooked matrices. The cooked matrices had percentage recoveries between 50 and 150% for all total soy protein levels. Other factors, such as type of ingredient, were determined to be not as impactful on recovery. The MS method described in this study was able to provide sensitive detection and accurate quantification of total soy protein from various soy-derived ingredients present in processed food matrices.

HIGHLIGHTS

Japanese Food Allergy-Labeling System and Comparison with the International Experience; Detection and Thresholds

In the Japanese allergy-labeling system, food labeling is mandated for 7 specific ingredients (egg, cow's milk, wheat, buckwheat, peanut, shrimp, and crab) and recommended for 21 food ingredients in reference to case numbers of actual illness and the degree of seriousness. To monitor the validity of the labeling system, official methods for the detection of specific ingredient proteins in processed foods were developed. The official methods consist of ELISA methods for screening, and western blot methods for egg and milk, and PCR methods for wheat, buckwheat, peanut, shrimp/prawn, and crab as confirmation tests. The official methods consist of ELISA methods for screening, and western blot methods for egg and milk, and PCR methods for wheat, buckwheat, peanut, shrimp/prawn, and crab as confirmation tests. Threshold amounts (a few mg/kg) for labeling were set based on the approach of the analytical detections. Any foods containing protein allergens should be labeled if these contain allergens at greater than 10 ppm (mg/kg). Validation protocol criteria were established to standardize the Japanese official method. Food Safety Commission of Japan conducted a risk assessment of egg as a specific ingredient and judged that current labeling system for foods containing allergens is generally appropriate for "eggs". In the future, it is important to accumulate necessary scientific knowledge in order to carry out food health impact assessment including further refinement. The Japanese experience and knowledge of food allergy-labeling system would contribute to harmonize international labeling guidelines to protect allergic consumers globally.

Bayesian hierarchical evaluation of dose-response for peanut allergy in clinical trial screening

Risk-based labeling based on the minimal eliciting doses (EDs) in sensitized populations is a potential replacement for precautionary allergen labeling of food allergens. We estimated the dose-response distribution for peanut allergen using data from double-blind placebo-controlled food challenges (DBPCFCs) conducted in the US at multiple sites, testing a population believed to be similar to the general U.S. food allergic population. Our final (placebo-adjusted) dataset included 548 challenges of 481 subjects. Bayesian hierarchical analysis facilitated model fitting, and accounted for variability associated with various levels of data organization. The data are best described using a complex hierarchical structure that accounts for inter-individual variability and variability across study locations or substudies. Bayesian model averaging could simultaneously consider the fit of multiple models, but the Weibull model dominated so strongly that model averaging was not needed. The ED01 and ED05 (and 95% credible intervals) are 0.052 (0.021, 0.13) and 0.49 (0.22, 0.97) mg peanut protein, respectively. Accounting for challenges with severe reactions at the LOAEL, by using the dose prior to the LOAEL as the new LOAEL, the ED01 drops to 0.029 (0.014, 0.074) mg peanut protein. Our results could aid in establishing improved food labeling guidelines in the management of food allergies.

Can we define a level of protection for allergic consumers that everyone can accept?

Substantial progress has been made in characterising the risk associated with exposure to allergens in food. However, absence of agreement on what risk is tolerable has made it difficult to set quantitative limits to manage that risk and protect allergic consumers effectively. This paper reviews scientific progress in the area and the diverse status of allergen management approaches and lack of common standards across different jurisdictions, including within the EU. This lack of regulation largely explains why allergic consumers find Precautionary Allergen Labelling confusing and cannot rely on it. We reviewed approaches to setting quantitative limits for a broad range of food safety hazards to identify the reasoning leading to their adoption. This revealed a diversity of approaches from pragmatic to risk-based, but we could not find clear evidence of the process leading to the decision on risk acceptability. We propose a framework built around the criteria suggested by Murphy and Gardoni (2008) for approaches to defining tolerable risks. Applying these criteria to food allergy, we concluded that sufficient knowledge exists to implement the framework, including sufficient expertise across the whole range of stakeholders to allow opinions to be heard and respected, and a consensus to be achieved.

