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Allergy to hen's egg is common in infancy and childhood. Oral food challenges are often required to diagnose egg allergy, because of the limitation in the diagnostic accuracy of skin test and specific IgE to egg white. New molecular diagnostic technologies have been recently introduced into allergological research. In this article, we will review the recent literature regarding the potential value of these tests for the clinical management of egg-allergic patients.Component-resolved diagnosis that can be combined with the microarray technology is promising as measurement of specific IgE antibodies to individual egg white components has been shown to predict different clinical patterns of egg allergy. Specific IgE to ovomucoid has been identified as a risk factor for persistent allergy and could indicate reactivity to heated egg. Ovomucoid and ovalbumin IgE and IgG4-binding epitope profiling could also help distinguish different clinical phenotypes of egg allergy. Particularly, egg-allergic patients with IgE antibodies reacting against sequential epitopes tend to have more persistent allergy.Using recombinant allergens, IgE-binding epitopes, and microarrays, molecular-based technologies show promising results. However, none of these tests is ready to be used in clinical practice and oral food challenge remains the standard for the diagnosis of egg allergy.

There is an unmet medical need for an effective food allergy therapy; thus, development of therapeutic interventions for food allergy is a top research priority. The food allergen-nonspecific therapies for food-induced anaphylaxis include monoclonal anti-IgE antibodies and Chinese herbs. The food allergen-specific therapies include oral, sublingual, and epicutaneous immunotherapy with native food allergens and mutated recombinant proteins. Diet containing heated milk and egg may represent an alternative approach to oral immunomodulation. Oral food immunotherapy remains an investigational treatment to be further studied before advancing into clinical practice.

The need for allergy prevention strategies has never been greater. Surging rates of food allergy and eczema are now adding to the already substantial burden of asthma and respiratory allergic diseases. The parallel rise in many other immune diseases suggests that the developing immune system is highly vulnerable to modern environmental changes. These strong environmental pressures may be one reason why simple allergen avoidance strategies have not been successful. Another more recent strategy to curtail the allergy epidemic has been to identify factors associated with modern lifestyle that may be causally linked with allergic disease, in an attempt to restore more favourable conditions for immune tolerance during early development. More hygienic conditions and disruption of microbial exposure have prompted strategies to restore this balance using probiotic and prebiotic supplements. Modern dietary changes linked with allergic diseases have prompted supplementation studies to assess the preventive merits of specific immunomodulatory dietary nutrients such as polyunsaturated fatty acids. Other nutrients such as antioxidants, folate, and vitamin D are also currently under investigation. Modern environmental pollutants have also been associated with adverse effects on immune development and the risk of disease. While many of these avenues have provided some promise, they have not yet translated into specific recommendations. Current evidence-based guidelines for allergy prevention remain limited to avoidance of cigarette smoke, promotion of breastfeeding and the use of hydrolysed formula when breastfeeding is not possible. Allergen avoidance strategies have been largely removed from most guidelines. It is hoped that a number of ongoing studies will help provide clearer recommendations around the use of probiotics, prebiotics, specific dietary nutrients and the role of early introduction of allergenic foods for the promotion of tolerance. Despite the current uncertainties, prevention remains the best long-term strategy to reduce the growing burden of allergic disease.

Introduction Many cow's milk allergic children can tolerate extensively heated forms milk. Tolerating baked milk products can even accelerate tolerance to less heated milk. The aims of this study are to follow-up patients who tolerated baked milk oral food challenges (BMC) and characterize their tolerance of less heated forms of milk. Methods We performed retrospective chart reviews of milk allergic patients who visited our pediatric allergy clinic from January 2008 to December 2017 and passed BMCs to muffin. We characterized their progression to lesser (un)heated milk products. Results Preliminary data demonstrates approximately 77 % of milk-allergic patients continued to tolerate baked products for at least 1 year after their BMC. 44% of subjects who passed a BMC and introduced baked milk at home ultimately tolerated unheated milk within the time frame of the study. Baked milk tolerant patients required a median of 36 months (IQR 38.5-37) to progress towards tolerance of unheated milk. Consumption of baked products after the BMC was not associated with severe symptoms including respiratory distress or anaphylaxis. Mild symptoms noted with ingestion of baked milk included oral itching, localized hives, and/or abdominal pain. Conclusions Overall, preliminary results confirm consuming baked products at home after challenges is safe, with minimal risk of severe reaction. Tolerance to lesser/ unheated milk is likely to be achieved if baked products are regularly kept in the diet.

