Natural history of cow's milk allergy in children aged 6-12 years

Long-term comparison of high- and low-dose oral immunotherapy in children with anaphylactic cow's milk allergy

BACKGROUND

Long-term evidence on maintenance doses of oral immunotherapy (OIT) for anaphylactic cow's milk allergy is insufficient.

METHODS

We retrospectively compared the three-year safety, efficacy, and adherence between OIT with a maintenance dose of 200 mL of cow's milk (HOIT, 2009-2013) and 3 mL of cow's milk (LOIT, 2013-2019). Patients aged 6-18 years with a history of anaphylaxis reacting to ≤3 mL of cow's milk during oral food challenge (OFC) were included. Adverse symptoms, OFC negative rate after 2 weeks of avoidance, dropout rate, and immunological changes were compared.

RESULTS

The median ages in the HOIT (n = 78) and LOIT (n = 99) groups were 8.1 and 7.8 years, with milk-specific IgE levels of 56.5 and 49.2 kUA/L, respectively. The percentages of doses triggering symptoms were 20.88%, 13.73%, and 7.31% in the HOIT group and 11.81%, 8.15%, and 6.30% in the LOIT group during years 1, 2, and 3, respectively. After 3 years, 29% of patients in the HOIT group passed the OFC with 200 mL, and 47%, 18%, and 5% of patients in the LOIT group passed the OFC with ≥25 mL, ≥50 mL, and 100 mL of cow's milk, respectively. After 3 years, the dropout rates were 24% and 11% in the HOIT and LOIT groups and milk-specific IgE levels decreased by 88% and 78% in the HOIT and LOIT groups, respectively.

CONCLUSION

HOIT enables higher dose consumptions. LOIT might be safer and have higher adherence in patients with anaphylactic cow's milk allergy.

Editorial comment on "Prevention of allergies and infections by minimally processed milk in infants-The MARTHA feasibility and safety trial"

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Safety of Oral Food Challenges for Individuals with Low Levels of Cow's Milk-Specific Immunoglobulin E Antibodies

INTRODUCTION

Cow's milk (CM) is one of the most common food allergens in Japan. The oral food challenge (OFC) of CM is important for the definite diagnosis of children with CM allergy, and it is recommended to be actively and safely performed in individuals with low CM-sIgE levels. This study aimed to investigate the safety of low-dose CM-OFC in individuals with low CM-sIgE levels and discuss the prognostic factors and appropriate approaches for assessing the starting doses of CM-OFC in these individuals.

METHODS

We retrospectively analyzed 6,929 OFC tests conducted between January 1, 2017, and December 31, 2021; of which, 1,390 were CM-OFC tests. The characteristics, OFC-positive rates, CM loading, and related factors were analyzed in 138 cases involving low CM-sIgE levels. Stepwise OFC tests were conducted according to the food allergies guidelines in Japan using an open and unblinded method.

RESULTS

Among 138 individuals with low CM-sIgE levels, 110 (79.7%) passed the OFC test without any symptoms. Among the cases with OFC-positive status, 50.0% (14/28) cases showed symptoms with low-dose OFC (30-105 mg CM protein). Moreover, complete CM elimination was associated with a significantly high OFC-positive rate, and 60.0% (12/20) of the cases involving complete CM elimination showed symptoms with low-dose OFC.

CONCLUSION

Eighty percent of the patients with low CM-sIgE levels safely completed the OFC test. Nevertheless, careful observation is essential during low-dose OFC test in cases with low CM-sIgE levels, especially in the cases with complete elimination. The starting dose of the OFC test should be reevaluated, and modified using baked milk or a lower dose of CM to ensure safety and early outgrowth of CM allergy.

Molecular characteristics of atopic dermatitis patients with clinical remission

Introduction

Atopic dermatitis (AD) is a frequent disease in infants with diverse clinical evolution. Although multiple studies have assessed inflammatory changes in chronic AD, little is known about the molecular transition from symptomatic stage to clinical remission without pharmacotherapy.

Objective

The aim of the study was to evaluate clinical and inflammatory factors and its relationship with AD clinical evolution.

Methods

Three groups of participants older than 10 years of age were recruited; 2 AD groups and 1 non-AD group. The AD-remission group (more than 1 year without AD symptoms and without pharmacotherapy), the AD-persistent group (AD symptoms and pharmacotherapy), and 1 non-AD group. We measured eosinophil peroxidase (EPX), eosinophil cationic protein (ECP), IgE autoantibodies against these antigens, and natural moisturizing factor (NMF).

Results

Different inflammatory profiles within each group were observed: AD-persistent group is characterized by a high frequency of IgE autoantibodies (55.5%), contrasting with the low occurrence in the non-AD group (2%) and a moderate frequency in the AD-remission group (21.4%). A similar distribution was observed for the other type 2 inflammatory biomarkers (Eosinophils, total IgE, EPX, ECP) and NMF.