Quantitative allergenicity risk assessment of food products containing yellow mealworm (Tenebrio molitor)

Insect-based foods are starting to enter the EU market, raising concerns about their safety. Allergic consumers might be exposed to even a greater risk, since insects have proven to trigger allergic symptoms, particularly in patients sensitised to crustaceans. Current legislation does not enforce producers to include insects in the list of allergenic ingredients. Food allergenicity risk assessment (FARA) is still at its infancy, and the debate on the need to define allergen thresholds is open. In this paper, we aimed at applying the concepts of stochastic quantitative FARA to describe present and future scenarios of exposure to foods containing Tenebrio molitor, the yellow mealworm. According to our risk characterisation, mealworm-based food products represent a major risk for individuals allergic to crustaceans to develop symptoms after the consumption of a dose lower than a serving size. Moreover, other allergic consumers might be at risk. A correct labelling of insect containing foods would help safeguarding the health of EU allergic consumers. Quantitatively assessing the risk of allergenicity provides a clear description of the problem, facilitating the decisional process of the risk manager, supporting the implementation of effective allergen management procedures and limiting the phenomenon of uninformative precautionary labelling.

Propofol use in children with allergies to egg, peanut, soybean or other legumes

Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic administered and any adverse events or signs of an allergic reaction in the peri-operative period. A convenience sample of patients without any known food allergies was identified from our prospective anaesthesia research database and acted as a control group. We identified 304 food-allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy-free patients who were exposed to propofol. In 10 (3%) allergy patients and 124 (14%) allergy-free patients, criteria for a possible allergic reaction were met. In nine of the food-allergic children and in all the controls valid non-allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

Insects in food and feed - allergenicity risk assessment and analytical detection

Insects and insect‐based food products have entered in the European market, carrying along issues of safety and the need of establishing a new legal framework. The consumption of massively reared insects can pose chemical and microbiological risks, and insect proteins are likely to represent a hazard for a subpopulation of allergic individuals. All insect‐based products are considered ‘Novel Food’ and fall under EU regulation 2015/2283, according to which a specific application to the European Commission, followed by EFSA scientific evaluation, is needed before the product is put on the market. The recent EU Regulation 2017/893, entered into force on 1 July 2017, allowed a shortlist of seven insect species to be included in the formulation of feeds for aquaculture. Previously, the addition of any insect to any feed for farmed animals was not allowed, due to the risk of prion‐derived diseases. The introduction of this new Regulation raises the issue to switch from a classical detection method based on microscopy to a more sophisticated and species‐specific method. The overall aims of this EU‐FORA project were (i) to set up a new next generation sequencing (NGS)‐based molecular method for the identification of insect DNA in feeds for aquaculture; and (ii) to carry out a conceptual work on a probabilistic quantitative risk assessment focused on the allergenicity of yellow mealworm (Tenebrio molitor) employed in foods.

An update on allergy and anaphylaxis in pediatric anesthesia

Childhood allergy is common, and increasing. Many children are incorrectly labeled as having allergy or adverse drug reactions. This can pose a dilemma for anesthetists and lead to a change in practice or drug selection. We review the pathophysiology of hypersensitivity reactions and the implications for anesthesia of food allergy, atopy, and family history of allergy in children. The epidemiology of anaphylaxis is discussed. We discuss the common triggers of perioperative anaphylaxis in children and explore emerging triggers including chlorhexidine and sugammadex. Accurate data on pediatric perioperative anaphylaxis is limited worldwide, with marked geographic variation. This highlights the need for accurate local, district and/or nationwide incident reporting. The clinical features, diagnosis, and management of anaphylaxis under anesthesia are discussed. We review the process of expert allergy testing following a suspected case of anaphylaxis to guide future safe anesthesia administration. The preoperative consultation is an opportunity for referral for allergy testing to allow de-labeling. This has the potential for improved antibiotic stewardship and more effective treatment with first-line therapeutic agents.

Feasibility of desensitizing children highly allergic to peanut by high-dose oral immunotherapy

BACKGROUND

There are limited data on the feasibility, efficacy and safety of high-dose oral immunotherapy (OIT) in children highly allergic to peanuts.

OBJECTIVE

In children highly allergic to peanut, we primarily aimed to determine the feasibility of reaching the maximum maintenance dose (MMD) of 5000 mg peanut protein or, alternatively, a lower individual maintenance dose (IMD), by OIT up-dosing. Secondarily, we aimed to identify adverse events (AEs) and determine factors associated with reaching a maintenance dose.

METHODS

The TAKE-AWAY peanut OIT trial enrolled 77 children 5-15 years old, with a positive oral peanut challenge. Fifty-seven were randomized to OIT with biweekly dose step-up until reaching MMD or IMD and 20 to observation only. Demographic and biological characteristics, AEs, medication and protocol deviations were explored for associations with reaching maintenance dose.

