In this issue: Graphical abstracts

A history of asthma was identified in more than one-third of cases mainly involving food anaphylaxis and children, whereas bronchospasm was documented in the half of the food anaphylaxis cases. GRAPH EPITHELIUM-DERIVED CYSTATIN SN INHIBITS HDM PROTEASE ACTIVITY IN ALLERGIC ASTHMA - P.1507 Lei Yao, Xijing Yuan, Heng Fu, Qinxing Guo, Yunhui Wu, Shurui Xuan, Nazanin Zounemat Kermani, Ian M. Adcock, Xiaoning Zeng, Yi Liu, Min Xie, Xin Yao Sputum and serum CST1 protein levels are elevated in asthma and negatively correlate with lung function. Qiuyan Liang, Jinrong Fu, Xiang Wang, Lijuan Liu, Wenfeng Xiao, Yajing Gao, Lan Yang, Hongmiao Yu, Xueru Xie, Zikun Tu, Saihua Huang, Xiao Han, Liling Qian, Yufeng Zhou circS100A11 was screened out by microarray analysis. [Extracted from the article] Copyright of Allergy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Mistakes and complications in the diagnosis and treatment of children with organic foreign body aspiration

The reason for the publication of this article was the increase in the number of children with long-standing organic foreign bodies in the respiratory tract, the late diagnosis of which causes severe complications. The article presents the three most significant cases from the general series, when the diagnosis and treatment tactics at the stages of treatment were associated with errors both at the prehospital stage and in the hospital. In the first clinical case, as it turned out, the child had aspired multiple foreign bodies. The first bronchoscopy revealed one solid foreign body. Due to severe fibrinous-purulent endobronchitis and contact bleeding, the bronchoscopy procedure was aborted. However, after 10 days, the child independently coughed up the second seed, which was a surprise to us. Control bronchoscopy after 3 weeks revealed no foreign bodies. In the second clinical observation, a child developed bronchiectasis due to a long stay of a foreign body in the respiratory tract. The third case demonstrates the diagnosis and treatment tactics in a child with a foreign body against the background of a coronavirus infection. In the first and third cases, the results of treatment were satisfactory. In the second case, a long stay of peanuts in the respiratory tract led to bronchiectasis in the lower lobe of the left lung, which required its removal. In the follow-up, there are no complaints, the child grows and develops according to age. The study analyzes the mistakes made at the stages of diagnosis and treatment of children with foreign bodies in the respiratory tract. Conclusion. Young children with long-term and atypically current respiratory diseases, dubious and even normal radiological picture with the absence of comprehensive information on the anamnesis of diseases should alert the doctor to the possibility of aspiration of a foreign body in the respiratory tract and serve as the basis for performing bronchoscopy.Copyright © 2023 National Academy of Pediatric Science and Innovation. All rights reserved.

Effect of Covid-19 on nasal allergies: A study from hilly regions of Himachal Pradesh

Background: The World Health Organization (WHO) designated SARS-CoV-2 infection as coronavirus disease 2019 (Covid-19).Due to the government implication of Covid-19 specific guideline of using mask, there could be a significant decrease in the allergic rhinitis. Objective(s): Present study aims to analyze the changes in the trends of nasal allergies from hilly regions of Himachal Pradesh following Covid-19 pandemic. Method(s): The prospective data obtained from January 2022 to November 2022 was compared from the retrospective data available between January 2019 to November 2019. Prospectively, a total of 596 patients were included in the study. All these patients underwent Skin prick tests for common allergens. All these patients also underwent testing for total IgE levels in biochemistry lab of the hospital by chemiluminescence method.The results were compared with retrospective dataof 728 age sex match patients. Result(s): A significant difference in the allergen sensitivity was observed. The number of patients who were sensitized during Covid was comparatively less than those during Pre covid period.Dust mite, Cockroach, Peanut and Wheat revealed a non-significant odds ratio indicating that they were not true predictors for sensitization and non-sensitization. Whereas Grass pollen, Mould mix and Pine mix revealed a significant odds ratio. Usage of mask found to have an impact on improvement in symptoms. Majority of the patients who did not use mask had no improvement in symptoms. Majority of the patients had high IgE levels in pre covid period whereas it was normal for majority of them during covid. Conclusion(s): In our study, allergic rhinitis incidence decreased throughout the pandemic period. After pandemic, there was a noticeably decreased level of sensitivity to grass pollen, mould, and pine mix. Use of face masks lead to significant decrease in symptoms of allergic rhinitis.Copyright © 2022, Anka Publishers. All rights reserved.

