Current Pediatric Reviews - Volume 14, Issue 3, 2018

An accurate diagnosis of food allergy is extremely important to guide safe and yet not overly restrictive dietary management. The cornerstone of the diagnosis of food allergy is the clinical history; it allows appropriate selection of the allergens to be tested and interpretation of the results of allergy tests, namely Skin Prick Test (SPT), Specific IgE (sIgE) to allergen extracts and, more recently, specific IgE to allergen components and the Basophil Activation Test (BAT). SPT and sIgE to allergen extracts are very sensitive methods to detect IgE sensitization to a specific food and assess the possibility of spontaneous resolution. Cut-offs have been generated based on the probability of clinical reactivity during oral food challenges and can improve the specificity of SPT and sIgE, helping to confirm the diagnosis of food allergy. Specific IgE to allergen components refines food allergy diagnosis as it allows differentiating species-specific from cross-reactive allergens, aiding the differential diagnosis between a true and potentially severe food allergy from pollen-food syndrome or clinically irrelevant sensitization. The BAT is a new diagnostic test which has high specificity and sensitivity and can complement specific IgE, allowing the deferral of OFC in patients with a positive BAT. Depending on the likelihood of clinical allergy determined based on the combination of the history and the results of allergy tests, an oral food challenge may be indicated to confirm or exclude the diagnosis. Oral food challenge is the gold standard for the diagnosis of food allergy, but is a resource-intensive procedure with some level of risk involved; thus they are reserved for the equivocal cases. This review article discusses the above diagnostic techniques detailing the methods, utility, advantages and disadvantages.

Food allergy is common in children. An accurate diagnosis remains a key element in order to instigate an effective management plan. Traditional management strategies have relied on a reactive approach, with allergen avoidance, management of accidental ingestion and monitoring for resolution. Active management of food allergies relies on strategies to prevent food allergy through early introduction of allergenic foods and anticipatory testing. With an established food allergy diagnosis, active management through modifying the natural history, and risk management strategies can be instigated. This review will discuss each of these areas in turn.

The growing burden of food allergy is being driven by environmental exposures and the potential role of gut micro-organisms (or ‘microbiota’) is hotly debated. Early culture-based studies outlined that imbalances between commensal gut constituents (‘dysbiosis’) early in life may raise the risk of developing allergic disease. A number of studies using animal models describe mechanisms by which specific bacterial taxa within the gut microbiota, their diversity and dietary substrates such as fibre may promote oral tolerance. Next-generation sequencing now allows the detailed characterization of the microbiota in relation to epidemiological exposures and clinical food allergy status in humans. Faecal samples from one birth cohort characterized for food allergy status have been sequenced and showed less gut microbiota richness amongst three month infants who later developed food sensitization at one year. A large cross-sectional survey of young children with milk allergy showed that greater gut microbiota diversity and enrichment of Clostridia and Firmicutes phyla during early infancy is associated with greater likelihood of out-growing milk allergy by eight years of age. Case control studies are limited to selecting participants from amongst hospital patients and have only allowed comparison of heterogeneous groups. To assess whether infants' gut microbiota may predispose towards the development of food allergy, cohort studies must be undertaken to evaluate gut microbiota development from early in infancy and prospectively characterise patterns according to whether challenge proven food allergy later develops, whilst adjusting for atopic dermatitis, dietary and antibiotic exposures.

Background: It is well known that there is a common interplay between atopic conditions and that having one atopic condition can predispose to the development of others. The link between asthma and food allergy has been well researched over the years; although the exact interplay between the two atopic conditions is yet to be fully described. Research suggests that children who have both asthma and food allergy are at greater risk of more severe asthmatic episodes. Conclusion: They are also at risk of food allergen triggered asthmatic episodes as well as foodallergen induced anaphylaxis. Therefore, it is important for clinicians to understand and recognise the association between these two atopic conditions to provide children and their families with the correct treatment and management to avoid potentially life-threatening events related to their disease.

Atopic dermatitis and food allergy are common conditions of childhood that are closely linked. 30% of children with moderate to severe eczema suffer from food allergy and can present with different types of reactions: immediate or IgE-mediated reactions, delayed or non-IgEmediated eczematous flares, or a combination of the two. A detailed history is very important when approaching such patients. The presence of IgE-mediated symptoms warrants investigation and management requires avoidance of the culprit allergen, an emergency care plan and appropriate follow up. Non-IgE-mediated reactions can be more difficult to diagnose, and investigations are more difficult to interpret. Topical treatment is paramount in all patients with atopic dermatitis, while food elimination diets remain the mainstay of the management of food allergy, and should be done under specialist supervision. In this review, we discuss the current understanding of atopic dermatitis and food allergy, the role of investigations and management of paediatric patients with both conditions. We propose an algorithm that can be used by paediatricians when dealing with children with food allergy and atopic dermatitis.

