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ABSTRACT: ABSTRACT: In 2008 the World Allergy Organization (WAO) verified that the existing guidelines on CMA were usually national position papers reflecting local views and needs, with flexible, sometimes evidence-based, strategies].Then, a global guideline for IgE-mediated CMA from diagnosis to treatment was developed using the GRADE approach. We review here the first steps of Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA) together with the changes in diagnostic and therapeutic behavior generated by the new guideline.
Italian Journal of Pediatrics 11/2011; 37:53.
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ABSTRACT: Accurate diagnosis is a fundamental aspect of appropriate healthcare. However, clinicians need guidance when implementing diagnostic tests given the number of tests available and resource constraints in healthcare. Practitioners of health often feel compelled to implement recommendations in guidelines, including recommendations about the use of diagnostic tests. However, the understanding about diagnostic tests by guideline panels and the methodology for developing recommendations is far from completely explored. Therefore, we evaluated the factors that guideline developers and users need to consider for the development of implementable recommendations about diagnostic tests.
Using a critical analysis of the process, we present the results of a case study using the Grading of Recommendations Applicability, Development and Evaluation (GRADE) approach to develop a clinical practice guideline for the diagnosis of Cow Milk Allergy with the World Allergy Organization.
To ensure that guideline panels can develop informed recommendations about diagnostic tests, it appears that more emphasis needs to be placed on group processes, including question formulation, defining patient-important outcomes for diagnostic tests, and summarizing evidence. Explicit consideration of concepts of diagnosis from evidence-based medicine, such as pre-test probability and treatment threshold, is required to facilitate the work of a guideline panel and to formulate implementable recommendations.
This case study provides useful guidance for guideline developers and clinicians about what they ought to demand from clinical practice guidelines to facilitate implementation and strengthen confidence in recommendations about diagnostic tests. Applying a structured framework like the GRADE approach with its requirement for transparency in the description of the evidence and factors that influence recommendations facilitates laying out the process and decision factors that are required for the development, interpretation, and implementation of recommendations about diagnostic tests.
Implementation Science 06/2011; 6:62. · 3.10 Impact Factor
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Alessandro Fiocchi,
Holger J Schünemann,
Jan Brozek,
Patrizia Restani,
Kirsten Beyer,
Riccardo Troncone,
Alberto Martelli, Luigi Terracciano,
Sami L Bahna,
Fabienne Rancé,
Motohiro Ebisawa,
Ralf G Heine,
Amal Assa'ad,
Hugh Sampson,
Elvira Verduci,
G R Bouygue,
Carlos Baena-Cagnani,
Walter Canonica,
Richard F Lockey
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ABSTRACT: The 2nd Milan Meeting on Adverse Reactions to Bovine Proteins was the venue for the presentation of the first consensus-based approach to the management of cow's milk allergy. It was also the first time that the Grading of Recommendations, Assessments, Development, and Evaluation approach for formulating guidelines and recommendations was applied to the field of food allergy. In this report we present the contributions in allergen science, epidemiology, natural history, evidence-based diagnosis, and therapy synthesized in the World Allergy Organization Diagnosis and Rationale for Action against Cow's Milk Allergy guidelines and presented during the meeting. A consensus emerged between discussants that cow's milk allergy management should reflect not only basic research but also a newer and better appraisal of the literature in the light of the values and preferences shared by patients and their caregivers in partnership. In the field of diagnosis, atopy patch testing and microarray technology have not yet evolved for use outside the research setting. With foreseeable breakthroughs (eg, immunotherapy and molecular diagnosis) in the offing, the step ahead in leadership can only stem from a worldwide organization implementing consensus-based clinical practice guidelines to diffuse and share clinical knowledge.
The Journal of allergy and clinical immunology 12/2010; 126(6):1119-28.e12. · 9.17 Impact Factor
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ABSTRACT: An exposition of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to recommendations.
In this review, we outline the process whereby the strength of evidence from the literature undergoes a systematic reappraisal. The GRADE system allows four grades of evidence (high quality, moderate, low, and very low) and strength of recommendation is qualified as strong, weak, or conditional to an intervention (pro or con) and defined as the level of confidence that desirable effects predominate over untoward ones with a certain intervention. We provide research and clinical reviews in various settings in which this approach has been used.