Conclusion

Patients with AD-remission maintain a minimal T2 inflammation. We identified different potential biomarkers for prognosis of AD evolution. Further studies are necessary to evaluate the mechanisms that allow the coexistence of the inflammatory process without clinical symptoms.

Current perspective on allergen immunotherapy for food allergies

Food allergies are an increasing global problem and societal issue. In addition to the potential for severe allergic reactions from accidental ingestion, food allergies impose a significant burden on the quality of life, nutrition, cost of living, and social activities of both those afflicted and their caregivers. Strict avoidance of allergens and use of emergency medications to treat allergic reactions are the traditional management and treatment strategies; however, significant progress has been made in recent years toward better treatment of food allergies. Many clinical trials on food allergen immunotherapy (oral, epicutaneous, and sublingual) have revealed its efficacy in increasing reaction thresholds and desensitization. These positive results led to the first FDA approval of peanut oral immunotherapy (OIT). However, safer and more effective approaches are required, and adjunct treatments and allergen modifications are being considered. More than 100 facilities in Japan conduct OIT, and numerous studies on it have been reported. Unlike in Europe and the US, stepwise oral food challenges with dietary guidance are conducted separately from the OIT. This review describes the current perspectives on allergen immunotherapy for the treatment of food allergies, focusing on evidence from Japan.

Precision allergy molecular diagnosis applications in food allergy

PURPOSE OF REVIEW

Precision medicine has become important in the diagnosis and management of food allergies. This review summarizes the latest information regarding molecular allergology, an essential component of food allergy managements.

RECENT FINDINGS

Component-resolved diagnostics (CRD) can be used to investigate sensitization to allergens based on symptoms and to reveal co-sensitization and/or cross-sensitization in patients with allergies. The following allergen components are known to be associated with symptoms: ovomucoid from eggs, omega-5 gliadin from wheat, and many storage proteins (Gly m 8 from soy, Ara h 2 from peanut, Cor a 14 from hazelnut, Ana o 3 from cashew nut, Jug r 1 from walnut, and Ses i 1 from sesame). Recent studies on allergens of macadamia nuts (Mac i 1 and Mac i 2), almonds (Pru du 6), fish (parvalbumin and collagen), and shrimp (Pem m 1 and Pem m 14) have provided additional information regarding CRD. In addition, Pru p 7 is a risk factor for systemic reactions to peaches and has recently been found to cross-react with cypress and Japanese cedar pollen.

SUMMARY

CRD provides information of individualized sensitization profiles related to symptoms and severity of allergies in patients. Clinical practice based on CRD offers many benefits, such as higher diagnostic accuracy and improved management of individual patients.

A practical guide for implementing omalizumab therapy for food allergy

The recent approval of omalizumab for the treatment of IgE-mediated food allergy is an important step forward for the millions of food allergy patients in the United States. Through the depletion of circulating IgE and the subsequent reduction of FcεR1 on key effector cells, patients increase their tolerance to food allergens. However, omalizumab does not permit patients to eat foods that they are allergic to with impunity. Rather, it protects them from most accidental exposures. In addition, omalizumab does not cure food allergy and has not demonstrated true immunomodulation. Thus, omalizumab might be a lifelong therapy for some patients. Furthermore, there are many important questions and issues surrounding the appropriate administration of omalizumab to treat food allergy, which we discuss. Managing treatment of patients with disease that falls outside the dosing range, assessing treatment response or nonresponse, addressing its appropriateness for patients older than 55, and determining whether immunotherapy plus omalizumab provides any advantage over omalizumab alone all need to be examined. Identifying appropriate patients for this therapy is critical given the cost of biologics. Indeed, not all food allergy patients are good candidates for this therapy. Also, when and how to stop omalizumab therapy in patients who may have outgrown their food allergy needs to be elucidated. Thus, although this therapy provides a good option for patients with food allergies, much information is needed to determine how best to use this therapy. Despite many unanswered questions and issues, we provide clinicians with some practical guidance on implementing this therapy in their patients.

Oral Immunotherapy With Extensively Hydrolyzed Milk for a 12-Year-Old Child With Persistent, Severe Cow's Milk Allergy

A 12-year-old girl with severe cow's milk allergy (CMA) was able to safely consume 300 mL of unhydrolyzed cow's milk after three and a half years of oral immunotherapy (OIT) with extensively hydrolyzed milk. The treatment consisted of gradually increasing the intake of hydrolyzed and partially hydrolyzed milk and reintroducing cow's milk. Despite some allergic reactions during treatment, the patient was able to consume more than 200 ml of milk consistently for more than six months without recurrence of symptoms. This case suggests the possibility of an alternative treatment for persistent CMA: not only OIT with cow's milk alone but also a safer introduction to treatment with extensively hydrolyzed formulas.