Sten Dreborg

A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force.

This report has been prepared by an EAACI task force representing the five EAACI Sections and the EAACI Executive Committee composed of specialists that reflect the broad opinion on allergy expressed by various clinical and basic specialties dealing with allergy. The aim of this report is to propose a revised nomenclature for allergic and related reactions that can be used independently of target organ or patient age group. The nomenclature is based on the present knowledge of the mechanisms which initiate and mediate allergic reactions. However, the intention has not been to revise the nomenclature of nonallergic hypersensitivity.

Allergy to Apple, Carrot and Potato in Children with Birch Pollen Allergy

Skin sensitivity to apple, carrot and potato, clinically related to birch pollinosis was investigated. Different skin test techniques using fresh fruit were compared. A simple prick test (SPI) technique with a lancet piercing the apple peel just before pricking the skin was shown to be the most practical and to give reproducible results. The allergenic activity in apple was found to be heat labile and deteriorated during storage at room temperature, Apple, carrot, potato, hazelnut and birch reactivity was transferable in Prausnitz‐Küstner test like IgE antibodies. SPT reactivity to fresh material from apple, carrot and potato was investigated in 174 children of whom 128 suffered from pollen allergy. Positive SPT results were obtained almost exclusively in children who were SPT positive to a birch pollen extract. Children who noticed clinical symptoms when eating apple, raw carrot or potato were found to have a significantly larger SPT reaction than children with a negative history.

Dietary products used in infants for treatment and prevention of food allergy.: Joint statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition

For more than 50 years, many children with food protein allergies and other forms of dietary protein intolerance have been treated successfully with protein hydrolysates with highly reduced allergenicity and, more recently, also with products based on amino acid mixtures. Strategies for the prevention of allergy have been proposed, including the use of products with extensively reduced allergenicity. Products designed to have a moderately reduced allergenicity have also been proposed and marketed in Europe as hypoallergenic formulas. The European Society for Paediatric Allergology and Clinical Immunology (ESPACI) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) have commented previously on these issues,1 2 and the Commission of the European Union has issued a regulation for the requirements of infant formulas with reduced allergenicity or reduced antigenicity.3 This paper comments on the current developments and unresolved issues in the dietary treatment and prevention of food allergy in infancy to help inform paediatricians and other health care professionals, as well as manufacturers of infant foods. Adverse reactions to foods are a problem, particularly in infancy and early childhood, and can present with a wide spectrum of clinical reactions such as cutaneous, gastrointestinal, respiratory, or other symptoms. Reproducible adverse reactions to food(s) can be the result of one or more immune mechanism(s) or they can be non-immunologically mediated. Immunologically mediated reactions, which are often immediate IgE mediated reactions, are defined as food protein allergy. Non-immunologically mediated reactions can be divided into enzymatic or transport defects (for example, lactase deficiency, or glucose/galactose malabsorption), pharmacological or other (undefined) reactions.2 4 The pattern and threshold of adverse reactions to foods varies. None of the symptoms related to immunologically or non- immunologically mediated adverse reactions to foods are pathognomonic, and no single laboratory test is diagnostic of food allergy. Therefore, the diagnosis …

Dietary prevention of allergic diseases in infants and small children.

