Chitra Dinakar

Section on allergy and immunology

Founded in 1948, the Section on Allergy and Immunology is dedicated to ensuring that children receive the highest quality of allergy and immunology care. To accomplish its mission, the Section provides a number of educational, training, and research programs and continually advocates for improved allergy and immunology care and services. The Section sponsors educational programs for both pediatric generalists and subspecialists at the American Academy of Pediatrics (AAP) National Conference and Exhibition (NCE) each fall and at the American Academy of Allergy Asthma & Immunology annual meeting each spring. The Section’s other educational endeavors include this annual “Best Articles Relevant to Pediatric Allergy and Immunology” supplement to Pediatrics, Visiting Professor Program, Pediatric Asthma Speaker’s Kit, online continuing medical education course on “asthma gadgets,” electronic quality improvement in practice program on asthma diagnosis and management (Education in Quality Improvement for Pediatric Practice [eQIPP], which meets the American Board of Pediatrics maintenance-ofcertification criteria), school nurse allergy tool kit, and a number of public education materials. The Section is also active in contributing to educational programs and resources such as AAP News, educational brochures, clinical reports, and many other endeavors. To support training and promote research in pediatric allergy and immunology, the Section awards travel grants to residents and training fellows to participate and present cases at the AAP NCE and provides outstanding abstract awards for training fellows and junior faculty for presentation at the American Academy of Allergy Asthma & Immunology annual meeting. In close collaboration with other subspecialty societies, the Section is actively involved with initiatives to improve subspecialty education such as the American Board of Allergy and Immunology maintenance-of-certification requirements. Section members represent the AAP in national and government conferences and provide input on federal legislation on behalf of the AAP. For more information on all AAP allergy and immunology resources and initiatives, visit www.aap.org/sections/allergy. The reviews contained in the 2011 synopsis were written by Fellows of the AAP Section on Allergy and Immunology and fellows in allergy and immunology training programs who contributed reviews with their mentors. The editor selected the journals to be reviewed on the basis of the likelihood that they would contain articles on allergy and immunology that would be of value and interest to the pediatrician. Each journal was assigned to a voluntary reviewer who was responsible for selecting articles and writing reviews of their articles. Only articles of original research were selected for review. Final selection of the articles to be included was made by the editor. The 2010–2011 journals chosen for review were Allergy, American Journal of Asthma & Allergy for Pediatricians, Archives of Pediatric and Adolescent Medicine, American Journal of Medicine, American Journal of Respiratory and Critical Care Medicine, Annals of Allergy, Asthma, and Immunology, Annals of Internal Medicine, Archives of Disease in Childhood, Archives of Internal Medicine, Blood, British Journal of Dermatology, British Medical Journal, Chest, Clinical and Experimental Allergy, Clinical Pharmacology and Therapeutics, Critical Care Medicine, European Journal of Pediatrics, European Respiratory Journal, Immunology, Journal of Allergy and Clinical Immunology, Journal of the American Academy of Dermatology, Journal of the American Medical Association, Journal of Applied Physiology, Journal of Experimental Medicine, Journal of Immunology, Journal of Infectious Diseases, Journal of Pediatric Gastroenterology and Nutrition, Journal of Pediatrics, Journal of Pharmacology and Experimental Therapeutics, Lancet, Nature, New England Journal of Medicine, Pediatrics, Medicine, Pediatric Allergy and Immunology, Pediatric Asthma, Allergy & Immunology, Pediatric Dermatology, Pediatric Infectious Disease Journal, and Science. The editor and the Section on Allergy and Immunology gratefully acknowledge the work of the reviewers and their trainees who assisted. The reviewers were Stuart L. Abramson, MD, PhD, Sugar Land, TX; James R. Banks, MD, Arnold, MD; Theresa A. Bingemann, MD, Rochester,

Stinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

Anaphylaxis in Children: Current Understanding and Key Issues in Diagnosis and Treatment

Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death. Since it is unpredictable and potentially fatal, prompt recognition and treatment are vital to maximize a positive outcome. The occurrence of anaphylaxis is increasing across all ages in the United States, with increased risk of worse outcome in teenagers/young adults and in those with comorbid conditions such as asthma. Gaps in the assessment of patient-specific risk factors, identification and prevention of triggers, recognition of signs/symptoms, and pharmacologic treatment of anaphylaxis have been identified at the physician and caregiver/patient level. A PubMed literature search (January 2000–December 2011) was conducted to identify publications on childhood anaphylaxis using the following terms: food allergy, food allergens, food hypersensitivity, epinephrine, epinephrine auto-injectors, anaphylactic triggers, and anaphylaxis. This review will critically appraise these key issues and highlight strategies that might result in improved management of anaphylaxis in children.