Evidence-based medicine requires integrating the best available 'benchmark' literature with patient preferences and values (bedside) and is an evaluation process involving both patient and clinician, with a systematic assessment of the rated evidence from state-of-the-art medical literature. The GRADE methodology was developed as an application of evidence-based medicine to the field of recommendations and their formulation. The GRADE working group brings together clinical researchers and methodologists who developed a rating system to assess the quality of evidence for the purpose of making clinical practice recommendations.
Current Opinion in Allergy and Clinical Immunology 08/2010; 10(4):377-83. · 4.11 Impact Factor
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Alessandro Fiocchi,
Jan Brozek,
Holger Schünemann,
Sami L. Bahna,
Andrea von Berg,
Kirsten Beyer,
Martin Bozzola,
Julia Bradsher,
Enrico Compalati,
Motohiro Ebisawa, [......],
Ralf G. Heine,
Paul Keith,
Gideon Lack,
Massimo Landi,
Alberto Martelli,
Fabienne Rancé,
Hugh Sampson,
Airton Stein, Luigi Terracciano,
Stefan Vieths
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ABSTRACT: SECTION 1: INTRODUCTION: Allergy and clinical immunology societies have issued guidance for the management of food allergy.1,2 Guidelines are now regarded as translational research instruments, designed to provide cutting-edge benchmarks for good practice and bedside evidence for clinicians to use in an interactive learning context with their national or international scientific communities. In the management of cow's milk allergy (CMA), both diagnosis and treatment would benefit from a reappraisal of the more recent literature, for “current” guidelines summarize the achievements of the preceding decade, deal mainly with prevention,3–6 do not always agree on recommendations and date back to the turn of the century.7,8 In 2008, the World Allergy Organization (WAO) Special Committee on Food Allergy identified CMA as an area in need of a rationale-based approach, informed by the consensus reached through an expert review of the available clinical evidence, to make inroads against a burdensome, world-wide public health problem. It is in this context that the WAO Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines was planned to provide physicians everywhere with a management tool to deal with CMA from suspicion to treatment. Targeted (and tapped for their expertise), both on the DRACMA panel or as nonsitting reviewers, were allergists, pediatricians (allergists and generalists), gastroenterologists, dermatologists, epidemiologists, methodologists, dieticians, food chemists, and representatives of allergic patient organizations. Ultimately, DRACMA is dedicated to our patients, especially the younger ones, whose burden of issues we hope to relieve through an ongoing and collective effort of more interactive debate and integrated learning.
Definitions: Adverse reactions after the ingestion of cow's milk can occur at any age from birth and even among infants fed exclusively at the breast, but not all such reactions are of an allergic nature. A revision of the allergy nomenclature was issued in Europe in 20019 and was later endorsed by the WAO10 under the overarching definition of “milk hypersensitivity,” to cover nonallergic hypersensitivity (traditionally termed “cow's milk intolerance”) and allergic milk hypersensitivity (or “cow's milk allergy”). The latter definition requires the activation of an underlying immune mechanism to fit. In DRACMA, the term “allergy” will abide by the WAO definition (“allergy is a hypersensitivity reaction initiated by specific immunologic mechanisms”). In most children with CMA, the condition can be immunoglobulin E (IgE)-mediated and is thought to manifest as a phenotypical expression of atopy, together with (or in the absence of) atopic eczema, allergic rhinitis and/or asthma. A subset of patients, however, have non-IgE mediated (probably cell-mediated) allergy and present mainly with gastro-intestinal symptoms in reaction to the ingestion of cow's milk.
REFERENCES, SECTION 1:
1. American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol. 2006;96(Suppl 2):S1–S68.
2. Mukoyama T, Nishima S, Arita M, Ito S, Urisu A, et al. Guidelines for diagnosis and management of pediatric food allergy in Japan. Allergol Int. 2007;56:349–361.
3. Prescott SL. The Australasian Society of Clinical Immunology and Allergy position statement: Summary of allergy prevention in children. Med J Aust. 2005;182:464–467.
4. Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, et al. Dietary prevention of allergic diseases in infants and small children. Part III: Critical review of published peer-reviewed observational and interventional studies and final recommendations. Pediatr Allergy Immunol. 2004;15:291–307.
5. Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, et al. Dietary prevention of allergic diseases in infants and small children. Part I: immunologic background and criteria for hypoallergenicity. Pediatr Allergy Immunol. 2004;15:103–11.
6. Muraro A, Dreborg S, Halken S, Høst A, Niggemann B, Aalberse R, et al. Dietary prevention of allergic diseases in infants and small children. Part II. Evaluation of methods in allergy prevention studies and sensitization markers. Definitions and diagnostic criteria of allergic diseases. Pediatr Allergy Immunol. 2004;15:196–205.
7. Høst A, Koletzko B, Dreborg S, Muraro A, Wahn U, et al. Dietary products used in infants for treatment and prevention of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child. 1999;81:80–84.
8. American Academy of Pediatrics Committee on Nutrition. Hypoallergenic infant formulae. Pediatrics. 2000;106:346–349.
9. Johansson SG, Hourihane JO, Bousquet J. A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force. Allergy. 2001;56:813–824.
10. Johansson SG, Bieber T, Dahl R. Revised nomenclature for allergy for global use: report of the Nomenclature Review Committee of the World Allergy Organization, 2003. J Allergy Clin Immunol. 2004;113:832–836.
World Allergy Organization Journal 03/2010; 3(4):57-161.
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ABSTRACT: The prognosis for many children with cow's milk allergy (CMA) is remission within 3 years, and the clinical parameters that predict duration of disease have not been measured incrementally.
To prospectively determine prognostic predictors of tolerance in a random cohort of referrals using CMA workup outcomes as covariates and tolerance as the status variable in a duration model of CMA.
The 2001-2006 Milan Cow's Milk Allergy Cohort (MiCMAC) enrolled children referrals using double-blind, placebo-controlled food challenges (DBPCFCs) as study end points (confirmation of CMA; onset of tolerance). The Cox regression model was used to analyze all clinical factors that contributed to tolerance. Covariates analyzed were skin, gastrointestinal, and respiratory symptoms; history and demographics at presentation; age at diagnosis and DBPCFC outcomes; sensitization (skin and serum) by cow's milk protein fractions; sensitization to other food and inhalant allergens; total IgE levels; specific IgE concentrations for cow's milk protein fractions, other ingestants, and aeroallergens; and threshold doses at DBPCFC. Sensitization and DBPCFC were performed at 6-month intervals.
A total of 112 infants were enrolled (mean [SD] age, 13.85 [9.84] months), and 59 achieved tolerance (mean [SD] age when tolerance was achieved, 27.58 [11.81] months). On univariate analysis, asthma and/or rhinitis at presentation was an independent predictor of persistence (hazard ratio [HR], 2.19; 95% confidence interval [CI], 1.26-3.82). On multivariate analysis, predictors of persistence were a fresh milk wheal diameter increment of 1 mm (HR, 1.18; 95% CI, 1.07-1.31) and a positive skin prick test result with soy (HR, 6.99; 95% CI, 1.56-31.25).
This is the first study, to our knowledge, to identify incremental biological predictors of delayed tolerance to cow's milk in children that should be integrated into DBPCFC schedules for CMA in infants.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 09/2008; 101(2):166-73. · 2.83 Impact Factor
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ABSTRACT: Correct management of anaphylactic manifestations in the emergency department is crucial to prevent mortality and future episodes, in particular for paediatric patients. We make here recommendations based on a critical review of the evidence for the management of anaphylaxis in emergency department with particular emphasis on children.
Available information suggests that anaphylaxis must be promptly recognized keeping in mind the airway patency, breathing (ventilation and respiration), circulation and mental status and treated. The first treatment is epinephrine. After successful treatment of an anaphylactic episode, attention must be paid at prevention of early recurrences (biphasic anaphylaxis) and assessment of causes. Patients should not be discharged before prescribing self-injectable epinephrine and explain how and in under what circumstances it must be injected; giving an action plan to be communicated to their communities; inform the school about the possible occurrence of reactions and the appropriate avoidance and rescue measures; and consider the necessity of a Medic-Alert identification.