An inactivated influenza vaccine produced in canine kidney cells (MDCK 33016-PF) contains no egg proteins and may be used to immunize egg-allergic patients. Although no major dog allergens were identified in MDCK 33016-PF cells, minor dog allergens might be present and cause reactions in dog-allergic individuals.To evaluate the allergenicity of the inactivated influenza vaccine produced in cell culture in a mediator release assay.Rat basophil leukemia (RBL) cells transfected with human IgE receptor-1 were sensitized with sera from dog-allergic adults with positive skin prick test reactions to dog extract and detectable dog dander IgE and were stimulated with serial dilutions of vaccine and dog dander extract. N-hexosaminidase release (NHR) was used as a marker of RBL cell degranulation. Western blots were performed, and UniCAP was used to measure dog-specific IgE antibody levels.The median (interquartile range) level of dog dander IgE was 8.31 kU(A)/L (1.895-14.5 kU(A)/L) and of dog epithelium IgE was 3.19 kU(A)/L (0.835-6.27 kU(A)L). Median (range) maximum NHR (at the first 10-fold dilution) was 0% (0%-1.4%) to vaccine and 10.2% (0%-35.9%) to dog dander (P.001). In an egg-allergic control subject, the maximum NHR to a vaccine cultured in chick embryo and containing egg protein was 10.2%. IgE antibodies in pooled sera did not bind to vaccine on immunoblots but produced strong binding to dog dander and epithelium extracts. Serum from an egg-allergic control subject strongly bound embryonated egg-derived vaccine.An influenza vaccine produced in continuous canine kidney cells did not trigger degranulation in RBL cells passively sensitized with human anti-dog IgE.

Background Most milk-allergic children tolerate baked milk. Objective To investigate the effect of more frequent versus less frequent introduction of higher doses of more allergenic (less heat-denatured) forms of milk (MAFM) on progression to tolerance. Methods Milk-allergic children were challenged with increasing doses of MAFM; baked foods were incorporated into the diet; challenges were repeated at 6- or 12-month intervals over 36 months. Results A total of 136 children (70% males) were enrolled in the active group (median age, 7 years). At baseline, 41 (30%) reacted to muffin, 31 (23%) to pizza, 11 (8%) to rice pudding, 43 (32%) to non–baked milk; and 10 (7%) tolerated non–baked milk. Children who tolerated baked milk but reacted to non–baked liquid milk were randomized to MAFM challenges every 6 months (n = 41) or 12 months (n = 44). At month 36, 61% children in the 6-month and 73% in the 12-month escalation groups tolerated MAFM. Overall, 41 (48%) children who ingested baked-milk diet became tolerant to non–baked milk; no difference was seen between 6- and 12- month escalations. Among children who reacted to muffin at baseline and continued avoidance, 20% developed tolerance to baked milk and 0% tolerated non–baked milk. None of the 34 children who qualified for inclusion but chose not to take part in the active study became tolerant to any form of milk by history. Conclusions Majority of children tolerated baked milk at baseline. Baked-milk diets were associated with progressive immunomodulation. Most children who incorporated baked milk into their diet progressed to tolerating MAFM, but there was no advantage to more frequent attempts to escalate to MAFM, per intention-to-treat analysis.

Background Data about epinephrine use and biphasic reactions in childhood food-induced anaphylaxis during oral food challenges are scarce. Objective To determine the prevalence and risk factors of reactions requiring epinephrine and the rate of biphasic reactions during oral food challenges (OFCs) in children. Methods Reaction details of positive OFCs in children between 1999 and 2007 were collected by using a computerized database. Selection of patients for OFCs was generally predicated on ≤50% likelihood of a positive challenge and a low likelihood of a severe reaction on the basis of the clinical history, specific IgE levels, and skin prick tests. Results A total of 436 of 1273 OFCs resulted in a reaction (34%). Epinephrine was administered in 50 challenges (11% of positive challenges, 3.9% overall) for egg (n = 15, 16% of positive OFCs to egg), milk (n = 14, 12%), peanut (n = 10, 26%), tree nuts (n = 4, 33%), soy (n = 3, 7%), wheat (n = 3, 9%), and fish (n = 1, 9%). Reactions requiring epinephrine occurred in older children (median, 7.9 vs 5.8 years; P P = .006) compared with reactions not treated with epinephrine. There was no difference in the sex, prevalence of asthma, history of anaphylaxis, specific IgE level, skin prick tests, or amount of food administered. Two doses of epinephrine were required in 3 of 50 patients (6%) reacting to wheat, cow's milk, and pistachio. There was 1 (2%) biphasic reaction. No reaction resulted in life-threatening respiratory or cardiovascular compromise. Conclusion Older age and reactions to peanuts were risk factors for anaphylaxis during oral food challenges. Reactions requiring multiple doses of epinephrine and biphasic reactions were infrequent.

