Matthew Greenhawt

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.

Adverse reactions to vaccines practice parameter 2012 update

Mild local reactions and fever after vaccinations are common and do not contraindicate future doses. Anaphylactic reactions to vaccines are rare and should be evaluated with skin tests to the vaccine and its components. If the skin test results are negative, subsequent doses can be administered in the usual manner but under observation. If the skin test results are positive and the patient requires subsequent doses, the vaccine can be administered in graded doses under observation. Some nonanaphylactic reactions to vaccines might also require evaluation, but only a few are contraindications to future doses. Pregnant women and persons who are immune compromised should generally not receive live vaccines. Purported long-term sequelae of vaccination, such as autism, are not supported by epidemiologic studies. Patients with egg allergy of any severity should receive annual influenza vaccinations because studies have demonstrated a very low rate of reactions. Studies to date have evaluated the injectable trivalent influenza vaccine (TIV), and thus TIV, rather than the live attenuated influenza vaccine (LAIV), should be used for recipients with egg allergy. All influenza vaccines available in the United States contain low amounts of ovalbumin. Neither skin testing with the vaccine nor dividing the dose is required; however, the vaccine should be administered in a setting in which anaphylaxis can be recognized and treated. EXECUTIVE SUMMARY Mild local reactions and constitutional symptoms, such as fever, after vaccinations are common and do not contraindicate future doses. Rarely, delayed-type hypersensitivity to a vaccine constituent can cause an injection-site nodule, but this is not a contraindication to subsequent vaccination. Anaphylactic reactions to vaccines are estimated to occur at a rate of approximately 1 per million doses. There are approximately 220million doses of vaccines distributed in the United States each year. All serious events occurring after vaccine administration should be reported to the Vaccine Adverse Event Reporting System (VAERS), even if it is not certain that the vaccine was the causal agent. Measuring levels of IgG antibodies to the immunizing agents in a vaccine suspected of causing a serious adverse reaction to determine whether they are at protective levels can help determine whether subsequent doses are required. All suspected anaphylactic reactions to vaccines should ideally be evaluated in an attempt to determine the culprit allergen. IgE-mediated reactions to vaccines are more often caused by additive or residual vaccine components, such as gelatin, rather than the microbial immunizing agent itself. Patients who have had an apparent anaphylactic reaction after immunization should undergo immediate-type allergy skin testing to help confirm that the reaction was IgE mediated and to determine the responsible component of the vaccine. If the intradermal skin test result is negative, the chance that the patient has IgE antibodies to any vaccine constituent is negligible, and the vaccine can be administered in the usual manner. Nonetheless, it is prudent in a patient with a history suggestive of an anaphylactic reaction to administer the vaccine under observation with epinephrine and other treatment available. In a patient with a history and skin test results consistent with an IgE-mediated reaction to a vaccine who requires additional doses of the suspect vaccine or other vaccines with common ingredients, consideration can be given to administering the vaccine in graded doses under observation. Some nonanaphylactic reactions to vaccines might also require evaluation, but only a few are absolute contraindications to future doses. Pregnant women should not be vaccinated with live vaccines. However, pregnant women should be given inactivated influenza vaccine, as well as tetanus and hepatitis B vaccine, if otherwise indicated. In general, live vaccines should not be given to persons who are immune compromised because of a risk of generalized infection with the immunizing agent. Specific vaccines or vaccination in general have been purported to have long-term consequences, including atopy, autism, and multiple sclerosis. Epidemiologic studies have not supported such associations. Patients with egg allergy should receive influenza vaccinations (TIV) because the risks of vaccinating are outweighed by the risks of not vaccinating. Persons with a history of suspected egg allergy should be evaluated by an allergist to determine the status of their egg allergy, but this should not delay their influenza vaccination. A growing number of studies suggest that influenza vaccines can be safely administered even to patients with a history of anaphylaxis to egg ingestion. Skin testing (prick, intradermal, or both) with the influenza vaccine itself in subjects with egg allergy (but without a history of reacting to the vaccine itself) does not reliably identify patients who are at increased risk of reacting to the vaccine and is not recommended. Influenza vaccine can be administered as a single dose to patients with egg allergy. Patients with egg allergy should receive influenza vaccines in a setting in which clinicians experienced in recognizing and treating anaphylaxis and equipment to manage anaphylaxis are immediately available and should be observed for 30minutes after vaccination. Patients with egg allergy with a history of only hives after egg ingestion can receive influenza vaccine in a primary care provider’s office provided the appropriate personnel and equipment are available, whereas those with a history of more severe reactions to egg ingestion should receive their vaccine in an allergist’s office. All influenza vaccines available in the United States contain low amounts of ovalbumin. Although the intranasally administered LAIV contains a low amount of ovalbumin, all published studies to date have evaluated the injectable TIV, and thus TIV rather than LAIV should be used for recipients with egg Category of evidence: Ia Evidence from meta-analysis of randomized controlled trials Ib Evidence from at least 1 randomized controlled trial IIa Evidence from at least 1 controlled study without randomization IIb Evidence from at least 1 other type of quasiexperimental study III Evidence from nonexperimental descriptive studies, such as comparative studies IV Evidence from expert committee reports or opinions or clinical experience of respected authorities or both Strength of recommendation: A Directly based on category I evidence B Directly based on category II evidence or extrapolated from category I evidence C Directly based on category III evidence or extrapolated from category I or II evidence D Directly based on category IV evidence or extrapolated from category I, II, or III evidence E Based on consensus of the Joint Task Force on Practice Parameters J ALLERGY CLIN IMMUNOL VOLUME nnn, NUMBER nn KELSO ET AL 3