How Frequent Are Asthma Exacerbations in a Pediatric Primary Care Setting and Do Written Asthma Action Plans Help in Their Management

Purpose. In the National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma, the expert panel recommends that a written asthma action plan be provided for all patients with asthma. Studies evaluating the usefulness of the asthma action plan in children are limited. We aim to determine exacerbation frequency and usefulness of the asthma action plan in managing exacerbations that occur in a pediatric primary care setting. Methods. Caretakers of asthmatic children attending the general pediatric clinic in an inner‐city hospital completed a one‐page questionnaire covering topics such as asthma severity, frequency of exacerbations, and possession/usefulness of an asthma action plan. Although controversy exists over the definition of yellow and red zone exacerbations, we defined the yellow zone as symptoms that require albuterol more than three times a day or more than two nights in succession. The red zone was defined as symptoms requiring systemic corticosteroids and/or an urgent physician visit. Results. Seventy of 75 subjects completed the survey. Almost 80% of respondents carried the diagnosis of persistent asthma, whereas the remainder had intermittent asthma. Exacerbation frequency over a 3‐month period was determined. Approximately 80% of children experienced at least one yellow zone episode: 42% had one or two yellow zone episodes, and 39.6% had between three and five episodes. Sixty‐three percent of patients did not experience a single red zone exacerbation. Almost 75% (44 of 59) of subjects possessed an asthma action plan. Ninety percent (37 of 41) of respondents with action plans found the plan to be useful in managing exacerbations. Conclusion. Approximately four of every five asthmatic children seen in this primary care setting experienced a yellow zone exacerbation at least once during a 3‐month period. One third experienced at least one red zone episode. Nine of every 10 caretakers with an action plan reported the asthma action plan to be of value in managing exacerbations.

Practice ParameterStinging insect hypersensitivity: A practice parameter update 2016

Reprints: David B. K. Golden, MD, Department o dbkgolden@gmail.com. Disclaimer: The American Academy of Allergy, A accepted responsibility for establishing “Stinging I time. The medical environment is a changing envi of many participants, no single individual, includ practice parameters. Any request for information a the AAAAI or the ACAAI. These parameters are no Disclosures: The following is a summary of inter family member interests). Completed Conflict of In its website. Dr Golden has served on the speaker’s witness for & Trifrolis, PC, and is a section editor UptoDate. The other Work Group members have n conflict with development of a completely unbiase conflicts from influencing the final document in discussions concerning topics related to the poten remove potential bias. In addition, the entire docu sent for review both by invited reviewers and by Chief Editor: David B. K. Golden, MD Practice Parameter Work Group: David B.K. Gold Allergy, Asthma & Immunology Center of Alaska, Allergy Clinic, San Antonio, Texas; David Graft, MD Minneapolis, Minnesota; Michael Tankersley, MD, of Nebraska College of Medicine, and Allergy, Asth University Medical Center, Palo Alto, California. Membersof theJointTaskForceonPracticeParame of Cincinnati CollegeofMedicine,Cincinnati, Ohio; Joa Department of Pediatrics, University ofMissouri-Kan City,Missouri;MatthewGreenhawt,MD,AllergySect of InternalMedicine, University of Texas Southweste Institute, ClevelandClinic, Cleveland,Ohio; RichardN Internal Medicine, New JerseyMedical School, Pulmo Mercy Hospital, and Department of Pediatrics, Unive AffiliatedHospitals, Center for Allergy, Asthma, & Imm Medical College, Hershey, Pennsylvania; and DanaW InvitedReviews(inalphabeticalorder):WesleyBurk Columbia, Maryland; AndrewMurphy, MD, Downin All published practice parameters are available at htt The Joint Task Force hasmade a concerted effort to ac appropriate recognition of such contributions is mad

Real-life environmental tobacco exposure does not affect exhaled nitric oxide levels in asthmatic children

Serial measurement of exhaled nitric oxide (eNO) has been shown to be a good noninvasive marker of asthma control. Active smoking decreases eNO levels. The effect of real-life environmental exposure to tobacco smoke (ETS) on eNO levels is not known. Our objective was to study the impact of environmental tobacco exposure on eNO levels in asthmatic and non-asthmatic children. Single breath off-line collection of eNO was performed in asthmatic and non-asthmatic children with and without ETS. Urine was collected for cotinine/nicotine analysis. Fifty-seven children were enrolled, of which 25 were asthmatic and 32 had smoke exposure. One active smoker was excluded from the data analysis. The mean eNO was 11.1 ppb (n = 31; SD = 18.5) in those passively exposed vs. 11.1 ppb (n = 25; SD = 19.9) among the unexposed (not statistically significant). The mean eNO was 6.1 (n = 32; SD = 4.4) among the non-asthmatics and 17.8 (n = 24; SD = 27.4) among the asthmatics (p = 0.02; CI: 1.9–21.6). Real-life environmental tobacco exposure does not appear to decrease eNO levels in asthmatic children. Off-line collection of exhaled nitric oxide with a Mylar collection device helps differentiate asthmatics from non-asthmatics.