Purpose of review To review recent advances in the area of food allergen processing and the effect on protein allergenicity. Recent findings Heating generally decreases protein allergenicity by destroying conformational epitopes. In peanut and shrimp, heat-induced Maillard reaction (glycation) may increase allergenicity. The majority of milk and egg-allergic children tolerate extensively heated (baked with wheat matrix) milk and egg. Introduction of extensively heated milk and egg proteins is associated with decreasing sizes of skin prick test wheals and increasing serum food-specific IgG4 levels. Summary Heating and other methods of food processing have different effects on food allergens, even those contained in the same complex food. Structural homology does not reliably predict the effect of processing on allergenicity, and individual food allergens have to be tested. Interactions with other proteins, fat, and carbohydrates in the food matrix are complex and poorly understood. Introduction of extensively heated milk and egg proteins into the diet of allergic children may represent an alternative approach to oral tolerance induction. Better characterization of these aspects of food allergy is critical for elucidation of food protein interactions with the gut-associated lymphoid tissue, the ability to induce IgE sensitization, the potential to trigger hypersensitivity reactions, and different clinical phenotypes of food allergy with regard to severity and persistence.

Food allergy is a serious medical problem without definitive treatment at this time. Intense research focuses on severe peanut allergy. Recombinant peanut major allergens engineered to lose IgE binding capacity mixed with E coli showed great promise in a murine model of peanut anaphylaxis. Rectal vaccine containing E.coli expressing engineered recombinant major peanut allergens Ara h 1, 2, 3 is in preparation for first human clinical trials. Oral desensitization and sublingual immunotherapy with food extracts represent another approach that is being actively explored. Novel therapies must be carefully evaluated in respect to safety and long-lasting effect on oral food tolerance before being applied in clinical practice. Diversity of approaches and promising preliminary results bring hope for patients with food allergy.

Food protein-induced enterocolitis (FPIES), allergic proctocolitis (FPIAP), and enteropathy (FPE) are among a number of immune-mediated reactions to food that are thought to occur primarily via non-IgE-mediated pathways. All three are typically present in infancy and are triggered most commonly by cow's milk protein. The usual presenting features are vomiting with lethargy and dehydration in FPIES; bloody and mucous stools in FPIAP; and diarrhea with malabsorption and failure to thrive in FPE. Diagnosis is based on convincing history and resolution of symptoms with food avoidance; confirmatory diagnostic testing other than food challenge is lacking. The mainstay of management is avoidance of the suspected inciting food, with interval challenge to assess for resolution, which usually occurs in the first years of life. Studies published in the past few years clarify common presenting features, report additional culprit foods, address potential biomarkers, and suggest new management strategies.

BACKGROUND Modification of native peanut extracts could reduce adverse effects of peanut immunotherapy. OBJECTIVE We sought to compare native and chemically modified crude peanut extract (CPE) and major peanut allergens Ara h 2 and Ara h 6 in a mediator-release assay based on the rat basophilic leukemia (RBL) cell line transfected with human Fce receptor. METHODS Native Ara h 2/6 was reduced and alkylated (RA), with or without additional glutaraldehyde treatment (RAGA). CPE was reduced and alkylated. Sera of subjects with peanut allergy (16 males; median age 7 years) were used for overnight RBL-passive sensitization. Cells were stimulated with 0.1 pg/mL to 10 μg/mL of peanut. β-N-acetylhexosaminidase release (NHR) was used as a marker of RBL degranulation, expressed as a percentage of total degranulation caused by Triton X. RESULTS Median peanut-specific immunoglobulin E was 233 kUA/L. Nineteen subjects were responders, NHR ≥ 10% in the mediator release assay. Responders had reduced NHR by RA and RAGA compared with the native Ara h 2/6. Modification resulted in a later onset of activation by 10- to 100-fold in concentration and a lowering of the maximum release. Modified RA-Ara h 2/6 and RAGA-Ara h 2/6 caused significantly lower maximum mediator release than native Ara h 2/6, at protein concentrations 0.1, 1, and 10 ng/mL (p < 0.001, < 0.001, and < 0.001, respectively, for RA; and < 0.001, 0.026, and 0.041, respectively, for RAGA). RA-CPE caused significantly lower maximum NHR than native CPE, at protein concentration 1 ng/mL (p < 0.001) and 10 ng/mL (p < 0.002). Responders had high rAra h 2 immunoglobulin E (mean, 61.1 kUA/L; p < 0.001) and higher NHR in mediator release assay to native Ara h 2/6 than CPE, which indicates that Ara h 2/6 were the most relevant peanut allergens in these responders. CONCLUSIONS Chemical modification of purified native Ara h 2 and Ara h 6 reduced mediator release in an in vitro assay ∼100-fold, which indicates decreased allergenicity for further development of the alternative candidate for safe peanut immunotherapy.