As gross differences have been described in the awareness of the disease and its management between allergists and nonallergists, allergists should interact with emergency doctors to improve education in this area.
Current Opinion in Allergy and Clinical Immunology 09/2008; 8(4):321-9. · 4.11 Impact Factor
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ABSTRACT: Observational studies have shown that allergic infants, irrespective of the type of diet, show various degrees of growth depression in the first year of life. We investigated whether the type of milk in the complementary feeding period (6-12 months of age) is associated with differences in the increase of standardized growth indices (weight-for-age, WA; length-for-age, LA; and weight-for-length, WL, z-scores) in infants with cow's milk allergy (CMA). Infants with immunoglobulin E-mediated CMA breastfed at least 4 months and progressively weaned in the 5- to 6-month period were randomly assigned to three special formulas, a soy formula (n = 32), a casein hydrolysate (n = 31), and a rice hydrolysate (n = 30). A fourth, non-randomized group was made up by allergic infants still breastfed up to 12 months (n = 32). Groups were compared for WA, LA, and WL z-scores at 6, 9 and 12 months of age. All groups showed low WA and LA z-scores at 6 months of age. Infants fed hydrolyzed products showed a trend toward higher WA z-score increments in the 6- to 12-month period. The use of casein- and rice-based hydrolyzed formulas resulted in higher changes in WA compared with soy formula. Further research should be aimed at optimizing the dietary needs and feeding regimens for infants with CMA.
Pediatric Allergy and Immunology 12/2007; 18(7):599-606. · 2.46 Impact Factor
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New England Journal of Medicine 09/2007; 357(5):506; author reply 506-7. · 53.30 Impact Factor
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Mathias Steinke,
Alessandro Fiocchi,
Veronika Kirchlechner,
Barbara Ballmer-Weber,
Knut Brockow,
Claudia Hischenhuber,
Manjula Dutta,
Johannes Ring,
Radvan Urbanek, Luigi Terracciano,
Rainer Wezel
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ABSTRACT: Food allergy is targeted as a public health priority by the European Union Commission. Parental perception of food allergy in their offspring is a proxy measure of the potential demand for allergy medicine services in the paediatric population.
A representative sample of the general population was contacted by a randomised telephone survey in Austria, Belgium, Denmark, Finland, Germany, Greece, Italy, Poland, Slovenia and Switzerland. A standardised questionnaire was administered regarding parentally perceived food allergy reports, symptoms, foods and medical service use by their live-in children.
40,246 adults were polled, yielding data on 8,825 children. Parentally perceived food allergy prevalence was 4.7% (90% CI 4.2-5.2%). The most affected age group was 2- to 3-year olds (7.2%). Single-country incidence ranged between 1.7% (Austria) to 11.7% (Finland). Milk (38.5%), fruits (29.5%), eggs (19.0%) and vegetables (13.5%) were most often implicated, although with significant age-linked variations. Medical treatment was needed by 75.7% of affected children because of a food reaction. This translates into a proxy measure for food allergy prevalence of 3.75%. Skin symptoms were widespread (71.5%), followed by gastrointestinal (27.6%) and respiratory (18.5%) symptoms.
We provide the first point prevalence of parentally perceived food allergy in the general paediatric population across the European Union. Parental reports confirm the public health significance of adverse reactions to some foods in specified age groups. Our data may inform intervention planning, cost of illness assessments and quality-of-life-enhancing public health measures.
International Archives of Allergy and Immunology 02/2007; 143(4):290-5. · 2.40 Impact Factor
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ABSTRACT: Several proteins have been identified as peanut allergens; among them, Ara h 1 (7S globulin) and Ara h 2 (2S globulin) are usually considered the major allergens.
To identify the major allergens in a group of children selected for their specific pattern of immunoreactivity.
We identified the dominant allergen by using (1) amino acid sequencing of the bands that show the strongest IgE immunoreactivity in 1-dimensional electrophoresis and immunoblotting and (2) specific animal IgGs raised against the dominant immunoreactive band to pinpoint the allergen(s) in peanut proteins separated by 2-dimensional electrophoresis and immunoblotting. To confirm these data, we further examined the peanut proteome using serum samples from the children with the unusual immunoreactivity.
