Consensus statement on the epidemiology, diagnosis, prevention, and management of cow's milk protein allergy in the Middle East: a modified Delphi-based study

Background This study aimed to develop an expert consensus regarding the epidemiology, diagnosis, and management of cow’s milk protein allergy (CMPA) in the Middle East. Methods A three-step modified Delphi method was utilized to develop the consensus. Fifteen specialized pediatricians participated in the development of this consensus. Each statement was considered a consensus if it achieved an agreement level of ≥ 80%. Results The experts agreed that the double-blind placebo-controlled oral challenge test (OCT) should be performed for 2–4 weeks using an amino acid formula (AAF) in formula-fed infants or children with suspected CMPA. Formula-fed infants with confirmed CMPA should be offered a therapeutic formula. The panel stated that an extensively hydrolyzed formula (eHF) is indicated in the absence of red flag signs. At the same time, the AAF is offered for infants with red flag signs, such as severe anaphylactic reactions. The panel agreed that infants on an eHF with resolved symptoms within 2–4 weeks should continue the eHF with particular attention to the growth and nutritional status. On the other hand, an AAF should be considered for infants with persistent symptoms; the AAF should be continued if the symptoms resolve within 2–4 weeks, with particular attention to the growth and nutritional status. In cases with no symptomatic improvements after the introduction of an AAF, other measures should be followed. The panel developed a management algorithm, which achieved an agreement level of 90.9%. Conclusion This consensus document combined the best available evidence and clinical experience to optimize the management of CMPA in the Middle East.

Screening for Cow Milk Allergy in Infants and Preschool Children

Background Cow milk allergy (CMA) is the third most common food allergy that triggers anaphylactic reactions. Lactose intolerence, infantile colic and gastroesophageal reflux are the most common conditions which overlap with CMA causing both over and underdiagnosis. There are no wide population based epidemiological studies for the prevalence of CMA among Egyptian children. We sought to evaluate the prevalence of CMA among infants and preschool children and to correlate the parental reporting of CMA to the available diagnostic tools. Methods We conducted a cross sectional study that included 800 Egyptian children aged 3 months -5 years, who were enrolled consecutively from the primary care units and outpatient clinics of Children’s Hospital, Ain Shams University. Detailed history taking and clinical examination were done and those with suggestive history of CMA were subjected to further evaluation including skin prick test (SPT) and oral challenge test (OCT). Results The study comprised 390 girls (48.8%) and 410 boys (51.2%). Their weight centiles ranged between 5th and 97th percentiles, with median (IQR)=25(5-50) percentiles and mean(SD)=36.1(31.9). CM was introduced at age of 1-12 months, mean (SD): 9 (6) months with median (IQR): 12 (9-12) months. Forty (5%) subjects had suggestive history of CMA, 32 of whom completed their evaluation. The diagnosis of cow milk allergy was confirmed in 8/40 children (20%), comprising 1 % of the whole study sample. CMA was probably excluded at the time of the study in 21 subjects (52.5%), while diagnosis remained undetermined in 11/40 cases (27.5%) (8 refused to undergo SPT & OCT while 3 were lost to follow up). Conclusion The prevalence of CMA in Egyptian infants and preschool children is estimated to be around 1 % with possible overestimation of cow milk allergy diagnosis according to parental reports.

Screening for Cow Milk Allergy Among Young Egyptian Children

Background There are insufficient published data on the prevalence of cow's milk protein allergy (CMPA) in Egypt. Aim of the Work The study aims to estimate the frequency of CMPA among young Egyptian children in a trial to delineate the magnitude of the problem in our population. Methods A cross-sectional, observational study was conducted on 500 young Egyptian children from the general population aged from 6 months to 5 years; 200 males and 300 females. Children were subjected to history taking and clinical examination. Suspected cases with suggestive clinical history of CMPA were subjected to skin prick test (SPT) with standardized cow’s milk protein allergen extract and open oral challenge test (OCT). Results In the present study, 6.2% of screened children had positive clinical history suggestive of CMPA, 35.5% of them had positive SPT and 51.6% had positive OCT. Based on clinical history and OCT, 3.2% were documented to have CMPA, 3% had undocumented CMPA or low probability of CMPA and 93.8% had no CMPA. The highest rate of initial onset of CMPA is seen before the first year of life (96.8%) and 81.3% of children with positive OCT were formula/mixed-fed. The clinical manifestations in infants with suspected CMPA were variable, and the main presenting feature was gastrointestinal tract manifestations (42%). The IgE-mediated CMPA was more common and constituted 56.3% of the CMPA cases. Conclusion The frequency of CMPA among Egyptian children up to 5 years of age is comparable to the reported frequencies worldwide. IgE-mediated CMPA accounts for more than 2/3 of the patients with proven CMPA in this study.

