Faculty Bibliography

Anaphylaxis is a rapid-onset, potentially life-threatening systemic allergic reaction that remains a significant clinical concern in pediatric practice. Food allergies are the most common trigger in children, and a substantial proportion of affected patients experience severe reactions. This review provides a practical, evidence-based framework for the diagnosis and management of IgE-mediated allergy in the pediatric setting, emphasizing recognition, treatment, and preparedness. Anaphylaxis is a clinical diagnosis based on established criteria, with age-specific presentations that may complicate recognition, particularly in infants and young children. Epinephrine is the cornerstone of treatment and the only therapy capable of reversing life-threatening respiratory and cardiovascular manifestations. Early epinephrine administration improves outcomes, yet real-world use remains suboptimal due to barriers such as needle aversion, device complexity, and access challenges. Pediatricians play a critical role in identifying at-risk patients, prescribing epinephrine, and reinforcing preparedness through education and individualized action plans across care settings. Integrating evolving therapeutic options with established best practices may help to address persistent gaps in care and improve outcomes for children at risk of anaphylaxis.

Pollen-food allergy syndrome is an IgE-mediated allergic condition resulting from cross-reactivity between pollen allergens and homologous proteins present in plant-derived foods. PFAS typically presents with rapid-onset itching, burning, swelling, and erythema of the oral cavity and pharynx, with symptoms usually limited to the oropharyngeal region, although systemic reactions, including respiratory or gastrointestinal symptoms and, rarely, anaphylaxis, may occur. PFAS is strongly associated with the atopic phenotype and frequently coexists with allergic rhinitis, atopic dermatitis, and asthma. Available studies show marked variability in prevalence, from a few percent in general pediatric populations to 50-80% among atopic children, especially those with allergic rhinitis, with regional differences likely reflecting pollen sensitization patterns and dietary habits. The aim of this review was to summarize current knowledge regarding the epidemiology, clinical characteristics, molecular determinants, and food-related aspects of PFAS in children across different regions of the world. PFAS is a common but still insufficiently studied condition in children. Standardized diagnostic criteria and large population-based studies incorporating molecular diagnostic approaches are needed to better define the true burden, risk factors, and clinical spectrum of PFAS in childhood.

BACKGROUND:AQST-109 is an investigational epinephrine prodrug sublingual film for anaphylaxis treatment, with well-characterized pharmacokinetics (PK) and pharmacodynamics (PD) in healthy adults. It is unclear how oral symptoms during allergic reactions may affect absorption and these parameters. OBJECTIVE:To compare AQST-109's PK and PD in adults with oral allergy syndrome (OAS) undergoing oral allergen challenge (OAC) to elicit symptoms METHODS: This was a phase 2, two-part, open-label, randomized, fixed-sequence, stratified, crossover study to evaluate the PK and PD of single (12mg) and repeat doses (12mg × 2) of AQST-109 in adults with screening-confirmed OAS administered with and without OAC, to single (0.3mg) and repeat doses (0.3mg × 2) of manual IM epinephrine injection (IM-EPI) given without OAC. Geometric means for PK and PD parameters were analyzed for PK, PD, and safety subsets. RESULTS:During screening OAC, 94.4% of n=36 subjects experienced moderate or severe oral symptoms. Pharmacodynamics were not impacted by OAC following single- and repeat-dose of AQST-109 vs without OAC. AQST-109 PK values were similar with or without OAC. Single and repeat-dosing PD parameters were higher with AQST-109 after OAC vs IM-EPI without OAC, and were non-significantly higher for AQST-109 with vs without OAC. Almost all participants experienced a related mild treatment-emergent adverse event, with four considered moderate in severity, and no new safety signals identified compared to prior studies. CONCLUSION/CONCLUSIONS:AQST-109 PK and PD are not diminished with oral symptoms and changes, supporting reliable absorption in allergic reactions with such contexts.

Current oral food challenge (OFC) protocols for food protein-induced enterocolitis syndrome (FPIES) exhibit significant variability, creating potential for inconsistent diagnostic outcomes and severe reactions. Based on the published evidence and our clinical experience, we propose a practical, standardized OFC dosing protocol that emphasizes patient safety, goals based on age-appropriate servings (AASs), and clinical monitoring. A recent systematic review reported that most patients with persistent FPIES who underwent OFCs reacted to just 25% of an AAS, with low rates of severe reactions. Thus, we recommend that most patients undergoing a medically supervised FPIES OFC receive a cumulative dose of 25% AAS, followed by observation for a minimum of 4 hours. Supervised challenges should be followed by gradual up-titration to an AAS at home. A lower dose may be considered for patients with a history of severe FPIES symptoms to trace amounts of food. For patients with atypical FPIES, we recommend a slightly modified protocol, using graded dosing per IgE-mediated food allergy protocols, followed by extended FPIES OFC monitoring. Anticipated outcomes from implementation of this standardized OFC protocol include improved diagnostic accuracy, enhanced patient safety, and a structured approach to food reintroduction. Standardizing practices for FPIES OFCs will also permit harmonization of data to advance research.

BACKGROUND:Pollen food allergy syndrome (PFAS), also called oral allergy syndrome, results from cross-reactivity between pollen allergens and plant-derived foods. While typically mild, PFAS can occasionally cause systemic reactions. A 2003 U.S. survey characterized its epidemiology and management; this study repeated the survey in 2023 to assess changes. OBJECTIVE:To evaluate changes in prevalence, clinical patterns, diagnostic practices, and management of PFAS among U.S. allergists over two decades. METHODS:A 16-question survey (7 original, 9 new) was electronically distributed to 737 randomly selected AAAAI members in October 2023, and results were compared with 2003 survey responses RESULTS: Sixty-seven allergists (9%) responded. Reported prevalence of PFAS increased in children (median 5% to 10%, p = 0.01) and adults (8% to 20%, p < 0.001). The proportion of allergists with patients experiencing systemic PFAS rose from 20% to 67%, though the median percentage of affected patients declined (5% to 1%). Grass pollen emerged as a key sensitizer, alongside birch and ragweed. Nut-induced PFAS was increasingly recognized, cited as a frequent trigger of systemic symptoms and a reason for epinephrine auto-injector (EAI) prescription. Overall, EAI prescribing declined, with 0% of allergists "always" prescribing in 2023 vs 30% in 2003. Diagnostic practices showed increased but limited use of component-resolved diagnostics, while dietary advice remained variable, especially for nut PFAS. CONCLUSION/CONCLUSIONS:Allergists report higher estimated prevalence of PFAS, greater recognition of nut-induced and systemic PFAS, and evolving diagnostic and management practices. Findings underscore the need for updated guidelines on PFAS diagnosis and management.