RESULTS

All children had anaphylaxis defined by objective symptoms in minimum two organ systems during baseline challenge. The MMD was reached by 21.1%, while 54.4% reached an IMD of median (minimum, maximum) 2700 (250, 4000) mg peanut protein, whereas 24.5% discontinued OIT. During up-dosing, 19.4% experienced anaphylaxis. Not reaching the MMD was caused by distaste for peanuts (66.7%), unacceptable AEs (26.7%) and social reasons (6.7%). Increased peanut s-IgG₄ /s-IgE ratio (OR [95% CI]: 1.02 [1.00, 1.04]) was associated with reaching MMD.

CONCLUSION

Although 75.5% of children with peanut anaphylaxis reached a maintenance dose of 0.25-5 g, only 21.1% reached the MMD. Distaste for peanuts and AEs, including high risk of anaphylaxis, limited the feasibility of reaching MMD.

Synthesis of gold-palladium nanowaxberries/dodecylamine-functionalized graphene quantum dots-graphene micro-aerogel for voltammetric determination of peanut allergen Ara h 1

The paper reports synthesis of gold-palladium nanowaxberries(AuPd NWs)/dodecylamine-functionalized graphene quantum dots(D-GQDs)-graphene micro-aerogel(GMA). D-GQDs was used as a solid particle surfactant for stabilizing Pickering emulsion of toluene-in-graphene oxide aqueous dispersion. Graphene oxide sheets in the aqueous phase are reduced by hydrazine hydrate, diffused into the toluene droplet and self-assembled into graphene oxide micro-gels. Followed by freeze-drying, thermal annealing and hybridized with AuPd NWs. The as-prepared AuPd NWs/D-GQDs-GMA shows an unique three-dimensional structure with the size of microns. The small size and strong polarity make it can be directly dispersed in ethanol to form stable dispersion for sensor preparation. The hybrid of GMA, D-GQDs and AuPd NWs greatly improves the electron transfer, electroactive surface area and ion diffusion. The architecture of conductor/semiconductor/conductor achieves to a significant amplification of detection signal. The DNA biosensor based on the AuPd NWs/D-GQDs-GMA exhibits ultrasensitive differential pulse voltammetric (DPV) response towards peanut allergen Ara h 1. The DPV signal linearly increases with increasing DNA concentration in the range of 1.0 × 10^-22-1.0 × 10^-17 M with the detection limit of 4.7 × 10^-23 M (S/N = 3). The analytical method was successfully applied to voltammetric determination of peanut allergen Ara h 1 in peanut milk beverage.

Recent Advances in the Detection of Allergens in Foods

Food allergy is a public health issue that has significantly increased worldwide in the past decade affecting consumers' quality of life and making increasing demands on health service resources. Despite recent advances in many areas of diagnosis and treatment, our general knowledge of the basic mechanisms of the disease remained limited, i.e., not at pace with the exponential number of new cases and the explosion of the new technologies. For sensitized individuals, the only effective way to prevent allergic reactions is the strict avoidance of the offending food. For this reason, a number of regulatory bodies in several countries have recognized the importance of providing information about the presence of food allergens by enacting laws, regulations, or standards for food labeling of "priority allergens." This has resulted in the need for the development of analytical methods for protection of food-allergic consumers that should be among others highly specific, sensitive, and not influenced by the presence of the food matrix components. Several analytical approaches target either the allergen itself or a corresponding allergen marker such as peptide fragment or gene segment and have been used in the detection and quantification of allergens in food products. In this short review, some of the conventional and new methods for the detection of allergens in food are listed and briefly discussed.

Food allergen detection by mass spectrometry: the role of systems biology

Food allergy prevalence is rising worldwide, motivating the development of assays that can sensitively and reliably detect trace amounts of allergens in manufactured food. Mass spectrometry (MS) is a promising alternative to commonly employed antibody-based assays owing to its ability to quantify multiple proteins in complex matrices with high sensitivity. In this review, we discuss a targeted MS workflow for the quantitation of allergenic protein in food products that employs selected reaction monitoring (SRM). We highlight the aspects of SRM method development unique to allergen quantitation and identify opportunities for simplifying the process. One promising avenue identified through a comprehensive survey of published MS literature is the use of proteotypic peptides, which are peptides whose presence appears robust to variations in food matrix, sample preparation protocol, and MS instrumentation. We conclude that proteotypic peptides exist for a subset of allergenic milk, egg, and peanut proteins. For less studied allergens such as soy, wheat, fish, shellfish, and tree nuts, we offer guidance and tools for peptide selection and specificity verification as part of an interactive web database, the Allergen Peptide Browser (http://www.AllergenPeptideBrowser.org). With ongoing improvements in MS instrumentation, analysis software, and strategies for targeted quantitation, we expect an increasing role of MS as an analytical tool for ensuring regulatory compliance.