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.

Food allergy and food allergy attitudes among college students

BACKGROUND Little information is known about food allergy among college students. OBJECTIVE We sought to assess food allergy trends and behavioral attitudes on a large university campus. METHODS An online survey was distributed by e-mail to local university undergraduate students. Symptom severity was determined based on previously published criteria for anaphylaxis. RESULTS A total of 513 individuals responded, with 57% reporting an allergic reaction to food. Of this group, 36.2% reported symptoms consistent with anaphylaxis, and these reactions frequently occurred while enrolled. Allergy to milk (P = .032), tree nut (P < .0001), shellfish (P < .0001), and peanut (P < .0001) was significantly associated with having symptoms of anaphylaxis. Some form of emergency medication was reportedly maintained in 47.7%, including self-injectable epinephrine (SIE; 21%), although only 6.6% reported always carrying this device. Medication maintenance was significantly lower among students who had not had a reaction while enrolled (P < .0001). Only 39.7% reported always avoiding foods to which they were allergic. Within the group that reported intentionally consuming known allergens, there were significantly lower numbers of individuals who reported carrying SIE (P < .0001) and significantly higher numbers of individuals with a history of a reaction that had not resulted in symptoms of anaphylaxis (P = .026). CONCLUSION Potentially life-threatening anaphylactic reactions to foods are occurring on college campuses. Only 39.7% of students with food allergy avoided a self-identified food allergen, and more than three fourths did not maintain SIE. Such behaviors might place these students at increased risk for adverse events.

International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology.

&NA; Food protein–induced enterocolitis (FPIES) is a non‐IgE cell‐ mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high‐quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence‐based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.

Safe administration of the seasonal trivalent influenza vaccine to children with severe egg allergy

BACKGROUND Anaphylaxis to egg or severe egg allergy has been considered a contraindication to receiving trivalent seasonal influenza vaccine (TIV). OBJECTIVE To evaluate the safety of TIV among severely egg allergic children. METHODS A 2-phase, multicenter study at 7 sites was conducted between October 2010 and March 2012. Inclusion criteria included a history of a severe reaction, including anaphylaxis, to the ingestion of egg and a positive skin test result or evidence of serum specific IgE antibody to egg. Phase 1 consisted of a randomized, prospective, double-blind, placebo controlled trial of TIV administration to egg allergic children, using a 2-step approach; group A received 0.1 mL of influenza vaccine, followed in 30 minutes if no reaction with the remainder of an age-appropriate dose, whereas group B received an injection of normal saline followed in 30 minutes if no reaction with the full 100% of the age-appropriate dose. Phase 2 was a retrospective analysis of single dose vs split-dose administration of TIV in eligible study participants who declined participation in the randomized controlled trial. RESULTS Thirty-one study participants were prospectively evaluated in the randomized controlled trial (group A, 14; group B, 17); 45.1% had a history of anaphylaxis after egg ingestion. A total of 112 participants were retrospectively evaluated (87 with the single dose and 25 with the split dose); 77.6% of participants had a history of anaphylaxis after egg ingestion. All participants in both phases received TIV without developing an allergic reaction. CONCLUSION TIV administration is safe even in children with histories of severe egg allergy. Use of 2-step split dosing appears unnecessary because a single dose was well tolerated.

