Evaluation of the triggers and the treatment models of anaphylaxis in pediatric patients.

OBJECTIVE: Anaphylaxis is an acute, life-threatening systemic hypersensitivity reaction. We aimed to evaluate the demographic and clinical characteristics of patients presenting with anaphylaxis, as well as triggers and risk factors, and to determine the rate of adrenaline auto-injector (AAI) usage. METHODS: The study was planned in the pediatric allergy outpatient clinic over a 1-year period. The data of children diagnosed with anaphylaxis were evaluated retrospectively; demographic characteristics, causes of anaphylaxis, and treatment modalities were recorded in the created study form. RESULTS: Eighty children (29 females) with a median age of 6.5 years (range: 1 month-17 years) were evaluated. The most common triggers were foods under 2 years of age (73%), and drugs (70%) above 2 years of age. Nearly half of the anaphylaxis episodes (n=41, 51.3%) occurred at home. Cutaneous and respiratory symptoms were the most commonly reported complaints (98.8%). The median age of the patients at the first attack with severe anaphylaxis (n=29, 36.3%) was significantly higher than the rest (p:0.007). The age at onset of the reaction (p:0.006) and occurrence of the reaction in hospital conditions (p<0.001) were determined to be significant risk factors for severe anaphylaxis. Most of them received antihistamines (95.7%) and corticosteroids (91.3%), while 78.3% received adrenaline. Only 9.5% of patients with recurrent episodes of anaphylaxis used AAIs. CONCLUSION: Foods in infants and drugs in older children were the leading causative allergens of anaphylaxis. The most common clinical manifestations were respiratory and cutaneous symptoms. The older age at onset of the reaction and the occurrence of the reaction in hospital conditions were determined to be significant risk factors for severe anaphylaxis. It was determined that the frequency of AAI use was low among patients and their families.

Risk Factors of Challenge-Proven Beta-Lactam Allergy in Children with Immediate and Non-Immediate Mild Cutaneous Reactions.

INTRODUCTION: Beta-lactam (BL) antibiotics are the most often involved drugs in allergic reactions. Mild cutaneous reactions such as maculopapular exanthema or urticaria are the most common presenting complaints of BL allergy in the pediatric population. However, it can be challenging to distinguish BL-induced allergy from reactions due to infections or other reasons. In this study, we aimed to determine the clinical characteristics and potential risk factors of true BL allergy in children with suspected mild cutaneous reactions to BLs. METHODS: We evaluated children who were admitted to our pediatric allergy clinic with suspected BL allergy in between January 2015 and March 2020. Patients with a history suggestive of immediate and non-immediate mild cutaneous reactions were included in the study. The oral challenge test (OCT) with the culprit drug was performed on all patients to confirm the diagnosis. RESULTS: Two hundred fourteen (119 male and 95 female) patients with a median age of 4.9 years were evaluated. BL allergy was confirmed in 10.7% (23) of the patients, according to the OCT results. Most of the proven allergic reactions were of the immediate type (73.9%), and urticaria was the most common presenting complaint (60.8%) in proven BL-allergic patients. The negative predictive value of penicillin-G skin testing was 89.7% for immediate-type penicillin allergy and 93.4% for non-immediate reactions. Also, positive predictive value of penicillin-G skin testing was 50% for immediate and 25% for non-immediate reactions. In the multivariate logistic regression analysis, a history of proven drug allergy (Exp (B): 7.76, 95% CI: 1.88-31.97, p = 0.005) was found to be the risk for BL allergy. CONCLUSION: This study highlighted that OCTs should be performed to confirm the diagnosis in patients suspected of immediate and non-immediate mild cutaneous reactions to BLs and remove the overestimated "BL allergy" label. In these patients, a history of proven drug allergy might be a risk factor for true BL allergy.

Expressive arts therapy with asthmatic children: The effects of an 8-week intervention study.

