Practical considerations in diagnosing inborn errors of immunity according to the Middle East and North Africa guidelines.

PURPOSE OF REVIEW: The rate of inborn errors of immunity (IEI) in the Middle East and North Africa (MENA) region is generally higher than in other parts of the world. IEI patients in MENA exhibit more severe disease phenotypes. One of the most important reasons for this is delayed diagnosis. In this review, we examine issues pertinent to primary, secondary, and tertiary physicians in diagnosing IEI in children and discuss the key points for pediatricians according to the MENA guideline. RECENT FINDINGS: Protocols and stepwise approaches designed by a panel of clinical immunologists included in the MENA-IEI registry network can help physicians facilitate the diagnosis of patients with IEI by providing recommendations. These recommendations for diagnostic approaches improve the care of patients within the MENA region and can also be applied to IEI patients in other parts of the world other regions. SUMMARY: Physicians in the MENA region should be aware of IEI, obtain a detailed family history, request tests that can be ordered in primary care when IEI is suspected, and refer patients to clinical immunologists without delay. Primary and secondary care physicians should be aware that patients with IEI may present with noninfectious manifestations and increased infection frequency, severity, and atypical infections.

Gastrointestinal system involvement in patients with primary immunodeficiency: a single center experience.

AIM: Primary immunodeficiencies (PIDs) are a heterogeneous disorder group characterized by an impaired immune system, leading to an increased susceptibility to infections and a wide range of clinical manifestations, including gastrointestinal (GI) complications. This study aimed to assess the GI manifestations of PID patients and highlight the significance of atypical gastrointestinal symptoms in the early diagnosis of these patients. METHODS: A retrospective analysis was conducted on pediatric patients diagnosed with PIDs at Selcuk University Medical Faculty from 2011 to 2021. The study focused on demographic data, clinical presentation, genetic mutations, and GI manifestations, including endoscopic evaluation. Patients were categorized according to the International Union of Immunological Societies (IUIS) PID classifications. Statistical analyses were performed to identify significant associations between PID types and GI manifestations. RESULTS: The cohort comprised 101 patients, with 46% presenting with GI symptoms, including malnutrition and chronic diarrhea, as the most common findings. Primary antibody deficiency (PAD) emerged as the most prevalent PID with GI involvement, followed by combined immunodeficiencies (CID) with associated or syndromic features. Endoscopic evaluations revealed inflammatory bowel disease (IBD)-like colitis in a significant subgroup of patients. The analysis showed that some GI symptoms were more common in specific PID categories, highlighting the importance of early gastroenterological assessment in PID patients. CONCLUSION: Recognition of common GI symptoms in pediatric patients with PIDs may facilitate early diagnosis and prompt multidisciplinary management, potentially improving patient outcomes. The study highlights the necessity of considering PIDs in diagnosing persistent or severe GI symptoms in children.

Evaluation of Healthy Eating Index and Children's Diet Inflammatory Index according to asthma severity group.

BACKGROUND: Diet may contribute to better asthma control in children by impacting the immune and inflammatory pathophysiology. Therefore, this study aimed to investigate differences in nutrient intake, Children's Dietary Inflammatory Index (C-DII), and dietary quality according to asthma severity. MATERIALS AND METHODS: Asthma severity, dietary inflammatory status, and diet quality were assessed in a sample of 202 children with asthma (55.6% males, aged 5-18 years) attending a pediatric allergy outpatient clinic. Asthma severity was evaluated according to the Global Initiative for Asthma criteria and categorized as mild, moderate, or severe. The Children's Dietary Inflammatory Index (C-DII) and Healthy Eating Index (HEI-2010) were calculated based on information collected by the 24-h dietary recall method. Dietary quality was categorized as poor, moderate, or good diet according to HEI-2010. RESULTS: The mean age of the participants was 9.6 ± 3.2 years. Children with severe asthma were younger on average (p < 0.05). Children with mild asthma had significantly higher fiber and iron intake than those with moderate asthma (p < 0.05). C-DII values did not differ significantly according to asthma severity (p > 0.05). Dietary quality was evaluated as moderate in 89.1% of the participants and also showed no difference based on asthma severity. CONCLUSIONS: These findings suggest that inflammatory status and diet quality may not affect asthma severity in children, highlighting the influence of various genetic and environmental factors on the association between diet and asthma severity. More comprehensive and longitudinal studies are needed to investigate the mechanisms linking diet and asthma.