Non-IgE-mediated food allergic disorders account for up to 40% of milk protein allergy in infants and young children. We aim to review the recent literature and to provide an update on diagnosis and management of food protein-induced enterocolitis syndrome (FPIES) and food protein-induced allergic proctocolitis (FPIAP). The peer-reviewed articles indexed in PubMed have been reviewed. FPIES manifests in infants as profuse, repetitive vomiting and lethargy, often with diarrhea, leading to acute dehydration, or weight loss and failure to thrive, in chronic form. FPIES is caused most commonly by cow's milk (CM) and soy proteins; rice, oat, and other solid foods may also trigger FPIES. FPIES rarely occurs in the exclusively breastfed infants. FPIES is underrecognized; children are often mismanaged as having acute viral gastrointestinal illness, sepsis, or surgical disease, delaying diagnosis of FPIES for many months. Approximately 25% of children with FPIES develop food-specific IgE antibodies and some transition to immediate food allergy; IgE positivity is associated with a more protracted course. FPIES is a self-limiting condition, with most cases resolving by age three to five years. Ondansetron may be helpful in managing acute FPIES. FPIAP is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. Up to 60% of cases occur in exclusively breastfed infants and resolve with maternal elimination of CM and soy proteins. The majority of cases resolve by age 12 months. FPIES may transition to IgE-mediated food allergy in some patients; IgE positivity to the FPIES food is a marker of a more persistent disease. FPIAP is benign and resolves by age 12 months in most patients.

Dietary intervention is a crucial component of food allergy management but can negatively impact nutrient intake. A comprehensive nutrition assessment with appropriate intervention is warranted in all children with food allergies to meet nutrient needs and optimize growth. Nutrition assessment may also be indicated in adults with food allergy. Frequently, an elimination diet is absolutely necessary to prevent potentially life-threatening anaphylaxis. Allergen elimination can also improve chronic symptoms, such as atopic dermatitis, when a food is proven to trigger symptoms. Allergen elimination goals are to prevent acute and chronic food-allergic reactions in the safest and least restrictive environment to supply a balanced diet that promotes health in children and adults.

Cow's milk (CM) and hen's egg allergies are among the most common food allergies in children. With evidence of increasing food allergy prevalence and more persistent disease, it has become vital to improve the management of CM and egg allergies. The ability to tolerate baked milk or egg, such as in a cake or muffin, has been associated with an increased chance of tolerance development. Studies report that about 70% of CM- and egg-allergic children can tolerate baked milk or egg and that incorporating baked milk or egg into the diet is well tolerated. Being able to add baked milk or egg into the diet can also increase quality of life by expanding the diet, boosting nutrition, and promoting inclusion in social activities. There is some debate over how baked milk and egg should be introduced, at home or in a supervised setting. Anaphylaxis and treatment with epinephrine during baked milk or egg challenges have been reported. Study of potential biomarkers to predict tolerability of baked milk and egg, such as serum specific IgE levels and skin prick test wheal diameters, is ongoing. Many parents can reliably report that their CM- or egg-allergic child is already consuming baked goods without symptoms. However, for those who cannot report such tolerance, the most prudent approach is to perform a supervised oral food challenge to determine the tolerability of baked milk and egg. The purpose of this article was to review the pathophysiology, clinical data, and safety of baked milk and egg and provide a practical guide to managing CM allergy and/or egg allergy. Recipes for baked milk and egg challenges and guidance on how to add baked milk and egg if tolerated to the child's regular diet are provided.