Because of scientific fraud four trials have been excluded from the original Cochrane meta‐analysis on formulas containing hydrolyzed protein for prevention of allergy and food intolerance in infants. Unlike the conclusions of the revised Cochrane review the export group set up by the Section on Paediatrics, European Academy of Allergology and Clinical Immunology (SP‐EAACI) do not find that the exclusion of the four trials demands a change of the previous recommendations regarding primary dietary prevention of allergic diseases. Ideally, recommendations on primary dietary prevention should be based only on the results of randomized and quasi‐randomized trials (selection criteria in the Cochrane review). However, regarding breastfeeding randomization is unethical, Therefore, in the development of recommendations on dietary primary prevention, high‐quality systematic reviews of high‐quality cohort studies should be included in the evidence base. The study type combined with assessment of the methodological quality determines the level of evidence. In view of some methodological concerns in the Cochrane meta‐analysis, particularly regarding definitions and diagnostic criteria for outcome measures and inclusion of non peer‐reviewed studies/reports, a revision of the Cochrane analysis may seem warranted. Based on analysis of published peer‐reviewed observational and interventional studies the results still indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is effective in the prevention of allergic diseases in high‐risk infants, particularly in early infancy regarding food allergy and eczema. The most effective dietary regimen is exclusively breastfeeding for at least 4–6 months or, in absence of breast milk, formulas with documented reduced allergenicity for at least the first 4 months, combined with avoidance of solid food and cows milk for the first 4 months.The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light on this issue, a group of experts of the Section of Pediatrics EAACI reviewed critically the existing literature on the subject. An analysis of published peer-reviewed observational and interventional studies was performed following the statements of evidence as defined by WHO. The results of the analysis indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is unequivocally effective in the prevention of allergic diseases in high-risk children. In these patients breastfeeding combined with avoidance of solid food and cows milk for at least 4-6 months is the most effective preventive regimen. In the absence of breast milk, formulas with documented reduced allergenicity for at least 4-6 months should be used.

Atopic sensitization and respiratory symptoms among Polish and Swedish school children

Allergic sensitization and symptoms from the airways in relation to air pollution were compared in 10–12‐year‐old school children (n= 1113) from urban Konin in central Poland and both urban and rural parts of Sundsvall in northern Sweden. The measurements included parental questionnaires, skin‐prick tests and serial peak flow measurements during 2 weeks with simultaneous monitoring of outdoor air pollutants. The skin‐prick test technique was validated by IgE antibody determinations. The levels of common industrial pollutants, SO2 and smoke particles were much higher in Konin than in urban Sundsvall and the levels of NO2 were similar. Various respiratory symptoms were more often reported among school children in Konin (except for wheezing and diagnosed asthma). Multiple logistic regression analyses yielded the following increased odds ratios for children in Konin as compared with the reference group (rural Sundsvall): chest tightness and breathlessness 348 (95% confidence interval 2.08–5.82), exercise‐induced coughing attacks 3.69 (95% confidence interval 1.68–8.10), recurrent episodes of common cold 2.79 (95% confidence interval 1.53–5.09) and prolonged cough 4–89 (95% confidence interval 2.59–9.23). In contrast, as compared with rural Sundsvall, the adjusted odds ratio for a positive skin‐prick test was decreased in Konin, but increased in urban Sundsvall, 0.58 (95% confidence interval 0.37–0.91) and 1.67 (95% confidence interval 1.15–2.42) respectively. The study confirms that living in urban, as compared with rural areas, is associated with an increased prevalence of respiratory symptoms and sensitization to allergens. These differences could be explained by air pollution. Respiratory symptoms were more common in a similar urban group of Polish children who were exposed to even higher levels of air pollution. These children, however, had a much lower prevalence of sensitization to allergens, as compared with the Swedish children. This indicates that differences in lifestyle and standard of living between western Europe and a former socialist country influences the prevalence of atopy.

Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations

The role of primary prevention of allergic diseases has been a matter of debate for the last 40 years. In order to shed some light on this issue, a group of experts of the Section of Pediatrics EAACI reviewed critically the existing literature on the subject. An analysis of published peer‐reviewed observational and interventional studies was performed following the statements of evidence as defined by WHO. The results of the analysis indicate that breastfeeding is highly recommended for all infants irrespective of atopic heredity. A dietary regimen is unequivocally effective in the prevention of allergic diseases in high‐risk children. In these patients breastfeeding combined with avoidance of solid food and cows milk for at least 4–6 months is the most effective preventive regimen. In the absence of breast milk, formulas with documented reduced allergenicity for at least 4–6 months should be used.

