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Background: Dupilumab is a monoclonal antibody that targets the interleukin (IL)-4 receptor alpha subunit, thus blocking the effects of IL-4 and IL-13, and has shown efficacy in treating various conditions including asthma, atopic dermatitis, eosinophilic esophagitis, and others. Because of its immune modulatory effects, clinical trials that studied dupilumab did not allow patients to receive live vaccines during the clinical trials because of an abundance of caution, and thus package inserts recommend that patients who are being treated with dupilumab should avoid live vaccines. Because dupilumab is now approved for use in patients from 6 months of age for the treatment of atopic dermatitis, this reported contraindication is now posing a clinical dilemma for patients and clinicians., Objective: To perform a systematic review of literature on the safety and efficacy of vaccinations in patients who are receiving dupilumab and to provide expert guidance on the use of vaccines in patients who are receiving dupilumab., Methods: A systematic review of the literature was performed, and an expert Delphi Panel was assembled., Results: The available literature on patients who received vaccinations while using dupilumab overall suggests that live vaccines are safe and that the vaccine efficacy, in general, is not affected by dupilumab. The expert Delphi panel agreed that the use of vaccines in patients receiving dupilumab was likely safe and effective., Conclusion: Vaccines (including live vaccines) can be administered to patients receiving dupilumab in a shared decision-making capacity., Competing Interests: Disclosures J.A.L. served as consultant for ARS, Aquestive, Bryn, ALK, and Novartis and Co-Chair Joint Task Force for Practice Parameters; received research money to institution from DBV and adjudication for Abvie and Siolta. T.E.D. the project described was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH), under Award Number 2UL1TR001425 - 05A1; the content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. E.M.A. is and employee of Public Health Agency of Canada, but the views in any paper are her own and not those of Public Health Agency of Canada. Board member of the Canadian Society of Allergy and Clinical Immunology and Head of Allergy Section, Canadian Pediatric Society. A.A. received institutional funding (Novartis) and consultation/speaker fees (ALK, EPG Health, MJH, Adelphi, Genentech, FARE, and Medscape) and served as advisory board member (Ready, Set, Food; Novartis; and Genentech). K.G.B. received grants from NIH (R01AI150295), AHRQ (R01HS029319), and Thermo Fisher Scientific and royalties from UpToDate and is consulting for Denali Therapeutics. M.B. serves as investigator and advisory board member for Regeneron and Sanofi. N.M.C. serves as clinical investigator; received research support from AstraZeneca, Genentech, and Kenota Health; serves as advisor, consultant, and/or speaker for Amgen, ARS Pharma, AstraZeneca, Blueprint Medicines, Bryn Pharma LLC, Freed AI, Genentech, GSK, Hikma, Incyte, Novartis, Regeneron, and Sanofi. D.B.K.G. is a consultant for Novartis, Aquestive, CellDex, and Kokua; received clinical trials support from Genentech, Novartis, Pfizer, GSK, Merck, Regeneron, Allergy Therapeutics, Eli Lilly, and AstraZeneca and royalties from UpToDate. N.L.H. is a speaker for Adma Bio and Takeda; speaker and advisor for Pharming, Horizon/Amgen, Horizon; advisory board member and speaker for Pharmaceuticals/Amgen. M.G.L. received research money to institution from Regeneron. S.S.M. is speaker for Genentech, Regeneron/Sanofi, GSK, and AstraZeneca and received grant from Takeda. J.J.O. consultant/advisor: GSK, Aquestive, Amgen, and ARS; adjudication/DSMB: AZ, Novartis, GSK, Sanofi, and AbbVie; reviewer/editor and executive editor: Annals of Allergy, Asthma & Immunology; reviewer: UpToDate; executive editor: Medscape; research/grants: NIH. A.R. speakers bureau member for Sanofi/Regeneron, GSK, and AstraZeneca. N.L.R. received funding from the Jeffrey Modell Foundation (58293-I), the NIH (R21AI164100), and Takeda Pharmaceuticals; is consultant for Takeda, Pharming Healthcare, and CSL Behring; received royalties from Wolters Kluwer and UpToDate. L.S. is clinical investigator for Regeneron and DBV Technologies and advisor for Sanofi and Leo pharmaceuticals. M.S.S. is member and co-chair of the Joint Task Force on Practice Parameters; serves