Melanie Gleason

Oral Food Challenges in Children with a Diagnosis of Food Allergy

OBJECTIVE To assess the outcome of oral food challenges in patients placed on elimination diets based primarily on positive serum immunoglobulin E (IgE) immunoassay results. STUDY DESIGN This is a retrospective chart review of 125 children aged 1-19 years (median age, 4 years) evaluated between January 2007 and August 2008 for IgE-mediated food allergy at National Jewish Health and who underwent an oral food challenge. Clinical history, prick skin test results, and serum allergen-specific IgE test results were obtained. RESULTS The data were summarized for food avoidance and oral food challenge results. Depending on the reason for avoidance, 84%-93% of the foods being avoided were returned to the diet after an oral food challenge, indicating that the vast majority of foods that had been restricted could be tolerated at discharge. CONCLUSIONS In the absence of anaphylaxis, the primary reliance on serum food-specific IgE testing to determine the need for a food elimination diet is not sufficient, especially in children with atopic dermatitis. In those circumstances, oral food challenges may be indicated to confirm food allergy status.

Effect of montelukast on peripheral airflow obstruction in children with asthma

BACKGROUND Montelukast is a widely used controller agent in childhood asthma. It is modestly effective in reducing symptoms, decreasing the need for rescue albuterol, and improving forced expiratory volume in 1 second (FEV1). OBJECTIVE To determine whether montelukast therapy improves peripheral airway obstruction as measured by lung volumes, air trapping, airway resistance (Raw), and specific conductance (Sgaw). METHODS Twenty-one children aged 9 to 18 years with mild-to-moderate asthma were randomized into a double-blind, placebo-controlled study to receive montelukast (5 or 10 mg) or matching placebo daily for 8 weeks. Symptoms and albuterol use were recorded twice daily, and exhaled nitric oxide measurement, forced oscillometry, spirometry, and body box plethysmography (before and after beta-agonist use) were performed at randomization and at 2, 4, 6, and 8 weeks. Circulating eosinophil counts and serum eosinophil cationic protein (ECP) levels were obtained at randomization and at 8 weeks. RESULTS Montelukast-treated patients had lower residual volume (P = .05), residual volume-total lung capacity ratio (P = .04), Raw (P = .02), Sgaw (P = .03), and serum ECP levels (P = .02) at 8 weeks compared with those treated with placebo. There was a trend toward reduced daytime and nighttime albuterol use, although the difference did not reach statistical significance. There were no significant differences in FEV1, FEV1-forced vital capacity ratio, exhaled nitric oxide levels, or daytime and nighttime symptom scores between the 2 groups. CONCLUSIONS Montelukast therapy was associated with less air trapping, hyperinflation, and Raw and better Sgaw compared with placebo. Lower serum ECP levels, a surrogate measure of airway inflammation, were associated with improvements in lung function.

High-dose systemic glucocorticoid therapy in the treatment of severe asthma: A case of resistance and patterns of response

At some frequent interval, perhaps once a month, REFERENCES these would be reported to a central data collection 1. Yunginger JW. Sweeney KG. Stumer WQ. ct ,jl. Fatal i’ood center. Of course it would be ideal if each patient induced anaphylaxis. JAMA 1988;260: 1450-2 could be evaluated to determine if a food (and which 2. Sampson HA. Mendelson L, Rosen JP. Patal and trear-fatal food food) was actually responsible for the symptoms, but anaphylaxis reactions in children. N Engl J 2lcd 1992327:

Minimizing attrition in a long-term clinical trial of pediatric asthma

BACKGROUND Despite increased attention focused on the need to prevent patient attrition in long-term clinical trials, high dropout rates have threatened the success of numerous studies. OBJECTIVE To evaluate the disease, demographic, and psychological factors associated with missed visits and study dropout to help improve patient management in long-term clinical trials. METHODS Predictors of attrition were examined within the Childhood Asthma Management Program (CAMP), a large, multicenter clinical trial that followed up 1,041 children with asthma for 4 to 6 years. RESULTS Eighty-two percent of patients attended all study visits. The tendency to miss visits was increased among older children with milder asthma, lower intellectual and social competence, and more symptoms of behavioral problems and emotional distress. Forty-two patients who missed 3 or more visits in a row and did not attend the final visit were considered study dropouts; these patients at baseline had milder asthma; lower cognitive, academic, and social competence skills; and more family conflict and distress than found among participants who remained in the study. The 49 children who had erratic attendance but did not drop out also had lower intellectual and academic skills and less family social support. CONCLUSIONS The 4% dropout rate in CAMP was lower than reported in any previous long-term asthma trial. The findings of milder disease, decreased psychological resources, and increased distress in problem-attendance patients can assist in identifying patients who are at risk for missed visits or dropout during the trial either to block their entry into the trial or to focus efforts at maintaining their attendance once enrolled in the trial.