Ecotoxicology, Environmental Risk Assessment and Potential Impact on Human Health

This chapter examines potential risks posed by active pharmaceutical ingredients (APIs) present in the aquatic environment to humans and aquatic life. We begin by describing the mechanisms by which pharmaceuticals enter the vertebrate body, produce effects and leave the body. Then we describe theoretical and practical issues limiting the certainty which can be expected from risk estimates. This is followed by a description of particular considerations applicable to evaluation of human risks, along with a summary of methods and conclusions from some important studies examining those risks. A similar discussion of theoretical issues and selected data relevant for estimating risks to aquatic life is then presented. We finish by discussing potential contributions of antibiotics present in the environment to the development and spread of antibiotic resistance. We conclude that there are too few data to definitively address every concern, particularly risks to aquatic life and contributions to development of antibiotic resistance. On the other hand, available data suggest risks to humans are very low for all active pharmaceutical ingredients (APIs) and risks to aquatic life are very low for most APIs. Although aquatic risks cannot be as confidently ruled out for a few APIs, potential risks are probably limited to particularly contaminated regions in close vicinity to concentrated pollution sources, such as wastewater treatment plant outfalls.

Position document: IgE-mediated cow's milk allergy

The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy.

Sesame allergy threshold dose distribution

BACKGROUND

Sesame is a relevant food allergen in France. Compared to other allergens there is a lack of food challenge data and more data could help sesame allergy risk management. The aim of this study is to collect more sesame challenge data and investigate the most efficient food challenge method for future studies.

METHOD

Records of patients at University Hospital in Nancy (France) with objective symptoms to sesame challenges were collected and combined with previously published data. An estimation of the sesame allergy population threshold was calculated based on individual NOAELs and LOAELs. Clinical dosing schemes at Nancy were investigated to see if the optimal protocol for sesame is currently used.

RESULTS

Fourteen patients (10 M/4 F, 22 ± 14.85 years old) with objective symptoms were added to previously published data making a total of 35 sesame allergic patients. The most sensitive patient reacted to the first dose at challenge of 1.02 mg sesame protein. The ED05 ranges between 1.2 and 4.0 mg of sesame protein (Log-Normal, Log-Logistic, and Weibull models) and the ED10 between 4.2 and 6.2 mg. The optimal food challenge dosing scheme for sesame follows semi-log dose increases from 0.3 to 3000 mg protein.

CONCLUSION

This article provides a valuable update to the existing clinical literature regarding sesame NOAELs and LOAELs. Establishment of a population threshold for sesame could help in increasing the credibility of precautionary labelling and decrease the costs associated with unexpected allergic reactions. Also, the use of an optimal dosing scheme would decrease time spent on diagnostic and thereafter on the economic burden of sesame allergy diagnosis.

Consensus document on the approach to children with allergic reactions after vaccination or allergy to vaccine components

Vaccinations are one of the main public health tools for the control of vaccine-preventable diseases. If a child is identified as having had an allergic reaction to a vaccine, subsequent immunisations will probably be suspended - with the risks such a decision implies. The incidence of severe allergic reactions is very low, ranging between 0.5 and 1 cases/100,000 doses. Rather than the vaccine antigens as such, the causes of allergic reactions to vaccines are often residual protein components of the manufacturing process such as gelatine or egg, and less commonly yeasts or latex. Most vaccine reactions are mild and circumscribed to the injection site; although in some cases severe anaphylactic reactions can be observed. If an immediate-type allergic reaction is suspected at vaccination, or if a child with allergy to some of the vaccine components is scheduled for vaccination, a correct diagnosis of the possible allergic process must be made. The usual vaccine components must be known in order to determine whether vaccination can be safely performed.

