Global assessment of the knowledge and confidence in managing allergic disorders among primary care pediatricians across Europe: An EAACI task force report.

BACKGROUND: Pediatricians are often the first point of contact for children in Primary Care (PC), but still perceive gaps in their allergy knowledge. We investigated self-perceived knowledge gaps and educational needs in pediatricians across healthcare systems in Europe so that future educational initiatives may better support the delivery of allergy services in PC. METHOD: A multinational survey was circulated to pediatricians who care for children and adolescents with allergy problems in PC by the EAACI Allergy Educational Needs in Primary Care Pediatricians Task Force from February to March 2023. A 5-point Likert scale was used to assess the level of agreement with questionnaire statements. Thirty surveys per country were the cut-off for inclusion and statistical analysis. RESULTS: In this study, 1991 respondents were obtained from 56 countries across Europe and 210 responses were from countries with a cut-off below 30 participants per country. Primary care pediatricians (PCPs) comprised 74.4% of the respondents. The majority (65.3%) were contracted to state or district health services. 61.7% had awareness of guidelines for onward allergy referral in their countries but only 22.3% were aware of the EAACI competencies document for allied health professionals for allergy. Total sample respondents versus PCPs showed 52% and 47% of them have access to allergy investigations in their PC facility (mainly specific IgE and skin prick tests); 67.6% and 58.9% have access to immunotherapy, respectively. The main barrier to referral to a specialist was a consideration that the patient's condition could be diagnosed and treated in this PC facility, (57.8% and 63.6% respectively). The main reasons for referral were the need for hospital assessment, and partial response to first-line treatment (55.4% and 59.2%, 47% and 50.7%, respectively). Learning and assessment methods preference was fairly equally divided between Traditional methods (45.7% and 50.1% respectively) and e-learning 45.5% and 44.9%, respectively. Generalist physicians (GPs) have the poorest access to allergy investigations (32.7%, p = .000). The majority of the total sample (91.9%) assess patients with allergic pathology. 868 (43.6%) and 1117 (46.1%), received allergy training as undergraduates and postgraduates respectively [these proportions in PCPs were higher (45% and 59%), respectively]. PCPs with a special interest in allergology experienced greater exposure to allergy teaching as postgraduates. GPs received the largest amount of allergy teaching as undergraduates. Identifying allergic disease based on clinical presentation, respondents felt most confident in the management of eczema/atopic dermatitis (87.4%) and rhinitis/asthma (86.2%), and least confident in allergen immunotherapy (36.9%) and latex allergy (30.8%). CONCLUSION: This study exploring the confidence of PCPs to diagnose, manage, and refer patients with allergies, demonstrated knowledge gaps and educational needs for allergy clinical practice. It detects areas in need of urgent improvement especially in latex and allergen immunotherapy. It is important to ensure the dissemination of allergy guidelines and supporting EAACI documents since the majority of PCPs lack awareness of them. This survey has enabled us to identify what the educational priorities of PCPs are and how they would like to have them met.

Allergen Immunotherapy in the Era of SARS-CoV-2

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Prevalence and longitudinal trends of food allergy during childhood and adolescence: Results of the Isle of Wight Birth Cohort study.

BACKGROUND: The prevalence and time trends of food allergy change during childhood depending on the age of the child and the type of food. OBJECTIVE: To study prevalence and longitudinal trends in food allergy from birth to 18 years in an unselected birth cohort in the Isle of Wight. METHOD: Information on food allergy was collected at ages 1, 2, 4, 10 and 18 years from the Isle of Wight Birth Cohort (n = 1456). Skin prick testing (SPT) was performed at the age of 1 and 2 years in symptomatic children. At 4, 10 and 18 years of age, participants were tested to a panel of food and aeroallergens. Food allergy was diagnosed based on the criteria: symptoms suggestive of a typical IgE-mediated reaction and reaction <4 hours following exposure to a known food allergen. McNemar's test was used to determine significance of changes in prevalence over time. RESULTS: The prevalence of food allergy remained relatively constant in early childhood (5.3%, 4.4% and 5.0% at 1, 2 and 4 years, respectively), with significant decline at 10 years (2.3%, P < .001 vs 4 years) followed by significant rise at 18 years (4%, P = .02 vs 10 years). Cow's milk (1.6%-3.5%) and egg (1.1%-1.4%) were the most common allergens in the first 10 years with peanut (1%) and tree nuts (0.5%) becoming more prevalent beyond 10 years. Fruit and wheat allergy were less common at 10 years, and shellfish and kiwi emerged during adolescence. The prevalence of food allergy plus positive SPT was 1.3%, 0.8%, 0.8%, 0.9% and 2.2% at 1, 2, 4, 10 and 18 years, respectively. CONCLUSION: Food allergy is highly prevalent in infancy with partial resolution during late childhood. However, a number of children acquire new food allergy during adolescence resulting in a relatively higher prevalence at 18 years.