Background Physicians who practice alternative medicine often prescribe bee pollen as a food supplement and a treatment for various ailments. Objectives To determine the qualitative and quantitative composition of bee pollen and to investigate the cutaneous reactivity of atopic patients to bee pollen extracts. Methods The absolute number of pollen grains per gram of bee pollen was calculated, and morphologic identification of the botanical family was performed. Five extracts of bee pollen were prepared for skin prick testing, according to standard methods. Two hundred two volunteers participated in the study; 145 were atopic patients with respiratory allergy. The remaining 57 were healthy volunteers or nonatopic patients and served as a control group. All participants underwent skin prick testing with a standard battery of 6 aeroallergens (olive, grasses mix, Parietaria , mugwort, Dermatophagoides pteronyssinus , and Dermatophagoides farinae ) and with all homemade bee pollen extracts. Results All samples of bee pollen contained Oleaceae pollen in high concentrations. Small amounts of anemophilous pollen (Compositeae, Chenopodiaceae) were detected in various samples. A strong positive correlation was observed between cutaneous reactivity to bee pollen extracts and olive, grasses, and mugwort. Conclusions Bee pollen contains a large amount of pollen, which belongs to various allergenic families of plants. Bee pollen retains its allergenic potential as demonstrated by strong cutaneous responses to bee pollen extracts observed in atopic patients in contrast to nonatopic subjects. Regarding pollen allergic individuals, further studies are needed to evaluate the safety of ingesting large amounts of bee pollen.

Food allergy encompasses a variety of immune-mediated adverse reactions to foods. IgE-mediated, cell-mediated, and mixed-mechanism food allergy disorders are recognized. Over the past 2 decades, the prevalence of food allergy doubled and its phenotypic expression increased in Westernized societies. Major food allergens have been identified for many common foods. Laboratory diagnosis of food allergy relies heavily on the detection of food-specific IgE antibodies, but novel approaches include tests for T-cell-mediated disorders and tests for prediction of tolerance. OFC remains the diagnostic standard for food allergy. Management of food allergy focuses on avoidance of the offending foods, nutritional support, and prompt recognition and treatment of acute food allergic reactions. Anti-IgE monoclonal antibody is the first potential therapy for food allergy that is under-going testing in clinical trials.

Novel approaches to the treatment and prevention of IgE-mediated food allergy include anti-IgE, food allergy vaccines, herbal preparations, and probiotics. They bring real hope to the patients for whom no specific therapy is available. These immunomodulatory therapies have to be evaluated carefully for potential side effects, such as overstimulation of T helper cell type 1 immune antibodies. Animal models of food allergy are invaluable in testing new therapies for food allergy.

Objective To characterize the immunodeficiency in ataxia-telangiectasia (A-T) and to determine whether the immunodeficiency is progressive and associated with increased susceptibility to infections. Study design Records of 100 consecutive patients with A-T from the Johns Hopkins Ataxia-Telangiectasia Clinical Center (ATCC) were reviewed. Results Immunoglobulin (Ig) deficiencies are common, affecting IgG4 in 65% of patients, IgA in 63%, IgG2 in 48%, IgE in 23%, and IgG in 18%. Lymphopenia affected 71% of patients, with reduced B-lymphocyte number in 75%, CD4 T lymphocytes in 69%, and CD8 T lymphocytes in 51%. There was no trend for increased frequency or severity of immune abnormalities with age. Recurrent upper and lower respiratory tract infections were frequent: otitis media in 46% of patients, sinusitis in 27%, bronchitis in 19%, and pneumonia in 15%. Sepsis occurred in 5 patients, in 2 patients concurrent with cancer chemotherapy. Warts affected 17% of patients, herpes simplex 8%, molluscum contagiosum 5%, candidal esophagitis 3%, and herpes zoster 2%. Uncomplicated varicella infection occurred in 44% of patients; 2 patients had more than one clinical episode. No patient had Pneumocystis jerovici pneumonia or a complication of live viral vaccine. Conclusions In spite of the high prevalence of laboratory immunologic abnormalities, systemic bacterial, severe viral, and opportunistic infections are uncommon in A-T. Cross-sectional analysis suggests that the immune defect is rarely progressive.

