Yolanda Meijer

Acute allergic reactions in children with AEDS after prolonged cow's milk elimination diets

Background:u2002 Food allergy is not always correctly diagnosed in children with atopic eczema dermatitis syndrome (AEDS) and treatment with an avoidance diet is not without danger.

Sensitization to Cor a 9 and Cor a 14 is highly specific for a hazelnut allergy with objective symptoms in Dutch children and adults

BACKGROUNDnComponent-resolved diagnosis has been shown to improve the diagnosis of food allergy.nnnOBJECTIVEnWe sought to evaluate whether component-resolved diagnosis might help to identify patients at risk of objective allergic reactions to hazelnut.nnnMETHODnA total of 161 hazelnut-sensitized patients were included: 40 children and 15 adults with objective symptoms on double-blind, placebo-controlled food challenges (DBPCFCs) and 24 adults with a convincing objective history were compared with 41 children and 41 adults with no or subjective symptoms on DBPCFCs (grouped together). IgE levels to hazelnut extract and single components were analyzed with ImmunoCAP.nnnRESULTSnIgE levels to hazelnut extract were significantly higher in children with objective than with no or subjective symptoms. In 13% of children and 49% of adults with hazelnut allergy with objective symptoms, only sensitization to rCor a 1.04 was observed and not to other water-soluble allergens. Sensitization to rCor a 8 was rare, which is in contrast to rCor a 1. Sensitization to nCor a 9, rCor a 14, or both was strongly associated with hazelnut allergy with objective symptoms. By using adapted cutoff levels, a diagnostic discrimination between severity groups was obtained. IgE levels to either nCor a 9 of 1 kUA/L or greater or rCor a 14 of 5 kUA/L or greater (children) and IgE levels to either nCor a 9 of 1 kUA/L or greater or rCor a 14 of 1 kUA/L or greater (adults) had a specificity of greater than 90% and accounted for 83% of children and 44% of adults with hazelnut allergy with objective symptoms.nnnCONCLUSIONnSensitization to Cor a 9 and Cor a 14 is highly specific for patients with objective symptoms in DBPCFCs as a marker for a more severe hazelnut allergic phenotype.

The diagnostic value of specific IgE to Ara h 2 to predict peanut allergy in children is comparable to a validated and updated diagnostic prediction model.

BACKGROUNDnA diagnostic prediction model for peanut allergy in children was recently published, using 6 predictors: sex, age, history, skin prick test, peanut specific immunoglobulin E (sIgE), and total IgE minus peanut sIgE.nnnOBJECTIVESnTo validate this model and update it by adding allergic rhinitis, atopic dermatitis, and sIgE to peanut components Ara h 1, 2, 3, and 8 as candidate predictors. To develop a new model based only on sIgE to peanut components.nnnMETHODSnValidation was performed by testing discrimination (diagnostic value) with an area under the receiver operating characteristic curve and calibration (agreement between predicted and observed frequencies of peanut allergy) with the Hosmer-Lemeshow test and a calibration plot. The performance of the (updated) models was similarly analyzed.nnnRESULTSnValidation of the model in 100 patients showed good discrimination (88%) but poor calibration (P < .001). In the updating process, age, history, and additional candidate predictors did not significantly increase discrimination, being 94%, and leaving only 4 predictors of the original model: sex, skin prick test, peanut sIgE, and total IgE minus sIgE. When building a model with sIgE to peanut components, Ara h 2 was the only predictor, with a discriminative ability of 90%. Cutoff values with 100% positive and negative predictive values could be calculated for both the updated model and sIgE to Ara h 2. In this way, the outcome of the food challenge could be predicted with 100% accuracy in 59% (updated model) and 50% (Ara h 2) of the patients.nnnCONCLUSIONSnDiscrimination of the validated model was good; however, calibration was poor. The discriminative ability of Ara h 2 was almost comparable to that of the updated model, containing 4 predictors. With both models, the need for peanut challenges could be reduced by at least 50%.

Moving from peanut extract to peanut components: towards validation of component‐resolved IgE tests

Replacement of peanut extracts by recombinant peanut components is an important step in allergy serologic testing. Criteria are needed for the unbiased inclusion of patients into a study to validate such a replacement.

Diagnostic value of hazelnut allergy tests including rCor a 1 spiking in double-blind challenged children

The diagnostic value of hazelnut allergy tests in double‐blind challenged children is largely unknown. The aim of this study was to analyze the performance of current diagnostic tests for hazelnut allergy in children and the effect of spiking.

Objective eliciting doses of peanut‐allergic adults and children can be combined for risk assessment purposes

To improve food labelling strategies, information regarding eliciting doses (EDs) and the effect of patient characteristics on these EDs is necessary.