Mistakes and complications in the diagnosis and treatment of children with organic foreign body aspiration.

The reason for the publication of this article was the increase in the number of children with long-standing organic foreign bodies in the respiratory tract, the late diagnosis of which causes severe complications. The article presents the three most significant cases from the general series, when the diagnosis and treatment tactics at the stages of treatment were associated with errors both at the prehospital stage and in the hospital. In the first clinical case, as it turned out, the child had aspired multiple foreign bodies. The first bronchoscopy revealed one solid foreign body. Due to severe fibrinous-purulent endobronchitis and contact bleeding, the bronchoscopy procedure was aborted. However, after 10 days, the child independently coughed up the second seed, which was a surprise to us. Control bronchoscopy after 3 weeks revealed no foreign bodies. In the second clinical observation, a child developed bronchiectasis due to a long stay of a foreign body in the respiratory tract. The third case demonstrates the diagnosis and treatment tactics in a child with a foreign body against the background of a coronavirus infection. In the first and third cases, the results of treatment were satisfactory. In the second case, a long stay of peanuts in the respiratory tract led to bronchiectasis in the lower lobe of the left lung, which required its removal. In the follow-up, there are no complaints, the child grows and develops according to age. The study analyzes the mistakes made at the stages of diagnosis and treatment of children with foreign bodies in the respiratory tract. Conclusion. Young children with long-term and atypically current respiratory diseases, dubious and even normal radiological picture with the absence of comprehensive information on the anamnesis of diseases should alert the doctor to the possibility of aspiration of a foreign body in the respiratory tract and serve as the basis for performing bronchoscopy.Copyright © 2023 National Academy of Pediatric Science and Innovation. All rights reserved.

Outcomes of chronic spontaneous urticaria in a patient with non-Hodgkin's lymphoma and SARS-Cov- 2 infection: Efficacy of treatment with omalizumab

Case report Background: Association of chronic spontaneous urticaria (CSU) with malignancies and worsening of urticaria during COVID-19 have been reported. The efficacy of treatment of CSU with omalizumab in the context of malignancies or COVID-19 is not well established. Method(s): Case report of a patient followed for 9 years with CSU. Data collected from Medical Records and interviews during consultations. Result(s): Female, 29 years-old, came to clinic in 2013 for investigation, diagnosed with CSU. She also presented mild asthma, allergic rhinitis and history of urticaria after taking amoxicillin. She had a positive autologous serum skin test, and positive skin tests to dust mite, cat, cockroach, peanut and milk. Her total IgE was 227IU/ mL. Anti-nuclear and anti-thyroid antibodies were negative;ERS 13mm, blood eosinophils 300/mm3, and stool exam negative for parasites. She showed no response to second generation antihistamines up to fourfold doses, with UCT < 6 and CU-QoL = 89. After 6 months, omalizumab was added at 300 mg subcutaneously, every 4 weeks. The patient showed immediate reactions after the two applications of omalizumab: first, diffuse pruritus and throat tightness;second, worsening of urticaria and pruritus, requiring iv medications. Treatment with omalizumab was stopped, she was kept on fourfold dose of bilastine with partial control of symptoms. In 2016, she presented worsening of urticaria (UCT = 1), weight loss of 6kg/2 months, daily fever and enlarged cervical lymph nodes, and was diagnosed with diffuse large B-cell non-Hodgkin's lymphoma. Following chemotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab, she presented complete resolution of urticaria. Two years after remission of the lymphoma, in 2019, she presented recurrence of urticaria, and treatment with fourfold dose of bilastine was reinitiated with control of symptoms (UCT = 16). Investigation ruled out recurrence of lymphoma. In May 2021, she was diagnosed with SARS-CoV- 2 infection. Symptoms of COVID-19 were runny nose and low grade fever, however urticaria got worse and no longer responsive to bilastine. Treatment with omalizumab was attempted, with no reactions and good efficacy after the first dose, with an UCT = 15, and urticaria remains controlled on treatment with omalizumab to present. Conclusion(s): In this report, we highlight the efficacy and safety of using omalizumab in a patient with refractory CSU associated with neoplasia and SARS-CoV- 2 infection.