Development of anaphylaxis upon oral food challenge and drug provocation tests in pediatric patients.

Background: The drug provocation test (DPT) and the oral food challenge (OFC) are considered as the criterion standard for the diagnosis of drug hypersensitivity reactions and food allergy. Severe allergic reactions may develop during these tests. Objective: To evaluate the frequency and features of anaphylaxis in pediatric patients undergoing OFCs and DPTs. Method: OFCs and DPTs performed in an open method in the pediatric allergy clinic of our institution between January 2014 and January 2021 were reviewed retrospectively. The characteristics of anaphylaxis that developed during these tests were evaluated. Results: A total of 3631 OFCs and/or DPTs were performed on 2588 pediatric patients. Reactions were recorded in 317 challenges (8.7%), including 42 (1.2%) in the form of anaphylaxis. Of the patients with anaphylaxis, 31 developed anaphylaxis during OFC and 11 during DPT. Anaphylaxis during OFCs was mostly triggered by yogurt (n = 8), hen's egg (n = 6), baked milk (n = 5), and baked egg (n = 4). Cases with anaphylaxis during DPT were recorded mostly with ibuprofen (54.5% [n = 6]). All patients who developed anaphylaxis during OFC had cutaneous manifestations, and 90.3% had respiratory symptoms. Gastrointestinal involvement was present in 32.3% of the patients. During DPT, cutaneous manifestations were observed in 90.9% in the patients who developed anaphylaxis and the respiratory tract was involved in 81.8%. In terms of concomitant allergic diseases, 51.6% of the patients who developed anaphylaxis during OFC had atopic dermatitis and 38.7% had asthma. All the patients with anaphylaxis triggered by nonsteroidal anti-inflammatory drug DPT had asthma. Of the anaphylaxis, 54.8% were mild, 35.7% were moderate, and 9.5% were severe. Severe anaphylaxis was recorded with baked milk (n = 2), baked egg and trimethoprim-sulfamethoxazole (n = 1, each). The patients did not require intensive care, and no death occurred. Conclusion: Anaphylaxis may develop during OFCs and DPTs. These tests should be carried out by experienced allergists in an appropriate setting where emergency equipment and medications, including epinephrine, are readily available.

The Etiology, Clinical Features, and Severity of Anaphylaxis in Childhood by Age Groups.

INTRODUCTION: Anaphylaxis is a severe, potentially fatal systemic hypersensitivity reaction with an acute onset. Etiology, clinical presentation, risk factors, comorbidities of pediatric anaphylaxis may vary depending on the age of the child. OBJECTIVE: The aim of this study was to investigate the etiology, clinical features, management of anaphylaxis in infants, preschoolers, school-age children, and adolescents. METHODS: The patients presenting with anaphylaxis between January 2015 and December 2018 in a single pediatric tertiary hospital were evaluated retrospectively. Demographic data, the triggers, sign-symptoms, severity, and the management of anaphylaxis were recorded. RESULTS: 239 patients were included in the study, 62.3% of whom were boys. The median age was 6.7 (IQR 2.33-12.83) years. 23.8% of the patients were infants, 15.5% were preschoolers, 33.5% were school-age children, and 27.2% were adolescents. Anaphylaxis mostly occurred at home. The most common causative agents were foods (39.3%), drugs (30.1%), and venoms (15.9%) of all cases. Main food allergens were cow's milk and hen's eggs in infants, cow's milk and tree nuts in preschoolers, and tree nuts and legumes in school-age children. Cases of drug-induced anaphylaxis (DIA) were recorded mostly with antibiotics (40.3%), followed by NSAIDs (23.6%). The primary trigger of anaphylaxis was foods in infants and preschoolers and drugs in school-age children and adolescents. There was no difference between age groups in terms of the system involved and severity. Severe anaphylaxis was more common with DIA. Adrenaline was used in 69.8% of all cases with no significant difference between age groups. CONCLUSION: Etiology and symptoms of anaphylaxis may differ between age groups. Raising awareness, educating patients and their parents on anaphylaxis and its management is essential.

Prognosis of food-induced anaphylaxis in children: A single-center real-life study.

