Carlo Caffarelli

The effect of component-resolved diagnosis on specific immunotherapy prescription in children with hay fever

BACKGROUND Sensitization to profilins and other cross-reacting molecules might hinder proper specific immunotherapy (SIT) prescription in polysensitized patients with pollen-related allergic rhinitis (AR). In these patients, component-resolved diagnosis (CRD) might modify SIT prescription by improving the identification of the disease-eliciting pollen sources. OBJECTIVES We sought to measure the effect of CRD on SIT prescription in children with pollen-related AR. METHODS Children (n = 651) with moderate-to-severe pollen-related AR were recruited between May 2009 and June 2011 in 16 Italian outpatient clinics. Skin prick test (SPT) reactivity to grass, cypress, olive, mugwort, pellitory, and/or Betulaceae pollen was considered clinically relevant if symptoms occurred during the corresponding peak pollen season. IgE sensitization to Phl p 1, Phl p 5, Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2, and Phl p 12 (profilin) was measured by using ImmunoCAP. SIT prescription was modeled on SPT responses first and then remodeled considering also CRD according to GA(2)LEN-European Academy of Allergology and Clinical Immunology guidelines and the opinions of 14 pediatric allergists. RESULTS No IgE to the respective major allergens was detected in significant proportions of patients with supposed clinically relevant sensitization to mugwort (45/65 [69%]), Betulaceae (146/252 [60%]), pellitory (78/257 [30%]), olive (111/390 [28%]), cypress (28/184 [15%]), and grass (56/568 [10%]). IgE to profilins, polcalcins, or both could justify 173 (37%) of 464 of these SPT reactions. After CRD, the SPT-based decision on SIT prescription or composition was changed in 277 (42%) of 651 or 315 (48%) of 651 children according to the European or American approach, respectively, and in 305 (47%) of 651 children according to the opinion of the 14 local pediatric allergists. CONCLUSIONS In children with pollen-related AR, applying CRD leads to changes in a large proportion of SIT prescriptions as opposed to relying on clinical history and SPT alone. The hypothesis that CRD-guided prescription improves SIT efficacy deserves to be tested.

Cow's milk protein allergy in children: a practical guide

A joint study group on cows milk allergy was convened by the Emilia-Romagna Working Group for Paediatric Allergy and by the Emilia-Romagna Working Group for Paediatric Gastroenterology to focus best practice for diagnosis, management and follow-up of cows milk allergy in children and to offer a common approach for allergologists, gastroenterologists, general paediatricians and primary care physicians.The report prepared by the study group was discussed by members of Working Groups who met three times in Italy. This guide is the result of a consensus reached in the following areas. Cows milk allergy should be suspected in children who have immediate symptoms such as acute urticaria/angioedema, wheezing, rhinitis, dry cough, vomiting, laryngeal edema, acute asthma with severe respiratory distress, anaphylaxis. Late reactions due to cows milk allergy are atopic dermatitis, chronic diarrhoea, blood in the stools, iron deficiency anaemia, gastroesophageal reflux disease, constipation, chronic vomiting, colic, poor growth (food refusal), enterocolitis syndrome, protein-losing enteropathy with hypoalbuminemia, eosinophilic oesophagogastroenteropathy. An overview of acceptable means for diagnosis is included. According to symptoms and infant diet, three different algorithms for diagnosis and follow-up have been suggested.

False-negative food challenges in children with suspected food allergy

Food allergy can be diagnosed from an immediate-onset reaction after oral food challenge. We administered 370 challenges in 242 children; five (3%) of the 193 children tolerating foods on challenges developed immediate symptoms when the same preparation of foods was ingested openly at home the next day. We confirmed the food allergy by subsequent double-blind challenges. All children had positive skin-prick test reactions and all, but one, specific IgE antibodies to the offending foods. Our findings suggest that open feedings under observation, the day after negative challenges, are useful to eliminate false-negative challenge results.

Relationship between oral challenges with previously uningested egg and egg-specific IgE antibodies and skin prick tests in infants with food allergy

BACKGROUND Positive skin prick test (SPT) and RAST reactions to egg that had never previously been ingested have been observed in infants with food allergy. The likelihood of having clinical hypersensitivity reactions when egg is first ingested and the predictive value of SPT and RAST remain to be elucidated. OBJECTIVE We investigated the relationship between egg-specific IgE antibodies and positive SPT reaction to egg, and the development of clinical hypersensitivity on the first exposure, in infants with food allergy. METHODS The patient group consisted of 21 infants with food allergy and positive SPT and/or RAST reaction to egg, which they had never previously ingested; the control group of 12 infants had food allergy and negative test results. All subjects underwent double-blind placebo-controlled food challenges with egg. RESULTS Thirteen of 21 patients (61%) and one of 12 control subjects (8%) had positive reactions to challenges (p < 0.01). Thirteen positive reactions to challenges (93%) elicited immediate symptoms. Late-onset eczema occurred in two children. SPT results showed a high sensitivity (0.92) and negative predictive accuracy (0.92), whereas specificity (0.57) and positive predictive accuracy (0.61) were poor. RAST did not have any diagnostic advantage over SPT. CONCLUSIONS In infants with food allergy SPT with egg may be helpful in predicting which patients will react to the first exposure.

