Edmond S. Chan

Consensus Communication on Early Peanut Introduction and the Prevention of Peanut Allergy in High-risk Infants

The purpose of this brief communication is to highlight emerging evidence to existing guidelines regarding potential benefits of supporting early, rather than delayed, peanut introduction during the period of complementary food introduction in infants. This document should be considered as interim guidance based on consensus among the following organizations: American Academy of Allergy, Asthma & Immunology; American Academy of Pediatrics; American College of Allergy, Asthma & Immunology; Australasian Society of Clinical Immunology and Allergy; Canadian Society of Allergy and Clinical Immunology; European Academy of Allergy and Clinical Immunology; Israel Association of Allergy and Clinical Immunology; Japanese Society for Allergology; Society for Pediatric Dermatology; and World Allergy Organization. More formal guidelines regarding early-life, complementary feeding practices and the risk of allergy development will follow in the next year from the National Institute of Allergy and Infectious Diseases – sponsored Working Group and the European Academy of Allergy and Clinical Immunology.

Reviews and feature articleConsensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants

The purpose of this brief communication is to highlight emerging evidence to existing guidelines regarding potential benefits of supporting early, rather than delayed, peanut introduction during the period of complementary food introduction in infants. This document should be considered as interim guidance based on consensus among the following organizations: American Academy of Allergy, Asthma & Immunology, American Academy of Pediatrics, American College of Allergy, Asthma & Immunology, Australasian Society of Clinical Immunology and Allergy, Canadian Society of Allergy and Clinical Immunology, European Academy of Allergy and Clinical Immunology, Israel Association of Allergy and Clinical Immunology, Japanese Society for Allergology, Society for Pediatric Dermatology, and World Allergy Organization. More formal guidelines regarding early-life, complementary feeding practices and the risk of allergy development will follow in the next year from the National Institute of Allergy and Infectious Diseases-sponsored Working Group and the European Academy of Allergy and Clinical Immunology.

Egg-allergic patients can be safely vaccinated against influenza

that additional factors are required. Our study also confirmed the association of FLG mutations and early-onset infantile eczema, which is in line with previous work. Our ability to interrogate the role of sensitization in the relationship between FLG mutations and food allergy in a large population-based, age-matched, challenge-proved food allergy cohort is a major and novel strength of this work. There is some potential participation bias among negative control subjects (higher immediate family history of allergic diseases compared with the general population); however, such a bias would be more likely to create a false-negative than a false-positive association. In conclusion, FLG mutations do not increase the risk of food allergy over and above that of food sensitization among 1-year-old infants. These results confirm the biological plausibility that decreased skin barrier function increases the risk of food sensitization in early life, but other as yet undetermined factors are important in the conversion from food sensitization to allergy.

Adrenal Suppression in Children Treated With Oral Viscous Budesonide for Eosinophilic Esophagitis.

ABSTRACT We sought to determine the prevalence of adrenal suppression (AS) in children with eosinophilic esophagitis treated with oral viscous budesonide (OVB). This was a retrospective review of a quality assurance initiative, whereby all children in our center treated with OVB for ≥3 months were referred over an 18-month time frame for endocrine assessment including 1 &mgr;g adrenocorticotropic hormone stimulation test. Fourteen of 19 children complied with the referral; of these 14 children, 6 (43%) had suboptimal stimulated cortisol (range 343–497 nmol/L, mean [±SD] 424.7 nmol/L [±52.4], normal ≥500 nmol/L). There was no significant association to treatment duration, dose, or concomitant use of inhaled/nasal corticosteroids. This study suggests that children treated with OVB may be at risk for AS.

Dietary exposures and allergy prevention in high-risk infants: a joint position statement of the Canadian Society of Allergy and Clinical Immunology and the Canadian Paediatric Society

Allergic conditions in children are a prevalent health concern in Canada. The burden of disease and the societal costs of proper diagnosis and management are considerable, making the primary prevention of allergic conditions a desirable health care objective. This position statement reviews current evidence on dietary exposures and allergy prevention in infants at high risk of developing allergic conditions. It revisits previous dietary recommendations for pregnancy, breastfeeding and formula-feeding, and provides an approach for introducing solid foods to high-risk infants. While there is no evidence that delaying the introduction of any specific food beyond six months of age helps to prevent allergy, the protective effect of early introduction of potentially allergenic foods (at four to six months) remains under investigation. Recent research appears to suggest that regularly ingesting a new, potentially allergenic food may be as important as when that food is first introduced. This article has already been published (Paediatr Child Health. 2013 Dec;18(10):545–54), and is being re-published with permission from the original publisher, the Canadian Paediatric Society.