BACKGROUND: Asthma is the most common chronic disease of childhood. Management of asthma mainly depends on compliance with long-term therapy. Art therapy, in which children express their experiences through artistic activities, is one of the psychosocial support treatments in chronic diseases. The aim of this study was to investigate the effects of expressive art therapy on asthma control and quality of life of asthmatic children. METHODS: A total of 20 children (9 females/11 males), aged 8-13 years, had a group art therapy program consisting of 90 min sessions per week for 8 weeks. Pulmonary function tests (PFTs) by spirometry, asthma control tests, and an asthma quality-of-life scale for children, the Pediatric Asthma Quality of Life Questionnaire (PAQLQ), were performed before and after art therapy. RESULTS: Although a statistically significant increase in PFTs (FEV1, PEF, p = 0.001) and improvement in the items of quality of life (activity limitation, symptoms, p < 0.001) were observed in our patients after art therapy, the increase in asthma control was not significant. CONCLUSION: Expressive art therapy can cause improvement in both pulmonary function tests and quality of life scales in children with asthma. Longer term art therapies planned by an experienced team may also be beneficial in achieving asthma control.

Hypersensitivity to Ibuprofen: Real-Life Experience in Children with History of Suspected Immediate Reactions.

INTRODUCTION: Ibuprofen is the most common culprit drug causing nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity in children. We aimed to evaluate the frequency, clinical characteristics, and risk factors of confirmed ibuprofen allergy in children presenting with a history of suspected immediate type ibuprofen-induced hypersensitivity reactions. METHODS: We evaluated 50 (35 M, 15 F) children with a median age of 7 years, who were referred to our clinic with suspected immediate ibuprofen hypersensitivity. Patients were subjected to a diagnostic work up including drug provocation tests (DPTs) with the culprit drug. Reactions were classified according to the European Academy of Allergy and Clinical Immunology Task Force recommendations for pediatric patients. Proven ibuprofen allergic patients underwent DPT to find a safe alternative drug. RESULTS: Ibuprofen allergy was confirmed in 34% (n: 17) of children; 9 patients were diagnosed by DPTs and 8 patients diagnosed based on their histories. Angioedema was the most common clinical manifestation (n: 30, 60%). Among patients with proven ibuprofen allergy, 7 of them were classified as cross-intolerant. Cross-intolerance reactions were further classified as NSAID-exacerbated cutaneous disease (n = 1) and NSAID-induced urticaria/angioedema/anaphylaxis (n = 6). As an alternative drug, paracetamol was safely tolerated, whereas 1 patient developed angioedema and urticaria with nimesulide. Older age and male gender were identified as independent risk factors for immediate-type ibuprofen allergy. CONCLUSION: DPTs should be performed to confirm or exclude ibuprofen allergy in children and to find safe alternative drugs. Male gender and older age are risk factors for ibuprofen allergy. NSAID-induced hypersensitivity reactions in the pediatric population cannot be well defined using the adult classification system.

COmparisoN of TastES of Available NutriTional integrated or non-integrated formulas for infants older than 1 year of age with cow's milk allergy: A multicenter, prospective, single blind, cross-sectional observational clinical study (CONTEST Study).

Palatability of the infant formulas lacking cow milk protein formulas is reported by parents to be an important drawback. The purpose of this study is to examine decisions made by mothers of infants having cow milk protein allergy, and physicians concerning the palatability of unflavored extensively hydrolyzed formulas and amino acid-based formulas. We conducted a multi-center, randomized, single-blinded, observational taste study involving 149 pediatricians from gastroenterology and allergy subspecialties at 14 tertiary healthcare units from different regions of Turkey and involving 94 mothers of infants with cow milk protein allergy. Blinding was performed for seven formulas available in the market, which were the most commonly prescribed for feeding: four AAFs (Neocate-Numil®, Aptamil Pregomin AS-Numil®, Alfamino-Nestle®, Comidagen-Mamma®), one AAF specifically designed to address the growing nutritional and lifestyle needs of children >1 year (Neocate Junior-Numil®), 2 eHFs (Bebelac Pepti Junior-Numil®, Similac Alimentum-Abott®). Considering all three formula characteristics, Neocate junior-Numil® ranked as the number 1 product among seven products by mothers (63.8%) and physicians (69.8%). The ratings of mothers were significantly higher than the physicians (8.1 points and 6.1 points, respectively; p < 0.001). No difference was found in terms of taste, smell, and appearance for Neocate junior-Numil® between the mothers' and physicians' ratings. Since caregivers have responsibility for careful selection of replacement products for infants with cow milk protein allergy, it is noteworthy that increased awareness and confidence in the palatability characteristics of these products should motivate mothers and physicians to comply with replacement treatment in the long term.

