Functional constipation related to cow's milk allergy in children: A management proposal.

Functional constipation (FC) is one of the most common disorders in childhood and has a negative impact on the quality of life of children. Scientific evidence regarding a causal relationship between FC and cow's milk allergy is controversial, as it is also reported by the latest European Society for Paediatric Gastroenterology, Hepatology and Nutrition-North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN-NASPGHAN) recommendations. In the case of FC, routine allergometric tests are not recommended and the cows' milk-free diet is only proposed in the case of laxative-resistant constipation and only following the advice of an expert. Instead, after a careful review of the literature and in view of the many clinical cases encountered in our clinical practice, we believe that it is useful to propose cows' milk-free diet as first line for the treatment of FC at least in pre-school children and in children with a personal or family history of atopy or with a previous diagnosis of cow's milk protein allergy.

Oral allergy syndrome by fruit and vegetable PR-10 allergy: Accuracy of in vivo diagnosis.

Routine diagnostic methods for allergies to plant-derived foods are based on skin prick test (SPT) with commercial extracts, prick-by-prick (PbP) with fresh food, serum-specific IgE measurement, and oral food challenge.We discuss the possibility and the advantages of performing, in patients with oral allergy syndrome (OAS) by fruit and vegetables (excluding nuts) PR-10 allergy, component-resolved diagnosis (CRD) by SPT and PbP with raw and cooked vegetables, rather than performing a CRD with in vitro tests by drawing blood.Based on our clinical experience and the studies published in the literature, we believe that, at least for the OAS by fruit and vegetables (excluding nuts) PR-10 allergy, the search for sensitizing allergens and related cross-reactive allergens with SPT and PbP can be performed routinely in clinical practice, even at the primary-care level.

International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology.

Food protein-induced enterocolitis (FPIES) is a non-IgE cell- mediated food allergy that can be severe and lead to shock. Despite the potential seriousness of reactions, awareness of FPIES is low; high-quality studies providing insight into the pathophysiology, diagnosis, and management are lacking; and clinical outcomes are poorly established. This consensus document is the result of work done by an international workgroup convened through the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology and the International FPIES Association advocacy group. These are the first international evidence-based guidelines to improve the diagnosis and management of patients with FPIES. Research on prevalence, pathophysiology, diagnostic markers, and future treatments is necessary to improve the care of patients with FPIES. These guidelines will be updated periodically as more evidence becomes available.

Isolated contact urticaria caused by immunoglobulin E-mediated fish allergy.

Fish is a common cause of food allergy. The reactions usually occur after its ingestion. In most immunoglobulin E-mediated reactions, the allergens are gastroresistant and heat-stable proteins of low molecularweight (parvalbumin). On the other hand, isolated contact urticaria following the handling of raw fish but without symptoms after its ingestion was found among cooks and professional fish handlers. In these cases, the fish allergens are gastrosensitive and thermolabile, as demonstrated by the decrease in the diameter of the wheal in the skin-prick test using cooked fish. To the best of our knowledge isolated fish contact urticaria in children has not been previously reported. We analyze the features of three pediatric cases of contact urticaria from cod (one of them was sensitized to parvalbumin), with tolerance after ingestion of this fish on oral food challenge.

A new model for conservative food challenge in children with immunoglobulin E-mediated cow's milk allergy.