Background: Food allergies are known to resolve over time, but there is little information on the natural history of food-induced anaphylaxis (FIA). Objective: This study aimed to evaluate the natural history of FIA in children and determine the factors that affect prognosis. Methods: Children with FIA who were followed up for at least 3 years, between 2010 and 2020, were included. Patients' families were contacted by telephone to question their child's tolerance status and invite them for reevaluation if uncertain. The patients were grouped as tolerant or persistent according to parent reports or reevaluation results. Logistic regression analysis was performed to determine the factors that affected persistence. Results: The study included 185 patients (62.2% boys) with 243 anaphylactic reactions to various foods. Fifty-eight patients (31%) gained tolerance within a 3-year follow-up period. Tolerance rates were higher in patients with FIA to milk (40%) and egg (43.9%) compared with to tree nuts (18.8%), legumes (5.6%), and/or seafood (11.1%) (p < 0.001). In a multivariate analysis, risk factors for persistent FIA were multiple food anaphylaxis (odds ratio [OR] 3.755 [95% confidence interval {CI}, 1.134-12.431]; p = 0.030), total IgE > 100 kU/L (OR 5.786 [95% CI, 2.065-16.207]; p = 0.001), and skin-prick test wheal size > 10 mm (OR 4.569 [95% CI, 1.395-14.964]; p = 0 .012) at presentation. Conclusion: Approximately a third of the patients with FIA developed tolerance within 3 years. Clinicians should remember that children with food allergies, even anaphylaxis, may develop tolerance over time. Regular follow up and reevaluation of tolerance status are necessary to avoid unnecessary elimination.

Evaluation of the Clinical and Laboratory Findings of Asthmatic Children with SARS-CoV-2 Infection.

INTRODUCTION: There are a limited number of studies about the clinical findings of coronavirus infection in pediatric patients with asthma. We aimed to evaluate the clinical and laboratory characteristics of pediatric patients with asthma and healthy children without chronic disease who infected with SARS-CoV-2. METHODS: This is a retrospective, case-control study comparing the asthma diagnosed and healthy children who were diagnosed as COVID-19 in our hospital between March 11 and November 10, 2020. RESULTS: During the study period, 6,205 children were diagnosed with CO-VID-19 in our hospital. Only 54 (0.87%) patients had a diagnosis of asthma. The mean of the age was 10.5 years and 53.7% (n:29) of the patients with asthma were male. Cough, shortness of breath, emesis, and diarrhea were found to be significantly higher in asthma group than in the control group (respectively p = 0.002, 0.000, 0.002, 0.019, 0.015). Patients who were given SABA was significantly higher in asthma diagnosed patients (p = 0.000). Hospitalization was significantly higher in asthma group (p = 0.025), and the duration of hospitalization was significantly higher in control group (p = 0.034). There was no significant difference between the 2 groups in terms of requiring oxygen treatment and in laboratory findings between groups. CONCLUSION: This study revealed that pediatric patients diagnosed with asthma were in a mild clinic. According to these findings, asthma may not affect the course of the COVID-19 in children.

Evaluation of Clinical Properties and Diagnostic Test Results of Cephalosporin Allergy in Children.

INTRODUCTION: Beta-lactams (BLs) are one of the most frequent causes of drug hypersensitivity reactions (HRs), and cephalosporins are a widely used subclass of BLs, especially in children. The aim of this study was to evaluate the clinical features and diagnostic test results of pediatric patients evaluated for suspected cephalosporin allergy. METHODS: This study included patients who presented to our pediatric allergy clinic with a history of reactions attributed to cephalosporins between January 1, 2011, and December 31, 2019, and whose diagnostic tests were completed for the diagnosis. RESULTS: This study included 120 pediatric patients and 69 (57.5%) of them were girls. The median age was 38.63 (interquartile range 10.5-85.7) months. Reactions occurring within 1 h of drug intake were reported in 33 patients (27.5%). Reactions were maculopapular rash in 55 (45.8%) patients, urticaria and/or angioedema in 49 (40.8%), anaphylaxis in 11 (9.2%), severe cutaneous drug reaction in 4 (3.3%), and fixed drug reaction in 1 patient (0.83%). The most frequently suspected agent was cefixime in 41 patients (34.2%). In total, 30 (25%) patients were diagnosed as having cephalosporin hypersensitivity. Confirmation of HRs was also significantly more frequent among patients who were older (p: 0.000), who had taken the drug parenterally (p: 0.000) and with immediate reactions (p: 0.000). CONCLUSION: Cephalosporin allergy has been confirmed in approximately one-fourth of the patients evaluated for suspected cephalosporin allergy. Confirmation of HRs was significantly more common among patients who were older, had immediate reactions, and had taken the drug parenterally.