on the editorial board of The Journal of Allergy and Clinical Immunology In Practice; is an associate editor of Annals of Allergy, Asthma, and Immunology; serves on the board of directors of the American Academy of Allergy, Asthma, and Immunology (views expressed are his own); has participated in research that has received funding from DBV. J.M.S. received grant support from and is consultant for Regeneron/Sanofi. C.A.S. recipient of a AAAAI Foundation Faculty Development Award. The views expressed in this work are the responsibility of the authors and do not necessarily represent the official views of the AAAAI. D.R.S. is consultant to ARS. J.W. received research support from NIAID, Aimmune, DBV Technologies, and Siolta and consultancy fees from ALK Abello, DBV Technologies, and Novartis. M.J.G. is consultant for Aquestive; is a member of physician/medical advisory boards for DBV Technologies, Sanofi/Regeneron, Nutricia, Novartis, Acquestive, Allergy Therapeutics, AstraZeneca, ALK-Abello, Bryn, Genentech, and Prota; is an unpaid member of the scientific advisory council for the National Peanut Board and medical advisory board of the International Food Protein Induced Enterocolitis Syndrome Association; is a member of the Brighton Collaboration Criteria Vaccine Anaphylaxis 2.0 working group; is the senior associate editor for the Annals of Allergy, Asthma, and Immunology; is member of the Joint Taskforce on Allergy Practice Parameters; received honorarium for lectures from ImSci, Red Nucleus, Medscape, Paradigm Medical Communications, Kaplan, Food Allergy Research and Education, and multiple state/local allergy societies. The remaining authors have no conflicts of interest to report., (Copyright © 2024 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Importance: Lifelong immunoglobulin replacement therapy (IRT) is standard-of-care treatment for congenital agammaglobulinemia but accrues high annual costs ($30 000-$90 000 per year) and decrements to quality of life over patients' life spans. Hematopoietic stem cell transplant (HSCT) offers an alternative 1-time therapy, but has high morbidity and mortality., Objective: To evaluate the cost utility of IRT vs matched sibling donor (MSD) and matched unrelated donor (MUD) HSCT to treat patients with agammaglobulinemia in the US., Design, Setting, and Participants: This economic evaluation used Markov analysis to model the base-case scenario of a patient aged 12 months with congenital agammaglobulinemia receiving lifelong IRT vs MSD or MUD HSCT. Costs, probabilities, and quality-of-life measures were derived from the literature. Microsimulations estimated premature deaths for each strategy in a virtual cohort. One-way sensitivity and probabilistic sensitivity analyses evaluated uncertainty around parameter estimates performed from a societal perspective over a 100-year time horizon. The threshold for cost-effective care was set at $100 000 per quality-adjusted life-year (QALY). This study was conducted from 2020 across a 100-year time horizon., Exposures: Immunoglobulin replacement therapy vs MSD or MUD HSCT for treatment of congenital agammaglobulinemia., Main Outcomes and Measures: The primary outcomes were incremental cost-effectiveness ratio (ICER) expressed in 2020 US dollars per QALY gained and premature deaths associated with each strategy., Results: In this economic evaluation of patients with congenital agammaglobulinemia, lifelong IRT cost more than HSCT ($1 512 946 compared with $563 776 [MSD] and $637 036 [MUD]) and generated similar QALYs (20.61 vs 17.25 [MSD] and 17.18 [MUD]). Choosing IRT over MSD or MUD HSCT yielded ICERs of $282 166 per QALY gained over MSD and $255 633 per QALY gained over MUD HSCT, exceeding the US willingness-to-pay threshold of $100 000/QALY. However, IRT prevented at least 2488 premature deaths per 10 000 microsimulations compared with HSCT. When annual IRT price was reduced from $60 145 to below $29 469, IRT became the cost-effective strategy. Findings remained robust in sensitivity and probabilistic sensitivity analyses., Conclusions and Relevance: In the US, IRT is more expensive than HSCT for agammaglobulinemia treatment. The findings of this study suggest that IRT prevents more premature deaths but does not substantially increase quality of life relative to HSCT. Reducing US IRT cost by 51% to a value similar to IRT prices in countries implementing value-based pricing may render it the more cost-effective strategy.

