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.