Clinical Relevance of Shrimp Sensitization in Patients with Allergic Rhinitis: Anti-Der p 10 IgE as Predictor

<b><i>Introduction:</i></b> Cross-reactivity between shrimp and house dust mite (HDM) proteins has been widely documented. In tropical region, shrimp (5–15%) and mite sensitization (80–95%) is prevalent in allergic patients. However, the clinical relevance of shrimp sensitization in patients with allergic rhinitis (AR) has been poorly studied. The aim of this study was to determine the prevalence and the clinical relevance shrimp IgE sensitization in AR patients sensitized to <i>Dermatophagoides pteronyssinus.</i> <b><i>Methods:</i></b> The study was conducted in Medellin (Colombia). A cross-sectional study in patients with AR sensitized to HDM was performed in 3 steps: (i) assessment of IgE sensitization frequency to shrimp <i>Penaeus azteca</i>, <i>Litopenaeus vannamei,</i> and tropomyosin homologous allergens rDer p 10, rPen a 1, and rLit v 1, (ii) evaluation of the clinical relevance of shrimp sensitization using oral challenge test (OCT) and (iii) identification of possible risk factors for positive-OCT results. Ethical committee approval was obtained. <b><i>Results:</i></b> From 443 patients with AR, 86 (19.4%) were sensitized to shrimp and 23 of them (26.7%) had shrimp allergy diagnosis. Thirty-six of the patients sensitized to shrimp (41.2%) reported not previously consumed this food and eleven of them had a positive-OCT (30.5%). There was not statistically significant difference in total IgE or sIgE (<i>D. pteronyssinus, P. azteca, L. vannamei</i>, rPen a 1, and rLit v 1) between OCT groups (positive vs. negative results). Anti-Der p 10 IgE was associated with risk for a positive-OCT in different multivariable scenarios. <b><i>Discussion/Conclusion:</i></b> Our results suggest that in patients with HDM-associated AR and shrimp IgE sensitization is necessary to evaluate the clinical relevance of shrimp IgE even if the patient has never consumed shrimp because of cross-reactivity. Anti-Der p 10 could be a possible biomarker of clinical relevance to shrimp sensitization and could reduce the need for OCTs.

Anafilassi a un FANS dopo assunzione di un farmaco da banco

The Authors report a case of an anaphylactic reaction to flurbiprofen in a 10-years old girl. The diagnosis was confirmed by an oral challenge test (OCT).

Flare-Up Phenomenon of Intradermal Test with Anaphylactic Reaction to Paracetamol (Acetaminophen)

Background: Paracetamol is a Non-Steroidal Anti-Inflammatory Drug (NSAID) that can produce hypersensitive reactions mediated by specific immunological mechanisms (IgE or T celldependent) or by a non-immunological mechanism (inhibition of cyclooxygenase COX-1). Objective: An 80-year-old man with a history of allergy to pyrazolones, with good tolerance to other NSAIDs was referred to our allergy department because he presented a generalized urticaria after the administration of Intravenous (IV) paracetamol. Methods: We performed an Intradermal Test (IDT) with paracetamol (0.02mg/ml) and later a Single Blind Oral Challenge Test (SBOCT) with oral paracetamol. Results: IDT reading at 15min showed negative result so an SBOCT was performed with oral paracetamol. With an accumulative dose of 250mg, after 20min, he developed discomfort, nausea and dizziness, urticarial, hypotension (BP 80/40) as well as flare-up phenomenon was observed in the site of the IDT with paracetamol. Tryptase levels during the reaction and 2hrs later were increased. Conclusions: We present an anaphylactic shock due to sensitization to paracetamol because of a type I hypersensitivity mechanism, diagnosed by SBOCT and a positive IDT because of flare-up phenomenon, in a patient with previous pyrazolones allergy and with tolerance to other NSAIDs. Some relevant patents are also summarized in this paper.

O03 Allergy to penicillins in a pediatric population: reported vs true

BackgroundReported allergy to penicillins is a major clinical problem. Over 10% of parents report drug allergy resulting in higher cost and less than optimum management of infectious diseases.ObjectivesTo determine the relative likelihood of true allergy in patients suspected to have a penicillin allergy and to investigate the risk factors involved. We hypothesized that the vast majority of self-reported penicillin allergies are less likely to be true allergies when proper immunological work up is performed.MethodsPaediatric patients aged 0–18 years presenting to the ADR clinic at the Children Hospital of Western Ontario (CHWO) with suspected antibiotic allergies were included. A retrospective review of charts was conducted to obtain demographic information and results from allergological and in vitro testing. Subjects were evaluated with a radioallergosorbent test (RAST) or the lymphocyte toxicity assay (LTA)/the invitro platelet toxicity assay (iPTA) depending on whether the history was most consistent with an immediate allergy or a delayed hypersensitivity, respectively. Patients with negative RAST or LTA/iPTA were recommended to undergo confirmatory oral challenge test (OCT).ResultsNinety subjects were identified including 75 with possible penicillin allergy and 10 with suspected allergy to a non-penicillin antibiotic. Five subjects presented with a mixed allergy. Based on the results from RAST, in vitro testing and OCTs, the prevalence of a true allergy in the penicillin group was 6.25% vs. 66.67% in the non-penicillin group (p< 0.001). Patients presenting with severe reactions were more likely to be truly allergic (p< 0.01). In-patients were more likely to present with non-penicillin allergies and were subsequently more likely to have a true allergy (p< 0.001).ConclusionsTrue allergy is very rare in patients with suspected penicillin allergies and can be determined with a proper work-up including OCT. Shorter protocols for the evaluation of these patients would be beneficial.Disclosure(s)Nothing to disclose