Background There is no consensus on the diagnosis and therapy of oral allergy syndrome (OAS; also known as pollen-food allergy syndrome), a disorder caused by IgE antibody-mediated reactions to homologous proteins in pollens and fruits and vegetables. Objective We sought to determine how practicing allergists define and treat OAS. Methods A questionnaire was mailed to 226 randomly selected US allergists from the American Academy of Allergy, Asthma and Immunology directory. Results One hundred twenty-two (54%) returned surveys were analyzed. Median estimates of the prevalence of OAS among the patients with pollen allergy were 5% among children and 8% among adults. Twenty percent of allergists reported that some patients progressed to systemic symptoms. Fifty-three percent of allergists recommended complete avoidance of causal foods to all patients, whereas 9% did not advocate any restrictions. Thirty percent never prescribed epinephrine for OAS, 3% always did, and the remainder did so on the basis of symptoms. When presented with clinical cases, 20% diagnosed systemic reactions to peach as OAS, 13% believed peanut could cause OAS, and 25% did not prescribe epinephrine for peanut allergy manifested by oral symptoms. Conclusion Allergists' estimates of the prevalence of OAS in patients with pollen allergy (5%-8%) are lower than the prevalence reported (approximately 50%) in the published studies of these patients, perhaps reflecting a low index of suspicion, underdiagnosis, or both. The wide range of responses regarding diagnosis and management indicates the need for a better definition for the disorder and standard therapeutic guidelines. Discrepancies might be related to the term OAS, and therefore use of the more specific term "pollen-food allergy syndrome" is suggested.

Background: Montelukast is a leukotriene antagonist approved for the treatment of childhood asthma in children age 2 years and older. There are limited studies on its effects on allergic asthma in children. Objective : We sought to evaluate montelukast's effects on upper and lower airway responses to intense cat allergen exposure. Methods : In a double-blind, placebo-controlled, cross-over trial 18 subjects aged 6 to 14 years with cat-induced asthma were randomly assigned to receive 1 week each of either montelukast or placebo, followed by a 1-hour cat challenge in an environmental exposure unit. Upper and lower respiratory tract symptoms were rated, and spirometry and acoustic rhinometry were performed. Challenges were stopped early if the subject became too uncomfortable or had a greater than 50% decrease in FEV 1 . Results : Overall changes in FEV 1 were significantly different with montelukast treatment and remained significant after adjusting for allergen level ( P = .02; adjusted P = .01). Lower respiratory tract symptom scores were significantly reduced with montelukast versus placebo ( P = .007) but lost significance after adjusting for allergen level ( P = .16). Challenge length was significantly longer with montelukast versus placebo ( P P = .019). Montelukast did not significantly affect upper respiratory responses, as measured by means of symptom scores ( P = .43) and changes in acoustic rhinometry ( P = .078). Conclusions : Montelukast was significantly more effective than placebo in attenuating lower respiratory responses and extending challenge length when cat-sensitive children with mild persistent asthma were exposed to high levels of cat allergen. (J Allergy Clin Immunol 2002;109:794-9.)

Results from the Learning Early About Peanut trial and its follow-up study suggest that early peanut introduction in the diets of high-risk infants may prevent the development of peanut allergy. Allergy organizations around the world released a unified statement, the Consensus Communication on Early Peanut Introduction and the Prevention of Peanut Allergy in High Risk Infants, in response to results from the Learning Early About Peanut trial, which recommends early introduction of peanut into the diet of those children at greatest risk of development of peanut allergy. As a result, it is expected that practicing allergists will experience an increased demand to perform an oral food challenge (OFC) in infants. Allergists often perform OFCs; however, conducting an OFC in an infant creates unique circumstances that have not been considered in previously published OFC guideline documents. The purpose of this workgroup report is to provide guidance to practitioners regarding the proper approach for conducting a peanut challenge in an infant.

Eosinophilic esophagitis (EoE) is a chronic/immune-antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Dietary elimination therapy has been shown to be an effective, drug-free prescription for the treatment of EoE. A range of different dietary elimination therapies have been used. Regardless of the elimination diet chosen, dietary therapy requires in-depth nutrition assessment and management. Elimination diets are not without risk and may impact nutritional status, eating pleasure, and overall quality of life. With adequate guidance, dietary therapy can be effective and nutritionally balanced, and the adverse impact on lifestyle can be minimized. This work group report addresses the potential challenges of implementing an elimination diet for the management of EoE and provides instructions and tools for physicians, dietitians, and other allied health professionals to help guide them in planning elimination diets for both children and adults.