Antibiotic allergy in children with cystic fibrosis: A retrospective case-control study.

Antibiotic allergy is a big problem that may affect the treatment and life quality of patients with cystic fibrosis (CF). AIM: To evaluate predictive factors for confirmed antibiotic hypersensitivity in children with CF. METHODS: In this case-controlled study, we examined 15 patients with CF who had been confirmed with antibiotic allergy. Additionally, we included a control group of age- and gender-matched 45 CF patients with no antibiotic allergy. The diagnosis of antibiotic allergy was confirmed in the presence of a compatible history and a positive response in the drug skin test or provocation test. Multiple drug hypersensitivity was classified according to the temporal relationship of antibiotics: (i) distant, (ii) simultaneous, and (iii) sequential. The data were analyzed by conditional logistic regression. RESULTS: ß-lactam allergy was confirmed in eight patients (ceftazidime n = 5, piperacillin-tazobactam n = 3) and non-ß-lactam allergy was confirmed in two patients (ciprofloxacin n = 1, azithromycin n = 1). Additionally, multiple drug hypersensitivity in five patients (distant n = 4, sequential n = 1), among whom two patients showed hypersensitivity against ceftazidime/piperacillin-tazobactam+ ciprofloxacin/levofloxacin, two patients showed hypersensitivity against ceftazidime+ ciprofloxacin n = 2, and one patient showed hypersensitivity against piperacillin-tazobactam+ amikacin+ trimethoprim-sulfamethoxazole. All patients (n = 13) with confirmed ß-lactam allergy were meropenem tolerant. Multivariate analysis indicated that immediate reactions (, p < 0.001) and allergic evaluation in the first six months after the reaction (p = 0.036) were significant risk factors for the prediction of antibiotic hypersensitivity. CONCLUSION: Beta-lactam antibiotic allergy is the most commonly confirmed drug allergy in children with CF. However, unlike normal children, ceftazidime and piperacillin-tazobactam account for the majority.

Risk Factors for Immediate-Type Local Anesthetic Hypersensitivity Reactions in Pediatric Patients: A Retrospective Case-Control Study.

Background: Local anesthetics (LA) are relatively safe and rarely cause immediate hypersensitivity reactions. The data on immediate LA hypersensitivity and its risk factors in children are limited. Aim: To evaluate risk factors of immediate LA hypersensitivity. Methods: The retrospective case-controlled study included 17 patients with confirmed immediate LA hypersensitivity. For each patient, three age- and gender-matched control subjects were included in the study. LA hypersensitivity was excluded by skin tests and subcutaneous drug provocation tests in all control subjects. Results: The most common allergic assessment in the patient/control group was for lidocaine (n=5; 29.4%, vs n=23; 45.1%). Suspected LA hypersensitivity reactions were found to be associated with cutaneous manifestations in 14 (82.4%) patients and in 7 (13.7%) of the controls. A history of exposure to local anesthetics twice or more was present in 11 (64.7%) patients vs 6 (11.8%) controls. In conditional regression analysis, repeated LA exposure (≥2) and cutaneous findings were determined as significant risk factors (Odds Ratio [OR]:5.7; 95% Confidence Interval [CI]:1.2-27.1; P=0.029 and (OR:17.3; 95% CI:3.6-82.5; P<0.001, respectively). Conclusion: Cutaneous manifestations and a history of LA exposure twice or more were predictive factors for LA allergy confirmed by skin test in children.

Evaluation of Suspected Macrolide Allergies in Children.

OBJECTIVE: Macrolides are often accepted as safe antibiotics due to their low allergenicity. However, studies on macrolides, particularly studies evaluating cross-reactivity in macrolides, are highly rare in children. This study aimed to evaluate the clinical manifestations, confirmation rate, and frequency of cross-reactivity in children admitted with suspicious clarithromycin or azithromycin allergy. MATERIALS AND METHODS: A total of 61 children suspected of macrolide antibiotic allergy (clarithromycin, n = 39 and azithromycin, n = 22) were evaluated. Allergy work-up including drug provocation tests were performed in all patients to confirm drug allergy. RESULTS: Macrolide allergy was confirmed in 9.8% (n = 6) of patients (azithromycin, 18.2% [n = 4] and clarithromycin, 5.1% [n = 2]). There was no significant difference between the confirmation rate of clarithromycin and azithromycin (P = .117). Cross-reaction with clarithromycin was confirmed in 2 (33.3%) patients with azithromycin allergy. CONCLUSION: Drug skin tests are not capable of confirming or ruling out macrolide allergy, and oral provocation tests are essential for a definitive diagnosis. Cross-reactivity, albeit rare, can occur between clarithromycin and azithromycin, which are the most frequently used macrolides in children.