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Food allergies are a significant public health issue, and the only effective management option currently available is strict avoidance of all foods containing the allergen. In view of the practical impossibility of limiting risks to zero, quantitative allergen risk assessment and management strategies are needed., Objective: We sought to develop appropriate methods for informing population-based risk assessments and risk management programs to benefit all stakeholders but particularly patients with food allergy., Methods: Individual thresholds for food allergens (maximum tolerable doses and minimum eliciting doses) can ideally be established through double-blind, placebo-controlled food challenges. If double-blind, placebo-controlled food challenge data are not available, data from widely used open food challenges using predefined objective criteria can also provide useful data regarding minimum eliciting doses. For more than 20 years, the Netherlands Organisation for Applied Scientific Research and the Food Allergy Research and Resource Program at the University of Nebraska-Lincoln have been collecting individual maximum tolerable doses and minimum eliciting doses that produce objective symptoms from published and unpublished clinical data to better refine knowledge regarding the sensitivity of the population to food allergens., Results: In this article we provide in-depth insights into the methodology applied by the Netherlands Organisation for Applied Scientific Research and Food Allergy Research and Resource Program to derive individual maximum tolerable doses and minimum eliciting doses for objective symptoms from clinical food challenge data. More than 90 examples for determining individual allergic thresholds are presented., Conclusion: With the methodology presented in this article, we aim to stimulate harmonization and transparency in quantitative food allergen risk assessment and risk management programs, encouraging their wider adoption., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Importance: Children experiencing anaphylaxis at school may lack access to a personal epinephrine device, prompting recent legislation permitting undesignated (eg, non-student specific) stock epinephrine autoinjector units at school. However, epinephrine device costs vary, and the cost-effectiveness of undesignated school stock epinephrine is uncharacterized to date., Objective: To define value-based strategies for undesignated school stock epinephrine programs., Design, Setting, and Participants: Markov simulations of the Chicago Public Schools system were used over extended time horizons to model 2 school stock epinephrine autoinjector policies to provide access for at-risk students. The dates of the data used in the analysis were September 2017 to June 2018 (the 2017-2018 school year)., Main Outcomes and Measures: This study compared the following 3 strategies: no school undesignated epinephrine supply, school undesignated supplemental epinephrine supply (supplemental model), and school undesignated universal epinephrine supply (universal model). The base-case model assumed a 10-fold reduced fatality risk with having undesignated stock epinephrine units available vs not having undesignated stock epinephrine units available. Costs of school stock epinephrine units available for acquisition by schools were evaluated from a societal perspective. Quality-adjusted life-years (QALYs) and total epinephrine acquisition expenses were calculated., Results: Based on Markov simulations of the Chicago Public Schools system (371 382 students), the cost was $107 816 (95% CI, $107 382-$108 250) for no school undesignated epinephrine supply compared with $108 160 (95% CI, $107 725-$108 595) for the supplemental model and $100 397 (95% CI, $99 979-$100 815) for the universal model. Undesignated stock epinephrine improved outcomes, with 26.869 (95% CI, 26.841-26.897) QALYs accrued as the model concluded compared with 26.867 (95% CI, 26.839-26.896) QALYs for the strategy without undesignated stock epinephrine. When comparing supplemental model stock epinephrine to the strategy without undesignated devices, the incremental cost-effectiveness ratio was high at $268 811 per QALY in the base-case simulation. However, the cost of the supplemental model fell below $100 000 per QALY when the annual undesignated epinephrine acquisition costs did not exceed $338 per school (compared with stock epinephrine unavailability). The universal model dominated all others and was associated with significant cost savings ($7419 per student at risk who would otherwise be prescribed an individual school epinephrine supply)., Conclusions and Relevance: Undesignated school stock epinephrine is cost-effective at device acquisition costs not exceeding $338 per school per year, although a universal model vs a supplemental model is associated with superior health and economic outcomes.