BACKGROUND: The diagnostic gold standard for food allergy is an oral food challenge (OFC) with the suspected food. Usually, an OFC is stopped at the onset of mild objective symptoms for fear of severe reactions, but there is no consensus on this issue. OBJECTIVES: To investigate the effectiveness and side effects of a new model of oral milk challenge in order to increase the diagnostic accuracy of cow's milk protein allergy and reduce the number of useless elimination diets. This model is characterized by a conservative diagnostic protocol and "step-up cow's milk dosing." The secondary aim was to investigate possible factors influencing severe reactions. METHODS: Sixty-six children (median age 1 year, range 1-18) with suspected immunoglobulin E (IgE)-mediated cow's milk allergy performed a conservative OFC, i.e., the OFC was continued even in the presence of subjective, even repeated, or mild local or multiple organ objective symptoms. If the first objective reaction occurred when the quantity of milk was > 10 ml, the investigator would decide whether to continue the OFC or prescribe a gradual increase in milk feeding at home. RESULTS: Symptoms developed during the OFC in 42.4% of the children. Local, generalized and severe generalized reactions developed in 11 (16.7%), 11 (16.7%) and 6 (9.1%) children, respectively. Only 14/28 (50%) who developed objective symptoms during the OFC were considered to be affected by cow's milk allergy. In the remaining 14 both subjective and objective symptoms developed and the OFC was continued without further symptoms. Epinephrine was administered to 6 of the 28 children (21.4%) who developed objective symptoms. All but one had subjective symptoms following the early doses of milk, whereas all children who later tolerated milk had their first subjective or mild symptoms following doses > or = 10 ml. CONCLUSIONS: This new model of OFC criteria led to frequent severe allergic reactions; hence its use in daily practice seems inadvisable. However, our study provides evidence that a severe allergic reaction does not invariably occur if, the offending food continues to be administered after the onset of symptoms. If mild symptoms appear at doses > 10 ml, continued milk administration, on the same day or in subsequent days, seems to facilitate the development of tolerance and may reduce the number of useless elimination diets.

Specific oral tolerance induction (SOTI) in pediatric age: clinical research or just routine practice?

Specific Oral Tolerance (SOTI) is a promising therapy of food allergy, specially for IgE-mediated cow milk allergy (CMA) in pediatric age. Randomized controlled trials have reported that about 35% of children, at least 5 years of age, became full tolerant to cow milk proteins after SOTI. Regard to the safety, literature describes about 200 children who underwent SOTI, with no fatal events. Nevertheless, a considerable percentage of those children (15%-20%) had to stop SOTI, because of important adverse effects. Numerous protocols have been described, some audacious and other prudent, however all demand an intense commitment either of the doctors and of the families. The information about the follow up of the children who underwent SOTI are still insufficient. For these reasons, we think that SOTI is still an experimental therapy.

Consumption of fish, butter and margarine during pregnancy and development of allergic sensitizations in the offspring: role of maternal atopy.

It has been suggested that changes in dietary habits, particularly increased consumption of omega-6 polyunsaturated fatty acids (PUFA) and decreased consumption of omega-3 PUFAs may explain the increase in atopic disease seen in recent years. Furthermore, it seems possible that it is mainly prenatal or very early life environmental factors that influence the development of allergic diseases. It has also been suggested that intrauterine risk factors may act differently if mother themselves suffer from allergic disease. The aim of this study was to investigate whether the consumption of fish, butter and margarine during pregnancy might influence the development of allergic sensitizations in the offspring. The study population was divided into the offspring of allergic and non-allergic mothers. This was a retrospective cohort study enrolling 295 offspring of allergic mothers and 693 of non-allergic mothers. Information regarding maternal intake of fish, butter and margarine during pregnancy as well as other prenatal and perinatal confounding factors were retrospectively assessed by parental report via a standardized questionnaire. Atopy was determined by skin-prick tests (SPT) to eight prevalent inhalant allergens and two foods. In the allergic mothers' group there is no clear correlation between maternal intakes of fish, butter and margarine and sensitizations to food or inhalants. In the non-allergic mothers' group there was no correlation between butter and margarine intake and food or inhalant sensitizations. On the contrary, a protective effect of fish intake on SPT positivity was observed. In particular, frequent maternal intake ('2-3 times/wk or more') of fish reduced the risk of food sensitizations by over a third (aOR 0.23; 95% CI: 0.08-0.69). A similar trend, even if not significant, was found for inhalants. Finally, even in the whole study population, i.e. allergic group plus non-allergic group, there was a similar trend between increased consumption of fish and decreased prevalence of SPT positivity for foods. This study shows that frequent intake of fish during pregnancy may contrast the development of SPT sensitizations for foods in the offspring of mothers without atopic disease. Therefore, larger prospective studies are needed, enrolling mothers with and without allergic disease, to confirm these results.

Candida albicans endocarditis diagnosed by PCR-based molecular assay in a critically ill pediatric patient.

A young Down's syndrome patient developed tricuspid valve endocarditis several years after undergoing surgical closure of a congenital ventricular septal defect. Fungal etiology was established by PCR amplification of the Candida albicans ERG11 gene. Although antifungal therapy was administered, surgical replacement of the infected valve was required to eliminate the infection.