Real-world experience of pediatric patients treated with peanut (Arachis hypogaea) allergen powder-dnfp.

BACKGROUND: Peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) is the first oral immunotherapy indicated for children aged 4 to 17 years with peanut allergy. There are limited real-world data on patients treated with PTAH. OBJECTIVE: To characterize pediatric patients treated with PTAH and associated treatment patterns in US clinical practice. METHODS: US-based physicians with allergy and immunology training treating patients with peanut allergy aged 4 to 17 years with PTAH were recruited from an existing physician panel and completed an online case report form (October to December 2021) with data abstracted from patient medical charts. Physician practice circumstances, patient characteristics, and PTAH treatment patterns were reported. Time to reach the 300-mg dose and treatment persistence were assessed using Kaplan-Meier analysis. RESULTS: A geographically balanced sample of 43 physicians contributed data for 118 demographically diverse pediatric patients. Patients had heterogeneous diagnostic test results, with a wide range of peanut-specific immunoglobulin E levels; 6.8% received an oral food challenge. During the updosing phase, there were no temporary interruptions and 5.1% of the patients required downdosing. Patients reached the 300-mg dose at a median of 21.3 weeks post-initiation. The rate of PTAH persistence at 24 weeks was 93.4%. Only 1 patient discontinued treatment because of treatment-related systemic allergic symptoms, and the remaining discontinuations were for reasons other than treatment-related symptoms. Prophylactic antihistamines were used by 33.9% of the patients to prevent PTAH adverse effects. CONCLUSION: PTAH was prescribed in demographically diverse patients with a wide range of peanut-specific immunoglobulin E levels. Treatment persistence with PTAH was high in this study population, with a small number of patients experiencing treatment modification.

Food Insecurity in the Food Allergic Population: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee.

Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.

Diagnosis of peanut allergy using continuous likelihood ratios.

BACKGROUND: Peanut allergy (PA) is associated with an economic and psychological burden on patients and families. Its diagnosis includes tests for peanut specific immunoglobulin E (sIgE), the values of which usually are categorized as positive or negative using a predefined cutoff (usually 0.35 kU/L). With the use of Bayes' theorem, this categorization can be replaced with a continuous interpretation of sIgE, which accounts for the prevalence of PA and history of ingestion. OBJECTIVE: To evaluate a method for estimating the likelihood ratio (LR) for each value of sIgE by performing a pilot investigation with the results of oral food challenges. The LR could be used to estimate the probability of PA. METHODS: The outcomes of oral food challenges and serum IgE values from 117 children seen in an allergy clinic between January 2017 and November 2019 were obtained. Polynomial regression of the receiver operation characteristics curve was used to determine an LR for each value of sIgE. Linear regression was used to estimate an LR for each value of sIgE. RESULTS: sIgE ranged from less than 0.1 kU/L to 35 kU/L. Bayes' theorem and a receiver operation characteristics curve were used to estimate LRs for each value of peanut sIgE. The value of IgE associated with an LR of 1 was 0.22 kU/L, which is comparable to other studies that used a value of 0.35 kU/L to separate positive from negative results. CONCLUSION: When combined with estimates of pretest probability, this method should permit the development of computerized decision-making algorithms to estimate the probability that a patient has PA.

Infant anaphylaxis: Diagnostic and treatment challenges.

Immediate administration of intramuscular epinephrine to a patient experiencing anaphylaxis is the first-line therapy for this life-threatening allergic reaction. Alhough anaphylaxis is generally a rare occurrence, it has dire consequences if left untreated. In infants, anaphylaxis is typically triggered by exposure to egg, cow's milk, or peanuts. The rapid onset of symptoms in multiple organ systems makes an accurate diagnosis in infants difficult because there are numerous ways in which anaphylaxis may present. The symptoms of infant anaphylaxis are often underrecognized or misdiagnosed for less serious illnesses or even normal findings, including drooling, loose stools, and irritability. Because infants are mostly nonverbal-and most pediatric emergency department visits for anaphylaxis cases are the first diagnosis-ascertaining potential exposure to common allergens is difficult; this further complicates diagnosis in these youngest patients for whom the clinical presentation of anaphylaxis varies widely. A key factor in diagnosing anaphylaxis is the temporal profile of symptom development following allergen exposure; however, some children with anaphylaxis develop symptoms that reoccur hours or days after an initial anaphylactic reaction, making diagnosis challenging. Advanced practice nurses are often the first health care provider to encounter a patient who may be experiencing anaphylaxis. Although diagnostic criteria exist for anaphylaxis, specific criteria for the diagnosis of anaphylaxis in infants have not been developed. As such, it is important to understand and recognize the variable presentation of anaphylaxis in infants and to rapidly diagnose and treat with epinephrine.

