Cherapat Sasisakulporn

Cow's milk protein allergy: immunological response in children with cow's milk protein tolerance.

OBJECTIVE To study changes in immunological responses in patients with CMPA during symptomatic and asymptomatic episodes of cows milk protein tolerance status. METHODS 27 CMPA patients were enrolled and underwent diagnostic evaluation, including CM challenge test, skin prick test and specific IgE to CM. Blood samples were collected in two periods from those who became tolerant (n = 13) and those with persistent CMA (n = 14), in order to measure in vitro PBMC responses to cows milk protein (IL-10, IFN-γ, IL-5), IgG4 to β-lactoglobulin, casein, BLG-IgG4/IgE ratio and the CAS-IgG4/IgE ratio. RESULTS Seventy percent of CMPA patients in our study were male with a mean age at diagnosis of 8 months and mean age of onset of 3 months. The reaction time to CM ranged from within 7 minutes to within 14 days. Positive IgE-sensitization was defined as either a specific IgE to CM of more than 0.35 kUA/L (N=11) or SPTs positive for CM and/or fresh cows milk (N=20). Forty-eight percent of the patients (n = 13) could tolerate CM by 13.38 months (8-19 months). Mean specific-IgE levels to CM were 4.1 kUA/L (range 0.35-14.3 kUA/L). Determination of the cytokine (IL-10, IFN-γ, IL-5) response to BLG revealed significantly higher IL-10 levels during the tolerance phase (212.93 vs 142.46 pg/ml, P = .011). There was a significant increase in BLG-IgG4 and the BLG-IgG4/IgE ratio in the tolerance phase when compared to the symptomatic phase. CONCLUSIONS IL-10, BLG-IgG4 and the BLG-IgG4/IgE ratio were higher in CMPA patients during the tolerance phase compared to the symptomatic phase.

Pediatric anaphylaxis: triggers, clinical features, and treatment in a tertiary-care hospital

BACKGROUND Anaphylaxis is a life-threatening condition. There are limited data about its etiology and clinical characteristics in Asian children with anaphylaxis. OBJECTIVE To investigate triggers, presenting symptoms, treatment and clinical course of anaphylaxis in Thai children. METHOD Medical record of children who were diagnosed with anaphylaxis between 2004 and 2013 at Ramathibodi Hospital, Bangkok, Thailand were reviewed. RESULTS One hundred-seventy two episodes of anaphylaxis occurred in 160 children (91 boys, 69 girls) aged 3 months to 18 years. Anaphylaxis increased from 2.7 cases/1000 pediatric admission to 4.51 cases/1000 pediatric admission between 2004-2008 and 2009-2013. The main causes were food (34.92%), drug (33.1%), blood components (23.8%), insect sting (9%), and unidentified causes (2.8%). Allergy to the triggers was known prior to anaphylaxis in 42 episodes (24.6%). Treatment consisted of epinephrine intramuscularly (93.8%), corticosteroids (92.5%), H₁antihistamines (96%), H₂antihistamines (50%), and β₂agonists nebulization (35.1%). Biphasic anaphylaxis occurred in 8.7% of the documented episodes and severe anaphylaxis in 34.3% of the documented episodes. Biphasic anaphylaxis and severe anaphylaxis were associated with fewer administrations of intramuscular epinephrine (OR 0.08 [95% CI 0.014-0.43]; p =0.01 and OR 9.36 [95% CI 2.5-34.7]; p <0.001 respectively). There were no fatality cases. There were associations between triggers of anaphylaxis and atopic histories, patients with severe anaphylaxis and cardiovascular involvement (p <0.01). CONCLUSIONS The incidence of anaphylaxis in Thai children is increasing. Anaphylaxis in children commonly occurred without the histories of prior reaction to the causative agent. Less frequent treatment with intramuscular epinephrine was associated with biphasic and severe anaphylaxis. A better knowledge of patterns and causes of anaphylaxis might contribute to a better management.