Multiplex detection of food allergens and gluten

To help safeguard the food supply and detect the presence of undeclared food allergens and gluten, most producers and regulatory agencies rely on commercial test kits. Most of these are ELISAs with a few being PCR-based. These methods are very sensitive and analyte specific, requiring different assays to detect each of the different food allergens. Mass spectrometry offers an alternative approach whereby multiple allergens may be detected simultaneously. However, mass spectrometry requires expensive equipment, highly trained analysts, and several years before a quantitative approach can be achieved. Using multianalyte profiling (xMAP®) technology, a commercial multiplex test kit based on the use of established antibodies was developed for the simultaneous detection of up to 14 different food allergens plus gluten. The assay simultaneously detects crustacean seafood, egg, gluten, milk, peanut, soy, and nine tree nuts (almond, Brazil nut, cashew, coconut, hazelnut, macadamia, pine nut, pistachio, and walnut). By simultaneously performing multiple tests (typically two) for each analyte, this magnetic bead-based assay offers built-in confirmatory analyses without the need for additional resources. Twenty-five of the assays were performed on buffer extracted samples, while five were conducted on samples extracted using reduced-denatured conditions. Thus, complete analysis for all 14 allergens and gluten requires only two wells of a 96-well microtiter plate. This makes it possible to include in a single analytical run up to 48 samples. All 30 bead sets in this multiplex assay detected 5 ng/mL of food allergen and gluten with responses greater than background. In addition, 26 of the bead sets displayed signal/noise ratios of five or greater. The bead-based design makes this 30-plex assay expandable to incorporate new antibodies and capture/detector methodologies by ascribing these new detectors to any of the unassigned bead sets that are commercially available.

A surface-enhanced Raman scattering strategy for detection of peanut allergen Ara h 1 using a bipyramid-shaped gold nanocrystal substrate with an improved synthesis

We report an improved synthesis of branched gold nanocrystals for detection of peanut allergen Ara h 1 through use of sodium dodecylbenzene sulfonate. The method allows reduction of CTAB to 0.05 M and accelerates growth of gold seeds.

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.

Analysis to support allergen risk management: Which way to go?

Food allergy represents an important food safety issue because of the potential lethal effects; the only effective treatment is the complete removal of the allergen involved from the diet. However, due to the growing complexity of food formulations and food processing, foods may be unintentionally contaminated via allergen-containing ingredients or cross-contamination. This affects not only consumers' well-being but also food producers and competent authorities involved in inspecting and auditing food companies. To address these issues, the food industry and control agencies rely on available analytical methods to quantify the amount of a particular allergic commodity in a food and thus to decide upon its safety. However, no "gold standard methods" exist for the quantitative detection of food allergens. Nowadays mostly receptor-based methods and in particular commercial kits are used in routine analysis. However, upon evaluation of their performances, commercial assays proved often to be unreliable in processed foods, attributed to the chemical changes in proteins that affect the molecular recognition with the receptor used. Unfortunately, the analytical outcome of other methods, among which are chromatographic combined with mass spectrometric techniques as well as DNA-based methods, seem to be affected in a comparable way by food processing. Several strategies can be employed to improve the quantitative analysis of allergens in foods. Nevertheless, issues related to extractability and matrix effects remain a permanent challenge. In view of the presented results, it is clear that the food industry needs to continue to make extra efforts to provide accurate labeling and to reduce the contamination with allergens to an acceptable level through the use of allergen risk management on a company level, which needs to be supported inevitably by a tailor-validated extraction and detection method.

Inability to detect significant absorption of immunoreactive soya protein in healthy adults may be relevant to its weak allergenicity

Soya and peanut are botanically closely related and share cross-reacting antigens, but compared to soya, peanut allergy has a higher prevalence with more severe allergic reactions. Furthermore, the threshold dose for eliciting reactions is higher for soya. A difference in undigested protein absorption between the two foods, might explain this diversity.

In the current study the amount of soya protein absorbed after soya bean ingestion in healthy adults was estimated. Ten subjects ingested 100 grams of soya beans (40 grams of soya protein) and blood was drawn before and 1, 3 and 24 hours after administration. Serum was analysed by ELISA and histamine release (HR). In all serum samples the soya protein concentration was below quantification limit (1.6 ng/ml which corresponds to 4.8 μg or 0.12 parts per million absorbed soya protein.

We could not detect any significant absorption of soya protein. While we cannot totally exlude technical reasons, it may also reflect a true poor absorption in healthy adult volunteers. This could, in turn, be relevant to the apparently weak allergenicity of soy protein by comparison with peanut protein in allergic subjects.

Anaphylactic reaction to probiotics. Cow's milk and hen's egg allergens in probiotic compounds

BACKGROUND

Probiotics are used in the treatment of allergic diseases. We investigated the safety of probiotics for subjects with food allergy.