Does anaphylaxis masquerade as asthma in children?

Anaphylaxis in children presents most frequently with respiratory features, and concern exists about the potential for diagnostic confusion with acute asthma. 84 cases of asthma requiring intensive care were identified. 11 cases met exclusion criteria, which left 73 cases for analysis using established anaphylaxis diagnostic criteria. 13/73 children (17.8%) were found to have sufficient clinical features for a diagnosis of anaphylaxis to be entertained, with 3/73 cases (4.1%) considered highly likely to be anaphylaxis. This study highlights the potential for diagnostic confusion and demonstrates the need to consider anaphylaxis in all children presenting with severe asthma.

Homeopathic medicines for children.

This article describes the homeopathic tradition and considers the safety, manufacture, effectiveness and regulation of homeopathic medicines. These medicines are commonly purchased without prescription for children, so an understanding of the basis of therapy is important to ensure appropriate and safe usage. The role of integrated medicine in the National Health Service is also reviewed with identification of research priorities.

The psychological impact of diagnostic food challenges to confirm the resolution of peanut or tree nut allergy.

BACKGROUND: Twenty percent of children outgrow peanut allergy and 10% outgrow tree nut allergy. Resolution can be confirmed by a food challenge. Little is known about the psychosocial impact of the challenge. We aimed to investigate effects of a food challenge on anxiety, stress and quality of life (QoL) in children and their mothers on the day of a food challenge to peanuts or nuts, and in the months following the challenge. METHODS: One hundred and three families participated. Forty children undergoing food challenges to access resolution of allergy, and their mothers, completed validated questionnaires to measure generic and food specific quality of life, stress and anxiety prior to challenge, on the day of investigation and 3-6 months later. Sixty-three children with no clinical indication to challenge (i.e. in the opinion of the allergist had persistent allergy) acted as comparison group completing questionnaires 3-6 months apart. RESULTS: Mothers reported raised anxiety on the day of challenge (P = 0.007), but children were less anxious. The children (P = 0.01) and mothers (P = 0.01) had improved food-related, but not general, QoL 3-6 months following challenge. Children reported lower anxiety levels following the challenge (P = 0.02), but anxiety remained unchanged in mothers. The improvements in maternal and children's QoL and anxiety levels were irrespective of the challenge outcome and despite co-existing food allergies in 50% of children. CONCLUSIONS: Mothers experienced increased anxiety on the day of food challenge, unlike the children, perhaps reflecting the differences in their perceived risks. Food challenges are associated with improved food-related QoL in the following months even in those with a positive challenge.

Unscrambling Egg Allergy: The Diagnostic Value of Specific IgE Concentrations and Skin Prick Tests for Ovomucoid and Egg White in the Management of Children with Hen's Egg Allergy.

Resolution of egg allergy occurs in the majority of egg allergic children. Positive specific IgE antibodies to ovomucoid (OVM) have been suggested to be of greater predictive value for persistent egg allergy than specific IgE to egg white. The performance of OVM-specific IgE antibody levels in a cohort of children referred for a routine egg challenge was compared with egg white specific IgE levels in predicting a positive egg challenge. 24/47 subjects had persistent egg allergy. Receiver operating characteristic analysis showed that OVM-specific IgE testing was the most useful test for the diagnosis of persistent egg allergy. The optimal decision points for the prediction of persistent egg allergy were >0.35 kUA/L for specific IgE levels to both EW and OVM, and ≥3 mm for SPT. Children with specific IgE levels suggestive of persistent egg allergy need not be subject to an egg provocation challenge, reducing both costs and risks to the child.

Influenza immunization in egg allergy: an update for the 2011-2012 season.

Flu vaccines contain detectable amounts of egg protein, which may pose a risk to egg-allergic individuals. The 2009 H1N1 influenza pandemic required mass vaccination in many countries, and the safety of flu immunization in egg allergy became of increasing public health importance. This article reviews recent literature and provides an updated guideline for immunization during the 2011-2012 flu season. Recent experience suggests that some vaccines with very low ovalbumin concentrations may be safe for use in primary care in carefully assessed low-risk individuals.

