A. S. Kemp

Skin test reactivity and clinical allergen sensitivity in infancy

We examined the development of skin test reactivity and clinical allergen sensitivity in infancy. Seventy-eight infants of atopic parents were skin prick tested every 4 mo from 4 to 16 mo and an additional 57 of these infants were tested at 20 mo. Wheal diameters were recorded for histamine (1 mg/ml) and specific allergen reactions by use of cows milk, egg albumen, wheat, and Dermatophagoides pteronyssinus. The histamine mean wheal diameter was significantly lower at 4 and 8 mo compared to the older infants. Infants at 20 mo also had significantly smaller wheals than adult controls. Histamine reactivity was greater in atopic infants at 4 mo compared to nonatopic infants. Reactions to ingested allergens occurred early in infancy but were usually transient. There was a good correlation between skin sensitivity and clinical immediate-food hypersensitivity to the food concerned. In contrast, reactions to the inhaled allergen, D. pteronyssinus, occurred later in infancy, were persistent, and increased in size with age. Although we found no relationship between the acquisition of skin reactivity to D. pteronyssinus and development of the respiratory symptoms of atopic disease during the period of the study, it is possible that inhaled allergen reactivity may be related to respiratory symptoms at later ages. Despite the decreased histamine reactivity in early infancy, skin tests proved reliable markers of clinical disease in ingested but not inhalant allergen sensitivity.

Immediate food hypersensitivity reactions on the first known exposure to the food.

We report 8 infants with immediate hypersensitivity reactions to foods (milk, egg, or peanut), occurring at the first-known exposure. Each developed symptoms within the first hour, but these generally settled within 2 hours. Sensitisation to the food concerned was demonstrated by positive immediate allergen skin prick tests in every case. Symptoms experienced included irritability, erythematous rash, urticaria, angio-oedema, vomiting, rhinorrhoea, and cough. Five infants were being followed prospectively and 4 were clinically tolerant of the food by age 16 months. The most likely route of sensitisation was via breast milk. None of the infants experienced similar reactions while being breast fed, suggesting that the reaction was dose dependent. As 5 out of a group of 80 infants being followed prospectively developed an immediate reaction at their first known exposure to a food, this appeared to be a not uncommon presentation of food hypersensitivity in infancy.

Relationship of diet in the development of atopy in infancy

We examined the relationship of diet to the development of atopic manifestations in a group of infants with an immediate family history of atopy, followed prospectively from birth for up to 20 months of age. There was no relationship between the development of atopic dermatitis, rhinitis and wheeze and either 2 or 4 months exclusive breast feeding, or the introduction of cows milk or solids in the first 4 months of life. In addition there was no relationship between the introduction of milk, egg or wheat into the diet and the development of skin‐test positivity to these foods. In fact, five infants developed positive skin tests to the food prior to its introduction into the diet, suggesting exposure via maternal breast milk. Thus we have been unable to show a protective effect of either breast feeding or cows milk or solid avoidance on the development of atopic disease in infancy.

A Prospective Study of the Clinical Manifestations of Atopic Disease in Infancy

ABSTRACT. We prospectively followed a group of infants with a family history of atopy, from birth for up to 20 months of age. All infants were seen every 4 months and a history, physical examination and skin tests obtained. Atopic dermatitis and rhinitis occurred in about half the infants at some time during the study, while wheezing occurred in about a quarter. Both atopic dermatitis and rhinitis were more common in the first 12 months whereas wheezing occurred later and increased in prevalence with age. Defining atopy by the presence of atopic dermatitis or positive skin tests, only immediate food reactions were significantly associated with atopic infants. In contrast, rhinitis, a single episode of wheezing, colic, vomiting and delayed food reactions were not associated with atopy and thus are unlikely to be due to IgE‐related mechanisms during infancy.