Comparison of conjunctival and nasal provocation tests in allergic rhinitis children with Dermatophagoides pteronyssinus sensitization

BACKGROUND Nasal provocation tests (NPTs) are indicated in confirming the diagnosis of allergic rhinitis if the clinical history, skin tests or sIgE are inconclusive. NPTs are time- consuming, technically difficult and expensive to perform. Consequently, conjunctival provocation tests (CPTs), which are easier, cheaper and safer should be considered as an alternative method. No recent study has compared CPTs with NPTs in allergic rhinitis children. OBJECTIVE To compare CPTs with NPTs in allergic rhinitis children with house dust mite sensitization METHODS Fifty-five children with allergic rhinitis were included. Thirty-six children had positive skin prick tests (SPTs) to Dermatophagoides pteronyssinus (Dp). NPTs were performed by spraying 0.1 ml of Dp extract with concentrations of 50, 200 and 500 AU/ml to each nostril at 15 minute interval. The clinical symptom scores, anterior rhinomanometry results and nasal peak flow testing were performed to assess the responses. For CPTs, 0.1 ml of the same concentration of allergen extract was droppedinto one eye and the control solution was dropped into the other. The responses were assessed by clinical symptom scores. The tests were stopped when the subject reported a positive response, or continued to the maximum concentration. RESULTS The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CPT compared with NPT are 97.1% (84.7-99.9), 90.5% (69.6-98.8), 94.3% (80.8-99.3), 95% (75.1-99.9) and 94.5 (84.9-98.9), respectively in all patients. Among individual allergic rhinitis subjects the sensitivity, specificity, PPV and NPV are 100%. CONCLUSIONS CPT can be an alternative test for NPT in allergic rhinitis children with house dust mite sensitization, even if they do not have conjunctival symptoms.

Efficacy of Nasal Cellulose Powder in the Symptomatic Treatment of Allergic Rhinitis: A Randomized, Double-Blind, Placebo-Controlled Trial

Purpose Nasal Cellulose Powder (NCP), which can prevent from binding an allergen to nasal mucosa, may reduce allergic rhinitis (AR) symptoms in dust mite-sensitized children. This study was conducted to assess the efficacy of NCP in improving clinical symptoms of a nasal airflow limitation and the response of nasal inflammatory cells. Methods Children with dust mite-sensitized AR aged 6-18 years were recruited. After a 4-week run-in period, NCP or a placebo was administered, 1 puff per nostril 3 times daily for 4 weeks. The nasal provocation test (NPT) with Dermatophagoides pteronyssinus (Der p) was performed before and after treatment. The daily symptom scores (DSS), daily medication scores (DMS), the peak nasal inspiratory flows (PNIF), nasal airway resistance (NAR), as well as the maximum tolerated dose of NPT and eosinophil counts in nasal scraping, were evaluated. Results Sixty children (30 NCP and 30 placebos) were enrolled. Before treatment, there were no significant differences in age, dust mite control measures, DSS, DMS, PNIF, NAR, the maximum tolerated dose of NPT, or nasal eosinophil scores between children receiving NCP and placebos. After treatment, there were no significant differences between the NCP and placebo groups in the median (range) of the outcomes—DSS: 2.06 (0.18-3.77) vs 1.79 (0.08-7.79), P=0.756; DMS: 1.60 (0-5.13) vs 0.56 (0-4.84), P=0.239; PNIF (L/min): 110 (60-160) vs 100 (50-180), P=0.870; NAR (Pa/cm3/s): 0.40 (0.20-0.97) vs 0.39 (0.24-1.32), P=0.690; the maximum tolerated dose of NPT and the nasal eosinophil scores: 1 (0-4) vs 1 (0-4), P=0.861. Conclusions NCP treatment may not be more effective than placebo treatment in dust mite-sensitized AR children.

Detection of β-lactoglobulin in human breast-milk 7 days after cow milk ingestion

Abstract Background: β-lactoglobulin (BLG), a major allergen in cow milk (CM) can be detected in human breast-milk (BM) and is associated with exacerbation of symptoms in breastfed infants with cow milk protein allergy (CMPA). Currently, it is not known how long lactating mothers who consume dairy products need to withhold breastfeeding. Objective: To elucidate the kinetics of BLG in BM after maternal ingestion of a single dose of CM. Methods: Nineteen lactating mothers, four of whom had infants with CMPA, were instructed to avoid CM for 7 days before ingesting a single dose of CM and to continue to withhold CM thereafter throughout the study period. BLG was measured by ELISA in BM from 15 mothers of healthy infants before and at 3, 6 and 24 h, and 3 and 7 days after CM ingestion. Four pairs of mothers and CMPA infants were enrolled for BM challenge after the mothers had ingested CM. Results: After CM ingestion, the level of BLG in BM increased significantly from 0.58 ng/ml (0.58 g/L) (IQR 0.38–0.88) to a peak level of 1.23 ng/ml (IQR 1.03–2.29), p < 0.001. The BLG level on day 3 (1.15 ng/ml, IQR 0.89–1.45) and day 7 (1.08 ng/ml (IQR 0.86–1.25) after CM ingestion was significantly higher than baseline (p = 0.01 and p = 0.001, respectively). BLG was detected in all BM samples from the four mothers of CMPA infants after CM ingestion, and the level was not different from that in the mothers of the 15 healthy infants. Three of the four CMPA infants developed symptoms such as maculopapular rash and hypersecretion in the airways after BM challenge. Conclusions: BLG can be detected in BM up to 7 days after CM ingestion. Lactating mothers should suspend breastfeeding to CMPA infants more than 7 days after CM ingestion.