Risk Factors for the Development of IgE-Mediated Food Allergy in Preschool Children with Asthma.

BACKGROUND: Food allergy is a component of the atopic march and may have effects on asthma. This study aimed to evaluate the risk factors for confirmed immunoglobulin E-mediated food allergies and their impact on the clinical picture in preschool children with asthma. METHODS: Clinical history and allergic assessment results were obtained from medical records and analyzed retrospectively. Preschool children with asthma were included in the study and the characteristics of food allergy and asthma were evaluated. The patients were grouped as those with food allergy (Group I, n = 60) and those without (Group II, n = 98). RESULTS: In patients with food allergy and asthma, the number of episodes requiring systemic steroids in the last year (p = 0.002), atopic dermatitis (p = 0.001), parental atopic disease (p = 0.009) and aeroallergen sensitivity rates (p < 0.001) was higher than patients without food allergies. The use of medium or high doses of inhaled steroids to achieve asthma control was more frequent in patients with food allergies (p = 0.014). Parental history of atopic disease [p = 0.007, odds ratio (OR): 3.27, 95% confidence interval (CI) 1.37-7.77)], atopic dermatitis (p = 0.017, OR: 2.80, 95% CI: 1.19-6.57), starting complementary food after 6 months (p = 0.004, OR: 3.9, 95% CI: 1.5-10.0) and having aeroallergen sensitivity (p < 0.001, OR: 6.01, 95% CI: 2.21-16.29) were identified as significant risk factors for food allergy. CONCLUSION: Asthmatic preschool children with food allergies are more likely to have a parental atopic disease, atopic dermatitis, aeroallergen sensitivity and starting complementary food after 6 months. These patients experience more asthma attacks and need higher doses of steroids.

Food allergy and asthma in preschool children affect each other mutually. Food allergy is a component of the atopic march, a risk factor for the development of asthma, and is also included in the modified asthma predictive index in children with wheezing. Therefore, the manifestation of asthma-related symptoms such as cough and wheezing along with food allergy in this age group may facilitate the decision to start asthma control therapy. On the other hand, having asthma is a risk factor for food-related reactions to be more serious. In the current study, we compared patients with and without food allergies. We determined that other atopic diseases (allergic rhinitis and atopic dermatitis) are more common in children with food allergies, and asthma control can be achieved with higher inhaler steroid doses.

Risk Stratification as a Predictive Factor for Cephalosporin Allergy: A Case-Controlled Study.

BACKGROUND: Compared to penicillin, cephalosporin allergies are less common in children, and their diagnostic approach is less standardized. A recent European Academy of Allergy and Clinical Immunology position paper provided a risk stratification system for patients with suspected ß-lactam hypersensitivity reactions. OBJECTIVE: This study aimed to evaluate risk stratification and predicting factors for confirmed cephalosporin hypersensitivity. METHODS: The case-controlled study included patients with confirmed cephalosporin hypersensitivity (skin tests, n = 53; drug provocation, n = 19). For each patient, 2 age- and gender-matched control subjects were included in the study. Data were retrieved from patients' records and analyzed retrospectively. Risk stratification was performed according to the severity of index reactions, which was initially divided as high and low risk and then further divided as immediate and nonimmediate. RESULTS: According to risk stratification, the patient and control groups were divided as follows: high-risk immediate (66.7% vs. 13%, respectively), high-risk delayed (1.4% vs. 8.3%, respectively), low-risk immediate (16.7% vs. 16%, respectively), and low-risk delayed (15.3% vs. 62.9%, respectively). Immediate reactions (odds ratio [OR]: 12.1, 95% confidence interval [CI]: 9-24.8, p < 0.001) and high-risk reactions (OR: 7.8, 95% CI: 4.1-14.6, p < 0.001) were associated with confirmed cephalosporin hypersensitivity in univariate analysis. Multivariate regression analysis indicated that immediate reactions (OR: 7.5, 95% CI: 3.3-16.8, p < 0.001) and high-risk reactions (OR: 5.2, 95% CI: 2.1-12.9, p < 0.001) were significant risk factors for the prediction of cephalosporin hypersensitivity. CONCLUSION: This model can be applied in children with suspected cephalosporin allergy. Skin testing provides diagnostic information in high-risk patients with immediate reactions and reduces the need for drug provocation testing in these patients. It is highly likely to confirm the diagnosis of low-risk patients directly with provocation tests without skin tests. High-risk and immediate reactions were found to be predictive factors for confirmed cephalosporin allergy.