Peanut is an allergenic legume that can cross-react with other plant-based foods, notably other legumes and tree nuts. Peanut-allergic individuals can be both cosensitized and coallergic to such items, requiring foresight when eliciting a clinical history of a reaction, in the diagnostic evaluation of such allergies, and in the counseling of patients as to food avoidances after a diagnosis is made. Legume allergens belong to the Fabaceae family and encompass the cupin, prolamin, PR-10, and lipid transfer protein families, which mediate cross-sensitization including that between peanut and tree nut. Among legumes, the most common patterns of clinical cross-reactivity are between peanut and lupine, peanut and soy, as well as chickpea and lentil, though this is highly dependent on geography and prevalence of these foods in the diet. Issues of cross-sensitization may exist between peanut and certain tree nuts, as well as among tree nuts though such patterns do not always result in clinically relevant allergy. Molecular diagnostic testing may be a future tool to help parse out the aforementioned patterns, but oral food challenges are still the gold standard for accurate diagnosis. Although potential desensitization treatments have emerged for peanut allergy, these have not been developed for other legumes and most tree nuts, and desensitization to peanut has not proven to have an effect on legume cross-sensitization., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objectives: Guidance and evidence supporting routine use of partially hydrolyzed formula (pHF) versus intact cows' milk protein (CMP) formula are limited in non-exclusively breastfed infants. The aim of this review was to better clarify issues of routine use of pHF in non-exclusively breastfed infants who are not at risk for allergic disease by using a systematic review and Delphi Panel consensus., Methods: A systematic review and Delphi consensus panel (consisting of eight8 international pediatric allergists and gastroenterologists) was conducted to evaluate evidence supporting growth, tolerability, and effectiveness of pHF in non-exclusively breastfed infants., Results: None of the studies reviewed identified potential harm of pHF use compared with CMP in non-exclusively breastfed infants. There was an expert consensus that pHF use is likely as safe as intact CMP formula, given studies suggesting these have comparable nutritional parameters. No high-quality studies were identified evaluating the use of pHF to prevent allergic disease in non-exclusively breastfed infants who are not at risk for allergic disease (e.g., lacking a parental history of allergy). Limited data suggest that pHF use in non-exclusively breastfed infants may be associated with improved gastric emptying, decreased colic incidence, and other common functional gastrointestinal symptoms compared with CMP. However, because the data are of insufficient quality, the findings from these studies have to be taken with caution. No studies were identified that directly compared the different types of pHF, but there was an expert consensus that growth, allergenicity, tolerability, effectiveness, and clinical role among such pHF products may differ., Conclusions: Limited data exist evaluating routine use of pHFs in non-exclusively breastfed infants, with no contraindications identified in the systematic review. An expert consensus considers pHFs for which data were available to be as safe as CMP formula as growth is normal. The preventive effect on allergy of pHF in infants who are not at risk for allergic disease has been poorly studied. Cost of pHF versus starter formula with intact protein differs from country to country. However, further studies in larger populations are needed to clinically confirm the benefits of routine use of pHF in non-exclusively breastfed infants. These studies should also address potential consumer preference bias., (Copyright © 2019. Published by Elsevier Inc.)

Food allergy is estimated to affect approximately 8% of children in the USA. This is a disease without any known treatment or cure and, for some, a disease that can be quite severe, even life-threatening. While recent advances in potential treatment have made remarkable strides, with two food-targeted immunotherapy products now in phase III trials, perhaps the biggest gains in the field have come in the advent of potential preventative strategies to avoid the development of food allergy in high-risk individuals. There have been multiple, randomized, controlled trials (RCTs) performed in the past 5 years that have demonstrated significant risk reduction from early allergen introduction. These include two trials for early peanut introduction and five trials for early egg introduction in the first year of life. The results indicate that primary prevention of food allergy through early allergen introduction may represent a strategy that could potentially avert tens of thousands of children from becoming food allergic. In support of the data for peanut, the National Institute of Allergy and Infectious Diseases recently sponsored an addendum to the 2010 food allergy guidelines, specifically recommending peanut be introduced in both high- and standard-risk infants to reduce the risk of developing peanut allergy. To date, no formal recommendations have been made for egg, however. This review will focus on the latest evidence supporting early introduction as a strategy to prevent food allergy, as well as on practical aspects for its successful implementation.