Assessing the efficacy of a novel temperature and humidity control machine to minimize house dust mite allergen exposure and clinical symptoms in allergic rhinitis children sensitized to dust mites: a pilot study

BACKGROUND House dust mite avoidance is advised in dust mite sensitized patients to decrease the risk to develop allergic symptoms. Maintaining a relative humidity (RH) of less than 50% in households is recommended to prevent dust mite proliferation. OBJECTIVE To investigate the efficacy of a novel temperature and humidity machine to control the level of dust mite allergens and total nasal symptom score (TNSS) in dust mite sensitized allergic rhinitis children. METHOD Children (8-15 years) with dust mite sensitized persistent allergic rhinitis (AR) were enrolled. The temperature and humidity control machine was installed in the bedroom where the enrolled children stayed for 6 months. TNSS was assessed before and every month after machine set up and the level of dust mite allergen (Der p 1 and Der f 1) from the mattress were measured before and every 2 months after machine set up using enzyme-linked immunosorbent assay (ELISA). RESULTS A total of 7 children were enrolled. Noticeable reduction of Der f 1 was observed as early as 2 months after installing the machine, but proper significant differences appeared 4 months after and remained low until the end of the experiment (p <0.05). Although no correlation was observed between TNSS and the level of dust mite allergens, there was a significant reduction in TNSS at 2 and 4 months (p <0.05) and 70% of the patients were able to stop using their intranasal corticosteroids by the end of the experiment. CONCLUSIONS The level of house dust mite in mattresses was significantly reduced after using the temperature and humidity control machine. This machine may be used as an effective tool to control clinical symptoms of dust mite sensitized AR children.

Sensitivity of Turbutester and Accuhaler tester in asthmatic children and adolescents.

Background:  Dry powder inhalers (DPI) are alternative devices for delivering medication for treatment of asthma. The amount of drug delivery to the lungs is directly influenced by peak inspiratory flow rate (PIFR). A minimum PIFR of −30 L/min is needed for the Turbuhaler and Accuhaler.

Skin testing with β-lactam Antibiotics for Diagnosis of β-lactam Hypersensitivity in Children

OBJECTIVE Skin testing with penicilloyl-polylysine (PPL) and a minor determinant mixture (MDM) were previously recommended for evaluating β-lactam hypersensitivity. However, PPL and MDM have not been commercially available. This study was to determine the negative predictive value (NPV) of skin testing with β-lactam antibiotics for the diagnosis of β-lactam hypersensitivity. METHOD Patients age 1-18 years old with a history of β-lactam hypersensitivity were evaluated by skin tests (a skin prick test, an intradermal test) with penicillin G, ampicillin, amoxicillin-clavulanic acid, and the suspect βlactam. The patients who had a negative skin test were performed with a drug provocation test (DPT) in a 3-dose-graded challenge. The hypersensitivity reactions were classified into immediate and non-immediate reactions. RESULTS A total of 126 patients were evaluated for β-lactam hypersensitivity. Twenty two patients (17.4%) were confirmed with a ?-lactam hypersensitivity. 12 (54.54 %) of them were confirmed by a skin test. There was no systemic reaction occurring after the skin tests. Ten patients (9.6%) from 104 patients with a negative skin test showed reactions after a DPT providing the NPV of the skin test with a 91.2% value. CONCLUSIONS Among those children with a history of β-lactam hypersensitivity, skin testing with penicillin G, ampicillin, amoxicillin-clavulanic acid, and the suspect β-lactam was safe and provided a good NPV when PPL and MDM were unavailable. However, a skin test with β-lactam antibiotics alone did not provide a high sensitivity, thus a DPT procedure was necessary in order to confirm the diagnosis of β-lactam hypersensitivity.