Can serum periostin, YKL-40, and osteopontin levels in pre-school children with recurrent wheezing predict later development of asthma?

BACKGROUND: Currently, there are no reliable clinical tools available for predicting asthma in pre-school-aged children with recurrent wheezing. The aim of this study was to evaluate the usefulness of serum periostin, YKL-40, and osteopontin biomarkers in wheezy pre-school-aged children for predicting the development of asthma in school ages. METHODS: The study was prospectively conducted between 2011 and 2017. The clinical features of the pre-school-aged children with recurrent wheezing and the levels of serum periostin, YKL-40, and osteopontin were measured. The same participants were reevaluated in school-age period, and participants with asthma were identified. Relative risk (RR) for the development of asthma was analyzed. RESULTS: Of the 197 pre-school-aged children with recurrent wheezing who were reevaluated in school-age years, 32% of them had asthma. Serum periostin, YKL-40, and osteopontin levels at admission could not predict participants who would have asthma symptoms in school-age years. The RR for continuing of asthma symptoms was higher in participants who had their first wheezing episode before 1 year of age, preterm birth, cesarean section delivery, prenatal smoking exposure, multi-trigger wheezing, parental asthma, modified asthma predictive index positivity, prophylactic vitamin D intake ≤ 12 months, breastfeeding time ≤ 12 month, and aeroallergen sensitivity [RR (95% CI) and P value: 2.813 (1.299-6.091), 0.002; 1.972 (1.274-3.052), 0.009; 1.929 (1.195-3.114), 0.004; 2.232 (1.463-3.406), <0.001; 3.152 (1.949-5.097), <0.001; 1.730 (1.144-2.615), 0.016; 2.427 (1.559-3.777), <0.001; 2.955 (1.558-5.604), <0.001; 1.767 (1.084-2.881), 0.016; 0.765 (0.556-1.053), 0.016; respectively]. CONCLUSION: Results have shown that clinical features were more valuable than biomarkers in predicting having asthma in school-age years in participants who had recurrent wheezing in pre-school-age period.

Frequency and clinical characteristics of allergic transfusion reactions in children.

Allergic transfusion reactions (ATRs)are a common form of acute transfusion reaction. It was aimed to determine the clinical characteristics and frequency of ATRs in children. This study included children who were transfused with red cell concentrate (RCC), fresh-frozen plasma (FFP), platelet concentrates(PC), apheresis granulocyte, and cryoprecipitate.The patients' sociodemographic characteristics, the blood product that caused the reaction, the type and timing of the reaction, the patient's age at time of reaction and their diagnosis, follow-up period, and clinical data were recorded. A total of 89703 bags of blood products were transfused to 4193 children.Two hundred eleven acute transfusion-related reactions occurred in 157 (3.74%) patients.Of these, 125 reactions (59%) were allergic. ATR occurred in 125 of 89703 infusions (0.14%).The median age of patients was 9.99 years (IQR:4.67-14.38) and ATRs occurred at a median of 30 minutes into the transfusion. Eighteen (18%) of the patients also had a history of drug reaction.When the blood products that caused ATRs were examined, 43(34.5%) occurred with apheresis and single-donor PC, 37(29.6%) with FFP, 32 (25.6%) with RCC, 10(8%) with pooled PC, 2(1.6%) with cryoprecipitate, 1(0.8%) with apheresis granulocyte.Ninety-nine(79%) of the reactions were minor allergic reactions and 26(21%) were anaphylaxis.Compared to minor allergic reactions, the proportion of PCs was statistically higher in anaphylaxis(p=0.02). Patients receiving PC should be monitored more carefully during the first half hour of transfusion. In addition, approximately one-fifth of the patients who developed ATR also had a history of drug reaction. Patients with previous reactions to drugs may be more likely to have ATR.

Evaluation of anaphylaxis recurrence and adrenaline autoinjector use in childhood.