Skin test, RAST and clinical reactions to peanut allergens in children

One‐hundred‐and‐four children were skin‐tested with four peanut‐allergen preparations, a commercial extract, extracts of raw and roast peanuts prepared by NH4HCO3 extraction, and a wheatgerm lectin‐reactive glycoprotein obtained by affinity chromatography. The presence of symptoms after ingestion of peanut or peanut products was also recorded. The roast allergen extract provided the greatest specificity with eight symptomatic children having a positive skin test and only one positive skin‐test reaction in an asymptomatic child in the group of 104 children tested. Despite differences in the incidence of skin‐test reactions there was a strong correlation between raw, roast and commercial RAST suggesting common allergens were being identified by circulating IgE. Clinical sensitivity was observed particularly in younger children with 75% of the children being under 4 years of age. A positive roast skin test or a RAST test adds confirmation to the clinical history of allergic reactions to peanuts.

Lymphomatoid Papulosis in an 11‐month‐old Infant

Abstract: Lymphomatoid papulosis was seen in an 11‐month‐old child. The condition resolved spontaneously after a course of only 8 weeks and the patient has now been disease free for 9 months. Electron microscopy showed infiltrating lymphocytes with cleaved nuclei suggestive of T cells. Monoclonal antibody studies confirmed the T cell nature of the infiltrate. In this case, suppressor (OKT8) T cells were more prominent than helper (OKT4) T cells, in contrast to previous reports.

Experience with an elimination diet in children with atopic dermatitis

In order to define possible food‐provoking factors, we placed twenty‐nine children with chronic atopic dermatitis on an elimination diet. The children remained on their normal diet for 2 weeks followed by 2 weeks on the elimination diet. Foods were then re‐introduced at the rate of a new one every 2 days in an attempt to identify foods exacerbating eczema. Thirteen children (45%) completed the elimination diet and seven of these were improved on parental assessment of sleeplessness, itchiness and area of eczema. Five were improved on the dermatologists assessment. Only two children were able to identify foods provoking their eczema. Sixteen children (55%) failed to complete the elimination diet. Eight felt it was too strict, while eight did not return for follow‐up. From our experience, dietary manipulation in older children with chronic atopic dermatitis offers only limited long‐term therapeutic gains.

The significance of nasal eosinophils and mast cells in children with nasal symptoms

Nasal smears from children with symptoms of nasal obstruction and/or discharge were examined for the presence of eosinophils, mucus-containing cells and mast cells. The presence of more than one eosinophil or any mast cells was significantly associated with atopy as determined by immediate hypersensitivity on skin prick testing. Twelve children with markedly increased numbers of nasal smear mast cells are described. In these children symptoms frequently commenced in the first 6 months of life. Nasal eosinophilia was not noted in any of the cases. Nasal smear mastocytosis was associated with significant perennial symptoms and would be missed if nasal smears are examined only for eosinophilia.

Complement C8 deficiency with recurrent meningococcemia: Examination of meningococcal opsonization

Abstract A 10 year old girl presented with recurrent febrile episodes over 2 months. A non‐typable strain of Neisseria meningitidis was grown from blood cultures on three occasions. She was found to lack functional C8 activity in serum but material with C8 antigenic activity was present. The opsonic activity of the C8 deficient serum for N. meningidis was equivalent to that of normal controls.

Milk antibodies in pulmonary inhalation

ABSTRACT. To determine the association between inhalation and increased circulating milk antibodies, the presence of milk precipitins and haemagglutinating titres of antibody to casein and lactalbumin were determined in a series of 100 children studied by radionuclide ‘milk scan’and/or barium swallow for possible milk inhalation. Sixty‐five were investigated because of reflux and/or inhalation (REFLUX), while 35 were evaluated after near‐miss sudden infant death (SID). Inhalation was demonstrated in 23/65 Reflux and 9/35 Sid patients. The incidence of milk precipitins was 22% (5/23) of the REFLUX with demonstrable inhalation, 12% (5/42) of the REFLUX without demonstrable inhalation, 0% (0/23) SID and 2% (21/1005) of an unselected series of hospital patient sera. The incidence of milk precipitins was increased in cases with demonstrated inhalation and lower respiratory tract symptoms. Determination of antibody titres to casein and lactalbumin did not provide additional benefit in the diagnosis of milk inhalation. Detection of milk precipitins can provide additional support to the diagnosis of milk inhalation.