Background: Food allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy., Objectives: Prompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy., Results: The addendum provides 3 separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider's office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation., Conclusions: Guidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy., (Published by Elsevier Inc.)

Recommendations for the timing of introducing major food allergens, such as peanut, into the diet of at-risk infants have undergone major changes in the past decade. The most substantial modification has been a shift toward advice that delaying beyond 4 to 6 months does not prevent and might actually increase the risk of food allergy. The Learning Early About Peanut (LEAP) study published last year provided strong evidence that early peanut introduction with regular ingestion has a potentially dramatic benefit. Although there is little current doubt of the effectiveness of early peanut introduction, many unanswered questions remain. Previous guidelines defined infants at risk as those with a first-degree relative with allergic disease, whereas the LEAP study defined high risk as severe eczema or egg allergy. The LEAP study chose to screen infants but did not have a comparison group randomized without screening. In the following case-based discussion, we explore the complexities of LEAP implementation for the practicing allergist. These include nonuniformity in the literature for defining at-risk infants, difficulties in assessing eczema severity objectively, variable adherence to current guidelines, proposed peanut screening methods contrasting with existing food allergy guidelines to not routinely screen before ingestion, unclear interpretation of positive test results if screened, risks of screening extending to foods not studied in the LEAP study, and uncertainties about the optimal dose and duration of peanut once introduced., (Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: To comprehensively characterize the immunologic characteristics of patients with protein-losing enteropathy (PLE) post-Fontan and compare them with patients without PLE post-Fontan., Study Design: Patients with PLE post-Fontan and age-matched controls post-Fontan were prospectively studied with laboratory markers of immune function. Infectious history was obtained by interview and chart review. The groups' demographics, cardiac history, immune characteristics, and infection history were compared using appropriate 2-group statistics., Results: A total of 16 patients enrolled (8 patients with PLE and 8 controls). All patients with PLE had lymphopenia compared with 25% of controls (P = .01). All patients with PLE had markedly depressed CD4 T cell counts (median 58 cells/μL) compared with controls (median 450 cells/μL, P = .0002); CD4% was also low in the PLE group (12.3%) and normal in control (36.9%, P = .004). Both groups had mildly depressed CD8 T cells and normal to slightly elevated natural killer and B-cell subsets. A majority of patients with PLE (62.5%) had negative titers to measles, mumps, and rubella vaccination, compared with no control Fontan with a negative titer (P = .03). Despite profoundly low CD4 counts, the frequency of infection was not different between groups with no reported opportunistic infections., Conclusions: Patients with Fontan-associated PLE have extensive quantitative immune abnormalities, particularly CD4 deficiency. These immune abnormalities are similar to those found in non-Fontan patients with PLE caused by intestinal lymphangiectasia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Caregivers of food-allergic individuals (FAIs) have decreased quality of life (QoL). The effects of epinephrine administration on QoL are poorly understood., Objective: To investigate the relation between QoL and epinephrine use., Methods: A de-identified 50-question online survey was administered to caregivers of FAIs across the United States through Web site, email, and social media networks of 2 national food allergy advocacy groups. QoL was assessed using the Food Allergy Quality of Life-Parental Burden questionnaire. The effect of prior epinephrine administration on QoL was analyzed using linear regression., Results: Of 3,541 respondents, 35.6% reported their FAIs received epinephrine. Mean Food Allergy Quality of Life-Parental Burden scores were higher (worse QoL) in those reporting FAIs receiving epinephrine (3.07 vs 2.84, P < .001), anaphylaxis (3.01 vs 2.75, P < .001), multiple food allergies (3.16 vs 2.67, P < .001), and multiple food allergies and epinephrine use (3.24 vs 2.57, P < .001) vs those who did not. In a regression model, reported epinephrine use; anaphylaxis; multiple FAIs; multiple food allergies; and egg or milk, wheat or soy, or seafood allergy (vs peanut or tree nut