Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report.

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.

Impact of dietary regimen on the duration of cow's milk allergy: a random allocation study.

BACKGROUND: The impact of diet on cow's milk allergy (CMA) duration and whether exposure to residual amounts of cow's milk protein influences the onset of tolerance are unknown. OBJECTIVE: To prospectively assess the dietary factors influencing disease duration in a randomized cohort. METHODS: We randomly switched the formula of symptomatic patients from the Milan Cow's Milk Allergy Cohort to one of three treatment groups according to the quarterly rotation of rice hydrolysate formula, extensively hydrolysed cow's milk formula and soy-based formula. In this intention-to-treat, randomized analysis, a hazard ratio (HR) estimation model was used to analyse dietary impact on disease duration. RESULTS: Seventy-two children aged a mean of 14.1+/-8.6 months at diagnosis were followed up for a median of 26 months. Fifty-one reached tolerance at a mean of 34.1+/-15.2 months. The mean duration of disease was 40.2+/-4.8 months with milk hydrolysate, 24.3+/-3.6 months with rice and 24.3+/-2.6 months with soy. Dietary choice independently predicted shorter duration of disease [adjusted HRs 3.09 (P=0.007) for rice, 2.54 (P=0.02) for soy, both against milk hydrolysate]. In 50 children not co-sensitized to soy, diet choice impacted the duration of disease more strongly [adjusted HRs 8.02 (P=0.006) for rice, 6.53 (P=0.015) for soy, both against milk hydrolysate]. DISCUSSION: Patients not exposed to cow's milk protein residue achieve cow's milk tolerance earlier than patients who follow an extensively hydrolysed cow's milk diet. This may be due to residual antigenicity in hydrolysed milks. As the effect of dietary intervention is stronger in patients not sensitized to soy, we infer that when atopic disease has progressed to multiple sensitizations, the elimination of allergenic exposure may not be sufficient to reduce the duration of CMA.

Topical treatment of rhinosinusitis.

We reviewed current clinical evidence for the use of topical treatments in pediatric rhinosinusitis. Repeated Entrez PubMed searches were done using the template algorithm [rhinosinusitis AND (...)] with the settings: [Humans; English; All Child 0-18; Clinical trial; Last 10 yr] for the following comparators: steroid, irrigation, saline, antihistamine, decongestant, antibiotic, antimycotic, fungicide. The authors' clinical experience in the pediatric allergy unit of a university hospital was also drawn upon. Pediatric studies were retrieved but only one satisfied current evidence-based medicine standards for reporting clinical trials. Studies could not be systematized because of methodological, analytical, and interpretation biases. While saline irrigation, nasal decongestants, steroids, antibiotics, antihistamines and fungicides are all in widespread pediatric use, comparing studies from the literature for evidence of efficacy implied subjective appraisal, except in the case of topical steroids. Evidence for the efficacy of topical treatment for pediatric rhinosinusitis is narrative albeit this modality cannot be excluded from individualized patient protocols on the basis of the clinical literature alone. With the exception of topical steroids, no weighable evidence of effectiveness supports the premise that topical treatments actually serve the purpose for which they are widely prescribed in pediatrics.

Oral food challenges in children in Italy.

BACKGROUND: Epidemiological surveys identify a 900,000-strong potential paediatric population who may self-report with food allergy in Italy. As the reference test is the double-blind, placebo-controlled food challenge for diagnosis, we carried out a nation-wide questionnaire survey of hospital-based paediatric allergy centres between 1 January and 30 June 2003. METHODS: All registered centres received a 27-point questionnaire polling logistics and protocols of oral food challenge. Items polled included medical facilities and personnel, selection of patients, foods tested, blinding, placebo use, evaluation criteria, number of tests and positive outcome rates in 2002. RESULTS: Two hundred and two of 456 responders (44.3%) carried out food challenges (a ratio of one centre to 37,400 children in the general population). 11,728 challenges were performed in 2002 (an average of 58 procedures per centre; range: 1-500) and 3350 procedures were claimed positive (28.6%). Cow's milk was tested by all centres, egg by 77.2%, beef by 19.8% and cereals, peanuts, fish or fruit collectively by 37.6%. Twenty-nine of 202 centres performed blinded tests, 18 of which under double-blinded conditions. In cow's milk challenges, placebos included lyophilized cow's milk capsules, soy formula, extensive whey hydrolysate or extensive casein hydrolysate. CONCLUSION: Our survey reveals great differences in challenge test criteria, facilities and procedures and that many centres perform relatively few procedures. This argues in favour of greater rationalization in the allocation of tertiary-level resources before procedure standardization can be contemplated in the diagnostic workup of food allergy.

Dietary treatment of childhood atopic eczema/dermatitis syndrome (AEDS).

OBJECTIVE: This review summarizes the research and clinical evidence in favour of dietary intervention aimed at eliminating allergenic foods in the management of atopic eczema/dermatitis syndrome (AEDS). DATA SOURCES: The data source was PubMed, using a search algorithm selecting for clinical studies of AEDS, diet therapy and food allergy in all children to October 2003. Also included is a commentary based on the authors' clinical experience in the allergy unit of a university hospital in Italy. RESULTS: Fourteen prospective studies matched the entry criteria. Diverse trial designs, diagnostic criteria, types of dietary intervention and length of observation periods precluded meta-analytic methods. Allergenic food exclusion claimed efficacy in 13 of the 14 studies and was most useful in infants, in patients with elevated immunoglobulin E levels and/or multiple food sensitization and in patients with a diagnosis of food allergy. CONCLUSION: Dietary intervention in the form of an elimination diet is efficacious in children with AEDS when a specific diagnosis of food allergy has been made. Diagnostic evaluation of food allergy should be performed in all children with eczema, particularly in younger children and those with severe forms of the disease.

Severe anaphylaxis induced by latex as a contaminant of plastic balls in play pits.

BACKGROUND: Latex causes anaphylaxis in specific contexts among children. We present 2 cases that show that severe reactions may occur in everyday circumstances with latex as a contaminant. OBJECTIVE: Because 2 cases of severe reactions to latex suggested similar circumstances of exposure, we investigated the immediate environment in which episodes occurred. METHODS: A 5-year-old girl presented to our casualty department with anaphylaxis after playing in a ball pit filled with approximately 10-cm diameter plastic balls in an American-style fast-food outlet. Two months later, a 9-year-old boy had severe anaphylaxis followed by an asthma attack with loss of consciousness while playing in the playpen of a different outlet belonging to the same company. Latex sensitization was confirmed in both cases by means of skin prick testing, latex glove skin prick testing, and 1-glove finger testing. Immunoblotting of elutions from a ball, the natural rubber latex foam pit lining, and its polyvinyl chloride sheet were performed. RESULTS: In the girl's immunoblot high levels of IgE specific to Hev b 4, Hev b 7, and Hev b 2 were found. The boy's immunoblot showed positivity to Hev b 7. The polyvinyl chloride ball sample showed a high concentration of specific Hevea species allergen similar to that of the foam layer sample. CONCLUSION: Severe anaphylaxis can result from contact with latex proteins as a contaminant, rather than as a component, of play area ball pits and therefore outside the reported settings. Emergency health care workers should be aware of this kind of risk. A latex-reduced environment might prevent potentially severe reactions in young customers of fast-food outlets.