We found a group of children with marked peanut allergy who are specifically sensitized to the basic subunit of Ara h 3 (11S globulin family).
That the dominant immunoreactivity in these patients is in a basic subunit of Ara h 3 was unexpected, because previous studies had indicated that Ara h 3 was only a minor peanut allergen and that the identified allergenic epitopes occurred mainly in the acidic Ara h 3 subunit.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 03/2005; 94(2):262-6. · 2.83 Impact Factor
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ABSTRACT: To review the effects of technological processing on selected foods of relevance to childhood allergy from the viewpoints of reduced allergenicity, contamination of processed foods by allergens introduced during processing, and ad hoc technologies to produce reduced hypoallergenic products.
We searched the literature (PubMed/MEDLINE) for articles published between January 1994 and April 2004 using the following keywords: food allergy AND process* OR heat* OR cooking OR toleran*.
We drew on our collective clinical and biological experience to restrict retrieved studies to those of more frequent relevance to a hospital allergy practice.
Comparatively few clinical studies address the modification of allergenicity of food through cooking or processing. Dairy foods are largely unaffected by processing and may be contaminated by, or themselves become, hidden allergens. Hypoallergenic formulas based on milk, soy, or rice and homogenized beef are successful applications of allergenicity reduction via technological processing. Egg, fish, condiments, and vegetables all carry heat-resistant allergens and should also be considered contaminants. Cereals and bakery products are generally well tolerated, but their allergenicity may be enhanced by processing; the case of rice is still open. Peanut allergens are stable, and the evidence is scant that thermal processing affects the allergenicity of soybean and soy hydrolysates. The debate is ongoing about the tolerance of vegetable oils.
It is too early to systematize clinical studies based on single procedures. Processing affects antigenicity, but this does not always translate into safety recommendations. Industrial processing is liable to contamination, and monitoring and labeling are industry priorities. Clinicians should evaluate foods by as complete a workup as possible before recommending processed foods.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 12/2004; 93(5 Suppl 3):S38-46. · 2.83 Impact Factor
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ABSTRACT: Allergy-like symptoms are common in young children, but the case history and physical examination cannot identify the underlying origins of overlapping symptom profiles.
To evaluate a blood test, Phadiatop Infant (Pharmacia Diagnostics AB, Uppsala, Sweden), for differentiating the capability of IgE-mediated disease in young children with recurrent wheezing, eczema, or both.
One hundred forty-seven children (mean age, 2.0 years) were consecutively referred to 2 allergy centers by their primary care physician for recurrent wheezing, eczema, or both. The allergist's clinical evaluation included medical history, physical examination, skin prick testing with inhalant and food allergens, and specific IgE determinations in blood. The accuracy of Phadiatop Infant was evaluated in a masked manner against the allergist's final diagnosis.
Sixty-nine children had wheezing, 69 had eczema, and 9 had both symptoms. Sixty-one children were clinically diagnosed as having IgE-mediated allergy, 78 as having non-IgE-associated disease, and 8 as having an inconclusive diagnosis. Fifty-six of the 61 children with IgE-mediated allergy had positive Phadiatop Infant test results, and 64 of 78 without the condition had negative results. Sensitivity was 92% and specificity was 82%, with positive and negative predictive values of 80% and 93%, respectively. Thirteen children with a positive Phadiatop Infant test result and a negative final diagnosis were retested after 2 years; 12 of them were diagnosed as having IgE-mediated allergy using a masked evaluation.
The Phadiatop Infant blood test discriminates between IgE- and non-IgE-mediated symptoms in children younger than 4 years.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 11/2004; 93(4):328-33. · 2.83 Impact Factor
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ABSTRACT: Adverse reactions following the ingestion of lactose have been reported in children with cow's milk (CM) allergy. Whether this is attributable to the contamination of lactose with CM proteins is unknown. In this paper, we assessed clinical tolerance of lactose derived from CM whey in children hypersensitive to CM from 2 university hospital pediatric departments.