allergy) were significantly associated with an increased (worse) QoL score. Caregiver college education and increasing FAI age were associated with a decreased QoL score (improved QoL). An interaction was noted between reported epinephrine use and anaphylaxis and was associated with a decreased QoL score., Conclusion: The effect of epinephrine use on caregiver QoL is conditional and depends on reaction severity. Having multiple FAIs and FAIs with multiple food allergies was associated with worsening QoL. Further studies are needed to better understand the effects of treating an allergic reaction on caregiver QoL., (Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Angioedema is swelling of the deep layers of the dermis and subcutaneous tissue due to an increase in vascular permeability. Angioedema sometimes occurs concomitantly with urticaria and represents an allergic disease. In other cases, angioedema is not associated with an allergic condition. We present the case of a 31-year-old woman with new-onset angioedema in the setting of her first pregnancy. After detailed history, physical examination, and laboratory evaluation, a cause for her angioedema was found that had not been considered previously and had significant implications for future management, particularly in light of her current pregnancy. Because allergists are commonly called on to evaluate and treat angioedema, we should be aware of the many disease processes that can present with this symptom and be well-versed in the workup of new-onset angioedema.

Background: Food allergy is associated with diminished patient and caregiver quality of life (QoL). Although oral food challenge (OFC) improves QoL of individuals with food allergy, its effects on caregiver QoL are unknown., Objectives: To determine if differences in caregiver QoL exist based on their child undergoing OFC., Methods: Caregivers of individuals with food allergy who underwent OFCs between 2001 and 2012 at the University of Michigan Food Allergy Center completed the Food Allergy Quality of Life-Parental Burden index and a questionnaire that assessed details of the most-severe reaction by an individual with food allergy. Results were compared with 305 caregivers of individuals with food allergy who were unchallenged. All questionnaire data regarding the characteristics of the reactions of individuals with food allergy were verified through chart review., Results: A total of 115 caregivers of individuals with food allergy who were undergoing OFC completed the QoL assessment. Caregivers of individuals with food allergy who were undergoing OFC had a significantly lower (better) QoL score than controls who were not challenged (1.5 vs 1.88; P = .02). Furthermore, within the challenged cohort, there was no significant difference in QoL score between those with a passing OFC (eg, non-reactive) and a failing OFC (eg, reactive) (1.42 vs 1.34; P = .83). In an adjusted linear regression model, the QoL score was significantly better among caregivers of individuals with food allergy who were undergoing OFC and with an income >$50,000 but significantly worsened for caregivers with multiple individuals with food allergy or if the individual with food allergy had atopic dermatitis., Conclusion: The caregiver QoL score is better with individuals with food allergy who underwent OFC versus controls who were unchallenged but not significantly different based on OFC outcome. QoL is, in addition, moderated by income, the presence of atopic dermatitis, and having multiple individuals with food allergy. OFC is associated with better caregiver QoL, irrespective of challenge outcome., (Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Food allergen oral immunotherapy (OIT) is an experimental, immune-modifying therapy that may induce clinical desensitization in some patients. OIT is still in early phase clinical research, but some providers may offer OIT as a clinical service. To understand the current practices of allergists who perform OIT, an online survey was sent by e-mail to members of the American Academy of Allergy Asthma & Immunology. Among 442 respondents, 61 reported participating in using OIT (13.8%), including 28 in nonacademic settings. Informed consent for OIT was obtained by 91.3%, institutional review board approval by 47.7% and Investigational New Drug approval by 38.1%. Compared with nonacademic participants, more academic participants used peanut OIT, obtained institutional review board and Investigational New Drug (P < .0001 respectively), and challenged patients before entry (P = .008). More nonacademic providers billed the patient or insurance for reimbursement (P < .0001). Low reported regard for the importance for US Food and Drug Administration approval or a standardized product (increased odds), and a high regard for better safety data (decreased odds) were associated with