Introduction: Limited data are available on recurrent anaphylaxis in childhood. Delayed adrenaline administration is the major cause of deaths due to anaphylaxis. As well as prescribing the adrenaline autoinjector (AAI), it is important to make sure that the patient carries the device at all times and uses it correctly for the appropriate indication. Objective: The aim of our study was to evaluate the recurrence of anaphylaxis and AAI use in childhood. Methods: Pediatric patients who were evaluated for anaphylaxis and prescribed AAI between January 2015 and December 2018, in the pediatric allergy and immunology clinic of our hospital were screened retrospectively. A telephone-based survey was conducted with the parents of the patients to investigate the recurrence of anaphylaxis in patients and the use of AAI by their parents for the management of anaphylaxis. Results: A total of 148 patients (64.9% boys) were prescribed an AAI for anaphylaxis. The telephone survey could be conducted with 111 parents (75%) with an AAI prescription. Of these patients, 23.4% (n = 26) of the parents reported that their children experienced recurrent episodes of anaphylaxis. In the recurrent anaphylaxis cases, the triggers were foods in 77%, venoms in 11.5%, drugs in 3.8%, and idiopathic anaphylaxis in 7.7% of the patients. AAI use at the time of anaphylaxis was reported by 42.3% of the parents. The reasons cited by the parents for not using AAI during an episode of anaphylaxis included the preference to have adrenaline administered at a health care facility because of its proximity (60%), fear of using the device (13.3%), hesitation (6.7%), not having the device with them (13.3%), and unavailability of the device (6.7%). Conclusion: Educating the patients and families about the importance of using AAI is crucial, and training on how to use the device should be repeated at each clinic visit and every opportunity.

Evaluation of drug patch tests in children.

Background: Patch tests are used to diagnose nonimmediate T-cell-mediated drug hypersensitivity reactions. The aim of this study was to evaluate the results of patch tests performed with suspect drugs in children. Methods: Patients < 18 years of age who had a drug patch test at the pediatric allergy outpatient clinic of our hospital between January 2014 and January 2020 were included in the study. Age, sex, culprit drug(s), reaction characteristics, and patch test results were recorded from the patients' files. Results: A total of 105 drug patch tests were performed on 71 patients during the study period. The patients' median age was 7 years (interquartile range, 4-11 years), and 57.7% (n = 41) were boys. Twenty-three patients (32.3%) had severe cutaneous adverse reaction (Stevens-Johnson syndrome in 11, drug reaction with eosinophilia and systemic symptoms in 9, and acute generalized exanthematous pustulosis in 3 patients), 45 (63.3%) had maculopapular rashes, and 3 (4.2%) had fixed drug eruption. A total of 20 patch test results (28%) were positive: 18 of 44 patch tests (40.9%) with antiepileptic drugs and 2 of 48 patch tests (4.1%) with antibiotics. Positive results were obtained in 23% of the patch tests (6/26) in 20 patients with severe cutaneous adverse reactions and in 17.7% of the patch tests (14/79) in 51 patients with mild cutaneous reactions. No adverse reactions occurred during or after the patch tests. Conclusion: In our study, patch test positivity was more common with antiepileptic drugs and in patients with severe cutaneous drug reaction.

Management of hypersensitivity reactions to enzyme replacement therapy in children with lysosomal storage diseases.

BACKGROUND: Intravenous recombinant enzyme replacement therapy (ERT) is currently available for 8 lysosomal diseases. Hypersensitivity reactions (HSRs) may be observed during this long-term treatment. OBJECTIVE: To evaluate the frequency and clinical treatment features of ERT HSRs and the management of desensitizations in children. METHODS: Medical records were reviewed retrospectively for patients who received ERT. Those who had experienced HSRs to ERT were included in the study. The demographic characteristics of the patients, culprit enzyme, signs and symptoms, diagnostic tests, management of the reaction, and the protocol employed for the maintenance of ERT were recorded. RESULTS: During the study period, 54 patients received ERT in our institution. A total of 11 patients (20.4%) experienced HSR to ERT. All reactions were of immediate type. The most common symptoms were cutaneous manifestations. A total of 9 patients experienced urticaria, and 2 had anaphylaxis as initial reaction. Patients who had isolated cutaneous symptoms continued their treatments with antihistamines, corticosteroid premedication, slower infusion rate or both. Patients who had recurrent urticaria with these modalities or those who had anaphylaxis continued their ERT with desensitization (n = 8). A total of 3 patients required revisions in desensitization protocols because of recurrent anaphylaxis. CONCLUSION: The reactions that develop during this long-term treatment may be treated by premedication-prolonged infusion, but in some patients, desensitization protocols are necessary for the continuation of therapy. Revisions in desensitization protocols may be required.