Twenty-four children (5 girls and 19 boys, median 25 months old; range: 2-107 months) with immediate CM allergy confirmed at history or during double-blind, placebo-controlled food challenge (DBPCFC) were enrolled. DBPCFC with CM could be conducted in 11 of 24 patients. Children with a history of immediate/delayed reactions to soy formula (SF) were excluded. Clinical tolerance to CM, SF, and SF + lactose was assessed by: 1) skin prick test with casein, lactalbumin, soy commercial allergen preparations, fresh CM, SF, SF and lactose, lactose (Official Pharmacopoeia) in 4 concentrations (0.01%, 0.1%, 1%, 10%); 2) specific serum immunoglobulin E determination by CAP system technology; 3) DBPCFC in 8 incremental doses of SF + lactose and using SF as a placebo to make up a total of 240 mL of reconstituted formula.
With a positive cutoff point of > or = 3 mm wheal diameter at SPT, all patients were sensitized to fresh CM, lactalbumin, and/or casein. Twenty-three of 24 patients (95.8%) were SPT-positive to CM formula, 16 of 24 to lactalbumin (66.6%), 14 of 24 to casein (58.3%), and none to SF, SF + lactose, or lactose alone at all dilutions. Complexed immunoglobulin E determinations were positive for CM in 23 of 24 cases and negative in all cases for soy. Challenge with SF + lactose was negative in all cases.
Even children hypersensitive to CM are clinically tolerant to lactose and can safely consume foods and drugs with lactose from bovine sources as an ingredient. Lactose exclusion is unwarranted from soy preparations on grounds of potential allergic reactions to CM protein residue.
PEDIATRICS 09/2003; 112(2):359-62. · 4.47 Impact Factor
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ABSTRACT: To present research and clinical evidence on the use of primary dietary prevention in food allergy management.
We conducted MEDLINE searches for pertinent articles published between January 1986 and October 2001 with use of the following keywords or phrases: prevention and diet and allergy, food allergy and prevention, and dietary prevention and food allergy or allergens. Also included are information and commentary reflecting the authors' cumulative clinical experience in an allergy unit of a city hospital.
We define as "proactive" those strategies centered on "success factors," such as the early postnatal environment, prolonged breast-feeding, and use of formula and probiotic supplementation, in contrast to earlier "prohibitionist" approaches to prevention of food allergy. These two approaches are not antagonistic and may even be synergistic. We introduce this distinction in light of epidemiologic evidence and out of concern about compliance and the quality of life for patients.
Inasmuch as nutritional and immune maturation are implicated, the prohibitionist measures that are most effective in primary prevention of food allergy are exclusive breast-feeding for at least 6 months (for lifelong immunity and other benefits), delayed (after the sixth month) introduction of solid foods, and on-indication use of "hypoallergenic" formulas. Whether proactive strategies can be contemplated remains a debatable issue. Evidence for and against the scientific use of probiotics as well as microbiologic, epidemiologic, and clinical data are discussed. Review of published epidemiologic studies and randomized clinical trials is essential before planning dietary intervention or prevention.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 08/2003; 91(1):3-12; quiz 12-5, 91. · 2.83 Impact Factor
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Journal of Allergy and Clinical Immunology 02/2003; 111(1):193-5. · 11.00 Impact Factor
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ABSTRACT: Hydrolyzed formulas (HFs) are in general well tolerated by children with cow's milk allergy (CMA), although cases of allergic reactions have been reported and residual allergenicity of HF has been demonstrated
To review the most relevant studies of the HFs for residual allergenicity, tolerance, and safety in the past 20 years.
MEDLINE searches for the years 1970 to 2001 using the following algorithm (hydrolysate and allergy; food intolerance/allergy; protein hydrolysate).
The literature confirmed that although some antigenicity remains, HFs are well tolerated by children with CMA. Rice HF has proven safe when tested by double-blind, placebo-controlled food challenge in a study population of 18 children allergic both to cow's milk (CM) and soy protein.
Absolute avoidance of CM proteins means substitution by soy-, rice-, or amino acid-based formulas. As 8 to 14% of infants allergic to CM react to soy and amino acid-based formulas are expensive, scientific societies recommend the use of formulas based on extensively hydrolyzed CM proteins as first alternatives in children with CMA. Although both soy- and rice-based HFs have now been shown to be safe for these children, further nutritional and clinical studies are needed.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 01/2003; 89(6 Suppl 1):86-90. · 2.83 Impact Factor
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ABSTRACT: To review the recent literature on the diagnostic accuracy of skin prick tests (SPTs) in pediatric food allergy, focusing on adverse reactions to milk and beef. To present data about the test performance characteristics of beef extracts used in SPTs among children with atopic dermatitis (AD) reporting immediate hypersensitivity to beef.