Review of cetirizine hydrochloride for the treatment of allergic disorders

Cetirizine hydrochloride is an orally-active and selective histamine (H1)-receptor antagonist. It is a second-generation antihistamine and a human metabolite of hydroxyzine. Therefore, its principal effects are mediated via selective inhibition of peripheral H1 receptors. The antihistaminic activity of cetirizine has been documented in a variety of animal and human models. In vivo and ex vivo animal models have shown negligible anticholinergic and antiserotonergic activity. In clinical studies, however, dry mouth has been seen more commonly with cetirizine than with placebo. In vitro receptor binding studies have shown no measurable affinity for receptors other than H1 receptors. Auto-radiographical studies with radiolabelled cetirizine in the rat have shown negligible penetration into the brain. Ex vivo experiments in the mouse have shown that systemically administered cetirizine does not significantly occupy cerebral H1 receptors. Impairment of CNS function is comparable to other low-sedating antihistamines at the recommended dose of 10 mg/day for adults. It has anti-inflammatory properties that may play a role in asthma management. It does not interact with concomitantly administered medications, it has no cardiac adverse effects, and it does not appear to be associated with teratogenicity. Cetirizine is predominantly eliminated by the kidneys with a mean elimination half-life is 8.3 h. It is rapidly absorbed, and significant clinical inhibition of a wheal and flare response occurs in infants, children and adults within 20 min of a single oral dose and persists for 24 h. No tolerance to the wheal and flare response occurs even after 1 month of daily treatment. The clinical efficacy of cetirizine for allergic respiratory diseases has been established in numerous trials. There is evidence that cetirizine improves symptoms of urticaria. Concomitant use of cetirizine also decreases the duration and amount of topical anti-inflammatory preparations needed for the treatment of atopic dermatitis. Interestingly, several clinical studies suggest that cetirizine may be useful in the treatment and prevention of mild asthma.

Learning preferences of caregivers of asthmatic children.

Background. People learn in different ways: visually, aurally, by reading/writing, and kinesthetically. In our clinic, we use color-coded Asthma Action Cards to educate our patients and their caregivers on asthma management. Our teaching is largely aural based, with the cards providing reading and visual stimulation and hands-on practice with devices offering kinesthetic stimulation. Objective. We sought to determine the learning styles of the caregivers of our asthmatic children. Methods. Caregivers in our Asthma/Allergy Clinic completed the Visual-Aural-Read/Write-Kinesthetic (VARK) questionnaire anonymously, and the responses were evaluated on the basis of previously validated scoring instructions. Results. Analysis of 98 respondents showed that 42% had a single learning modality preference, and the remaining 58% were multimodal learners. Of those who reported a single mode of learning, 61% preferred kinesthetic, 27% preferred reading/writing, and less than 1% each preferred aural or visual stimuli. Of all 98 caregivers, 82% included kinesthetic as a learning preference, 59% included read/write, 50% included aural, and 41% included visual. Conclusion. The majority of caregivers preferred the kinesthetic learning method, whether as a single learning preference or in combination with other approaches. Incorporating kinesthetic methods of learning, such as role plays and problem-solving case scenarios, into standardized asthma education curricula may be beneficial to patients and families in terms of understanding and using their regimen.

Management of acute loss of asthma control in the yellow zone: a practice parameter.

Chitra Dinakar, MD; John Oppenheimer, MD; Jay Portnoy, MD; Leonard B. Bacharier, MD; James Li, MD; Carolyn M. Kercsmar, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Chitra Dinakar, MD; John Oppenheimer, MD; Jay Portnoy, MD Members of the Joint Task Force on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD Practice Parameter Workgroup: Chitra Dinakar, MD; John Oppenheimer, MD; Jay Portnoy, MD; Leonard Bacharier, MD; James Li, MD; Carolyn Kercsmar, MD

Office-based exhaled nitric oxide measurement in children 4 years of age and older.

BACKGROUND Fractional exhaled nitric oxide (FENO) is increasingly being used in the office-based management of asthma, but data in children are limited. OBJECTIVES To report FENO values in 4- to 7-year-old children with suspected asthma and characterize their relation to clinical variables and describe the relation among FENO levels, age, and sex in 4- to 18-year-old children with suspected asthma. METHODS Retrospective data in 4- to 18-year-old children (n = 825) who underwent FENO testing using the NIOX MINO device were collected and analyzed. Chart reviews were performed for the 4- to 7-year-old children (n = 75). RESULTS FENO values ranged from less than or equal to 5 to 89 ppb in 75 4- to 7-year-old children and less than or equal to 5 to 300 ppb in 750 > 7 to 18-year-old children. Approximately one tenth of 4- to 7-year-old children and one third of > 7 to 18-year-old children had FENO values indicative of eosinophilic/allergic inflammation (>35 ppb). In regression analysis of the 4- to 7-year-old children, increasing age (P = .03) and asthma severity (P = .01) were associated with higher FENO levels. Atopic dermatitis was significantly associated (P = .03), whereas allergic rhinitis was marginally associated (P = .06), with higher FENO levels. Inhaled corticosteroid use was associated with lower FENO levels (P = .02). CONCLUSION This study characterizes the largest cohort of 4- to 7-year-old children to undergo FENO testing in ambulatory asthma management. Correlations between FENO levels and clinical variables were consistent with established findings in older children. This preliminary real-world study suggests that FENO assessment may be feasible and useful in the office-based asthma management of children as young as 4 years.