Adam T. Fox

Household peanut consumption as a risk factor for the development of peanut allergy

BACKGROUND Most children with peanut allergy (PA) react on first known oral exposure to peanut. Recent data suggest cutaneous exposure as a route of sensitization. OBJECTIVES This study aimed to establish the relevant route of peanut exposure in the development of allergy. METHODS Questionnaires were administered to children with PA and to high-risk controls (with egg allergy) and controls without allergy. Questionnaires were completed before subjects were aware of their PA status, avoiding recall bias. Questionnaires recorded maternal peanut consumption during pregnancy, breast-feeding, and the first year of life. Peanut consumption was determined among all household members, allowing quantification of environmental household exposure (household peanut). RESULTS Median weekly household peanut in the 133 PA cases was significantly elevated (18.8 g) compared with 150 controls without allergy (6.9 g) and 160 high-risk controls (1.9 g). There were no differences in infant peanut consumption between groups. Differences in maternal peanut consumption during pregnancy (and lactation) were significant but become nonsignificant after adjusting for household peanut. A dose-response relationship was observed between environmental (nonoral) peanut exposure and the development of PA, which was strongest for peanut butter. Early oral exposure to peanut in infants with high environmental peanut exposure may have had a protective effect against the development of PA. CONCLUSIONS High levels of environmental exposure to peanut during infancy appear to promote sensitization, whereas low levels may be protective in atopic children. No effect of maternal peanut consumption during pregnancy or lactation is observed, supporting the hypothesis that peanut sensitization occurs as a result of environmental exposure.

Food allergy as a risk factor for nutritional rickets

The case of a 14‐month‐old boy with vitamin D deficiency rickets as a result of unsupervised dietary manipulation in the context of cows milk allergy is presented. Adequate supervision by a qualified dietician, coupled with appropriate supplementation, is essential if nutritional compromise is to be avoided in children with food allergy.

Diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy - a UK primary care practical guide

The UK NICE guideline on the Diagnosis and Assessment of Food Allergy in Children and Young People was published in 2011, highlighting the important role of primary care physicians, dietitians, nurses and other community based health care professionals in the diagnosis and assessment of IgE and non-IgE-mediated food allergies in children. The guideline suggests that those with suspected IgE-mediated disease and those suspected to suffer from severe non-IgE-mediated disease are referred on to secondary or tertiary level care. What is evident from this guideline is that the responsibility for the diagnostic food challenge, ongoing management and determining of tolerance to cow’s milk in children with less severe non-IgE-mediated food allergies is ultimately that of the primary care/community based health care staff, but this discussion fell outside of the current NICE guideline. Some clinical members of the guideline development group (CV, JW, ATF, TB) therefore felt that there was a particular need to extend this into a more practical guideline for cow’s milk allergy. This subset of the guideline development group with the additional expertise of a paediatric gastroenterologist (NS) therefore aimed to produce a UK Primary Care Guideline for the initial clinical recognition of all forms of cow’s milk allergy and the ongoing management of those with non-severe non-IgE-mediated cow’s milk allergy in the form of algorithms. These algorithms will be discussed in this review paper, drawing on guidance primarily from the UK NICE guideline, but also from the DRACMA guidelines, ESPGHAN guidelines, Australian guidelines and the US NIAID guidelines.

Physicians as barriers to successful transitional care

There has been a dramatic increase in the number of sufferers of chronic childhood diseases surviving into adulthood. Effective transition of these children from paediatric to adult medical services is a considerable challenge. A lack of integrated planning for this event can present barriers to successful transition. These barriers may be generated by the patient, his family or by political or logistical factors. However, physicians themselves can also become barriers in this process. Paediatricians may resist the transition process as they lack confidence in their adult colleagues. Emotional, academic, financial and cultural issues will also influence both child and adult physicians attitude to the hand-over of care. Increasingly poor understanding of their disease process by Paediatric trained doctors, makes transfer of care essential for adolescents. The move towards a culture of personal responsibility for health care is also crucial for the promotion of the maturing patients independence. Development of adolescent services and closer links between the services could do much to enhance the transition experience of emerging adults.

Identifying and managing cow's milk protein allergy

Cows milk protein (CMP) is usually one of the first complementary foods to be introduced into the infants diet and is commonly consumed throughout childhood as part of a balanced diet. CMP is capable of inducing a multitude of adverse reactions in children, which may involve organs like the skin, gastrointestinal (GI) tract or respiratory system. The diagnosis of CMP-induced adverse reactions requires an understanding of their classification and immunological basis as well as the strengths and limitations of diagnostic modalities. In addition to the well-recognised, immediate-onset IgE-mediated allergies, there is increasing evidence to support the role of CMP-induced allergy in a spectrum of delayed-onset disorders ranging from GI symptoms to chronic eczema. The mainstay of treatment is avoidance of CMP; this requires dietetic input to ensure that this does not lead to any nutritional compromise. This review is intended to highlight the broad spectrum of manifestations of CMP allergy and to offer an approach to the diagnosis and treatment thereof.