MEDLINE search using the following algorithm ["skin prick test" AND "food allergy" OR allergen; 1997-2002; English; all children]. Prospective sensitivity study of SPTs in 34 patients.
Thirty-four children with AD (median age 2.29 years) were consecutively recruited between 1992 and 2000 because of immediate reactions to beef. On double-blind, placebo-controlled food challenges (entry criterion), 20 of the patients reacted to beef and 14 did not. Cut-off points for skin prick test wheal positivity was selected by receiving-operator characteristic analysis for fresh and commercial beef allergens. Sensitivity and specificity of skin tests and indices of reproducibility were calculated.
In the literature, the positive predictive accuracies of skin prick tests vary between 69 and 100% and the negative predictive accuracies between 20 to 86% for cow's milk. In our series, SPTs with commercial beef extracts were highly diagnostic (100% sensitivity; 10% false positive rate) and SPTs with fresh beef were highly specific (100%), albeit with a false-positive rate of 21.42%.
From the literature, we conclude that the diagnostic accuracy of SPTs with milk should be reappraised in the workup of cow's milk allergy. Carrying out commercial and fresh food SPTs at the same time substantially reduces costs and diagnostic work. Oral provocation is necessary in 20.68% of children with AD who have immediate symptoms to beef. Greater allergen standardization and streamlining of the workup of cow's milk allergy are desirable future goals.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 01/2003; 89(6 Suppl 1):26-32. · 2.83 Impact Factor
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ABSTRACT: A knowledge of the natural history of asthma in first years of life is necessary to establish preventive and therapeutic plans. The aim of this study was to overview the clinical evidence about the natural history of asthma in different pediatric ages, with emphasis on risk factors and prediction indexes. We used the data source PubMed, using a search algorithm selecting for natural history studies of asthma and respiratory allergy in all children to August 2005. A few studies prospectively assessed the natural history of asthma from infancy to childhood to adulthood to mature age. Some risk factors from these studies can be translated into prognostic indexes. The accuracy of such indexes seems skewed toward screening rather than diagnostic ability. Natural history is the basis on which accurate predictors of the persistence of wheezing and asthma can be predicated. In the absence of genetic markers, parental history of asthma, personal history of eczema, and immunologic tests such as serum IgE, peripheral eosinophilia, and serum eosinophilic cationic protein are the better indicators of the development of asthma in infants.
Allergy and Asthma Proceedings 27(3):178-85. · 2.17 Impact Factor
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ABSTRACT: When a child presents with an allergic symptom, the general pediatrician needs to discriminate which patient has to be sent to the specialist for an allergologic evaluation. If referred, the child will undergo not only skin-prick test, but also more complex specialistic evaluations that we define here as "the march of allergic children." The objective of this article is to overview the clinical evidence about possible diagnostic interventions to avoid unuseful referrals of children reported with allergy from the general to the specialist level. Data sources include PubMed, using a search algorithm selecting for diagnostic studies of respiratory and food allergy in all children to August 2005. Also included are commentaries based on the authors' clinical experience in the allergy unit of a University Hospital in Italy. No study prospectively assessed the rule-out efficacy of clinical history, physical evaluation, and skin-prick test panels on the allergic disease. Three prospective studies on in vitro panels of specific IgE sensitization matched entry criteria. Diverse trial designs and diagnostic criteria precluded meta-analytic methods. The use of in vitro panels proved effective in ruling out the allergic condition in children. The screening efficacy of panels of food and respiratory skin-prick tests remains to be evaluated. With sensitivities and negative predictive values exceeding 90%, in vitro panels can inform the decisions of pediatricians in their capacity as gateway to specialist care. Avoiding the march of allergic children from the GPs to the secondary level is a more realistic goal than preventing the allergic march.
Allergy and Asthma Proceedings 27(4):306-11. · 2.17 Impact Factor
