Faculty Bibliography

Rationale: The Peanut Allergy Burden Study (PABS) assessed the real-world burden of peanut allergy (PA) on patients and caregivers in the United States.
Method(s): Adolescents 13-17-years-old with self-reported, provider-diagnosed PA participated in the PABS online survey. Medical and treatment history and the validated Pediatric Quality of Life Inventory PedsQL (scores 0-100, higher is better) were collected. Between-group analyses were conducted (chi square; t-test).
Result(s): Adolescents with PA (n=102) completed PABS; mean+/-SD age was 14.7+/-1.4 years, 55.9% were male, 62.8% were white. The mean PedsQL Total score was 48.8; mean subscale scores were: Physical (53.6), Emotional (43.0), Social (48.2), School (46.0), and Psychosocial (44.5). These scores were significantly below the scale scores from a general population of 8-16-year-olds (n>5900; range: 78.2-87.0) and exceeded the minimum clinically important difference (4.36-9.12 points). Adolescents experiencing >=1 PA-related reaction in the past year had significantly lower PedsQL Total score (p=0.008), as did those receiving clinician intervention for >=1 PA reaction in the past year (p<0.001), those "not at all" to "somewhat satisfied" with current approaches to PA reaction prevention (p=0.012), those saying PA limited their day-to-day life "somewhat" to "completely" (p=0.013), or who reported a "great" to "100% chance" of not effectively dealing with a reaction (p<0.001).
Conclusion(s): Adolescents with PA have substantially lower PedsQL scores than the general population of similarly aged individuals. PedsQL Total scores were significantly different between subgroups defined by recent allergic reaction/need for clinician intervention, satisfaction with reaction prevention, perceived limitations on day-to-day life, and concern about their ability to deal with a reaction.
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Rationale: Eczema is a chronic inflammatory skin disorder. We sought to evaluate efficacy and safety of TCM in humans and animal model of eczema.
Method(s): We retrospectively analyzed data of 28 patients with moderate-to-severe eczema who received TCM for at least 3 months in three cohorts based on eczema phenotype/endotype. Cohort #1 (n=10), ages 6 to 48 months, used topical steroids for at least 3 months prior to TCM with inadequate response. Cohort #2 (n=8), ages 2-40 years, had worsening eczema associated with sudden topical steroid withdrawal (TSW, n=8) at least 3 months prior to TCM. Cohort #3 had a very high total IgE (>5,000 kIU/L, n=10), ages 1-13 years. The TCM regimen included external herbal bath, cream, and oral tea. We also tested the TCM effects in a mouse model of eczema treated daily for 9 days.
Result(s): Following TCM treatment, cohort #1 showed reduced SCORAD and steroid use as early as one month (p<0.001) and close to zero by 6 months. Cohort #2 showed improved SCORAD (73.6%, p<0.001), and markedly decreased sleep disturbance (80%, p<0.001) as early as one month. Cohort #3 had markedly reduced total IgE from median 12,328 to 3,994 kIU/L after 6-24 months. TCM significantly reduced elevated blood eosinophils (p<0.05). No liver or kidney function abnormality was observed. Animal model of eczema showed distinctly reduced SCORAD, scratching scores, and skin eosinophil counts. TCM tea also showed dose dependent reduction of IgE, TNF-alpha and exotoxin production in vitro.
Conclusion(s): TCM is efficacious and safe in children and adults with steroid dependent-eczema.
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Rationale: With peanut allergy therapies under development, peanut-allergic children are completing clinical trials wishing to maintain desensitization. We describe our experience transitioning children to real food equivalents of peanut following trial completion.
Method(s): Children who completed peanut clinical trials with interest in continuing (post-oral immunotherapy [OIT]) or starting (post-epicutaneous immunotherapy [EPIT]) daily peanut ingestion were offered an oral food challenge (OFC) for the starting dose, which was determined based on study dose/eliciting dose during exit OFC. Dose-escalation to 2000 mg peanut protein was offered. The charts of post-study participants transitioned to daily peanut ingestion from May 2016-May 2019 were reviewed. Families without recent follow-up were contacted by telephone. This study was IRB approved.
Result(s): Twenty children (80% male; median age 7.6 years, range 4-15 years; n=5 post-EPIT, n=15 post-OIT) were transitioned to daily peanut ingestion. The median starting dose was 300 mg (post-EPIT: 100 mg [range 30-300 mg]; post-OIT: 400 mg [range 30-2000 mg]). Four participants started at 2000 mg; 11/16 dose-escalated. Thirteen participants reached a daily dose >1000 mg. Median follow-up was 1.7 years. Seventeen participants (85%) continued dosing for at least one year or were confirmed to currently actively dose if transitioned in the past year. Two participants discontinued due to side effects (gastrointestinal, hives, wheezing); one was lost to follow-up.
Conclusion(s): Most post-study children transitioned to daily peanut reached a maintenance dose of >1000 mg and continued dosing long-term with real food equivalents. This suggests that families are motivated to follow-through with daily peanut to maintain desensitization after study completion.
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PURPOSE OF REVIEW/OBJECTIVE:First described in the mid 20th century, it was just in the last decade that diagnostic and treatment guidelines for food protein-induced enterocolitis syndrome (FPIES) were established. Awareness of the diagnosis is improving, and epidemiologic data are emerging. RECENT FINDINGS/RESULTS:Recent studies suggest that FPIES may affect as many as 0.5% of children worldwide. FPIES in adults is usually triggered by seafood and may be more common than previously thought. Many patients with FPIES have other allergic disorders. SUMMARY/CONCLUSIONS:With refined diagnostic criteria and improved awareness, FPIES is now diagnosed with increasing frequency, and epidemiologic data are emerging. FPIES appears to be increasing in prevalence, and the frequent association with other allergic disorders suggests a shared predisposition or immune mechanism that remains to be elucidated.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that manifests with projectile, repetitive emesis that can be followed by diarrhea and may be accompanied by lethargy, hypotonia, hypothermia, hypotension, and metabolic derangements. FPIES usually starts in infancy although onset at older ages is being increasingly recognized. FPIES is not rare, with the cumulative incidence of FPIES in infants estimated to be 0.015% to 0.7%, whereas the population prevalence in the US infants was 0.51%. FPIES diagnosis is challenging and might be missed because of later (1-4 hours) onset of symptoms after food ingestion, lack of typical allergic skin and respiratory symptoms, and food triggers that are perceived to be hypoallergenic. Diagnosis is based on the recognition of symptoms because there are no biomarkers of FPIES. The pathophysiology remains obscure although activation of the innate immune compartment has been detected. Management relies of avoidance of food triggers, treatment of accidental exposures, and periodic re-evaluations with supervised oral food challenges to monitor for resolution. There are no strategies to accelerate development of tolerance in FPIES. Here we review the most important current concepts in epidemiology, pathophysiology, diagnosis, and management of FPIES.