considering offering OIT as a service. Significant differences exist with OITs that occur in academic versus nonacademic settings. Further assessment is needed regarding the different motivations and practice styles among providers who offer OIT and those who are considering doing so., (Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The 2007 immunotherapy practice parameters advocate maintenance dosing at 1:1 (1:20 maintenance concentrate). There is limited literature exploring the effect of 1:1 dosing on the rate of systemic reactions to subcutaneous immunotherapy (SRITs)., Objective: To investigate the effects of 1:1 dosing on SRITs in a large, academic practice., Methods: We conducted a retrospective cohort study of all nonvenom and noncluster SRITs that occurred between 2005 and 2011. SRITs that occurred from August 2008 through December 2011, postparameter dosing (post-PD) was initiated, were compared to SRITs that occurred from January 2005 to July 2008 with preparameter dosing (pre-PD) using 1:50 as a maintenance concentrate., Results: A total of 269 SRITs occurred in a 7-year period. Significantly more post-PD SRITs (131 of 38,548 injections) occurred than pre-PD SRITs (132 of 52,833 injections) (0.34% vs 0.25%, P = .01). However, when excluding 44 SRITs that occurred in established pre-PD patients transitioned to post-PD, there was no significant difference in SRIT rate (0.25% vs 0.22%), World Allergy Organization (WAO) grade, or SRIT time to onset. Nonred (non-1:1) vials accounted for a significantly larger proportion of all post-PD SRITs compared with all pre-PD SRITs (50.7% vs 31.1%, adjusted P = .009). Prior SRITs were reported less frequently among persons with post-PD SRITs (29.2% vs 70.8%, adjusted P = .009). In an adjusted logistic regression model, male sex (odds ratio, 7.9; 95% CI, 2.4-26) and longer time to reaction onset (odds ratio, 0.94; 95% CI, 0.89-0.99) were associated with higher WAO severity grade reactions., Conclusion: Pre-PD vs post-PD SRIT rates were not significantly different, adjusting for patients transitioned from established pre-PD to post-PD. This finding suggests that post-PD is as safe as pre-PD. Male sex and faster time to reaction onset were associated with higher WAO grade reactions., (Copyright © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Limited studies exist on predictors of food allergy tolerance., Objective: To describe factors associated with tolerance to 9 common food allergens based on caregiver report in a nationally representative survey., Methods: Data from children with current and outgrown food allergies were identified for analysis from a randomized, cross-sectional survey administered in US households with children from June 2009 through February 2010. Allergies were analyzed based on type of allergy, age at which allergies were outgrown, and reaction history. Adjusted models were formulated to examine the association of child and food allergy characteristics with odds of reporting an allergy as being outgrown., Results: Of 40,104 children surveyed, 1,245 cases of outgrown food allergy were identified. The frequency of tolerance in children with food allergy was 26.6% at a mean age of 5.4 years. Children with milk (41.1%), egg (40.2%), or soy (35.7%) allergy had significantly higher frequencies of tolerance, whereas children with shellfish (13.0%), tree nut (14.3%), and peanut (15.6%) allergies had significantly lower frequencies (P < .05). Factors significantly associated with a report of outgrowing an allergy included a mild to moderate reaction history, being allergic to only 1 food, eczema as the sole allergy symptom, and white compared with black race (P < .05). Probability of tolerance also was significantly higher at younger ages of first reaction and decreased for first reactions occurring later in life, irrespective of allergen, severity, or presentation (P < .05)., Conclusion: Multiple factors were associated with a report of outgrowing an allergy. Understanding factors associated with outgrowing an allergy can improve disease management and counseling., (Copyright © 2013 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Reports suggest that perioperative anaphylaxis in patients undergoing general anesthesia range from 1 in 5000 to 1 in 20,000 with mortality rates as high as 9%. Because of the variety of medications that are used for general anesthesia and the rapid succession in which they are administered, it is often difficult to determine the etiology of a severe allergic episode in this setting. Antibiotics and anesthetics are notorious for precipitating allergic reactions and are often implicated. Other perioperative exposures and patient risk factors must also be considered. In this article, we describe the case of a patient who exhibited recurrent anaphylaxis episodes while trying to undergo a vital cardiac surgery.