Using Component-Resolved Diagnostics in the Management of Peanut-Allergic Patients

Opinion statementInstead of relying on crude peanut extract, component-resolved diagnostics (CRD) uses sensitization to allergenic proteins within peanut. In this review, we describe the recent advances and future perspectives of the use of CRD in the management of peanut-allergic patients. There is strong evidence that sensitization to Ara h 2 is the best predictor for clinically relevant peanut allergy in children and adults. Isolated sensitization to other peanut components is only rarely present in patients with systemic reactions to peanut. It is, however, important to remark that cut-off points of sIgE to Ara h 2 that predict tolerance or allergy vary between different study populations, different age groups and geographical regions, and validation studies performed in different settings are necessary to implement cut-offs in daily practice. Future studies should focus on the role of CRD in risk-assessment early in life, predicting long-term tolerance and monitoring treatment responses following immunotherapy.

Suspected cow’s milk allergy in everyday general practice: a retrospective cohort study on health care burden and guideline adherence

BackgroundCow’s milk allergy (CMA) is the most common food allergy among infants. No data are available on the health care burden of suspected CMA in general practice. This study was conducted to evaluate the burden of suspected CMA in general practice (GP): (a) prevalence, (b) presenting symptoms, (c) diagnostic process, (d) guideline adherence, and (e) dietary measures.MethodsA retrospective cohort study was carried out in four Julius Healthcare Centers (JHCs). These JHCs form the core primary care academic network of the department of general practice of the University Medical Center of Utrecht. Electronic records of the first year of infants born May 2009 - April 2010 registered in the JHCs were screened for possible CMA suspicion. Preventive child healthcare (PCH) records were reviewed for additional information. Clinical presentation, diagnostic strategies and dietary measures were extracted.ResultsOf 804 infants evaluated, 55 presented with symptoms fitting the suspicion of CMA (prevalence of 7%). Presenting complaints involved the skin (71%); the gastrointestinal tract (60%); the respiratory tract (13%) or other symptoms (36%) and 23 infants presented with symptoms of two or more organ systems. In 31 children (56%) a food challenge was performed (nu2009=u200928 open and nu2009=u20093 double-blind). Open challenge test results were difficult to interpret due to inadequate implementation or reporting. None had confirmed CMA after an adequate challenge test. Long term milk substitute formulas were prescribed in 39 (71%) infants.ConclusionOn a yearly basis seven percent of children visit their GP for suspected CMA. A positive CMA diagnosis was rarely established after adequate implementation and reporting of diagnostics, yet long term dietary measures were prescribed in >70% of patients. There is definitely need for improvement of diagnosing CMA in primary care.

Comparing high altitude treatment with current best care in Dutch children with moderate to severe atopic dermatitis (and asthma): study protocol for a pragmatic randomized controlled trial (DAVOS trial)

BackgroundAbout 10 to 20% of children in West European countries have atopic dermatitis (AD), often as part of the atopic syndrome. The full atopic syndrome also consists of allergic asthma, allergic rhinitis and food allergy. Treatment approaches for atopic dermatitis and asthma include intermittent anti-inflammatory therapy with corticosteroids, health education and self-management training. However, symptoms persist in a subgroup of patients. Several observational studies have shown significant improvement in clinical symptoms in children and adults with atopic dermatitis or asthma after treatment at high altitude, but evidence on the efficacy when compared to treatment at sea level is still lacking.Methods/DesignThis study is a pragmatic randomized controlled trial for children with moderate to severe AD within the atopic syndrome. Patients are eligible for enrolment in the study if they are: diagnosed with moderate to severe AD within the atopic syndrome, aged between 8 and 18xa0years, fluent in the Dutch language, have internet access at home, able to use the digital patient system Digital Eczema Center Utrecht (DECU), willing and able to stay in Davos for a six week treatment period. All data are collected at the Wilhelmina Children’s Hospital and DECU. Patients are randomized over two groups. The first group receives multidisciplinary inpatient treatment during six weeks at the Dutch Asthma Center in Davos, Switzerland. The second group receives multidisciplinary treatment during six weeks at the outpatient clinic of the Wilhelmina Children’s Hospital, Utrecht, the Netherlands. The trial is not conducted as a blind trial. The trial is designed with three components: psychosocial, clinical and translational. Primary outcomes are coping with itch, quality of life and disease activity. Secondary outcomes include asthma control, medication use, parental quality of life, social and emotional wellbeing of the child and translational parameters.DiscussionThe results of this trial will provide evidence for the efficacy of high altitude treatment compared to treatment at sea level for children with moderate to severe AD.Trial RegistrationCurrent Controlled Trials ISRCTN88136485.

Effectiveness of alpine climate treatment for children with difficult to treat atopic dermatitis : results of a pragmatic randomized controlled trial (DAVOS trial)

Alpine climate treatment has historically been used in Europe to treat atopic dermatitis (AD), but no randomized trials have been conducted to provide evidence for its effectiveness.