MATERIAL AND METHODS

Labels of probiotics commercially available in Spain were examined to assess their content of cow's milk or hen's egg. Skin prick tests with these compounds (20 mg/ml) were performed in five children allergic to cow's milk, five children allergic to hen's white egg, and five control subjects non-allergic to food. Three serum pools: I (positive-specific IgE to cow's milk and hen's egg white proteins), II (positive-specific IgE to cow's milk and negative to hen's egg white proteins), and III (negative-specific IgE to cow's milk and positive to hen's egg white proteins) were used to detect cow's milk and hen's egg white allergens in probiotics. ImmunoCAP(®) (Phadia), in-house ELISA, SDS-PAGE immunoblotting, and inhibition studies of these assays were performed. Proteins were quantified by enzyme-immunoassay.

RESULTS

Eleven probiotics were studied. No label advertised about egg content, eight labels warned about lactose, lactic acid or cow's milk, one label claimed to be milk-free, and two gave no information. Cow's milk proteins were detected, by at least one lab technique, in 10/11 probiotics, three over 2.5 mg/kg (21, 52, 112 mg/kg). Hen's egg white proteins were detected in 3/11 probiotics, only one had more than 2.5 mg/kg (47 mg/kg).

CONCLUSION

Probiotic compounds may contain hidden allergens of food and may not be safe for subjects with allergy to cow's milk or hen's egg.

Electrochemical detection of peanut allergen Ara h 1 using a sensitive DNA biosensor based on stem-loop probe

A novel electrochemical DNA sensor was developed by using a stem-loop probe for peanut allergen Ara h 1 detection. The probe was modified with a thiol at its 5' end and a biotin at its 3' end. The biotin-tagged "molecular beacon"-like probe was attached to the surface of a gold electrode to form a stem-loop structure by self-assembly through facile gold-thiol affinity. 6-Mercaptohexanol (MCH) was used to cover the remnant bare region. The stem--loop probe was "closed" when the target was absent, and then the hybridization of the target induced the conformational change to "open", along with the biotin at its 3' end moved away from the electrode surface. The probe conformational change process was verified by circular dichroism (CD); meanwhile, electron-transfer efficiency changes between probe and electrode were proved by electrochemical impedance spectroscopy (EIS). The detection limit of this method was 0.35 fM with the linear response ranging from 10(-15) to 10(-10) M. Moreover, a complementary target could be discriminated from one-base mismatch and noncomplementarity. The proposed strategy has been successfully applied to detect Ara h 1 in the peanut DNA extracts of peanut milk beverage, and the concentration of it was 3.2 × 10(-13) mol/L.

Outcome of oral food challenges in children in relation to symptom-eliciting allergen dose and allergen-specific IgE

BACKGROUND

Oral food challenge (FC) protocols are discussed with reference to starting doses, dose increments, safety, and predictability of results. The aim of this study was to evaluate the relation of eliciting allergen doses, specific IgE levels and predictive factors to the outcome of FCs in children.

METHODS

In 869 children (median age 1.2 years), FCs were performed with cow's milk (n = 633), hen's egg (n = 456), wheat (n = 265) and/or soy (n = 317) starting at 3-5 mg of protein. Each of the seven doses was administered every 30 min using semi-log increases. Severity of symptoms was graded from I to V. IgE was determined prior to challenges.

RESULTS

Of the children allergic to egg or milk, 9% and 10%, respectively, experienced reactions already at the first dose. Of these, 14% (egg) and 4% (milk) experienced grade IV reactions. In contrast, few children reacted to the first doses of wheat or soy, and most reactions occurred after the maximum dose. For all allergens, grade V reactions did not occur. However, grade IV reactions were seen at all eliciting doses. Elevated specific IgE level, young age and a history of atopic dermatitis were associated with a positive challenge outcome for milk or egg, and also IgE levels were associated with lower eliciting allergen doses and more severe symptoms.

CONCLUSION

Oral FCs bear a risk of severe reactions at all dose levels. Doses of 3-5 mg protein induced symptoms in up to 10% of children allergic to milk or egg. However, food-specific IgE levels are of limited clinical value for the estimation of FC reactions.

Determinants of food allergy

Food allergy is an emerging epidemic in the United States and the Western world. The determination of factors that make certain foods allergenic is still not clearly understood. Only a tiny fraction of thousands of proteins and other molecules is responsible for inducing food allergy. In this review, the authors present 3 examples of food allergies with disparate clinical presentations: peanut, soy, and mammalian meat. The potential relationships between allergen structure and function, emphasizing the importance of cross-reactive determinants, immunoglobulin E antibodies to the oligosaccharides, and the immune responses induced in humans are discussed.