Success of long term OIT maintenance tree nut and peanut "bite proof” dosing

Rationale: To seek optimal dosing regimens for Oral immunotherapy (OIT). Methods: A retrospective chart review of 93 patients undergoing "bite proof” nut OIT dosing was undertaken. Patients were escalated to doses of 250-500mg of nut protein for a 6-12 month period and then completed a 2gm nut challenge. Results: Among 93 patients, a total of 209 2g Nut Oral Food Challenges (OFCs) were conducted. 202 of the 209 administered 2g OFCs were passed (96.65%). Among the 6 patients who did not tolerate the initial 2gm OFC, there were no obvious differentiating characteristics identified including single vs multiple food OIT administration, age, concomitant omalizumab, or change in IgE levels from baseline. 12 of the 93 patients who successfully passed the 2gm challenge elected to reduce their dose to the bite proof dosing 3x weekly. 7 of these 12 patients completed a subsequent 2gm OFC 1 year after the initial OFC. All 7 patients successfully tolerated the second 2gm OFC. Conclusions: Patients undergoing a 6-12 month course of 250-500mg daily nut protein dosing exhibited robust success in passing a 2gm OFC. Defining characteristics of patients who failed initial 2gm OFCs could not be determined due to the small number of OFC failures. A subset of patients passing the 2gm OFC demonstrated continued success in tolerating a 2gm nut challenge following a decrease in dosing frequency. Unfortunately the COVID pandemic prohibited further OFCs study of such patients. Future studies of such patients will help elucidate ideal long term OIT dosing strategies.

Normative Data for the Impairment Measure for Parental Food Allergy-Associated Anxiety and Coping Tool (IMPAACT) in a Canadian Sample

Rationale: The Impairment Measure for Parental Food Allergy-Associated Anxiety and Coping Tool (IMPAACT) is a food-allergy anxiety questionnaire for parents of children with food allergy. While the measure has been recently validated, normative data has not yet been presented. As such, the current study provides preliminary cut-scores and percentiles to help facilitate its use as a screening tool. Methods: Parents of children with food allergy were largely recruited through national and local patient organizations and were asked to complete questionnaires aimed at assessing their demographics and IMPAACT scores pre/post COVID-19. While the data was primarily analyzed descriptively (n/N, %, mean, SD, percentiles), inferential statistics were used to assess the relationship between the IMPAACT and various participant characteristics. Results: The final sample consisted of 281 parents (mothers=92%) and ranged in age from 27-64 years. The majority of participants reported having one child with a food allergy (85%). Allergies to peanuts were most common (79%), followed by tree nuts (56%), eggs (33%), and cow's milk (24%). IMPAACT scores were significantly lower following the outbreak of COVID-19 relative to the period prior to the outbreak (mean 87.89 [SD=36.44] vs. 102.97 [SD=33.71], p<0.001;maximum possible score: 196). Given these differences in food allergy anxiety before and after the pandemic, percentiles and cut-scores for both periods are presented. IMPAACT scores greater than 125, or 112 during periods of public health restrictions/reduced socialization, may merit further evaluation. Conclusions: Findings provide preliminary cut-points and percentiles that may help identify parents with elevated levels of food allergy anxiety.

Rates of New Peanut Allergy and Discontinuation Following Introduction in High-Risk Infants