Including young children in their food allergy care: A pilot study.

Rationale: Food allergy education is often directed toward adult caregivers. However, once children go to school, they must participate in their food allergy care to remain safe. The purpose of this study was to assess food allergy knowledge and test an educational intervention targeted toward the child. We hypothesized that child-based teaching will be equal in safety and knowledge outcomes compared with standard parental education. Methods: Twenty-nine children between the ages of 5-11 years and their caregivers were enrolled. Child subjects completed a food allergy knowledge questionnaire. Each caregiver/child dyad was randomized to receive parent-targeted education (control) or child-targeted education (treatment) and was given an educational booklet. Six weeks later, the child completed the same knowledge questionnaire. At the end of the semester, the caregivers were asked to report allergic reactions that occurred at school. Results: There were no differences between the groups on age or type of school attended. All the subjects demonstrated a statistically significant increase in allergy knowledge from time 1 (completion of survey 1) to time 2 (completion of survey 2) (t = -6.301; p < 0.001) There was no difference in knowledge between the groups at time 2 (t = -1.782; p = 0.089) and no difference between the groups on allergic reactions during the study period (χ2 = 2.33; p = 0.13). Conclusion: This pilot study, with a small sample size, demonstrated that child-based education was comparable with education targeted toward caregivers, with no difference in allergic events. Children can take an active role in education and management of their food allergies at school.

Possible Role of Environmental Factors in the Development of Food Allergies.

The development of food allergies is thought to involve multiple factors, and it is unclear which conveys the most risk regarding this process. Since food allergy is a chronic disease without a cure at this time, understanding its development could provide an avenue for preventive practices and development of a curative treatment. Both historical and current data implicate maternal factors, genetics, and environmental exposures as major risk factors in the development of food allergy. An immature gut of the infant has been hypothesized as a possible route of sensitization. Breastfeeding until at least 6 months of age has been shown to have protective factors for the newborn and may possibly improve gut permeability. Newer studies such as the LEAP and EAT investigations also looked at early exposure and prevention of food allergies; their long-term results are critical in understanding early introduction and tolerance. Cutaneous exposure, oral exposure, and food protein exposure in house dust with their relation to the food allergy course are also a path of interest. Current research has shown sensitization can occur through impaired skin such as those with eczema and a filaggrin mutation. Tropomyosin and alpha-gal also are related to the complicated immunomodulatory factors involved in food allergy and allergic response. Cross-reactivity with plant allergens, sensitization to house dust mite and cockroach, and lone star tick bites can also induce food allergens in children and adults. Together, these factors provide a cohesive beginning to understanding how food allergies can occur and can influence further investigation into prevention, treatment, and eventual cure of food allergies.

Ara h2 levels in dust from homes of individuals with peanut allergy and individuals with peanut tolerance.