CME EDUCATIONAL OBJECTIVES 1. Understand that trivalent influenza vaccine is safe for patients with egg allergy, including patients with severe egg allergy. 2. Understand that egg-allergic patients no longer require any special precautions to safely receive trivalent influenza vaccine. 3. Recognize that the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices advises that most egg-allergic patients can now receive trivalent influenza vaccine from their primary care physician. Trivalent influenza vaccine is grown in chick embryos and contains residual egg protein (ovalbumin). Historically, trivalent influenza vaccine (TIV) has been contraindicated in egg-allergic individuals (EAI) and the vaccine was withheld in many of these individuals due to the ovalbumin. However, protocols were developed that allowed EAIs to safely receive TIV, including stepwise desensitization, vaccine skin testing, and use of low ovalbumin containing vaccine. In the past 3 years, several groups have systematically disproven that EAI are at any increased risk for an allergic reaction than the general population and withholding TIV is not necessary. To date, approximately 4,315 patients have safely received 4,872 total doses of TIV, including 656 EAI with severe egg allergy (including anaphylaxis to egg) who safely received 740 doses of TIV. Thus, it is as safe to provide TIV to EAI as providing it to a non-EAI. This article will trace the evolution of this practice., (Copyright 2013, SLACK Incorporated.)

Food allergy is a growing public health concern in the United States that affects an estimated 8% of children. Food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a specific food. Nearly 40% of children with food allergy have a history of severe reactions that if not treated immediately with proper medication can lead to hospitalization or even death. The National Institute of Allergy and Infectious Diseases (NIAID) convened an expert panel in 2010 to develop guidelines outlining evidence-based practices in diagnosing and managing food allergy. The purpose of this review is to aid clinicians in translating the NIAID guidelines into primary care practice and includes the following content domains: (1) the definition and mechanism of childhood food allergy, (2) differences between food allergy and food intolerance, (3) the epidemiology of childhood food allergy in the United States, (4) best practices derived from the NIAID guidelines focused on primary care clinicians' management of childhood food allergy, (5) emerging food allergy treatments, and (6) future directions in food allergy research and practice. Articles focused on childhood food allergy were considered for inclusion in this review. Studies were restricted to the English language and to those published within the past 40 years. A cross-listed combination of the following words, phrases, and MeSH terms was searched in PubMed and Google Scholar to identify relevant articles: food allergy, food hypersensitivity, child, pediatric, prevalence, and epidemiology. Additional sources were identified through the bibliographies of the retrieved articles., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Initial food-allergic reactions are often poorly recognized and under-treated., Methods: Parents of food-allergic children were invited to complete an online questionnaire, designed with Kids with Food Allergies Foundation, about their children's first food-allergic reactions resulting in urgent medical evaluation., Results: Among 1361 reactions, 76% (95% CI 74-79%) were highly likely to represent anaphylaxis based on NIAID/FAAN criteria. Only 34% (95% CI 31-37%) of these were administered epinephrine. In 56% of these, epinephrine was administered by emergency departments; 20% by parents; 9% by paramedics; 8% by primary care physicians; and 6% by urgent care centers. In 26% of these, epinephrine was given within 15 min of the onset of symptoms; 54% within 30 min; 82% within 1 h; and 93% within 2 h. Factors associated with a decreased likelihood of receiving epinephrine for anaphylaxis included age <12 months, milk and egg triggers, and symptoms of abdominal pain and/or diarrhea. Epinephrine was more likely to be given to asthmatic children and children with peanut or tree nut ingestion prior to event. Post-treatment, 42% of reactions likely to represent anaphylaxis were referred to allergists, 34% prescribed and/or given epinephrine auto-injectors, 17% trained to use epinephrine auto-injectors, and 19% given emergency action plans. Of patients treated with epinephrine, only half (47%) were prescribed epinephrine auto-injectors., Conclusions: Only one-third of initial food-allergic reactions with symptoms of anaphylaxis were recognized and treated with epinephrine. Fewer than half of patients were referred to allergists. There is still a need to increase education and awareness about food-induced anaphylaxis., (© 2012 John Wiley & Sons A/S.)

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., (Copyright © 2010 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

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.