Early Solid Food Introduction: Role in Food Allergy Prevention and Implications for Breastfeeding

Food allergy is estimated to affect 2%-10% of the population worldwide. The US Centers for Disease Control and Prevention reported an increase in food allergy prevalence in the US from 3.4% to 5.1% between 1997 and 2011. As a result, the focus in food allergy research has shifted from treatment to prevention. Some studies have suggested that early introduction of allergenic solids, before age 6 months, may be an effective means of prevention, particularly for egg and peanut allergy. However, earlier introduction of solid food risks directly contradicting current World Health Organization (WHO) recommendations, as well as many general pediatric guidelines, specifying exclusive breastfeeding until age 6 months. The WHO recommendations were not meant for allergy prevention and were developed before recent research that has solidified a relationship between food allergy prevention and early solid food introduction. However, the potential implications of earlier solid food introduction on the benefits of exclusive breastfeeding, as well as total breastfeeding duration, must be evaluated as well. Here we explore the evidence suggesting that introduction of solid foods before age 6 months might reduce the risk of food allergy. In addition, we review the possible implications of earlier solid food introduction on both the benefits of exclusive breastfeeding and the total duration of breastfeeding.

Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel

BackgroundFood allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy.ObjectivesPrompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy.ResultsThe addendum provides 3 separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider’s office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation.ConclusionsGuidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy.

The Complexities of Early Peanut Introduction for the Practicing Allergist.

Recommendations for the timing of introducing major food allergens, such as peanut, into the diet of at-risk infants have undergone major changes in the past decade. The most substantial modification has been a shift toward advice that delaying beyond 4 to 6 months does not prevent and might actually increase the risk of food allergy. The Learning Early About Peanut (LEAP) study published last year provided strong evidence that early peanut introduction with regular ingestion has a potentially dramatic benefit. Although there is little current doubt of the effectiveness of early peanut introduction, many unanswered questions remain. Previous guidelines defined infants at risk as those with a first-degree relative with allergic disease, whereas the LEAP study defined high risk as severe eczema or egg allergy. The LEAP study chose to screen infants but did not have a comparison group randomized without screening. In the following case-based discussion, we explore the complexities of LEAP implementation for the practicing allergist. These include nonuniformity in the literature for defining at-risk infants, difficulties in assessing eczema severity objectively, variable adherence to current guidelines, proposed peanut screening methods contrasting with existing food allergy guidelines to not routinely screen before ingestion, unclear interpretation of positive test results if screened, risks of screening extending to foods not studied in the LEAP study, and uncertainties about the optimal dose and duration of peanut once introduced.

Anaphylaxis across two Canadian pediatric centers: evaluating management disparities

Background There are no data on the percentage of visits due to anaphylaxis in the emergency department (ED), triggers, and management of anaphylaxis across different provinces in Canada. Objective To compare the percentage of anaphylaxis cases among all ED visits, as well as the triggers and management of anaphylaxis between two Canadian pediatric EDs (PEDs). Methods As part of the Cross-Canada Anaphylaxis Registry (C-CARE), children presenting to the British Columbia Children’s Hospital (BCCH) and Montreal Children’s Hospital (MCH) EDs with anaphylaxis were recruited. Characteristics, triggers, and management of anaphylaxis were documented using a standardized data entry form. Differences in demographics, triggers, and management were determined by comparing the difference of proportions and 95% confidence interval. Results Between June 2014 and June 2016, there were 346 visits due to anaphylaxis among 93,730 PED visits at the BCCH ED and 631 anaphylaxis visits among 164,669 pediatric visits at the MCH ED. In both centers, the majority of cases were triggered by food (BCCH 91.3% [88.7, 94.0], MCH 82.4% [79.7, 85.3]), of which peanuts were the most common culprit (24.7% [20.9, 29.9] and 19.0% [15.8, 22.7], respectively). Pre-hospital administration of epinephrine (BCCH 27.7% [23.2, 32.8], MCH 33.1% [29.5, 37.0]) and antihistamines (BCCH 50.6% [45.2, 56.0], MCH 47.1% [43.1, 51.0]) was similar. In-hospital management differed in terms of increased epinephrine, antihistamine, and steroid use at the BCCH (59.2% [53.9, 64.4], 59.8% [54.4, 65.0], and 60.1% [54.7, 65.3], respectively) compared to the MCH (42.2% [38.3, 46.2], 36.2% [32.5, 40.1], and 11.9% [9.5, 14.8], respectively). Despite differences in management, percentage of cases admitted to the intensive care unit was similar between the two centers. Conclusion Compared to previous European and North American reports, there is a high percentage of anaphylaxis cases in two PEDs across Canada with substantial differences in hospital management practices. It is crucial to develop training programs that aim to increase epinephrine use in anaphylaxis.

Peanut avoidance and peanut allergy diagnosis in siblings of peanut allergic children

Studies suggest that siblings of children with peanut allergy (PNA) have a higher prevalence of PNA than the general population.