Clinical thresholds to egg, hazelnut, milk and peanut: results from a single-center study using standardized challenges

BACKGROUND

Large studies of individual thresholds and risk profiles for foods are sparse. Previous reports indicate that thresholds adjusted for the protein content in foods would be comparable.

OBJECTIVE

To establish and compare clinical threshold values for egg, hazelnut, milk and peanut, and correlating them to severity of symptoms.

METHODS

Seven hundred eighty-one challenges were performed in 487 patients (age range, 0.5-73.5 years). Using interval censoring survival analysis, the dose distribution of thresholds was fitted to a log-normal function. Symptom score was correlated to thresholds.

RESULTS

Based on the 405 challenges resulting in objective signs, similar distribution of thresholds for hazelnut, milk, and peanut challenges were found, whereas individuals with egg allergy were bimodally distributed with a high or a low threshold. Eliciting dose in 10% (95% confidence interval) was 42.9 (24-76.8) mg whole eggs, 133.8 (95.9-186.6) mg whole hazelnut, 106.5 (59.7-190.6) mg roasted peanut, and 2.9 (1.5-5.4) mL milk. Adults showed more severe symptoms and signs than children, and peanut caused more severe reactions than the 3 other foods.

CONCLUSION

Thresholds for the different foods were not comparable, and eliciting dose for the 4 foods differed, even if adjusted for protein content. Increasing age but not a low threshold dose is associated with severe symptoms on challenge. Peanuts elicit more severe reactions than the other foods.

Effect of simulated gastro-duodenal digestion on the allergenic reactivity of beta-lactoglobulin

Background

Cow's milk (CM) allergy affects about 2% of infants. The allergenicity of dietary proteins, including those from CM, has been related to their digestibility although the generality of the link and its causality remains to be demonstrated. In this study we use an in vitro digestion system, to investigate the digestibility of β-lactoglobulin (blg) during gastrointestinal transit and to assess the impact of this process on blg allergenic reactivity in CM allergic children.

Methods

Blg digesta were prepared using an in vitro digestion protocol simulating either gastric digestion alone or followed by duodenal digestion with or without phosphatidylcholine (PC). Biochemical analysis of blg digesta was performed by SDS-PAGE and their concentration was measured by a sandwich ELISA. Assessment of their allergenic reactivity was done in vitro by EAST inhibition, specific basophil activation (basotest) and lymphocyte proliferation (PCNA-flow cytometry) assays using sera and cells from patients allergic to blg and in vivo by skin prick testing (SPT) of these patients.

Results

Blg was only broken down to smaller peptides after gastro-duodenal digestion although a sizeable amount of intact protein still remained. Digestion did not modify the IgE binding capacity of blg except for gastro-duodenal digestion performed in the absence of PC. These results are consistent with the quantity of intact blg remaining in the digesta. Overall both gastric and gastroduodenal digestion enhanced activation of sensitized basophils and proliferation of sensitized lymphocytes by blg. However, there was a tendency towards reduction in mean diameter of SPT following digestion, the PC alone during phase 1 digestion causing a significant increase in mean diameter.

Conclusions

Digestion did not reduce the allergenic reactivity of blg to a clinically insignificant extent, PC inhibiting digestion and thereby protecting blg allergenic reactivity. SPT reactivity was reduced compared to blg immunoreactivity in in vitro tests.

Endogenous allergen upregulation: transgenic vs. traditionally bred crops

The safety assessment for transgenic food crops currently includes an evaluation of the endogenous allergy potential (via serum IgE screening) when the non-transgenic counterpart is a commonly allergenic food. The value of this analysis in the safety assessment of transgenic crops, especially with reference to recent requests to quantify individual allergen concentrations in raw commodities, is examined. We conclude that the likelihood of upregulating an endogenous allergen due to transgenesis is no greater than from traditional breeding which has a history of safety and is largely unregulated. The potential consequences of upregulating an endogenous allergen are also unclear.

Threshold dose for peanut: Risk characterization based upon diagnostic oral challenge of a series of 286 peanut-allergic individuals

Clinical records of 286 consecutive patients reacting positively with objective symptoms to double-blind, placebo-controlled oral peanut challenges at University Hospital, Nancy, France were examined for individual No Observed Adverse Effect Levels (NOAELs) and Lowest Observed Adverse Effect Levels (LOAELs). After fitting to a log-normal probability distribution model, the ED(10) and ED(05) were 14.4 and 7.3mg (expressed as whole peanut), respectively, with 95% lower confidence intervals of 10.7 and 5.2mg, respectively. Compared to results from a previous study where the ED(10) was based upon individual peanut thresholds gleaned from 12 publications, a statistically significant difference was observed between the ED(50)'s, but not the ED(10)'s of the two probability distribution curves. The Nancy patient group contains more sensitive subjects than the group from the published literature thus contributing to the observed differences. Minimum eliciting dose-distributions for patients with histories of more severe reactions (grade 4 or 5; 40 subjects) did not differ significantly from those of patients with histories of less severe reactions (grades 1-3; 123 subjects). These data and this modeling approach could be used to establish population thresholds for peanut-allergic consumers and thereby provide a sound basis for allergen control measures in the food industry.