ß-Lactam Allergy in Children.

OBJECTIVE: ß-lactam antibiotic allergy is the most common drug allergy in children. Most of the patients with suspected reactions to ß-lactam antibiotics can actually tolerate these drugs. The aim of this study is to evaluate clinical and laboratory characteristics of children with ß-lactam allergy and to determine cross-reactivity between penicillin and cephalosporins. METHODS: The diagnosis of ß-lactam allergy was made based on the results of skin tests and/or drug provocation tests (DPT). Penicillin allergy skin tests were performed with DAP penicillin® (Diater laboratories, Madrid, Spain), penicillin G, and ampicillin/amoxicillin preparations. Skin and provocation tests were performed with the culprit cephalosporin in addition to the penicillin skin and/or provocation tests to evaluate cephalosporin allergy. RESULTS: We found that 87.7% (71/81) of patients with ß-lactam allergy were able to tolerate the culprit drug. Among ten patients with confirmed diagnosis, two had cross-reactivity (penicillin and cephalosporin) and 8 had a various ß-lactam (aminopenicillin n=6, ceftriaxone n=2) allergies. We identified older age and early-type clinical reactions as risk factors for a confirmed ß-lactam allergy. CONCLUSION: Skin tests and DPT appear to be useful procedures in the diagnosis, and determination of an alternative safe antibiotic in patients with ß-lactam allergy. Most of the patients tolerated the drugs. A minority of the patients with confirmed allergy should avoid all ß-lactam antibiotics due to the probability of cross-reactivity.

Food-induced anaphylaxis in early childhood and factors associated with its severity.

Background: Several factors that increase the risk of severe food-induced anaphylaxis have been identified. Objective: We aimed to determine the demographic, etiologic, and clinical features of food-induced anaphylaxis in early childhood and also any other factors associated with severe anaphylaxis. Methods: We carried out a medical chart review of anaphylaxis cases from 16 pediatric allergy and immunology centers in Turkey. Results: The data of 227 patients with 266 food-induced anaphylaxis episodes were included in the study. The median (interquartile range) age of the first anaphylaxis episode was 9 months (6-18 months); 160 of these patients were boys (70.5%). The anaphylaxis episodes were mild in 75 cases (28.2%), moderate in 154 cases (57.9%), and severe in 37 cases (13.9%). The most frequent food allergens involved were cow's milk (47.4%), nuts (16.7%), and hen's egg (15.8%). Epinephrine was administered in only 98 (36.8%) of these anaphylaxis episodes. A logistic regression analysis revealed two statistically significant factors that were independently associated with severe anaphylaxis: the presence of angioedema and hoarseness during the anaphylactic episode. Urticaria was observed less frequently in patients who developed hypotension. In addition, confusion and syncope were associated with 25.9- and 44.6-fold increases, respectively, in the risk of concomitant hypotension. Conclusion: Cow's milk, nuts, and hen's egg caused the majority of mild and moderate-to-severe anaphylaxis episodes. The presence of angioedema and hoarseness in any patient who presents with a history of food-induced anaphylaxis should alert clinicians that the reaction may be severe. In addition, the presence of confusion, syncope, or stridor probably indicates concomitant hypotension.

Clarithromycin hypersensitivity in children: Is there a link with ß-lactam hypersensitivity?