BACKGROUND: Approximately 1% of the U.S. population has a peanut allergy. Previous studies that measured peanut protein in house dust support the hypothesis that household peanut consumption may lead to clinical sensitization through transdermal exposure. OBJECTIVE: The aim of this pilot study was to characterize Ara h2 levels in house dust from homes with and without individuals with peanut allergy. METHODS: Household dust was obtained from homes with an individual with peanut allergy and from homes with no individual with peanut allergy. Ara h2 levels were determined by using a monoclonal antibody-based immunoassay with a level of determination of 150 ng per gram of dust. Peanut consumption information was obtained by questionnaire. RESULTS: A total of 85 dust samples were collected: 38 from homes with a individual with peanut allergy and 47 from control homes. The median Ara h2 level in homes with an individual with peanut allergy was 1236 ng/g (interquartile range [IQR], 256-1342 ng/g), whereas the median Ara h2 level in homes without an individual with peanut allergy was 650 ng/g (IQR, 163-2201 ng/g). Ara h2 levels in dust from homes of individuals with peanut allergy were not significantly lower than in dust from control homes. Of the homes with an individual with peanut allergy, 15 reported complete avoidance of peanut in the home (39%). Ara h2 levels in homes that completely avoided peanuts were not significantly lower than Ara h2 levels in homes that did not restrict peanuts (p = 0.531). CONCLUSION: Although families may restrict peanuts and peanut products in the home, there was still detectable Ara h2 levels found in homes. Each subject's definition of restriction may vary, there seemed to be peanut protein entering the home, although the protein origin is not known. Possibilities include cross-reactivity with another antigen or transport into the home on some vector. Further investigation of hypotheses regarding cross-reactivity and environmental exposure to Ara h2 is necessary.

Current treatment options for idiopathic angioedema.

BACKGROUND: Idiopathic angioedema is defined as localized swelling of the cutaneous and mucosal tissue that occurs in episodes without a clear etiology. It can be problematic to treat when the underlying pathophysiology is not well understood. OBJECTIVE: To identify successful treatments of idiopathic angioedema reported in the literature. METHODS: A literature search was performed using PubMed. Published case reports and articles discussing treatment of idiopathic angioedema were used in the formulation of this review. In addition, 2 case reports are provided. RESULTS: Although there are no approved treatments for idiopathic angioedema, several medications used for the treatment of hereditary angioedema, such as bradykinin receptor antagonists (icatibant), kallikrein inhibitors (ecallantide), and C1 inhibitors, were successful in 10 patients. Anti-IgE monoclonal antibody (omalizumab) proved successful in 5 patients. The most widely used and successful medication was tranexamic acid (154 patients). CONCLUSION: Despite an unknown etiology, this article highlights viable treatment options for idiopathic angioedema. More clinical trials and better markers identifying the cause of angioedema are needed.

Managing food allergies in schools.

Food allergies are estimated to affect as many as 8 % of children with 2.5 % being allergic to peanut products. Based on the results of recent surveys, this prevalence has been increasing over the last few decades for unknown reasons. As children with food allergies reach school age, the issue is becoming more common in schools. For that reason, schools are now required to be prepared to take responsibility for the safety of food-allergic students. This review discusses the common problems surrounding management of food allergies in the school setting along with reasonable recommendations for addressing those problems. The most important component of food allergy management is for the student to get an accurate diagnosis and to then discuss development of an anaphylaxis action plan with their health-care provider. Each school should insist that a copy of such a plan be provided for each student with food allergy and that epinephrine is readily available should a student have an anaphylactic reaction. In addition to epinephrine, it is essential that school personnel be properly trained to recognize and treat allergic reactions should they occur. Known deficiencies in school preparedness have been documented in previous literature, and consequently, both state and the federal government have begun to implement policies to help with school preparedness.

A large outbreak of Trichophyton tonsurans among health care workers in a pediatric hospital.

BACKGROUND: Although Trichophyton tonsurans remains a major cause of dermataophytoses in US children, nosocomial spread may go unrecognized in health care settings. We describe a staff outbreak of T tonsurans infection among health care workers in a freestanding pediatric hospital. METHODS: Epidemiologic evaluation (retrospective and prospective) was performed in the health care providers and ancillary staff assigned to a 27-bed inpatient medical unit in which the suspected outbreak occurred. RESULTS: Twenty-one individuals, including staff, a hospital volunteer, and a patient, developed tinea corporis during a 5-month period. All infections coincided with multiple admissions of a 2-year-old suspected index patient who demonstrated persistent infections of the scalp and arm. Fungal isolates obtained from the index patient and affected staff (when available) were subjected to multilocus strain typing, which revealed an identical genetic match between the index case and infected hospital personnel. CONCLUSION: T tonsurans can spread widely among staff members caring for children with recalcitrant dermatophyte infections. Recognition that workplace transmission may be the etiology of a succession of infections occurring in a single inpatient unit is necessary to limit the number of infected individuals.