Cite this as: S. A. Leonard and A. Nowak-Wegrzyn, Clinical & Experimental Allergy, 2011 (41) 609–611.

body. Component-resolved diagnostics (CRD) has been introduced recently as a promising tool to assess specific IgE antibodies against multiple recombinant or purified natural allergen components. CRD has been widely utilized for research purposes with the application of protein as well as peptide microarray chip technology. One of the advantages of the chip technology is the ability to obtain a wealth of information from a minute amount of blood, which is particularly helpful in infants and young children. CRD provides significant insights into the process of sensitization by defining the primary sensitizers, cross-reactivity patterns, and potential markers of systemic reactions in plant food allergy. This issue’s article by Moverare et al. [3] evaluates 74 Swedish subjects with known peanut sensitization and a history of suspected peanut allergy. Within this cohort, 65% of subjects had specific IgE antibodies to Ara h 1, 2, or 3 whereas 35% had no detectable IgE antibodies to these recombinant peanut storage proteins. Among the group positive to Ara h 1–3, 60% of subjects had peanutspecific IgE levels 1 15 kU A /l (median 21 kU A /l) whereas all subjects in the group negative to Ara h 1–3 had peanutRecently, the editors of the New York Times invited knowledgeable outside contributors to discuss the systematic review of the available evidence on the prevalence, diagnosis, management, and prevention of food allergies published in the Journal of the American Medical Association in 2010 [1] . They entitled their blog ‘The Squishy Science of Food Allergies’ [2] , and it was a discussion triggered by the commissioned federal report which found that a uniform definition of what a food allergy is or how to test for one was lacking. There were few highquality studies. The New York Times title may somewhat belittle the complexities of the diagnosis of food allergies but also conveys the difficulties inherent in our less-thanperfect testing modalities available for food allergy. Modern society favors instant and definitive outcomes, primarily because technology has allowed for such. However, immediate conclusions cannot always be reasonably delivered in medicine and particularly in food allergy. Certainly, the diagnostic value of our current testing modalities via the blood and skin are limited by the relatively low positive predictive value (PPV) and are overly sensitive in detecting relevant specific IgE antiPublished online: June 29, 2011

The American Academy of Pediatrics (AAP) defined a formula as hypoallergenic if it ensures with 95% confidence that 90% of infants with confirmed cow’s milk allergy (CMA) will not react with defined symptoms under double-blind, placebo-controlled conditions. This study’s objective was to determine whether a new amino acid–based formula (AAF) meets the AAP hypoallergenicity criteria. Methods. Children with CMA were randomized to double-blind placebo-controlled food challenges (DBPCFC) with a new AAF and a commercial AAF in crossover fashion followed by an at-home open challenge with the new AAF. Allergic reactions were assessed using a scoring system. Results. Thirty-three subjects completed DBPCFCs with both formulas without acute allergic reactions. The lower bound 95% confidence interval for hypoallergenicity was 91.3%. No unusual stool patterns, allergic symptoms, or signs of intolerance were reported during the open challenge. Conclusion. The new AAF meets AAP hypoallergenicity criteria and can be recommended for the management of CMA.

C Roduit, R Frei, M Depner; PASTURE study group. J Allergy Clin Immunol. 2014;133(4):1056–1064 The investigators sought to test the relationship between food diversity in the first year of life and outcome of allergic diseases. There were a total of 856 children included in this study with data available on allergic diseases up to 6 years of age. They were part of a prospective birth cohort called Protection Against Allergy Study in Rural Environments/EFRIAM in which pregnant women were recruited during the third trimester of pregnancy in 2002–2005 in rural Austria, Finland, France, Germany, and Switzerland. Data were collected by using questionnaires identifying a physician’s diagnosis of asthma or food allergy, as well …

Food protein-induced enterocolitis syndrome (FPIES) is a gastrointestinal hypersensitivity disorder with a poorly understood pathophysiology and no biomarkers to aid in diagnosis.To investigate humoral and cellular responses to casein in children with milk-FPIES, including the role of casein-specific (cs) IgA and T-cell mediated TGF-β responses.Thirty-one children previously diagnosed with milk-FPIES were challenged with milk. Twelve age-matched children with FPIES to other foods and 6 milk-tolerant children without a history of FPIES were used as controls. Casein-specific IgE, IgG, IgG4, and IgA were measured in serum and TGF-β levels in supernatants of casein-stimulated PBMCs.Twenty-six children with milk-FPIES reacted (active milk-FPIES) and five tolerated milk (milk-FPIES resolved) during food challenge. All of them had significantly lower levels of csIgG, csIgG4, and csIgA than control children (p-value0.001). There were no TGF-β responses in supernatants of active milk-FPIES children.Children with milk-FPIES have low levels of csIgG, csIgG4, and csIgA. In particular, children with active FPIES to cow's milk have deficient T-cell mediated TGF-β responses to casein, rendering TGF-β a promising biomarker in identifying children who are likely to experience FPIES reactions to this allergen. Prospective studies are needed to validate these findings, elucidate their role in FPIES pathophysiology, and establish the diagnostic utility of TGF-β in milk-induced FPIES.