Rationale: Current guidelines recommend peanut introduction to high-risk infants. However, compliance and rates of new peanut allergy (PA) require further study. Methods: Participants aged 4-11 months with no prior peanut exposure and (i) diagnosis of non-peanut food allergy, (ii) moderate-severe atopic dermatitis, or (iii) first degree relative with PA were enrolled. PA status was determined by skin testing and food challenge. Participants without PA were advised to consume 2 grams of peanut protein three times/week. Monthly questionnaires were administered, with follow-up visits at 18 and 30 months. Results: At baseline, 35/326 (11%) participants were peanut allergic. Of 291 without PA, 78 (27%) discontinued peanut at least temporarily 115 times during follow-up because of suspected participant reaction (40%), fear of reaction (3%), reaction or fear of reaction in a family member (21%), participant refusal (9%), peanut introduction was too much work (3%), or other reasons (23%), including the COVID-19 pandemic. Six of 291 participants (2.1%) who consumed peanut developed PA (2 consistent with FPIES). Among 291 participants without PA at baseline, none of the 17 participants with initial skin prick test of at least 4 mm and <10 mm developed PA. Conclusions: New PA after early introduction recommendations was rare, confirming the LEAP study findings. Transient discontinuation was common, mostly due to suspected participant reaction. High-risk children may require substantial support to keep peanut in their diet.

SCARED INTO SCURVY: NUTRITIONAL DEFICIENCIES DUE TO FEAR OF COVID-19

CASE: A 26-year-old male presented to the hospital with 2 weeks of difficulty ambulating, bilateral lower extremity rash, and diffuse myalgia with arthralgia. Symptoms began suddenly with lower extremity pain and difficulty getting up from his chair. He denied sensory changes, and pain was most prominent at the hips and knees. He also noticed a new rash on his thighs and mild bleeding from his gums. All other review of systems were negative. He denied family history of autoimmune disease and was without any personal chronic medical conditions. He was the primary caretaker of his grandmother and had stayed isolated at home throughout the COVID-19 pandemic. Vital signs were normal, and physical exam revealed 3/5 right hip flexion, 4/5 left hip flexion, and 4/5 right knee flexion and extension. Inspection of his rash demonstrated follicular hyperkeratosis, perifollicular erythema, and corkscrew hairs. Initial lab work revealed anemia, hypothyroidism, hypotonic hyponatremia, hypocalcemia, an elevated CK, ESR, and CRP. Extensive infectious and autoimmune workup was unrevealing. Further interview revealed that his diet consisted of soy milk, potato chips, crackers, peanut butter, and water in the preceding 6 months. This was intentionally done to reduce exposure to SARS- CoV-2. Further evaluation revealed Vitamin C, Vitamin D, Zinc, and Iron deficiencies. His presenting symptoms and rash were ultimately attributed to hypothyroid myopathy and Scurvy. Following thyroid replacement therapy, dietary education, and nutritional supplementation, he experienced improvement in his symptoms and rash. IMPACT/DISCUSSION: It has become evident that the COVID-19 pandemic has had significant psychosocial impact on the public, with substantial portions of our population experiencing increased fear and anxiety. Interestingly, a longitudinal study by Pan et al. found that Dutch patients without prior mental health disorders, such as our patient, had a more significant increase in depression, anxiety, and worry during the pandemic. To add to this, a study by Izzo et al. found that a substantial part of their study population had turned to unhealthy nutritional behaviors during the pandemic. Furthermore, Nguyen et al. demonstrated that increased health literacy was protective against the negative psychological impacts of the COVID-19 pandemic. Our case presents an outcome of merging pandemic fears with poor health literacy. It also highlights the critical role of the clinician as historian. Conceptualizing the patient's clinical presentation with their daily life ultimately led to appropriate diagnostic workup and treatment. CONCLUSION: As the COVID-19 pandemic continues, its broader and less apparent effects will continue to be seen. Clinicians must remain vigilant in assessing the changes in their patients' daily lives with open and invested communication. Early identification of potentially harmful changes and improved health education could prevent potential complications.

In this issue: Graphical abstract

Moritz M. Hollstein, Lennart Münsterkötter, Michael P. Schön, Armin Bergmann, Thea M. Husar, Anna Abratis, Abass Eidizadeh, Meike Schaffrinski, Karolin Zachmann, Anne Schmitz, Jason S. Holsapple, Hedwig Stanisz-Bogeski, Julie Schanz, Andreas Fischer, UWE GROß, Andreas Leha, Andreas E. Zautner, Moritz Schnelle, Luise Erpenbeck Booster with BNT162b2 elicits strong humoral and cellular immune responses independent of the prime vaccination, whereas ChAdOx1 nCoV-19 booster does not further enhance the cellular response. We demonstrate that the vaccine candidate (CuMV SB TT sb -RBD) is highly immunogenic in mice and is capable of inducing mucosal and systemic RBD as well as spike specific antibody responses. GRAPH Abbreviations: CDX-0159, anti-KIT inhibitory monoclonal antibody;FcR, Fc receptor;KIT, KIT proto-oncogene, receptor tyrosine kinase;MRGPRX2, mas-related G protein-coupled receptor-X2;SCF, stem cell factor. [Extracted from the article] Copyright of Allergy is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Peanut Butter Food Safety Concerns-Prevalence, Mitigation and Control of Salmonella spp., and Aflatoxins in Peanut Butter.