Cutaneous lymphocyte antigen and α4β7 T-lymphocyte responses are associated with peanut allergy and tolerance in children.

It is unclear whether the initial route of allergen exposure in early life could influence the subsequent development of allergy, with cutaneous sensitization leading to peanut allergy (PA), and tolerance induced by oral exposure. The skin‐ and gastrointestinal (GI)‐homing markers, cutaneous lymphocyte antigen (CLA) and α4β7 integrin, are used to determine whether the state of PA correlates with peanut‐specific CLA responses, with tolerance associated with predominant α4β7 responses.

Dietary management of peanut and tree nut allergy: What exactly should patients avoid?

Peanut and tree nut allergies are the commonest cause of life‐threatening food‐allergic reactions and significantly affect quality of life in children and their families. Dietary nut avoidance and provision of emergency medication is currently the mainstay of treatment. Nut avoidance has consequences on both quality of life and nutrition. We review the terminology that may cause confusion and lead to unnecessary dietary restrictions. In peanut or tree nut‐allergic children, introduction of specific nuts to which the child is not allergic may improve quality of life and should be considered in patients with multiple foods allergies, vegan or ethnic‐specific diets, in whom nuts are an important source of protein. Nut‐allergic consumers do not just need to avoid foods containing nuts as an ingredient, but also contend with pre‐packed foods which frequently have precautionary allergen labelling (PAL) referring to possible nut contamination. Although the published rate of peanut contamination in ‘snack’ foods with PAL (see Box ) ranges from 0.9–32.4%, peanut contamination in non‐snack items with PAL is far less common. We propose that in some peanut‐allergic patients (depending on history of reactivity to trace levels of peanut, reaction severity, other medical conditions, willingness to always carry adrenaline, etc.), consideration may be given to allow the consumption of non‐snack foods containing PAL following discussion with the patients (and their familys) specialist. More work is needed to provide consumers with clearer information on the risk of potential nut contamination in pre‐packed food. We also draw attention to the change in legislation in December 2014 that require mandatory disclosure of allergens in non‐pre‐packed foods.

Improving the quality of outpatient clinic letters using the Sheffield Assessment Instrument for Letters (SAIL)

Aim  To improve the quality of outpatient letters used as communication between hospital and primary care doctors.

Preventing progression of allergic rhinitis: the role of specific immunotherapy

Allergic rhinitis and asthma are examples of allergic airways disease. Despite their differing symptomatology, both disorders affect the mucosal lining of the respiratory tract and are linked by common underlying cellular processes, thus, using the ‘united airways’ approach, they can be considered part of the same allergic disease. The conditions are often comorbid, and there is evidence to suggest that allergic rhinitis in children is a significant risk factor for subsequent development of asthma. Management strategies that target the underlying cause of allergic rhinitis in children have the potential to offer additional symptom control above that of symptomatic medications, and prevent disease progression. Specific immunotherapy (SIT) is the only currently available treatment that is proven to target the disease in this way. SIT affects the underlying cause of allergic rhinitis, producing changes in antibody responses to allergens. It has been shown to be effective in the reduction of allergic rhinitis symptoms in both children and adults, with effects being sustained for several years after treatment completion. Furthermore, a number of trials provide evidence that SIT may prevent the development of new sensitisations and asthma in children and adults with allergic rhinitis. One such open-label, randomised controlled study in children/adolescents (the Preventive Allergy Treatment Study) showed that significantly fewer patients who received 3 years of SIT for grass/birch pollen-induced allergic rhinitis had developed asthma 10 years after treatment initiation versus controls. Some clinical guidelines acknowledge this potential asthma preventive effect in children and the need for additional data from double-blind, placebo-controlled trials to support these findings.

Managing cows’ milk allergy in children

Cows’ milk allergy mainly affects young children and because it is often outgrown is less commonly seen in older children and adults. It is one of the most common childhood food allergies in the developed world, second to egg allergy,1 affecting 2-7.5% of children under 1 year of age.2 The mainstay of treatment is to remove cows’ milk protein from the diet while ensuring the nutritional adequacy of any alternative. #### Summary points Cows’ milk allergy can often be recognised and managed in primary care. Patients warranting a referral to specialist care include those with severe reactions, faltering growth, atopic comorbidities, multiple food allergies, complex symptoms, diagnostic uncertainty, and incomplete resolution after cows’ milk protein has been excluded. Although there are non-immune reactions to cows’ milk, such as primary lactose intolerance (when malabsorption of sugar can cause bloating and diarrhoea), these are extremely rare in very young children. Except after a gastrointestinal infection, infants with gastrointestinal symptoms on exposure to cows’ milk are more likely to have cows’ milk allergy than lactose intolerance. This article focuses on immune mediated reactions to cows’ milk in children and reviews the evidence on how to diagnose and manage the condition #### Sources and selection criteria Our search included PubMed, the Cochrane Collaboration using the search terms …