Gideon Lack

The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology

Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first‐line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child’s previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients’ organizations. Absolute indications for prescribing self‐injectable adrenaline are prior cardiorespiratory reactions, exercise‐induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better‐quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.

A consensus protocol for the determination of the threshold doses for allergenic foods: how much is too much?

Background While the ingestion of small amounts of an offending food can elicit adverse reactions in individuals with IgE‐mediated food allergies, little information is known regarding these threshold doses for specific allergenic foods. While low‐dose challenge trials have been conducted on an appreciable number of allergic individuals, a variety of different clinical protocols were used making the estimation of the threshold dose very difficult.

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.

Specific oral tolerance induction in food allergic children: is oral desensitisation more effective than allergen avoidance?: a meta-analysis of published RCTs.

Objective To determine whether specific oral tolerance induction (SOTI) is more effective than avoidance in inducing tolerance in children aged 0–18 years who have immunoglobulin E (IgE)–mediated food allergy. Data sources MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009) and all EBM Reviews: Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database (from start date to November 2008). The online table of contents (November 2003 to July 2009) of the Journal of Allergy and Clinical Immunology, Pediatric Allergy and Immunology and Allergy were also searched, and reference lists of retrieved articles were scrutinised for relevant studies. Study selection Randomised controlled trials (RCT) were included providing they enrolled children with IgE-mediated food allergy diagnosed using the criterion standard tool (double-blind placebo-controlled food challenge) before randomisation and also compared posttreatment tolerance between groups using the criterion standard measures. Results Three studies met the inclusion criteria, and two proved a statistically significant reduction in endpoint allergy (determined by oral food challenge) after SOTI compared with the control. The meta-analysis of the included studies found a lower RR of allergy after SOTI, but this did not meet statistical significance (0.606783; 95% CI 0.317733 to 1.158791). Conclusions SOTI cannot yet be recommended in routine practice as a means to induce tolerance in children with IgE-mediated food allergy. Further research is needed using large, high-quality RCT that investigate a variety of food allergens and assesses the long-term efficacy, safety and cost-effectiveness of SOTI.

Specific oral tolerance induction in food allergic children: is oral desensitisation more effective than allergen avoidance?

Objective To determine whether specific oral tolerance induction (SOTI) is more effective than avoidance in inducing tolerance in children aged 0–18 years who have immunoglobulin E (IgE)–mediated food allergy. Data sources MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009) and all EBM Reviews: Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database (from start date to November 2008). The online table of contents (November 2003 to July 2009) of the Journal of Allergy and Clinical Immunology, Pediatric Allergy and Immunology and Allergy were also searched, and reference lists of retrieved articles were scrutinised for relevant studies. Study selection Randomised controlled trials (RCT) were included providing they enrolled children with IgE-mediated food allergy diagnosed using the criterion standard tool (double-blind placebo-controlled food challenge) before randomisation and also compared posttreatment tolerance between groups using the criterion standard measures. Results Three studies met the inclusion criteria, and two proved a statistically significant reduction in endpoint allergy (determined by oral food challenge) after SOTI compared with the control. The meta-analysis of the included studies found a lower RR of allergy after SOTI, but this did not meet statistical significance (0.606783; 95% CI 0.317733 to 1.158791). Conclusions SOTI cannot yet be recommended in routine practice as a means to induce tolerance in children with IgE-mediated food allergy. Further research is needed using large, high-quality RCT that investigate a variety of food allergens and assesses the long-term efficacy, safety and cost-effectiveness of SOTI.