BACKGROUND: Clarithromycin hypersensitivity is reported as the most common cause of non-ß-lactam antibiotic allergy in children. Clarithromycin is frequently prescribed in cases of suspected ß-lactam hypersensitivity. Oral provocation tests stand as the gold standard to confirm drug hypersensitivity as diagnostic value of skin tests is variable. We analyzed the frequency of true clarithromycin hypersensitivity ratio and its relationship with ß-lactam allergy among children with suspected clarithromycin hypersensitivity and evaluated the diagnostic value of skin tests. METHODS: The study included 160 children referred with suspected clarithromycin hypersensitivity. Clinical history and allergy workups including skin tests or/and oral provocation tests were retrieved from medical records. RESULTS: Oral provocation test confirmed clarithromycin hypersensitivity rate was 5.6% (n = 9/160). Skin tests with clarithromycin showed positivity in 32.6% (n = 29/89) of the tested patients. The sensitivity of clarithromycin skin tests was negligible, and specificity was 73.9% (95% confidence interval [CI], 64.7-81.8). Eighty-eight of the patients (55%) reported that they had previously tolerated a ß-lactam antibiotic. ß-lactam hypersensitivity was suspected in 40% (n = 64/160) of the patients (simultaneous [n = 10], sequential [n = 19], distant form [n = 35]) in relation with clarithromycin usage. ß-lactam hypersensitivity (95% CI, 2.1-70.6, p = .005) and sequential usage of clarithromycin after the development of a rash with amoxicillin-clavulanic acid (95% CI, 2.0-96.4, p = .007) were found as risk factors for confirmed clarithromycin hypersensitivity. CONCLUSION: The frequency of confirmed clarithromycin hypersensitivity was found low among suspected patients. Oral provocation test is crucial for definite diagnosis. Confirmed ß-lactam allergy may be attributed as a risk factor for clarithromycin hypersensitivity, particularly clarithromycin treatment after a developing rash with amoxicillin-clavulanic acid in sequential usage.

'Stay at home': Is it good or not for house dust mite sensitized children with respiratory allergies?

BACKGROUND: Lockdown was imposed for children for 75 days in Turkey to limit the spread of COVID-19. During this period, children have to stay indoors, which might probably increase their exposures to indoor allergens and pollutants. Besides, reduced exposures to respiratory tract infections and outdoor pollutants might be favorable outcomes of this lockdown period. We evaluated the effects of the lockdown on house dust mite (HDM)-sensitized children with respiratory allergies. METHODS: Three-month clinical and medication data of 165 mild-moderate asthmatic children with or without allergic rhinitis (AR), who were grouped according to their HDM sensitization status, were retrieved from patient records. Demographics, asthma control tests, nasal visual analog scores, and outdoor air quality monitoring data were used for assessments in comparisons with the same period in the previous year. RESULTS: Eighty-four patients had asthma, and 81 patients had asthma with AR. Sensitization to HDM was present in 61.8% of the children. Patients experienced reduced numbers of upper respiratory tract infections (P = .008) and reduced asthma exacerbations (P < .001) compared with the same period in the previous year. Asthma control tests were significantly improved (P < .001), and cumulative inhaled corticosteroid usages were significantly reduced (P < .001). Noteworthily, nasal symptoms were significantly worsened in HDM-sensitized asthmatics with AR (P < .001). CONCLUSIONS: This study highlighted that reduction in respiratory tract infections and outdoor pollution may play roles in asthma control and prevent exacerbations despite continuous indoor allergen exposure. Besides, worsening of nasal symptoms in HDM-sensitized asthmatics with AR implies the importance of indoor avoidance measures for AR control.

Proven Food-Induced Acute Urticaria and Predictive Factors for Definitive Diagnosis in Childhood.

BACKGROUND: Urticaria can be the only sign of a food allergy or can be seen together with other signs and symptoms of a food allergy. OBJECTIVE: To determine the demographic, etiologic, and clinical features of food-induced acute urticaria in childhood. METHODS: Patients suspected of food-induced acute urticaria were included in this prospective cross-sectional multicenter study. RESULTS: Two hundred twenty-nine urticaria cases were included in this study. Seventeen patients who did not meet the inclusion criteria of the study were excluded. Of the 212 included cases, 179 (84.4%) were diagnosed with definitive food-induced acute urticaria. The most common foods causing acute urticaria were cow's milk, hen's eggs, and nuts in 56.4, 35.2, and 19% of cases, respectively. The positive predictive value of a history of milk-induced acute urticaria together with a milk-specific IgE >5 kU/L for cow's milk-induced acute urticaria was 92% (95% CI: 81-96%). A history of cow's milk-induced and/or hen's egg-induced acute urticaria was consistent with a definitive diagnosis of food-induced urticaria (Chen's kappa: 0.664 and 0.627 for milk and eggs, respectively). Urticaria activity scores were higher in patients with food-induced acute urticaria (p = 0.002). CONCLUSION: Cow's milk, hen's eggs, and nuts were the most common allergens in the etiology of childhood food-induced acute urticaria. Although the urticaria activity score provides guidance for diagnosis, an oral food challenge is often essential for the definitive diagnosis of a patient with a history of food-induced acute urticaria.