Background: Anaphylaxis is defined as a serious, generalized or systemic allergic reaction that is rapid in onset and may cause death. It is unpredictable and can be the result of various allergic triggers including food, insect venom and medication. The European Anaphylaxis Registry confirmed food as the major elicitor of anaphylaxis in children, specifically hen's egg, cow's milk and nuts. Objectives: It has been reported that the incidence of anaphylaxis is on the rise. In the US, there is a continued trend of increasing food-induced anaphylaxis hospitalizations among children, which is supported by nationally representative data. Methods: Anaphylaxis can occur both in the home and outdoors and can be life-threatening, however, fatalities are a rare occurrence. A recent systematic review and meta-analysis reported that fatal food anaphylaxis is rarer than accidental death in the general population. Studies of fatal and near-fatal allergic reactions have identified potential risk factors for fatalities and have provided important information that may help minimize future risk. Following confirmation of the relevant allergen trigger, prevention of anaphylaxis is through strict avoidance of the allergen and optimal management of existing co-morbidities. The cornerstone in the successful management of anaphylaxis is early recognition of signs and symptoms and the prompt administration of intramuscular adrenaline. Result and Conclusion: Patients and their families need to be well educated on how to manage potential anaphylactic reactions with training in the use of adrenaline auto-injectors and personalized emergency management plans. Healthcare professionals must be familiar with this clinical emergency and able to respond to anaphylaxis in a timely and appropriate manner.

Background: Autoimmune hepatitis is a rare inflammatory disease of the liver that most frequently affects children and young adults. It is a multifactorial disease of unknown etiology, characteristically progressive in nature, and if left untreated, may lead to cirrhosis and terminal liver failure. It has been known for several decades now that immunosuppressive treatment convincingly alters the outcome of most patients with autoimmune hepatitis and as such it should be started as soon as diagnosis is made. Primary goals of treatment are: normalization of hepatocellular function, extinction of the hepatic necroinflammatory process, and maintenance of a stable remission, thus preventing progression to cirrhosis and its complications. This article aims to review old and new treatments for this rare chronic disorder, from the oldest and most frequently used treatment consisting of the association of prednisone and azathioprine, to alternative medical treatments, liver transplant and promising medical strategies currently under investigation. Result and Conclusion: The review will focus on the efficacy and safety profile of each drug, as well as on the published clinical experience with them in pediatric patients with autoimmune hepatitis.

Background and Objective: Melkersson Rosenthal syndrome (MRS) is a rare disorder of unknown etiology and comprises the triad: orofacial edema, recurrent facial paralysis and lingua plicata. In the current literature confusing heterogeneity exists, mixing together the historically grown terms cheilitis granulomatosa or granulomatous cheilitis, Melkersson Rosenthal syndrome and the umbrella term Orofacial Granulomatosis (OFG). Methods: We provide a systematic review comprising all three disease entities of orofacial granulomatosis using the computerized database “Pubmed Medline” entering the keywords “orofacial granulomatosis” (141 references), “Melkersson-Rosenthal syndrome” (207 references), “granulomatous cheilitis” or “cheilitis granulomatosa” (102 references) back to 1956. Full-text journals and case studies were included, and data synthesis was performed individually. Results: Etiology remains unclear for all three disease entities. Etiological relatedness to chronic inflammatory bowel disease is under discussion and effectiveness was found for different treatments, e.g. local triamcinolone injections, antibiotics, surgical interventions, TNF alpha blockers or exclusive enteral nutrition. No randomized controlled trial concerning the therapy of orofacial granulomatosis was found. As a consequence, the therapeutic conclusion is drawn mainly from small case series, thus limiting the evidence of therapeutic interventions. Conclusion: OFG with the sub-entities MRS and cheilitis granulomatosa is an etiological obscure disease process with various possible therapeutic interventions potentially alleviating the disease course but to broaden treatment knowledge further study in randomized controlled trials is needed.

Background: Febrile neutropenia is one of the major acute side effects of intensive treatment in pediatric cancer, necessitating prompt initiation of empirical broad-spectrum antibiotics. Patients may be classified as low or high risk according some risk factors (duration of neutropenia, depth of neutropenia, type of cancer, state of disease, bone marrow involvement, type of treatment, additional health problems). Initial evaluation of the febrile neutropenic child should include the history of the child, a detailed physical examination, blood culture (peripheral and catheter), urinalysis and culture, cultures of lesions. Result & Conclusion: The standard of care in febrile neutropenic children is that they should be hospitalized, especially if high risk, and should be treated urgently with intravenous wide spectrum empiric antibiotics, the spectrum covering P. Aeruginosa. Empiric treatment should be modified according to culture results and clinical situation. Other options for low risk patients are starting with intravenous treatment and continuing with per oral treatment or giving per oral antibiotic treatment from the beginning.