Oral food challenges are an integral part of an allergist's practice and are used to evaluate the presence or absence of allergic reactivity to foods. A work group within the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology was formed to update a previously published oral food challenge report. The intention of this document was to supplement the previous publication with additional focus on safety, treatment of IgE-mediated allergic reactions, guidance for challenges in infants and adults, psychosocial considerations for children and families participating in an oral food challenge, specific guidance for baked milk or baked egg challenges, masking agents and validated blinding recipes for common food allergens, and recommendations for conducting and interpreting challenges in patients with suspected food protein-induced enterocolitis syndrome. Tables and figures within the report and an extensive online appendix detail age-specific portion sizes, appropriate timing for antihistamine discontinuation, serum and skin test result interpretation, written consents, and instructional handouts that may be used in clinical practice.

BACKGROUND:Sesame is an allergen of increasing importance. OBJECTIVE:We sought to characterize the outcomes of oral food challenges (OFCs) to sesame and evaluate the diagnostic accuracy of skin prick testing (SPT), sesame, and Ses i 1-specific IgE (sIgE). METHODS:We reviewed sesame OFCs performed at the Mount Sinai pediatric allergy clinic between January 2010 and April 2018. We assessed the accuracy of diagnostic tests by calculating the area under the curve (AUC) of the receiver operating characteristic curves. The association between OFC outcome and sesame sensitization was analyzed using a logistic regression, which was then used to estimate the 95% positive predictive value (PPV) of these tests. RESULTS:We identified 341 patients (69% male, mean age 7.7 years) who underwent sesame OFC. Among 106 (31%) positive OFCs, the median cumulative eliciting dose was 500 mg sesame protein (1/2 teaspoon tahini). Sesame SPT wheal ≥6 mm had sensitivity 54.1% and specificity 87.8%; AUC 0.756 (95% confidence interval [CI], 0.699-0.814). SPT wheal size ≥14 mm had 95% PPV. Sesame-sIgE level did not correlate with OFC outcome. Ses i-sIgE levels were analyzed in 30 patients using the Immuno Solid-phase Allergen Chip (ISAC) microarray and were significantly associated with OFC outcome (AUC: 0.715 [95% CI, 0.541-0.890]). Ses i 1-sIgE ≥0.3 ISAC Standardized Units had sensitivity 58.3% and specificity 83.3%. CONCLUSIONS:This is the largest study of sesame allergy to date. Sesame SPT is a more accurate predictor of sesame allergy compared with sesame sIgE. Ses i 1-sIgE appears promising but requires further study regarding diagnostic accuracy.

Eosinophilic esophagitis (EoE) is an atopic disease characterized by eosinophilic inflammation in the esophagus.

Professor Hugh A. Sampson, MD is a Canadian- born American clinician and translational researcher, whose evidence-based approach validated food allergy as a legitimate allergic disorder. He single-handedly transformed the management of patients with food allergies and initiated investigations that led to novel diagnostic tests and therapies giving hope to millions of individuals and their families worldwide. Hugh Sampson's immense impact on the rapidly developing field of food allergy makes him a true legend in allergy/immunology.