Behind the scene: Paracetamol hypersensitivity in children.

BACKGROUND: Paracetamol, a non-steroidal anti-inflammatory drug, is commonly being used for fever and pain relief worldwide. The aim of this study was to evaluate children with a suspected history of paracetamol hypersensitivity. METHODS: Sixty patients who were referred to our clinic in between January 2015 and December 2018 with a suspected history of paracetamol hypersensitivity were included. Reactions were classified according to the European Network for Drug Allergy (ENDA)/Global Allergy and Asthma European Network classification and European Academy of Allergy and Clinical Immunology (EAACI)/ENDA Position Paper. Diagnoses were confirmed by skin tests and oral challenge tests (OCTs). In those with verified paracetamol hypersensitivity, an OCT with a strong COX-1 inhibitor was performed to classify the type of the reaction to refer as either selective or cross-intolerance hypersensitivity. A subsequent OCT with a selective COX-2 inhibitor was performed in those cross-intolerant patients to find out a safe alternative drug. RESULTS: Sixty OCTs with paracetamol were performed to patients with a median age of 8.5 years, and hypersensitivity to paracetamol was verified in 8 patients. Four children were classified as selective responders, and 3 were classified as cross-intolerant after OCT with a COX-1 inhibitor. Overall, skin test positivity for paracetamol was detected in only one patient, in whom OCT with paracetamol was negative. In all 3 cross-intolerant patients, a safe alternative non-steroidal anti-inflammatory drug was identified after an OCT with a selective COX-2 inhibitor. CONCLUSION: OCT stands as the gold-standard procedure in verifying the diagnosis of patients with paracetamol-induced drug hypersensitivity, as well as, in defining the type of reactions and finding out safe alternative drugs.

Can allergy patch tests with food additives help to diagnose the cause in childhood chronic spontaneous urticaria?

INTRODUCTION: Chronic spontaneous urticaria (CSU) is characterized by the onset of symptoms which are not induced by specific triggers, but are rather spontaneous. A considerable number of patients report that foods or food additives might be responsible for their chronic urticaria. AIM: To determine the prevalence of sensitization to food additives in children with CSU using atopy patch tests (ATP). MATERIAL AND METHODS: Atopy patch tests for 23 different food additives were applied to 120 children with CSU and 61 healthy controls. RESULTS: Seventeen (14.1%) children with CSU were sensitized with food additives. None of the control group had positive APT. Azorubine and Cochineal red were the food additives detected with the highest sensitization rates (5.8% (n = 7) and 6.7% (n = 8), respectively). CONCLUSIONS: There can be an association between food additives and CSU. APT tests may be a helpful tool in the assessment and management of CSU so that easier to follow diets and effective treatments can be offered to families.

Evaluation of periostin level for predicting severity and chronicity of childhood atopic dermatitis.