Single‐Dose Pharmacokinetics of Roflumilast in Children and Adolescents

Roflumilast is an orally administered phosphodiesterase 4 inhibitor that has potential for use in pediatric patients with asthma. The pharmacokinetics of roflumilast and roflumilast N‐oxide were examined in adolescents and children with stable mild to moderate asthma in an open‐label crossover study with age‐stratification and 2 treatment periods (100‐μg dose in period 1, 250‐μg dose in period 2) separated by a washout period. Plasma concentrations were measured by high‐performance liquid chromatography tandem mass spectrometry. Pharmacokinetic parameters were determined using standard noncompartmental methods and compared between study groups and within the entire cohort. Roflumilast was well tolerated. Linear relationships were evident for dose and area under the plasma drug concentration‐time curve extrapolated to infinity for both roflumilast (r2 = 0.36, P < .01) and roflumilast N‐oxide (r2 = 0.39, P < .01). With the exception of dose‐normalized maximum plasma concentration (mean 1.1 and 0.8 μg/L per 1 μg/kg dose for adolescents and children, respectively), pharmacokinetic parameters for roflumilast and roflumilast N‐oxide were not different between age groups and were similar to adults.

Does access to care equal asthma control in school-age children?

especially in patients with bee venom allergy. Female sex, adulthood, and a history of a previous severe allergic reaction to Hymenoptera stings are additional risk factors, yet the most important risk factors, not only for reactions but also for VIT failures, are underlying mastocytosis, increased baseline serum tryptase levels, and ‘‘mast cell activation disorders.’’ In our study the relative incidence was 13.8% (19.3% in honeybee venom–treated patients and 5.9% in vespid venom– treated patients). In the AAAAI study involving 1226 patients who reached the maintenance dose, SRs during updosing occurred with a lower frequency (9.7%); the higher incidence noted in the present study might relate to the exclusive application of rush regimens and the high percentage of patients with bee venom allergy in our patient population (54.9% vs 31.9% of the AAAAI study). The latter is consistent with the fact that our country maintains the highest concentration of beehives per square meter of land. Other studies involving smaller numbers of patients receiving ultrarush immunotherapy have reported an incidence of SRs in the range of 7% to 12.8%. The use of an initial dose of 1 mg in both the modified rush and ultrarush protocols was shown to be safe. This is supported by our SR rate being similar or lower in magnitude than those reported by other investigators, even though most of our patients were treated with bee venom, including our pediatric group, which was almost exclusively bee venom sensitive. Perhaps when starting at a higher venom dose, one bypasses the low, IgE-stimulating doses while saving time, money, and discomfort for the patients. In conclusion, initiating VIT at the 1-mg dose can be applied safely in rush protocols. Areti Roumana, MD Constantinos Pitsios, MD, PhD Stamatios Vartholomaios, MD Evangelia Kompoti, MD Kalliopi Kontou-Fili, MD, PhD

Leveraging Partnerships: Families, Schools, and Providers Working Together to Improve Asthma Management

Asthma is one of the most common illnesses of school-aged children and can lead to both health and educational disparities. Children from low socioeconomic backgrounds and racial/ethnic minorities suffer the greatest impact. They often lack the asthma self-management skills to successfully monitor, navigate, and negotiate appropriate asthma care. School settings are a strategic point of contact for this additional support. School nurses can monitor for signs of asthma worsening, manage symptoms, provide care coordination, and reinforce self-management skills. Likewise, school-based asthma programs have the potential to reduce health and educational disparities, but it is the strong linkage to the asthma care provider that is critical to successful school-based asthma management. Healthcare providers are encouraged to establish partnerships with families through patient-centered care and schools through clear communication and care coordination to ensure asthma is well controlled so the child is in school and ready to learn.

Use of an asthma risk questionnaire to identify young children likely to benefit from controller therapy

Abstract Rationale To date, no validated scoring system is available to assess young children with suspected asthma who may benefit from asthma controller therapy. Methods As part of a larger study evaluating the utility of an asthma risk questionnaire (ARQ), clinical data for preschool children with ≥1 episode of wheeze and not on controller agents were analyzed. Children were enrolled during their pediatric office visit in the summer months. The ARQ assigns points to the following categories: asthma symptoms (56), history of acute episodes (36), family/personal atopic history (30), triggers (8). A score of >45 was chosen to indicate a potential need for controller therapy. Results 173 were enrolled (mean age: 31.5 ± 19.4 months; 55% male). The mean ARQ score was 40.2 ± 19.2; 40% scored >45. Those who scored >45 had the following scores: asthma symptoms 14.5 ± 12.3; history of acute episodes 14.9 ± 8.2; atopy 27.1 ± 7.8; triggers 2.3 ± 1.9. Although only 5% of parents listed wheezing as the primary reason for the office visit, many children had active asthma symptoms: 21% had >2 daytime symptoms/week; 56% had nighttime symptoms at least once a week; 20% had activity limitation. Bronchodilators were previously prescribed in 66%, but only 11% used albuterol in the previous week. Conclusion The ARQ identified a number of young children with a history of wheezing as potential candidates for controller therapy. The ARQ provides a systematic way of gathering information to assist primary care physicians in decision-making regarding the need for controller therapy in children at risk for asthma.