Coexistence of IgE-Mediated Allergy and Type 1 Diabetes in Childhood

Background: Autoimmune disorders are considered to be associated with a Th1 immune response while allergic diseases with a Th2 response. We carried out a study to determine whether there is an inverse relationship between allergic diseases in IgE-sensitized children or positive skin-prick test reactions to allergens and type 1 diabetes mellitus (DM1) in children. Methods: Sixty-three children with DM1 and 108 controls were enrolled. Parents of all children compiled a questionnaire on allergic diseases. All children underwent skin-prick tests for common aero-allergens and food-allergens. Results: A history of allergic symptoms, especially wheezing, asthma and allergic rhinitis was significantly less common in the group with DM1. Allergic symptoms in children with IgE sensitization or parental atopy were no more likely in children with DM1 than in normal control subjects. There was no association between skin-prick test results to inhalants and food allergens and DM1. Conclusions: Consistently with the Th1/Th2 paradigm, we observed a reduction in the frequency of allergic symptoms in children with DM1. However, our study did not succeed in demonstrating an inverse relation between Th1- and Th2-mediated diseases in children with IgE sensitization or an atopic genetic predisposition.

Gastrointestinal symptoms in patients with asthma

AIMS Minor gastrointestinal abnormalities have been reported in children with asthma, but the prevalence of gastrointestinal symptoms in these children has not been studied. METHODS 75 children with bronchial asthma and an age and sex matched control group were recruited. Parents completed a questionnaire on gastrointestinal symptoms and on asthma. Weight and height were measured; a clinical evaluation of asthma was undertaken and skin prick tests were performed. RESULTS Children with asthma had a significantly greater frequency of gastrointestinal symptoms, particularly diarrhoea, vomiting, and abdominal pain, than did controls. Gastrointestinal symptoms were slightly more common in children with atopic symptoms other than asthma, or with positive skin prick tests to foods. There was no association between current gastrointestinal symptoms and medications or attacks of asthma. CONCLUSIONS The occurrence of gastrointestinal symptoms appears to be common in children with asthma. These symptoms might be caused by an atopic gastroenteropathy, which might play a part in the pathogenesis of asthma in some cases.

Gastrointestinal symptoms in atopic eczema

AIMS To determine the prevalence of gastrointestinal symptoms in children with eczema and the association of such symptoms with the extent of eczema or skin prick test results. METHODS Sixty five children with atopic eczema and a control group matched for age and sex were recruited. Their parents completed a questionnaire about the children’s gastrointestinal symptoms. The children’s skin was examined; their weight, height, and abdominal circumference were measured; and skin prick tests were carried out. RESULTS Gastrointestinal symptoms, especially diarrhoea, vomiting, and regurgitation, were more common in the children with eczema. Diarrhoea appeared to be associated with the ingestion of specific foods. Gastrointestinal symptoms were related to diffuse eczema and positive skin prick tests to foods. There was no anthropometric differences between the patient and control groups. CONCLUSIONS A gastrointestinal disorder is common in children with eczema, especially with diffuse distribution. This may be responsible for substantial symptoms and may play a part in the pathogenesis of the disease and in the failure to thrive with which it is sometimes associated. Key messages Gastrointestinal symptoms are common in children with atopic eczema Gastrointestinal symptoms are more frequent in children with extensive skin disease Gastrointestinal symptoms may be troublesome and should not be ignored, albeit there is no association with failure to thrive An aetiological role for foods may be suspected in some of these children

Pollen-induced allergic rhinitis in 1360 Italian children: comorbidities and determinants of severity.

Pollen‐induced allergic rhinoconjunctivitis (AR) is highly prevalent and rapidly evolving during childhood. General practitioners may not be fully aware of the nature and severity of symptoms experienced by patients and might underestimate the prevalence of moderate or severe disease. Thus, the relevance of early diagnosis and intervention may be overlooked.

Nutritional management and follow up of infants and children with food allergy: Italian Society of Pediatric Nutrition/Italian Society of Pediatric Allergy and Immunology Task Force Position Statement

Although the guidelines on the diagnosis and treatment of food allergy recognize the role of nutrition, there is few literature on the practical issues concerning the nutritional management of children with food allergies.This Consensus Position Statement focuses on the nutritional management and follow-up of infants and children with food allergy.It provides practical advices for the management of children on exclusion diet and it represents an evidence-based consensus on nutritional intervention and follow-up of infants and children with food allergy.Children with food allergies have poor growth compared to non-affected subjects directly proportional to the quantity of foods excluded and the duration of the diet. Nutritional intervention, if properly planned and properly monitored, has proven to be an effective mean to substantiate a recovery in growth.Nutritional intervention depends on the subject’s nutritional status at the time of the diagnosis.The assessment of the nutritional status of children with food allergies should follow a diagnostic pathway that involves a series of successive steps, beginning from the collection of a detailed diet-history.It is essential that children following an exclusion diet are followed up regularly.The periodic re-evaluation of the child is needed to assess the nutritional needs, changing with the age, and the compliance to the diet.The follow- up plan should be established on the basis of the age of the child and following the growth pattern.

Parents' estimate of food allergy prevalence and management in Italian school-aged children

Background:  Despite the increasing prevalence of food allergy, few studies have assessed the prevalence of perceived food‐induced symptoms among school‐aged children. There is also a paucity of data on how children with food reactions are managed. We investigated the frequency and characteristics of perceived food reactions in school‐aged children.