How do teenagers manage their food allergies?

BACKGROUND: The peak incidence of deaths from anaphylaxis associated with nut allergy occurs in teenagers and young adults. During adolescence, the management of food allergy shifts from being the responsibility of parents to that of the young person. This is a group who therefore need special attention in the clinic. OBJECTIVE: This study aimed to understand the practical challenges that teenagers with food allergy experience using a qualitative approach and generate potential interventions for tackling these. METHODS: Teenagers aged 1118 years with food allergy completed a questionnaire about their food allergy and underwent a focused, semi-structured interview with open questions guided by a priori topic areas. Interviews were recorded, transcribed and analysed using a thematic approach. RESULTS: The study enrolled 18 teenagers with a median age of 15 years (10 females); the most common food allergens were peanuts and tree nuts. Three key themes emerged: avoidance of allergens, preparation for reactions and the treatment of reactions. The majority of teenagers reported eating foods labelled as 'may contain' an allergen as they perceive that they are actually very unlikely to contain an allergen. Many of the teenagers only carried their self-injectable adrenaline when they thought they are particularly at risk of a reaction. Some do not know how to appropriately treat an allergic reaction. More than half believed that educating other students at school about the seriousness of food allergies would make it easier to live with their food allergy. CONCLUSIONS: A significant number of teenagers demonstrate risk-taking behaviour in the management of their food allergies. Teenagers also felt it would be helpful for their peers to be educated about food allergy. This novel strategy might help them to avoid trigger foods and enable teenagers to access help more readily if they suffer a reaction.

Anaphylaxis following single component measles and rubella immunisation.

Anaphylaxis as an adverse event following immunisation (AEFI) is a rare occurrence. We report four cases of anaphylaxis following administration of single component measles or rubella vaccine between January 2003 and June 2007. We estimate that the incidence of anaphylaxis to measles and rubella single component vaccines is 18.9 and 22.4 cases/100,000 doses, respectively. These figures are likely to be an underestimate but are higher than expected. Our calculations were hampered by lack of immunisation reporting data from the private sector. We recommend that NHS standards of vaccine data reporting are also applied to private clinics.

Randomised controlled trial of combined paracetamol and ibuprofen for fever.

A randomised open label study of the combined use of paracetamol and ibuprofen to rapidly reduce fever is reported. The advantage of using both medications is less than half a degree centigrade in the first hour, and insufficient to warrant routine use.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status.

BACKGROUND: Active paediatric Crohn's disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and alpha-linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein-energy malnutrition in children and in Crohn's disease in adults. AIM: To investigate the relationship of fatty acid phospholipid profiles with disease activity and nutritional status in paediatric Crohn's disease. METHODS: The fatty acid (proportionate) composition of plasma and erythrocyte phosphatidylcholine was determined in 30 patients (10.3-17.0 years) stratified into active and quiescent Crohn's disease (paediatric Crohn's disease activity index) and high and low body mass (body mass index centile). RESULTS: In plasma phosphatidylcholine, active disease activity was associated with a lower level of alpha-linolenic acid compared with that in quiescent disease (P < 0.05). A body mass index below the 50th centile was associated with active Crohn's disease, low linoleic and alpha-linolenic acids and high arachidonic acid (P < 0.05) in plasma phosphatidylcholine, and low alpha-linolenic acid in erythrocyte phosphatidylcholine. These findings could not be explained through differences in habitual dietary fat intake. CONCLUSION: In paediatric Crohn's disease, a low body mass index centile and high disease activity are associated with altered profiles of essential fatty acids and their derivatives, which may reflect altered metabolic demand.

Diagnosing the hyper-IgE syndrome: incidence of clinical features

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Hyperimmunoglobulin-E syndrome with recurrent infection: a review of current opinion and treatment.

Hyperimmunoglobulin E (hyper-IgE) syndrome with recurrent infection is a rare idiopathic primary immunodeficiency. It consists of a severe dermatitis with recurrent abscess formation, respiratory tract infections and very high titres of serum immunoglobulin E (IgE). Hyper-IgE syndrome is also associated with skeletal abnormalities. Variability of presentation makes it easy to confuse the diagnosis with that of severe atopy or other rare immunodeficiencies. The aim of this article is to review the literature in order to consider the clinical findings, etiology and treatment of this syndrome.