Psychosocial Impact of Food Allergy on Children and Adults and Practical Interventions.

PURPOSE OF REVIEW: IgE- and non-IgE-mediated food allergies are increasing in prevalence in children and adults worldwide. A food allergy diagnosis can be associated with a sense of overwhelm and stress and commonly has a negative impact on quality of life. RECENT FINDINGS: While there is an increased recognition of the psychosocial effects of food allergy, the current research reflects the experience of mostly White, well-educated wealthier populations. Some studies have now explored the psychosocial impact among other populations; however, further study is needed. It is important that physicians and allied health professionals screen for the potentially negative psychosocial effects of food allergy and provide education to promote safety and self-efficacy at each visit; however, time may be a limiting factor. Numerous validated questionnaires are now available to help assess the psychosocial impact of food allergies. Allergy-friendly foods are typically more expensive, and thus, it is imperative that physicians screen for food insecurity as well. Educational resources should be offered regarding living well with food allergies at each visit. For patients and families experiencing anxiety or food allergy burden that is difficult to manage, referral to a mental health provider should be considered. Resources regarding programs to help accessing safe foods should also be available. Further research is needed among diverse populations focusing on interventions to best support patients and families with food allergy.

Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach.

This guidance updates 2021 GRADE (Grading of Recommendations Assessment, Development and Evaluation) recommendations regarding immediate allergic reactions following coronavirus disease 2019 (COVID-19) vaccines and addresses revaccinating individuals with first-dose allergic reactions and allergy testing to determine revaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 revaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommendations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the United Kingdom, and the United States formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy and revaccination after a prior immediate allergic reaction. We suggest against >15-minute postvaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest revaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise in a properly equipped setting. We suggest against premedication, split-dosing, or special precautions because of a comorbid allergic history.

Epinephrine autoinjector prescribing following anaphylaxis presentation to the emergency department.

Background: Guidelines recommend patients with anaphylaxis are prescribed epinephrine autoinjectors (EAI), carry the EAI with them, and are referred to an allergist. There also are barriers to EAI administration, such as acquiring the medication, having it available, recognizing when to use it, and administering it appropriately. Objective: The objective was to describe how often patients with anaphylaxis discharged from the emergency department (ED) receive an EAI prescription and allergist referral; also, to assess the frequency of EAI pick-up by the patient from the outpatient pharmacy, out-of-pocket cost, change in EAI device during dispensing, and if patient training on EAI use and allergist follow-up occurred. Patient-specific factors associated with the occurrence of these variables were investigated. Methods: This was a retrospective, observational study of adult and pediatric ED patients who presented with anaphylaxis between July and December 2020. Data were collected from medical records and telephone calls to outpatient pharmacies and included patient demographics; ED treatment; EAI prescribing, EAI pick-up from the outpatient pharmacy, and cost; device changes; EAI training; and allergist referral and follow-up. Data are presented descriptively, and bivariate analyses were used for comparisons between patient-specific factors and incidence of EAI prescribing, patient pick-up, and allergist referral. Results: A total of 102 patients were included; mean age ± standard deviation 34 ± 7 years, 52% were < 18 years of age; and 54% had a history of allergy and/or anaphylaxis. EAI prescribing occurred in 79% of the patients. Of these, 71% picked up the EAI from the outpatient pharmacy, the median cost to the patient was $5 (range, $0-$379), 18% had an EAI device change at dispensing, and 23% received EAI training. Allergist referral occurred in 22%, and 28% followed up with an allergist within 60 days. Presenting symptoms of mucosal edema and respiratory stridor were associated with the occurrence of EAI prescribing. Presenting symptoms of respiratory wheezing, hoarseness, throat itching, skin flushing and allergist referral from the ED were associated with the occurrence of EAI pick-up from the outpatient pharmacy. Conclusion: Overall, 79% of ED patients with anaphylaxis had an EAI prescribed and 22% had an allergist referral; 71% picked up the EAI from the outpatient pharmacy, EAI dispensing changes occurred, and training was infrequent. Collaboration between emergency medicine clinicians, allergists, and pharmacists is needed to streamline treatment and follow-up.

Delayed allergic skin reactions to vaccines.

Background: Recent advances in vaccination against the severe acute respiratory syndrome coronavirus 2 pandemic have brought allergists and dermatologists to the forefront because both immediate and delayed hypersensitivity reactions have been reported. Objective: This literature review focused on delayed reactions to vaccines, including possible causative agents and practical information on how to diagnose, evaluate with patch testing, and manage subsequent dose administration. Methods: Currently published reviews and case reports in PubMed, along with data on vaccines from the Centers for Disease Control and Prevention web site. Relevant case reports and reviews that focused on delayed reactions to vaccines were selected. Results: Most delayed hypersensitivity reactions to vaccines include cutaneous manifestations, which vary from local persistent pruritic nodules to systemic rashes. The onset is usually within a few days but can be delayed by weeks. Multiple excipients have been identified that have been implicated in delayed vaccine reactions, including thimerosal, formaldehyde, aluminum, antibiotics, and gelatin. Treatment with antihistamines, topical corticosteroids, or systemic corticosteroids alleviates symptoms in most patients. Such reactions are generally not contraindications to future vaccination. However, for more-severe reactions, patch testing for causative agents can be used to aid in diagnosis and approach further vaccination. Conclusion: Delayed-type hypersensitivity reactions to vaccines are not uncommon. If needed, patch testing can be used to confirm agents, including antibiotics, formaldehyde, thimerosal, and aluminum. In most cases, delayed cutaneous reactions are not contraindications to further vaccine administration.

