Elisabetta Calamelli

Consensus Conference on Clinical Management of pediatric Atopic Dermatitis

The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.

Prevalence and Clinical Relevance of IgE Sensitization to Profilin in Childhood: A Multicenter Study

Background: Little is known about the prevalence and clinical relevance of hypersensitivity to the plant panallergen profilin in children. Objectives: The present study aimed to investigate prevalence, risk factors and clinical relevance of profilin sensitization in a large cohort of Italian children of different ages living in different geographic areas. Methods: Children with pollen allergy enrolled by 16 pediatric outpatient clinics sited in three main geographic areas of Italy were studied. SPT were carried out with commercial pollen extracts and a commercial purified date palm pollen profilin. IgE specific for allergenic pollen molecules, Phl p 12 (grass profilin) and Pru p 3 (peach lipid transfer protein) were tested by ImmunoCAP FEIA. Results: IgE to Phl p 12 (≥0.35 kU/l) was observed in 296 of the 1,271 participants (23%), including 17 of the 108 (16%) preschool children. Profilin SPT was positive (≥3 mm) in 320/1,271 (25%) participants. The two diagnostic methods were concordant in 1,151 (91%, p < 0.0001) cases. Phl p 12 IgE prevalence declined from northern to southern Italy and was directly associated with IgE to Phl p 1 and/or Phl p 5 and Ole e 1. Among children with IgE to Phl p 12, OAS was provoked by kiwi, melon, watermelon, banana, apricot and cucumber. Conclusions: Profilin sensitization is very frequent among pollen-allergic children, occurs at a very young age and contributes to the development of childhood OAS with a typical pattern of offending foods. Pediatricians should always consider IgE sensitization to profilin while examining pollen-allergic children, even if they are at preschool age.

Citrus Allergy from Pollen to Clinical Symptoms

Allergy to citrus fruits is often associated with pollinosis and sensitization to other plants due to a phenomenon of cross-reactivity. The aims of the present study were to highlight the cross-reactivity among citrus and the major allergenic pollens/fruits, throughout clinical and molecular investigations, and to evaluate the sensitization frequency to citrus fruits in a population of children and adults with pollinosis. We found a relevant percentage of sensitisation (39%) to citrus fruits in the patients recruited and in all of them the IgE-mediated mechanism has been confirmed by the positive response to the prick-to-prick test. RT-PCR experiments showed the expression of Cit s 1, Cit s 3 and a profilin isoform, already described in apple, also in Citrus clementine pollen. Data of multiple sequence alignments demonstrated that Citrus allergens shared high percentage identity values with other clinically relevant species (i.e. Triticum aestivum, Malus domestica), confirming the possible cross-allergenicity citrus/grasses and citrus/apple. Finally, a novelty of the present work has been the expression of two phospholipaseA2 isoforms (PLA2 α and β) in Citrus as well as in Triticum pollens; being PLA2 able to generate pro-inflammatory factors, this enzyme could participate in the activation of the allergenic inflammatory cascade.

Clinical practice recommendations for allergen-specific immunotherapy in children: the Italian consensus report

Allergen-specific immunotherapy (AIT) is currently recognized as a clinically effective treatment for allergic diseases, with a unique disease-modifying effect. AIT was introduced in clinical practice one century ago, and performed in the early years with allergenic extracts of poor quality and definition. After the mechanism of allergic reaction were recognized, the practice of AIT was refined, leading to remarkable improvement in the efficacy and safety profile of the treatment. Currently AIT is accepted and routinely prescribed worldwide for respiratory allergies and hymenoptera venom allergy. Both the subcutaneous (SCIT) and sublingual (SLIT) routes of administration are used in the pediatric population.AIT is recommended in allergic rhinitis/conjunctivitis with/without allergic asthma, with an evidence of specific IgE-sensitization towards clinically relevant inhalant allergens. Long-term studies provided evidence that AIT can also prevent the onset of asthma and of new sensitizations. The favorable response to AIT is strictly linked to adherence to treatment, that lasts 3–5 years. Therefore, several factors should be carefully evaluated before starting this intervention, including the severity of symptoms, pharmacotherapy requirements and children and caregivers’ preference and compliance.In recent years, there have been increasing interest in the role of AIT for the treatment of IgE-associated food allergy and extrinsic atopic dermatitis. A growing body of evidence shows that oral immunotherapy represents a promising treatment option for IgE-associated food allergy. On the contrary, there are still controversies on the effectiveness of AIT for patients with atopic dermatitis.This consensus document was promoted by the Italian Society of Pediatric Allergy and Immunology (SIAIP) to provide evidence-based recommendations on AIT in order to implement and optimize current prescription practices of this treatment for allergic children.

Cytokines Levels in Children Affected by Atopic and Nonatopic Eczema

Patients with atopic eczema present higher serum levels of total IgE and different pattern of cytokines, com- pared to nonatopic eczematous patients. This study aimed to evaluate serum levels of IL-2, IL-4, IL-5, IL-10, IFN� , TNF� in eczematous children in relation to atopic and nonatopic form. We enrolled 45 eczematous children and 12 controls. To- tal IgE and specific IgE against principal food and inhalant allergens were evaluated by UniCap1000 and levels of cytoki- nes by Cytometric Bead Array System. The geometric means of levels of IL-4 were higher in eczematous patients than controls (P=0.036). Serum levels of IL-10 and IFNwere higher in nonatopic eczematous children than in atopic eczema- tous patients and controls (P= 0.004, P= 0.003). Our data confirm that cytokines may play an important role in the patho- genesis of eczema: nonatopic eczema seems to be characterized by increased levels of IL-10 and IFNcompared to atopic form.