Peanut butter has a very large and continuously increasing global market. The food safety risks associated with its consumption are also likely to have impacts on a correspondingly large global population. In terms of prevalence and potential magnitude of impact, contamination by Salmonella spp., and aflatoxins, are the major food safety risks associated with peanut butter consumption. The inherent nature of the Salmonella spp., coupled with the unique chemical composition and structure of peanut butter, present serious technical challenges when inactivating Salmonella spp. in contaminated peanut butter. Thermal treatment, microwave, radiofrequency, irradiation, and high-pressure processing all are of limited efficacy in inactivating Salmonella spp. in contaminated peanut butter. The removal of aflatoxins in contaminated peanut butter is equally problematic and for all practical purposes almost impossible at the moment. Adopting good manufacturing hygiene practices from farm to table and avoiding the processing of contaminated peanuts are probably some of the few practically viable strategies for minimising these peanut butter food safety risks. The purpose of this review is to highlight the nature of food safety risks associated with peanut butter and to discuss the effectiveness of the initiatives that are aimed at minimising these risks.

Basophil activation test: current applications and future perspectives

The basophil activation test (BAT) is a flow cytometric assay that evaluates the percentage of activation or degranulation of peripheral blood basophils, after “in vitro” exposure to specific allergens. In sensitized patients, the stimulation of peripheral blood basophils with a specific allergen induces or up-regulates the expression of molecules, such as CD63 and CD203c, which represent, markers of degranulation and activation of basophils, respectively. The validity of the BAT requires a negative control (sterile saline) and a positive control (anti-IgE molecules). Several studies have demonstrated the role of the BAT in supporting the diagnosis of drug, food and hymenoptera venom allergy. The BAT has shown a low sensitivity but good specificity in diagnosing allergy to drugs such as NSAIDs, beta-lactam antibiotics, quinolones and muscle relaxants. In food allergy, the sensitivity and specificity of the BAT depends on the food;in the case of peanut allergy the sensitivity reaches 96% while the specificity the 100%. In addition, the BAT is an useful tool to monitor the natural resolution of allergies and the clinical effects induced by either immunotherapy or anti-IgE treatment. Finally, the BAT has been utilized to study the pathogenetic mechanisms underlying several IgE-mediated diseases. For example, in patients affected by severe bronchial asthma, the BAT has demonstrated the ability of Staphylococcus aureus enterotoxins to induce the activation of basophils supporting the role of these enterotoxins as “triggers” of the inflammatory cascade in bronchial asthma. In patients with cystic fibrosis the BAT can be used to dis-criminate allergic bronchopulmonary aspergillosis from Aspergillus colonization. More recently, the BAT has been demonstrated as a potential diagnostic tool to evaluate allergy to the polyethylene glycol (PEG) present in the anti-SARS-CoV-2 BNT162b2 mRNA vaccine.

Home-Based Peanut Oral Immunotherapy for Low-Risk Peanut-Allergic Preschoolers During the COVID-19 Pandemic and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic has led to the deprioritization of non-emergency services, such as oral food challenges and the initiation of oral immunotherapy (OIT) for food-allergic children. Recent studies have suggested that home-based peanut OIT could be a safe and effective option for low-risk peanut-allergic children. In the period between September 1, 2020, and January 31, 2021, nine preschoolers with a history of mild allergic reactions to peanut underwent home-based peanut OIT. Eight of them (88.9%) completed the build-up phase at home in 11-28 weeks, tolerating a daily maintenance dose of 320 mg peanut protein. During the build-up, six patients (75.0%) reported urticaria, three (33.3%) reported gastrointestinal tract symptoms, and one (14.3%) reported oral pruritis. None of the patients developed anaphylaxis, required epinephrine, or attended emergency services related to OIT. One or two virtual follow-up visits were completed per patient during the build-up phase. Our case series shows that home-based OIT could be offered to the low-risk preschoolers during the COVID-19 pandemic when non-emergency services are limited and could be considered beyond the pandemic, especially for the families living in the rural or remote areas that may otherwise be unable to access OIT.