Prevention and management of allergic reactions to food in child care centers and schools: Practice guidelines.

Food allergy management in child care centers and schools is a controversial topic, for which evidence-based guidance is needed. Following the Grading of Recommendations Assessment, Development, and Evaluation approach, we conducted systematic literature reviews of the anticipated health effects of selected interventions for managing food allergy in child care centers and schools; we compiled data about the costs, feasibility, acceptability, and effects on health equity of the selected interventions; and we developed the following conditional recommendations: we suggest that child care centers and schools implement allergy training and action plans; we suggest that they use epinephrine (adrenaline) to treat suspected anaphylaxis; we suggest that they stock unassigned epinephrine autoinjectors, instead of requiring students to supply their own personal autoinjectors to be stored on site for designated at-school use; and we suggest that they do not implement site-wide food prohibitions (eg, "nut-free" schools) or allergen-restricted zones (eg, "milk-free" tables), except in the special circumstances identified in this document. The recommendations are labeled "conditional" due to the low quality of available evidence. More research is needed to determine with greater certainty which interventions are likely to be the most beneficial. Policymakers might need to adapt the recommendations to fit local circumstances.

Physician well-being in allergy and immunology: Creating a culture of wellness.

OBJECTIVE: There are 3 domains of physician wellness: (1) the culture of wellness, (2) efficiency of practice, and (3) physician resilience. The culture of wellness encompasses an organization's values, environment, and behaviors that foster compassion and growth in its physicians. DATA SOURCES: Studies have reported that burnout affects a physician's professionalism, altruism, and a sense of calling. Furthermore, burnout increases the risk of cardiovascular disease, alcohol abuse, divorce, depression, and even suicide among physicians. Physician burnout is associated with decreased efficiency at work, which can affect patient care, patient satisfaction, and even patient safety. As such, it is imperative that we develop a culture of wellness. STUDY SELECTIONS: A culture of wellness reflects shared values and a sense of community within an organization. When a culture of wellness is present, leaders prioritize the personal and professional growth of its team members. RESULTS: This article instructs readers on methods that can be used to develop a culture of wellness. CONCLUSION: We need to address burnout at every level in health care, namely at health care organization and system levels, individual teams and offices, and at an individual level. In doing so, it becomes obvious that a lack of wellness (burnout) is a systems problem and not an individual's fault. We are all responsible for taking steps to change the culture to one of wellness. Working within our practices, organization, and allergy societies, we can change the culture to one of wellness.

The evolution of food protein-induced enterocolitis syndrome: From a diagnosis that did not exist to a condition in need of answers.

OBJECTIVE: Although food protein-induced enterocolitis syndrome (FPIES) was first described approximately 50 years ago and research is increasing, there are still considerable unmet needs in FPIES. This article catalogs the areas of progress and areas for further research. DATA SOURCES: Through our personal experiences in caring for patients with FPIES, our personal research, and a review of the existing FPIES literature as indexed in PubMed, we explored what is known and what is needed in FPIES. STUDY SELECTIONS: The studies that have improved the knowledge of FPIES, defined phenotypes, allowed for better-informed management of FPIES, and laid the groundwork for further research. RESULTS: Further research is needed in the areas of prevalence, natural history, trigger foods, threshold doses, how and when to perform oral food challenges, and immunopathogenesis of this disorder. Development of a biomarker and determination of the best method to treat reactions is also needed. Furthermore, FPIES has a substantial psychosocial and economic impact on families, and more research is needed in developing and implementing ameliorating strategies. CONCLUSION: By partnering together, health care providers, advocacy organizations, and families can continue to advance our understanding and improve the care of patients and families living with FPIES.

Real-world tree nut consumption in peanut-allergic individuals.

BACKGROUND: Individuals with peanut allergy often avoid tree nuts, yet true rates of tree nut allergy in peanut-allergic individuals are as low as 7%. OBJECTIVE: To examine tree nut sensitization patterns in peanut-allergic individuals, patient and family choice regarding tree nut consumption, and factors that influence consumption of tree nuts. METHODS: All patients presenting for peanut allergy evaluation to an outpatient allergy office were included during a 4-month period. In addition to demographic information, sensitization to tree nuts and tree nut consumption were collected. Logistic regression was performed to generate odds ratios with 95% CIs in univariate and multivariate analyses for variables that predict tree nut consumption. RESULTS: A total of 258 individuals with peanut allergy were enrolled. Ninety-five (36.8%) consumed all tree nuts ad libitum, 63 (24.4%) consumed some but not all tree nuts, and 100 (38.8%) consumed no tree nuts. Of the 100 electively avoiding all tree nuts, the most commonly reported reason was fear of cross-contact (50%). Although there was no difference between rates of sensitization between individual tree nuts (P = .056), cashew and pistachio had higher serum specific IgE levels compared with other tree nuts (P < .001). The tree nut most commonly consumed by peanut-allergic individuals was almond (P < .001). Consumption of foods with precautionary labeling was the strongest predictor of tree nut consumption in peanut allergic individuals (P < .001) CONCLUSION: Our data highlight the potential for safe introduction of tree nuts in peanut-allergic individuals and indicate that peanut-allergic individuals who consume foods with precautionary labeling are most likely to consume tree nuts.