Topical corticosteroid phobia in parents of pediatric patients with atopic dermatitis: a multicentre survey

BackgroundFamilies of children affected with atopic dermatitis (AD) often report fear and anxiety regarding treatment with topical corticosteroids (TCS), which may lead to reduced compliance. The objective of our study was to measure, through a standardized questionnaire, fear of TCS in families of pediatric patients with AD and to identify items associated with fear.MethodsFamilies of pediatric patients with AD were enrolled in 9 Italian centers of pediatric dermatology. Enrolled parents were invited to fill in a questionnaire including questions on sociodemographic and clinical characteristics and 3 sets of questions on corticosteroid phobia (general fear, specific fears, behaviours regarding TCS). Determinants of the level of general fear were investigated through multivariable analysis.ResultsA total of 300 outpatients with AD were enrolled. Most parents (80%) had a high instruction level. Eighty-one percent reported to have a certain amount of fear of TCS. At the multivariable analysis, fear of TCS was associated with the following items: believing that TCS treatment advantages do not overweight disadvantages (P = 0.011); believing that TCS may be dangerous independently from the specific side effect (P < 0.001). Moreover, TCS fear was associated with fear of applying too much cream (P = 0.001).ConclusionTCS phobia is widespread among Italian families of children with AD. Fear of TCS is associated with fear of applying too much cream, thus increasing the risk of poor compliance and treatment failure. Therapeutic education of families on the use of TCS should be implemented.

Peanut Sensitization Profiles in Italian Children and Adolescents with Specific IgE to Peanuts

Peanuts are one of the most relevant foods implicated in IgE-mediated adverse reactions in pediatric population. This study aimed to evaluate the pattern of sensitization towards five peanut allergenic components (rAra h 1, 2, 3, 8 and 9) in a population of Italian children and adolescents with specific IgE (sIgE) to peanut. rAra h 9 was the main allergen implicated in peanut sensitization (58%), followed by rAra h 8 (35%), rAra h 2 (27%), rAra h 3 (23%) and rAra h 1 (12.5%). rAra h 1, 2, and 3 were the main allergenic components in young children: 8/13 (62%) between 2 and 5 years, 8/23 (35%) between 6 and 11 years, and 3/12 (25%) between 1 and 16 years. No differences were found among the levels of sIgE towards rAra h 1, 2, 3, and 9 in the three groups; in contrast, the levels of sIgE against rAra h 8 showed an increasing trend according to age. In conclusion rAra h 1, 2, and 3 were the prevalent sensitizing allergens during the first years of life in Italian patients with sIgE to peanuts (“genuine” allergy); in contrast rAra h 9 and 8 were mainly involved in school-age children and adolescents with pollen allergy (“secondary” sensitization).

Food Allergy in Children with Asthma: Prevalence and Correlation with Clinical Severity of Respiratory Disease

Epidemiological evidence suggests that there is a link between asthma and food allergy. The aim of this study was to estimate the prevalence of food allergy in asthmatic children and to evaluate a possible impact of food allergy on asthma severity. The study enrolled 103 asthmatic children (mean age: 11 years). Skin prick-test, dosage of specific IgE to a standardized panel of inhalant and food allergens and spirometric evaluation was made for each patient. Twenty-four (23%) patients presented food allergy, 75 (77%) were sensitized to at least one food. A lower rate of children with con- trolled symptoms was found in children with food allergy and a higher rate of persistent asthma was found in children sensitized to at least 4 foods. In conclusion, food allergy/sensitization should always be investigated in asthmatic children for its association with increasing severity (only in food sensitized patients) and reduced control of asthmatic symptoms.

Immune and inflammatory response in bronchiolitis due to respiratory Syncytial Virus and Rhinovirus infections in infants

Bronchiolitis is a common disease in infancy, mostly due to Respiratory Syncytial Virus and Rhinovirus. In addition to acute infection, viral bronchiolitis is responsible for sequelae including recurrent wheezing and asthma. The analysis of the viral characteristics and of the pathogenesis of the infection shows differences between the two viruses that may be helpful for the development of therapies and preventive strategies.

Management and treatment of anaphylaxis in children: still too low the rate of prescription and administration of intramuscular epinephrine.

Despite it being well known that anaphylaxis is a severe life-threatening reaction requiring prompt management and treatment, this entity is still under-recognized and not correctly managed, above all in children. The aim of this study was to analyze the most frequent features of anaphylaxis in a pediatric population (n=65 patients) and to identify factors predicting more severe reactions. Among the 70 recorded episodes, food was the main culprit of anaphylaxis, and patients with a positive history for allergic asthma had more severe episodes (P=0.008). A self-injectable adrenaline was used only in 2 of the 70 episodes and none of the 50 episodes managed in the Emergency Department was treated with intramuscular adrenaline. Only 10/65 patients (15%) had a prescription for an auto-injector prior to the first episode of anaphylaxis. The retrospective analysis of the risk factors potentially requiring an epinephrine auto-injector prescription before the first anaphylactic episode, showed that of the 55 patients without prescription, at least 10 (18%) should have been provided with a device, according to the most recent guidelines. In conclusion, notwithstanding intramuscular adrenaline being the first-line treatment of anaphylaxis, many episodes are still undertreated and the risk of anaphylaxis is still underestimated. More efforts should be made to promote the correct management of anaphylaxis among both healthcare-providers and patients.