Bruce J. Lanser

Current Options for the Treatment of Food Allergy

Food allergy is increasing in prevalence; as a result, there is intense focus on developing safe and effective therapies. Current methods of specific immunotherapy include oral, sublingual, and epicutaneous, while nonspecific methods that have been investigated include: Chinese herbal medicine, probiotics, and anti-IgE antibodies. Although some studies have demonstrated efficacy in inducing desensitization, questions regarding safety and the potential for achieving immune tolerance remain. Although some of these therapies demonstrate promise, further investigation is required before their incorporation into routine clinical practice.

Look before you LEAP: Risk of anaphylaxis in high-risk infants with early introduction of peanut

To the Editor: As a result of the compelling results of the Learning Early About Peanut Allergy (LEAP) study, a new consensus communication on early peanut introduction has recently been published. This communication states that ‘‘healthcare providers should recommend introducing peanut-containing products to high risk infants early in life (between 4 and 11 months of age)’’ and that ‘‘The clinician may perform an observed peanut challenge for those with evidence of a positive peanut skin test to determine if they are clinically reactive, before initiating at-home peanut introduction.’’ The inference is that initiation of peanut products can be performed safely in a medically unsupervised setting if skin prick test (SPT) responses to peanut are completely negative. We present a recent case of anaphylaxis in a high-risk infant introduced to peanut who had a negative skin test result to commercial peanut extract. DA is an African American male infant with Nigerian parents whowas born full term bymeans of vaginal delivery. At 2 months of age, he had eczema initially on his face and then involving his neck, the back of his legs, and his antecubital fossae. The rash responded to twice-daily soaking baths and application of topical steroids but would recur if baths or application of topical steroids were missed. Both parents and siblings (2 brothers and 1 sister; age, 3-6 years) had no reported allergies. There was no pet exposure and no history of persistent cough or wheezing episodes. When he first presented to the clinic at 5 months of age, DAwas breast-feeding, with supplementation of cow’s milk–based formula. SPTs were performed, and responses were negative (no wheal or erythema) for all foods tested (milk, egg, wheat, soy, and peanut with commercial extracts [Greer, Lenoir, NC]; histamine control, 103 8–mmwheal; saline control, negative). Specific IgE (ImmunoCAP; Phadia, Uppsala, Sweden) testing resulted in undetectable (<0.35 kUA/L) results for milk, casein, egg white, ovomucoid, wheat, soy, and peanut, with a total IgE level of less than 2 kUA/L. Because of the results in the LEAP study, we recommended a supervised peanut oral food challenge in the pediatric care unit at National Jewish Health. This was performed 1 month later when the patient was 6 months of age. DAwas first given 5 g of peanut butter (1.1 g of peanut protein) and after a 30-minute waiting period, was offered the 15-g dose. He ate approximately two thirds of this dose, for a total of approximately 3.3 g of peanut protein, when he started to become very fussy and experienced significant pruritis. He had facial hives, with erythema to his face and the back of his head. He was administered 0.15 mg of intramuscular epinephrine but continued to scratch his skin and thus was subsequently given 12.5 mg of oral diphenhydramine. During sleep, his oxygen saturation was observed to be 86%, and therefore he was started on oxygen administered through a facemask and received 2.5mg of albuterol administered by using a nebulizer. On awakening, his oxygen saturations normalized. Approximately 1 hour after therapy, his hives and pruritis subsided, and his behavior returned to normal. He was watched for 4 hours after the reaction, during which time he slept on room air and his oxygen saturation stayed greater than 90%. He was discharged home in stable condition after receiving Epi-Pen (Mylan, Canonsburg, Pa) training, a food allergy action plan, and recommendations for mom and baby to avoid peanuts. Although results from the LEAP study regarding the efficacy of early peanut introduction are compelling, there are a number of limitations that we think should be considered when the new guidelines are issued. In the LEAP study 1 (0.37%) of 272 children with negative skin test responses who were randomized to the peanut consumption group failed the initial food challenge. Although this is a relatively small percentage, it is not negligible, considering the potential widespread use of primary prevention. In addition, because more than 70% of these children were white, this rate might not accurately reflect the risk in children of different ethnicity and racial origin, such as the infant described above. Given the potential for significant morbidity and possibly mortality in infants, we would advise caution for now until a larger data set is available to more precisely describe the predictive value of a negative skin test at 4 to 11 months across different populations. Until then we recommend medically supervised graded peanut challenges in all high-risk infants with SPT responses of less than 4 mm in diameter, including those with completely negative results. Nathan Rabinovitch, MD, MPH Dimple Shah, MD Bruce J. Lanser, MD From the Departments of Pediatrics and Medicine, National Jewish Health, Denver, Colo. E-mail: rabinovitchn@njhealth.org. Disclosure of potential conflcit of interest: The authors declare that they have no relevant conflicts of interest.

Food allergy needs assessment, training curriculum, and knowledge assessment for child care

BACKGROUND More than half of preschool-aged children are enrolled in child care in the United States. Roughly 8% of children between 3 and 5 years of age have a food allergy. Child care center workers (CCCWs) are important caregivers who frequently encounter food allergies, but little is known about their education and understanding of food allergy and anaphylaxis. OBJECTIVE To perform a food allergy and anaphylaxis educational needs assessment, provide a training curriculum for CCCWs, and assess the effectiveness of the training curriculum. METHODS An online educational needs assessment and live training curriculum addressing food allergy recognition, treatment, and food labeling with pretests and posttests were created, and content and face validity were obtained. A needs assessment survey was sent to centers in Dallas and Tarrant counties. The training curriculum was performed at continuing education conferences. RESULTS Seventy-three workers responded to the needs assessment, with 46% reporting prior food allergy training. They reported information sources as parents (73%), self (54%), educational curricula (21%), and conferences (19%). Most believed they have a high or moderately high proficiency in food allergy management. Forty-five workers participated in the training curriculum. Total scores improved from 54% correct on the pretest to 83% correct on the posttest (P < .001). Categorical subanalysis reveals similar results, with statistically significant improvement in all areas. CONCLUSION CCCWs have diverse educational backgrounds and infrequently experience standardized training about food allergies. There is a significant lack of knowledge regarding food allergies and anaphylaxis. The curriculum was successful at increasing food allergy knowledge among CCCWs.

The Role of Baked Egg and Milk in the Diets of Allergic Children

Baked egg and baked milk are tolerated by most children who are allergic to hens egg and cows milk. Incorporating baked goods into the diets of allergic children may help them outgrow their primary allergy more quickly, with changes observed akin to immunotherapy. Benefits may also include increased quality of life and improved nutritional status. The search for a reliable biomarker to predict tolerance to baked goods is ongoing. Most children with a milk or egg allergy who are not previously tolerating egg or milk in baked goods should be offered an observed oral food challenge.