Results of NSAID provocation tests and difficulties in the classification of children with nonsteroidal anti-inflammatory drug hypersensitivity.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in children and can frequently cause hypersensitivity reactions. Rates of confirmed NSAID hypersensitivity (NSAID-H) in children are low. OBJECTIVE: To evaluate the results of drug provocation tests (DPTs) with NSAIDs and to evaluate the difficulties encountered in the classification of NSAID-H in children. METHODS: The study included patients with suspected NSAID-H who were examined in our clinic between January 1, 2015, and December 31, 2018. Oral provocation tests with NSAIDs were performed and reactions were classified according to the European Academy of Allergy and Clinical Immunology position paper on NSAID-H. RESULTS: A total of 243 patients (57.2% male patients) presented with suspected NSAID-H during the study period. Of these, 168 patients (69.1%) had a history of reaction to ibuprofen. Isolated skin involvement was the most frequent symptom (86%). A total of 238 DPTs were performed with the suspected agents and 34 had positive results. The families of 12 patients refused provocation testing with the suspected agent or aspirin and these patients could not be diagnosed. Of the 231 patients, 47 patients (20.3%) received a diagnosis of NSAID-H. Twenty patients with NSAID-H could not be classified because their guardians did not consent to further testing with aspirin. CONCLUSION: Performing diagnostic tests is important in patients with no contraindications. Characterizing these reactions in children can be difficult because of the coexistence of indistinguishable symptoms in their history and DPTs, as well as the need for multiple provocation tests. Therefore, further research is needed on this subject.

The negative predictive value of 5-day drug provocation test in nonimmediate beta-lactam allergy in children.

BACKGROUND: Extending the drug provocation test (DPT) period is recommended for patients with suspected nonimmediate beta-lactam antibiotic (BLA) allergy and negative DPT. No consensus has been reached regarding the duration of prolonged provocation. OBJECTIVE: We aimed to determine the negative predictive value (NPV) of the 5-day extended DPT. METHODS: Parents of patients with suspected nonimmediate mild cutaneous reactions with BLAs who had been subjected to 5-day DPT with culprit drugs were questioned by telephone interview about reexposure to the tested drug. Patients with reported reaction during reexposure were reevaluated. Skin tests and serum-specific immunoglobulin E (IgE) analysis were not performed before first DPT. RESULTS: A total of 355 patients had negative results in 5-day DPT. The median age at DPT was 4.2 years, and 52.9% were male. The families of 255 patients (72%) could be contacted. Of these 255 patients, 179 (70%) had used the same drug, and reactions were reported for 6 (3.4%) of those patients, who were subsequently reevaluated. Five of the 6 patients had DPT with amoxicillin-clavulanate and 1 with cefixime. When detailed history was taken, 2 of the 5 patients with amoxicillin-clavulanate reaction were found to have used the drug unintentionally after their reaction to reexposure and did not have any symptoms. One of the patients underwent allergy workup and tested negative, and the other 2 refused the test. The patient with reported cefixime reaction underwent repeated allergy workup and tested negative. Therefore, the NPV of 5-day prolonged DPT was 98.9%. CONCLUSION: The 5-day prolonged DPT has high NPV and seems appropriate in duration for children with suspected nonimmediate-BLA allergy.

Risk Factors Influencing Tolerance and Clinical Features of Food Protein-induced Allergic Proctocolitis.