OUTCOMES OF PEANUT ORAL IMMUNOTHERAPY IN AN ALLERGY CLINIC

Introduction: A single tertiary care center has offered oral immunotherapy (OIT) as a clinical service since 2018 using commercial products and subsequently has offered FDA-approved Peanut (Arachis- hypogaea) Allergen Powder-dnfp (PNAP) since July 2020. Shared decision making regarding OIT was based on previous IgE testing, history, and family preference. Methods: A retrospective chart review was performed in REDCap database. Results: A total of 37 patients initiated OIT (21 commercial products and 16 PNAP). The mean age was 9.25 for commercial product and 7.25 for PNAP with more males than females participating. Co-morbid conditions included allergic rhinitis, asthma, and eczema. Mean peanut IgE prior to starting was 49.75 and Ara h2 was 32.73. Prior reactions to peanut included skin, GI and anaphylaxis. Three children failed an oral challenge prior to starting OIT. There were 5 children that had never ingested peanuts but completed OIT. Minor intermittent side effects including stomach upset and itchy mouth were reported during escalation of both products. Dose adjustment was required for 1 PNAP patient for complaint of dysphagia and pain. There were 4 patients who dropped out of OIT: refusal to eat (1), unrelated GI disease (1) and the COVID-19 pandemic (2). All patients upon reaching maintenance are daily dosing with peanuts or chocolate-covered peanut candy. Lifestyle changes reported since reaching maintenance include eating in restaurants previously avoided and ingesting foods with labels stating: “may contain peanuts,” and “foods processed in a facility with peanuts.” Conclusions: Peanut OIT is safe and well tolerated in our patient population.

REAL-WORLD PERSPECTIVES OF HEALTH CARE PROVIDERS DELIVERING THE FIRST APPROVED TREATMENT FOR PEANUT ALLERGY

Introduction: In January 2020, Peanut (Arachis hypogaea) Allergen Powder-dnfp (PTAH) became the first treatment for Peanut Allergy (PA) approved by the US Food and Drug Administration (FDA). The adoption of innovative new therapies requires consideration of the skills, logistics and practicalities required for implementation. Methods: Qualitative interviews were conducted to explore health care providers’ (HCPs) experiences of delivering PTAH, challenges encountered, and successful implementation strategies. HCPs who had initiated PTAH treatment with ≥3 patients since FDA approval were eligible. Semi-structured interviews were conducted via videoconference. Interviews were audio-recorded, transcribed, and analyzed using content analysis. The study was exempted by the Western Institutional Review Board. Results: Eight allergists and three nurse practitioners participated. Their experiences are characterized by four key themes: 1. factors influencing adoption, 2. factors related to delivering the treatment in everyday practice, 3. learnings and reflections, and 4. delivering PTAH during the COVID-19 pandemic. HCPs described how successful implementation of PTAH requires them to be thoughtful about their clinic’s abilities to integrate complex, time-consuming treatments into their practice. Prior experience of oral immunotherapy was deemed beneficial, but not essential for implementation and learning from others’ experience was suggested as a way of helping new prescribers overcome perceived and actual implementation challenges. Conclusion: The experiences described by the treatment pioneers included in this research serve to benefit the wider allergy community by providing practical solutions, successful implementation strategies and opportunities to share information as new innovative treatments become available to patients.