The prevalence of food hypersensitivity in young adults

rising prevalence of food hypersensitivity (FHS) and severe allergic reactions to foods have been reported in the last decade. However, little is known on the prevalence in young adults. This study estimated the prevalence of FHS to the most common allergenic foods in an unselected population of young adults. We investigated a cohort of 1272 young adults 22 years of age by questionnaire, skin prick test (SPT) and histamin release (HR) followed by oral challenge to the most common allergenic foods. FHS was divided into primary and secondary FHS. Primary FHS was defined as being independent of pollen sensitization, whereas secondary FHS was defined as reactions to pollen related fruits and vegetables in pollen allergic patients. The questionnaire was returned by 77.1%. Primary FHS was reported by 19.6% and secondary FHS by 16.7% of the participants. Confirmed primary FHS by oral challenge was 1.7% [1.1% - 2.95%]. In primary FHS, the most common allergenic food was peanut (0.6%) followed by additives (0.5%), shrimp (0.2%), codfish (0.1%), cow's milk (0.1%), octopus (0.1%) and soy (0.1%). In secondary FHS, kiwi allergy was reported by 7.8% of the participants followed by hazelnut (6.6%), pineapple (4.4%), apple (4.3%), orange (4.2%), tomato (3.8%), peach (3.0%) and brazil nut (2.7%). This study found a 1.7% [1.1% - 2.95%] prevalence of primary FHS confirmed by oral challenge to the most common allergenic foods in an unselected population of young adults.

The Key Events Dose-Response Framework: a foundation for examining variability in elicitation thresholds for food allergens

Food allergies are caused by immunological reactions in individuals sensitized to normal protein components of foods. For any given sensitized individual, the severity of a reaction is generally assumed to be proportional to the dose of allergenic protein. There is substantial clinical evidence that "threshold" doses exist for the elicitation of an allergic reaction; however, the threshold (i.e., lowest dose that elicits a reaction) varies substantially across the sensitized population. Current approaches to protecting sensitized individuals from exposure to food allergens are highly qualitative (i.e., they rely on food avoidance). The Key Events Dose-Response Framework is an analytical approach for refining understanding of the biological basis of the dose-response. Application of this approach to food allergy provides a foundation for a more rigorous quantitative understanding of variability in allergic response. This study reviews the allergic disease process and the current approaches to identifying thresholds for food allergens. The pathway of key biological events occurring between food intake and allergic response is considered, along with factors that may determine the nature and severity of response to food allergens. Data needs, as well as implications for identifying thresholds, and for characterizing variability in thresholds, are also discussed.

Threshold dose for peanut: risk characterization based upon published results from challenges of peanut-allergic individuals

Population thresholds for peanut are unknown. However, lowest- and no-observed adverse effect levels (LOAELs and NOAELs) are published for an unknown number of peanut-allergic individuals. Publications were screened for LOAELs and NOAELs from blinded, low-dose oral challenges. Data were obtained from 185 peanut-allergic individuals (12 publications). Data were analyzed by interval-censoring survival analysis and three probability distribution models fitted to it (Log-Normal, Log-Logistic, and Weibull) to estimate the ED(10). All three models described the data well and provided ED(10)'s in close agreement: 17.6, 17.0, and 14.6 mg of whole peanut for the Log-Normal, Log-Logistic, and Weibull models, respectively. The 95% lower confidence intervals for the ED(10)'s were 9.2, 8.1, and 6.0mg of whole peanut for the Log-Normal, Log-Logistic, and Weibull models, respectively. The modeling of individual NOAELs and LOAELs identified from three different types of published studies - diagnostic series, threshold studies, and immunotherapy trials - yielded significantly different whole peanut ED(10)'s of 11.9 mg for threshold studies, 18.0mg for diagnostic series and 65.5mg for immunotherapy trials; patient selection and other biases may have influenced the estimates. These data and risk assessment models provide the type of information that is necessary to establish regulatory thresholds for peanut.