The precision of the conjunctival provocation test

Repeated conjunctiva] provocation tests ICPT) were done in 20 children with rhino‐conjunctivitis due to birch pollen allergy. Compared with the first open challenge, three successive blinded CPTs were reproducible within an allergen strength difference of one 10‐potency in 92 of the tests. Based on the data, a power function was constructed, making it possible to determine the number of patients needed to discriminate CRT sensitivity of a given magnitude between two populations. During the study period specific serum‐IgE increased in only three of 19 patients, indicating that stimulation of IgE antibody production is not a common consequence of repeated tests. We conclude that CPT is useful in clinical research. When indicated in clinical routine. CPT is a sale and easy test with good precision.

A Double-Blind, Multicenter Immunotherapy Trial in Children, Using a Purified and Standardized Cladosporium herbarum Preparation I. Clinical Results

A double‐blind histamine placebo controlled immunotherapy trial was performed to investigate the clinical effect of a purified and standardized Cladosporium herbarum allergen preparation. Thirty children with a clinical history suggesting mould‐induced asthma and/or rhinoconjuctivitis were included. The diagnosis was confirmed by positive skin prick test and Phadebas RAST® as well as positive bronchial and/or conjunctival provocation test to Cladosporium herbarum. Immunotherapy was given for 10 months in a double‐blind manner to randomized groups with either Pharmalgen®/Cladosporium herbarum preparation or histamine placebo. Allergic side effects to injections were common, especially during the peak of the mould season (July‐September in Scandinavia). In the active group, 13/16 patients experienced general reactions during the first 10 months of treatment. After 6 months of treatment, eye, nose and bronchial symptom scores and peak expiratory flow rates were similar for the groups, maybe because most of the children were also sensitive to many other allergens, including Alternaria alternala. However, medication scores were significantly lower in the treated group (P < 0.01). Bronchial (P < 0.01) and conjunctival sensitivity (P= 0.01) were significantly reduced in the Cladosporium‐treated group but not in the placebo group after 10 mouths of treatment. This is the first double‐blind clinical trial showing the clinical efficacy of immunotherapy in children with mould‐induced asthma.

Oral immunotherapy in birch pollen hay fever

Previous controlled trials with oral administration of allergen have not demonstrated any treatment effect in patients with allergic rhinoconjunctivitis or asthma. In the present double-blind, placebo-controlled trial, we have tested the effect of oral immunotherapy in adult patients with birch pollinosis. Thirty-nine patients completed this 18-month study comprising two birch pollen seasons. The patients received enterosoluble capsules daily, and the actively treated patients reached a cumulated dose of 280 times 10(6) biologic units of birch pollen extract, which is about 200 times higher than the dose used in conventional subcutaneous immunotherapy. We found a significant decrease in eye symptom scores and conjunctival sensitivity to birch pollen, as determined by conjunctival provocation test, as well as a numerical but nonsignificant decrease in nasal symptom scores, nasal sensitivity as determined by nasal provocation test, and antiallergic medication. The treatment was safe, and only a few slight side effects were observed. We thus conclude that our study demonstrates a clinical effect of oral immunotherapy in birch pollinosis.

Precision of skin prick and puncture tests with nine methods

New devices for puncture tests have been proposed recently, but their precision by comparison to the prick test method is poorly known. Seven puncture tests (Allerprick, Morrow Brown standardized needle, Phazer, Pricker, Stallerpointe, Stallerkit, and Wyeth bifucated needle) were compared with the modified prick test performed with hypodermic or intradermal needles in eight carefully selected normal volunteers. Skin tests with histamine hydrochloride (10 mg/ml) were only performed when there was no factor that might interfere with their interpretation. The site of skin tests on the forearm was demonstrated not to significantly influence the reaction size. The coefficient of variation of the tests ranged from 8.4% to 21.7%. Modified skin prick tests are satisfactory since they are highly reproducible (coefficient of variation: 13.4% and 16.5%) and there is no subject effect. Phazet was found to be more reproducible without subject effect. Pricker is satisfactory since it has no subject effect and a reproducibility similar to that of modified prick tests. Other tests are less reproducible (Stallerkit or Morrow Brown) or vary between subjects (Allerkit, Stallerkit, Stallerpointe, and Wyeth Needle).