INTRODUCTION: Periostin has some effects on the pathogenesis of atopic dermatitis (AD) via release of pro-inflammatory cytokines and chemokines from activated keratinocytes and it is related to chronicity of skin lesions. AIM: To evaluate the relationship between plasma periostin levels and severity and chronicity of AD in children. MATERIAL AND METHODS: The study population consisted of 29 children with atopic dermatitis without concomitant allergic disease such as asthma or allergic rhinitis and 31 healthy controls. Data of demographic features, serum eosinophil, total IgE and skin prick test results were collected through the patient's medical records. The severity of the disease was assessed by the SCORAD index. Serum periostin levels were measured with a human periostin ELISA kit. RESULTS: The mean ages of the AD patients and the control group participants were 80.7 ±52.8 and 90.3 ±41.6 months, respectively. Mean plasma periostin levels were 63.0 ±19.0 ng/ml in AD patients, and 23.6 ±7.3 in healthy controls, and there was a statistically significant difference between the two groups (p = 0.001). Plasma periostin level did not vary according to total IgE or serum eosinophil count (p > 0.05). Age of onset and duration of symptoms also were not correlated with plasma periostin levels. Although there was a positive relationship between plasma periostin level and the SCORAD index of patients, it was not statistically significant (r = 0.19, p > 0.05). CONCLUSIONS: This study showed that plasma periostin levels were increased in children with atopic dermatitis. Periostin may have a partial role in the pathogenesis of atopic dermatitis, but it is not associated with severity or chronicity in children with atopic dermatitis.

A Case of Anaphylaxis to Measles Vaccination in an Infant with Cow's Milk Allergy.

Background: Cow's milk is one of the most common of the foods that cause food allergies in children. Here, we present a 10-month-old male who was diagnosed with having an allergy to cow's milk and who developed an anaphylactic reaction after being recently vaccinated with a measles vaccine. Case: The patient had been diagnosed with atopic dermatitis and cow's milk allergy at 40 days old after a rash appeared on his face and arms while exclusively breastfeeding. At 9 months, on his routine welfare outpatient appointment, he developed a facial rash and swelling, wheezing, difficulty breathing, and cyanosis within 10 min of having his first measles vaccination (M-VAC®; Serum Institute of India, Hadapsar, Pune, India). After an allergy evaluation and a physical examination that showed that he was otherwise healthy, he was diagnosed with an allergy to cow's milk, which was then eliminated from his diet. Laboratory evaluations were as follows: serum immunoglobulin E (IgE) to cow's milk: 36.2 kU/L, α-lactalbumin: 9.39 kU/L, ß-lactoglobulin: 8.74 kU/L, casein: 34.2 kU/L, latex-specific (sp)IgE: 0.10 kU/L, gelatin spIgE: <0.35 kU/L (normal levels <0.35 kU/L; Pharmacia, Uppsala, Sweden). Results revealed lactalbumin hydrolysate as one of the M-VAC ingredients according to the manufacturer's package insert. Conclusion: In most cases with a cow's milk allergy, vaccines are administered without any problems because the amount of milk proteins contained in the vaccines is not sufficient to represent a risk factor for anaphylaxis; however, the vaccine content should be examined for possible allergens, particularly for children with food allergies, before vaccinating. We should keep in mind when determining the agent responsible for an allergic reaction that the risk from a residual component of milk protein in vaccines can differ according to the nutritional habits of the population.

Corticosteroid phobia among parents of asthmatic children.

Özçeker D, Uçkun U, Islamova D, Tamay Z, Güler N. Corticosteroid phobia among parents of asthmatic children. Turk J Pediatr 2018; 60: 142-146. Asthma is one of the most prevalent chronic diseases among children. Its prevalence and morbidity have been rising in recent decades. Pediatric asthma causes a significant burden on families; allergen-avoidance measures, uncontrolled disease, and disease severity which are the major cost predictors of childhood asthma in Turkey. Inhaled corticosteroids (ICS) are considered as cornerstone medications in asthma management which reduce asthma morbidity and mortality. Our aim was to address corticosteroid phobia in caregivers of asthmatic children and its impact on asthma management. Five hundred caregivers of asthmatic children were interviewed using structured questionnaire in this study. Over fifty percent of the caregivers (56.8%), most of whom (82.6%) are already aware of using corticosteroids in their anti-asthma drug regimen, mentioned that they are afraid of using them. Almost one fourth of caregivers (24.8%) made either some changes in their treatment regimen or stopped using the drugs due to corticophobia. Of the caregivers 55.2% had no idea about the side effects of corticosteroids and only 12.6% of them mentioned that they were informed by their physicians about the effects of corticosteroids. Any change in asthma treatment regimen due to corticophobia was found to be related with poor asthma control level (p: 0.004). The impact of parental information about the effects and importance of steroids given by the physicians on better asthma control was found to be highly significant (p < 0.001). That`s why physicians and health care providers should spend enough time explaining the importance of adherence to treatment in asthma management, which may help in overcoming the fear of using ICS.