Efficacy of epinephrine and diphenhydramine rinses in decreasing local reactions to subcutaneous aeroallergen immunotherapy.

Background: Although local reactions (LR) to subcutaneous immunotherapy (SCIT) occur in 26-86% of patients, there are no well-studied strategies to manage LRs. Objective: To complete a prospective, randomized, single-blind, controlled trial that compared pre-rinsing SCIT syringes with diphenhydramine, epinephrine, or placebo in patients who were receiving aeroallergen SCIT and experiencing LRs despite pretreatment with an antihistamine. Methods: Patients ages ≥5 years who were receiving aeroallergen SCIT per a conventional dosing schedule and who were experiencing LRs despite premedicating with an oral antihistamine were randomized to diphenhydramine, epinephrine, or placebo rinse, and were followed up for three subsequent visits. At each visit, the patients were asked (yes or no) if LRs improved. Results: A total of 490 patients were enrolled in the study. Seventy-four of the 490 patients (15.1%) experienced an LR despite pretreatment with an oral antihistamine and were randomized into an intervention group. At visit 1, an epinephrine rinse was strongly associated with decreasing LR compared with both diphenhydramine rinse and placebo (p < 0.001). There was no difference among the intervention groups at visits 2 and 3. In patients who reported a consistent outcome at all three visits, the epinephrine rinse was significantly associated with a decrease in LR compared with both diphenhydramine rinse and placebo rinse (p = 0.05). Conclusion: In patients who received aeroallergen SCIT per a conventional dosing schedule, an epinephrine rinse significantly decreased LR at the first visit, and also within a population that reported a consistent outcome at all three study visits. In patients already premedicating with an oral antihistamine, adding an epinephrine rinse is a safe and effective strategy to decrease LRs to aeroallergen SCIT.

Urticaria, Angioedema, and Anaphylaxis.

Urticaria and, to a lesser extent, angioedema are common occurrences in the pediatric population. There are multiple causes of acute and chronic urticaria and angioedema. Most causes are benign, although they can be worrisome for patients and their parents. An allergist should evaluate acute urticaria and/or angioedema if there are concerns of an external cause, such as foods or medications. Chronic urticaria and angioedema can severely affect quality of life and should be managed aggressively with antihistamines and immunomodulators if poorly controlled. Chronic symptoms are unlikely to be due to an external cause. Anaphylaxis is a more serious allergic condition characterized by a systemic reaction involving at least 2 organ systems. Anaphylaxis should be initially managed with intramuscular epinephrine. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. All patients should also be given an epinephrine autoinjector and an action plan. Foods are a common cause of anaphylaxis in the pediatric population. New evidence suggests that the introduction of highly allergic foods is safe in infancy and should not be delayed. In addition, the early introduction of foods such as peanuts may help prevent the development of food allergies.

Systemic reactions to subcutaneous immunotherapy: Effects of dosing and aeroallergen content.

BACKGROUND: Systemic reactions are a known risk of subcutaneous immunotherapy (SCIT) for aeroallergens. OBJECTIVE: To identify the dose of SCIT that results in the most systemic reactions to SCIT (SCITSRs) and other risk factors for SCITSRs. METHODS: We performed a retrospective review of all SCIT encounters from 2013 to 2017 at a multisite allergy/immunology practice. SCITSRs were identified from the electronic health record through immunotherapy encounters in which epinephrine was administered. Collected data included patient demographics, the dose of immunotherapy at the time of the SCITSR, the presence or absence of asthma, and aeroallergen content. The control group was generated randomly from the same cohort during the same period. RESULTS: There were 86,949 SCIT visits, with 81 SCITSRs (0.9 per 1000 injections). A total of 77.8% of reactions occurred at a dose of 1:1 0.1 mL and above. The presence of cat (81.5% vs 63.0%, P = .01), dog (67.9% vs 37.0%, P < .001), and grass extracts (85.2% vs 67.5%, P = .01) were associated with SCITSRs. Asthma was not significantly associated with SCITSRs. The presence of dust mites, trees, weeds, and molds was not associated with SCITSRs. There were no months or seasons where SCITSRs were more likely to occur. Individuals who experienced SCITSRs had a mean (SD) higher number of included aeroallergenic groups compared with controls (5.86 [1.88] vs 5.00 [1.92], P < .001). CONCLUSION: Risk factors for SCITSRs in a multisite allergy/immunology practice included administration of the highest immunotherapy doses; inclusion of cat, dog, and grass extracts; and the number of aeroallergenic groups included in the extract. This information helps further characterize risk for patients receiving SCIT.