Background Studies show that anaphylaxis is under-recognized and epinephrine (adrenaline) is under-used by medical personnel as well as patients and their families. This study assesses the knowledge of food-induced anaphylaxis diagnosis and management across different populations of providers and caregivers and other interested respondents. Methods An online survey embedded in a case discussion of food-induced anaphylaxis was distributed by Medscape to registered members. Results A total of 7822 responders who started the activity chose to answer at least some of the questions presented (response rate 39.5%). Over 80% of responders in all groups correctly identified the case of anaphylaxis with prominent skin and respiratory symptoms; however, only 55% correctly recognized the case without skin symptoms as anaphylaxis. Only 23% of responders correctly selected risk factors for anaphylaxis, with physicians significantly more likely to choose the correct answers as compared to allied health, other health professionals, and medical students (p

With the emergence of food allergy as an important public health problem, it has become clear that there is an unmet need in regard to treatment. In particular, IgE-mediated food allergy that is associated with risk of fatal anaphylaxis has been the subject of multiple studies in the past decade. The growing body of evidence derived from multiple centres and various study designs indicates that for IgE-mediated food allergy, immunomodulation through food immunotherapy is possible; however, the extent of protection afforded by such treatment is highly variable. At this time, the capacity for food immunotherapy to restore permanent tolerance to food has not been demonstrated conclusively. This review will discuss these topics as they apply to the most important studies of food oral immunotherapy.

Purpose of review Food protein-induced enterocolitis syndrome (FPIES) is a poorly understood non-IgE-mediated food hypersensitivity, primarily affecting infants and toddlers. There are few data regarding pathophysiology of FPIES that suggest local intestinal imbalance between TNF-α and TGF-β. Patients frequently present with multiple reactions, which are characterized by projectile, repetitive emesis, dehydration, lethargy, and failure to thrive. Despite the severity of presentation, the diagnosis is frequently delayed, and patients often undergo extensive and invasive evaluation prior to reaching the diagnosis. Recent findings Reviews published in the last year provide a general approach to diagnosis and management of FPIES and aim to increase awareness and understanding of FPIES among general pediatricians. Summary Multicenter studies are necessary to reevaluate and modify the oral food challenge criteria. Research on the pathophysiology of FPIES reactions is necessary to provide insight into the evidence-based approach to diagnosis and management of FPIES. Registries are needed to understand the phenotype, triggers, and prevalence of FPIES.

SLIT (sublingual immunotherapy) is a therapeutic method aiming at producing allergen-specific tolerance of the immune system to a gradually increasing dose of an allergen that is administered sublingually. SLIT initiates similar immune mechanisms as does subcutaneous immunotherapy (SCIT). The aim of the study at this position is to update the current knowledge on sublingual immunotherapy. Randomized double-blind, placebo-controlled (RDBPC) studies that compared both immunotherapy forms point to an advantage of SCIT over SLIT in decreasing symptoms of asthma and allergic rhinitis, a comparable effect of both the methods on immune parameters (sIgE, IL-10) and upper respiratory tract inflammations and an advantage of SCIT over SLIT with respect to lower respiratory tract inflammations as based on provocation tests. At present, there are no grounds for recommending SLIT in food allergy. In view of the high safety profile and absence of anxiety-provoking infections, SLIT may be the method that is more often selected in children as compared to adults. On the other hand, immune mechanisms and results of clinical trials provide an argument for preferential employment of SCIT in adults. It should be borne in mind, however, that SLIT is effective if a good quality vaccine with a high allergen dose, is employed for at least three years. National and international reports indicate the necessity of conducting further clinical trials, especially including a direct comparison between SCIT and SLIT with respect to effectiveness and safety.

Pneumococcal infections are an important cause of morbidity and mortality in children with sickle-cell disease (SCD). Pneumococcal conjugate vaccines (PCVs) are immunogenic in healthy infants