The safety of the H1N1 influenza A vaccine in egg allergic individuals

BACKGROUND The safety of H1N1 vaccine is unknown in egg allergic (EA) recipients. OBJECTIVES To establish the safety of administering H1N1 vaccine and to evaluate the predictability of H1N1 skin testing in EA patients. METHODS In a controlled, prospective trial, H1N1 skin testing and vaccination was compared between EA patients (n = 105) and non-EA controls (n = 19). Those with negative H1N1 skin test results received a full H1N1 dose; those with a positive skin test result received a graded challenge (10%, 90%). Booster vaccine, if required, was given as a single dose from a different lot without prior testing. RESULTS Prick and intradermal test results were positive in 3 (2.4%) of 124 and 41 (33.1%) of 124 study participants, respectively. Forty-one individuals received a 2-step graded vaccine challenge, including 13 of 25 with a history of egg anaphylaxis. No significant allergic reactions resulted from either method of vaccination or from subsequent booster doses. CONCLUSION All study participants received the H1N1 vaccine without significant allergic reactions. Skin testing is unnecessary and does not predict vaccine tolerance. All study participants who received a graded challenge tolerated a single dose booster from a different, untested lot, including 7 individuals with a history of egg-induced anaphylaxis. We recommend administration of H1N1 vaccine to EA children without prior skin testing or graded challenge dosing.

The Management of Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a clinicopathologic, chronic esophageal inflammatory disease resistant to acid suppressive therapy and is associated with variable symptoms indicative of upper gastrointestinal dysfunction. Per current guidelines established by The International Group of Eosinophil Researchers (TIGERS), the diagnosis is made in symptomatic patients after a biopsy that confirms a peak eosinophil level of ≥15 eosinophils/high-powered field (HPF). The esophagus is distinguished by pronounced tissue eosinophilia in which dietary antigens are key inciting factors for disease pathogenesis; EoE being reversed by elimination of triggering food allergens suggests that the disease is mediated in part by allergic sensitization to foods. Moreover, experimental EoE in mice can be induced not only via food exposure but also via aeroallergen exposure. Consistent with an allergic etiology rather than an acid-induced esophagitis, swallowed glucocorticoids are effective for the treatment of EoE. Evaluation by an allergist is a recommended part of the diagnostic workup, especially for management of allergic comorbidities. Clinical practice for the evaluation of patients with EoE mainly relies on prick skin tests due to the ease and validation of these tests in the context of immediate hypersensitivity. However, both atopy patch testing and serum IgE testing have been used in EoE. Herein, we reviewed the basic clinical features of EoE with a focus on the approach to diagnosing causative food allergens and to dietary therapy.

Mastocytosis and allergy

Purpose of reviewTo illustrate features of allergy in mastocytosis. Recent findingsThe rates of atopy in patients with mastocytosis have generally been found to be similar to those of the normal population, although the incidence of anaphylaxis is much higher in mastocytosis. Introduction of objective pathologic criteria by the WHO for the diagnosis of mastocytosis has greatly facilitated the workup of patients with suspected mastocytosis, and has led to identification of mast cell disease in a subset of patients with anaphylaxis. There is increasing evidence that an activating c-kit mutation (D816V) exists in a subset of patients with recurrent mast cell activation symptoms who have normal-appearing bone marrow biopsies in routine evaluations without skin lesions. The genetic deficiency of α tryptase has not been found to influence serum tryptase levels in patients with mastocytosis. SummaryPathologic mast cell activation is a key finding in both allergic diseases and mastocytosis, albeit caused by entirely different mechanisms. Mastocytosis should be suspected in patients with recurrent anaphylaxis, who present with syncopal or near-syncopal episodes without associated hives or angioedema.

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