Development of an energy-dense biscuit suitable for primary school learners for the South African national school nutrition programme

South Africa has a well established National School Nutrition Programme (NSNP). Despite rescheduling the mealtime to two hours after the start of the school day to accommodate learners who come to school on an empty stomach, a gap still exists as many children start their learning day with low energy and concentration levels. A costeffective, energy-dense snack served at the start of the school day can be a solution to sustain learners until the main meal is served. Cross-sectional surveys were used to determine the snack preferences of children and the product development process was used to develop a suitable snack. An energy-dense peanut butter biscuit was developed based on those surveys as well as a scoping review of previous snack studies. The energydense developed product provided 1388kJ (61.0%) of energy from fat, 688kJ (30.2%) of energy from carbohydrates and 201kJ (8.8%) of energy from protein per 100g. The biscuit conformed to microbial testing standards. Shelf-life analysis projected a shelf-life of five weeks fresh and five months in food grade packaging. Sensory results showed that there was no significant difference in sensory scores across gender (p=0.691) and age (p=0.706). More of the learners (n=56, 69.1%) found the biscuit to be 'Super good' than the other ratings (p < .0005). When compared with similar biscuit products currently on the market, it was found that the developed biscuit was the most reasonably priced. The developed biscuit has the potential to serve as a solution to hidden hunger for children that come to school on an empty stomach. This versatile snack solution has potential for continuity of use even during periods of national crisis as with COVID-19, when learners' nutritional needs may be most vulnerable.

Linseed allergy in an infant: A rare but increasing allergen

Case Report: With the growing trend of incorporating seeds in diet, hypersensitivity reactions have been progressively occurring but are rarely suspected. Linseed is a plant from the Linaceae family, and its seeds are increasingly used in bread. Despite being identified as an allergen capable of causing anaphylaxis, case reports are scarce. Female infant, 11 months old, with atopic dermatitis (AD), has been under cow's milk (CM) avoidance diet in the last 3 months due to CM allergy. At 10 months old, 15 minutes after ingesting a maze and sweet potato's bread, a perioral, axillar, and ear's pruriginous erythema developed, as well as nasal, palpebral, and malleolar angioedema. It was medicated with second-generation H1 antihistamine with symptom resolution after 6 hours. She avoided that bread and tolerated wheat bread. Prick to prick tests were positive for the suspected bread but negative for maze flour and raw and cooked sweet potato. After a detailed analysis of the bread's composition, linseed was identified, and prick to prick tests were positive with it. Due to COVID-19 restrictions, the patient has not yet performed oral challenge. A linseed allergy was the most likely diagnosis. Thus, we recommended avoiding this seed or any food that can contain it. Crossreactivity with other foods (wheat, peanut, rapeseed) and rape pollen is poorly understood, and its clinical relevance has not yet been determined. Hence, we did not perform any further investigation. This was a rare finding, and we did not find any report on infancy. This case should raise awareness for a growing trend of seed hypersensitivity. Therefore, this group of foods should be taken into account while we're investigating suspected allergic reactions to cereals and other grains.

Babies born in the 1st 2020 lockdown: Early data from the CORAL study

Background: The CORAL study is a cross-sectional study of the impact of the Coronavirus pandemic on allergic and autoimmune dysregulation of infants born in March, April and May 2020, during Ireland's 1 st COVID-19 pandemic Lockdown. Method: Invitations were sent to families of 3065 term, singleton babies. Exclusion criteria were ante-natal PCR-proven SARSCoV-2 in a parent or co-dwelling person, IV antibiotics in neonatal period, multiple births and major congenital anomalies. At 6 months babies were invited to attend CHI Connolly for point-of-care SARSCoV-2 antibody testing. Results: Of the 3065 letters sent 353 babies were enrolled.53.7% of enrolled infants were male, 78.4% were white-Irish, average birth weight was 3.506kg. 45% were first-born and 95.5% of mothers were educated at 3 rd level or higher. Babies' average number of close contacts other than household members was 2.3 during lockdown and 5.6 afterwards. 42.5% were reported to be currently breast-fed at enrolment. By 6 months, 97% of infants had solid foods introduced but only 24.5% had tried egg and 9.6% had tried peanut. Complete primary immunisation uptake at 6 months was 99%. Lastly, 3 babies out of 200 (1.3%) tested showed presence of IgM & IgG SARSCoV-2 antibodies;2 were PCR negative, the other PCR positive. Conclusion: Initial breastfeeding and immunisation uptake to 6 months are reassuringly high in this self-selected, highly-educated cohort. The rare positive antibody tests suggest recent or current infection, so newborn babies appear to have been protected from SARSCoV-2 exposure during the 1 st COVID Pandemic lockdown.

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change.

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.