OBJECTIVE: Continued progress in our understanding of the food protein-induced allergic proctocolitis (FPIAP) will provide the development of diagnostic tests and treatments. We aimed to identify precisely the clinical features and natural course of the disease in a large group of patients. Also, we investigated the predicting risk factors for persistent course since influencing parameters has not yet been established. METHODS: Infants who were admitted with rectal bleeding and had a diagnosis of food protein-induced allergic proctocolitis in 5 different allergy or gastroenterology outpatient clinics were enrolled. Clinical features, laboratory tests, and prognosis were evaluated. Risk factors for persistent course were determined by logistic regression analyses. RESULTS: Among the 257 infants, 50.2% (n = 129) were girls and cow's milk (99.2%) was the most common trigger. Twenty-four percent of the patients had multiple food allergies and had more common antibiotic use (41.9% vs 11.8%), atopic dermatitis (21% vs 10.2%), wheezing (11.3% vs 1.5%), colic (33.8% vs 11.2%), and IgE sensitization (50% vs 13.5%) compared to the single-food allergic group (P < 0.001, P = 0.025, P = 0.003, P < 0.001, respectively). In multivariate logistic regression analysis, presence of colic (odds ratio [OR]: 5.128, 95% confidence interval [CI]: 1.926-13.655, P = 0.001), IgE sensitization (OR: 3.964, 95% CI: 1.424-11.034, P = 0.008), and having allergy to multiple foods (OR: 3.679, 95% CI: 1.278-10.593, P = 0.001] were found to be risk factors for continuing disease after 1 year of age. CONCLUSION: Although most children achieve tolerance at 1 year of age, IgE sensitization, allergy to multiple foods, and presence of colic were risk factors for persistent course and late tolerance. In this context, these children may require more close and extended follow-up.

Diagnostic value and safety of penicillin skin tests in children with immediate penicillin allergy.

Background: The first-line method in the diagnosis of patients who describe an immediate reaction after penicillin intake is a skin test (ST) with penicillin reagents. Objectives: We aimed to determine the safety and diagnostic value of penicillin STs in the diagnosis of immediate reactions to penicillins in pediatric patients. Methods: The study included pediatric patients with suspected immediate reaction to penicillin who were subjected to STs by using a standard penicillin test kit as well as suspected penicillin and the drug provocation tests (DPT) with the suspected penicillin at our clinic. Results: A total of 191 patients (53.9% boys) with a median age of 6.83 years (interquartile range, 4.2-12 years) were included in the study. The time from drug intake to the onset of reaction was ≤1 hour in 138 patients (72.3%) and 1 to 6 hours in 53 patients (27.7%). Penicillin allergy (PA) was confirmed by diagnostic tests in 36 of the 191 patients (18.8%). In multivariate logistic regression analysis, the history of both urticaria and angioedema (odds ratio [OR] 27.683 [95% confidence interval {CI}, 3.143-243.837]; p = 0.003) and anaphylaxis (OR 56.246 [95% CI, 6.598-479.489]; p < 0.001) were the main predictors of a PA diagnosis. Although ST results were positive in 23 patients (63.8%), 13 patients (26.2%) had positive DPT results despite negative ST results. The negative predictive value (NPV) of STs was calculated 92.2% (155/168). None of our patients experienced immediate or delayed systemic and/or local reactions in relation to the STs. Conclusion: A history of urticaria with angioedema and anaphylaxis were the main predictors of true PA in children with suspected immediate reactions. STs with penicillin reagents are safe for use in children. Although STs have a high NPV, DPT is the gold standard for diagnosis. DPTs should be performed as the final step of the diagnostic evaluation of PA in patients with negative ST results.

Comparison of reference systems in the assessment of age-related serum immunoglobulin levels in pediatric patients

Background/aim: Ig level assessment is frequently used in the diagnosis and follow-up of immunodeficiency, as well as in studies investigating the prevalence of low serum Ig level in specific diseases. Materials and methods: Patients who underwent Ig testing in the inpatient and outpatient clinics of our hospital in the years 2010­2016 were included. The Ig levels of the patients were assessed separately according to two reference systems commonly used in Turkey and another reference system used in the USA. Results: A total of 20,138 patients (57.6% male) were included in the study. The median age of the patients was 55.7 months (interquartile range: 23.1­96.7). According to the reference intervals determined by Tezcan et al., 30.6% of the patients were deficient in one or more Ig values. This rate was 4 times higher than those based on the reference intervals determined by Aksu et al. (7.7%) and those in the Nelson Textbook of Pediatrics (6.8%). We also determined that the frequency of low Ig levels with three reference systems Conclusion: In this study, we found that the rates of low Ig level in a group of pediatric patients differed significantly when evaluated using three different reference systems for age-related serum Ig levels