muffin had 88% negative predictive value and a skin prick test size of $11 mm to ovomucoid had a positive predictive value of 100%.
and no or subjective symptoms was determined by calculating the area under the curve of the receiver-operating characteristic.
CONCLUSIONS. The results of this study found that skin prick
RESULTS. Asthma was more common among adults with hazelnut allergy with objective symptoms than those with no or subjective symptoms (P 5 .03). Asthma was more common in children than adults with no or subjective symptoms of hazelnut allergy (P 5 .04). All children and most adults (97%) with subjective hazelnut allergy were sensitized to birch pollen. Sensitization to nCor a 9, rCor a 14, or both was strongly associated with hazelnut allergy with objective symptoms. IgE levels to either nCor a 9 of $1 kUA/L or rCor a 14 of $5 kUA/L in children had a sensitivity of 83% and a specificity of 93%. In adults, the combination of IgE to either nCor a 9 or rCor a 14 of $1 kUA/L had a specificity of 98%.
tests to ovomucoid and to baked egg muffin homogenized with normal saline could be helpful in deciding if eggallergic patients are ready for OFC to baked egg. A skin prick test result of ,2 mm to muffin had an 88% negative predictive value and an ovomucoid skin prick test result $11 mm had a positive predictive value of 100%. REVIEWER COMMENTS. Although it is known that 60% to 70%
of egg-allergic children can tolerate “baked egg” in their diet, it is often difficult to identify this subpopulation. Recently, ovomucoid-specific IgE levels have been shown to be useful in helping predict the outcome of OFCs to baked egg, but only when the levels are .10 kUA/L (97% positive predictive value). This study uses 2 new skin testing reagents (ovomucoid and muffin suspension) in an attempt to identify who might be able to eat baked egg. Using this approach, a 100% positive predictive value and an 88% negative predictive value have been determined. Although the majority of egg-allergic children will fall outside of these parameters, this approach could reduce the need for OFCs. Importantly, the skin response did not predict the severity of the reaction. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817GG
Heather Minto, MD Angela Hogan, MD Norfolk, VA
CONCLUSIONS. Sensitization to Cor a 9 and Cor a 14 is specific
for patients with objective symptoms in DBPCFCs to hazelnut. REVIEWER COMMENTS. IgE-specific food allergy testing has been
plagued by poor specificity, resulting in many patients being incorrectly labeled food allergic. Component testing as demonstrated in this study may improve specificity for certain foods. As the authors note, food challenges are still needed to confirm tolerance, but component testing may allow additional patients to proceed to food challenge. Patient’s sensitivities to specific components have been shown to vary regionally. When treating diverse patient populations, we must consider these possible regional variations. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817HH
Sensitization to Cor a 9 and Cor a 14 Is Highly Specific for a Hazelnut Allergy With Objective Symptoms in Dutch Children and Adults Masthoff LJ, Mattsson L, Zuidmeer-Jongejan L, et al. J Allergy Clin Immunol. 2013;132(2):393–399 PURPOSE OF THE STUDY. The goal of this study was to determine if component-resolved testing will aid in determining patients at risk for allergic reactions to hazelnut. STUDY POPULATION. A total of 161 adults and children with
sensitization ($0.35 kUA/L) to hazelnut were retrospectively recruited between 2010 and 2012 at the University Medical Center Utrecht (Utrecht, the Netherlands). METHODS. Forty children and 15 adults with objective symptoms on double-blind, placebo-controlled food challenges (DBPCFCs) and 24 adults with a convincing history of reaction were compared with 41 children and 41 adults with no symptoms on DBPCFCs. Specific IgE levels to hazelnut extract and single components were analyzed with ImmunoCAP and compared between the study groups. The diagnostic value of IgE levels for discrimination between hazelnut allergy with objective symptoms
S152
BEST ARTICLES RELEVANT TO PEDIATRIC ALLERGY AND IMMUNOLOGY
Timothy Andrews, MD James R. Banks, MD Arnold, MD
Factors Associated With Reported Food Allergy Tolerance Among US Children Gupta RS, Lau CH, Sita EE, Smith B, Greenhawt MJ. Ann Allergy Asthma Immunol. 2013;111(3):194–198.e4 PURPOSE OF THE STUDY. The goal of this study was to in-
vestigate factors associated with development of tolerance to 9 common food allergens. STUDY POPULATION. The study population included 40 000 households with children in the United States. METHODS. A randomized, cross-sectional survey was completed by eligible adult caregivers regarding a child in the home. Allergies to the 9 most frequently reported current and outgrown food allergens (milk, peanut, shellfish, tree nut, egg, fish, wheat, soy, and sesame) were analyzed. Data regarding the age of first reaction, age at which the allergy was outgrown, and severity of the reaction (mild, moderate, or severe) were obtained.
RESULTS. Of the total 38 840 final surveys regarding children submitted, 8.3% of children had current food allergies, whereas 3.2% had outgrown food allergies. The data showed an average age of 3.6 years for the first reaction to any food. However, the mean age of the first reaction was younger for milk, egg, and soy reactions. Overall, the mean age for outgrowing food allergy was 5.4 years, although a younger mean age of tolerance was reported for milk, wheat, egg, and soy. Significantly higher frequency of tolerance was seen in milk, egg, or soy allergy, in contrast to those with shellfish, tree nut, and peanut allergies. Factors such as gender and race also influenced odds of tolerance, with boys having a higher tolerance rate than girls and a higher number of white versus black children reporting tolerance. Children with multiple food allergies showed significantly lower odds of developing tolerance, whereas those with a single food allergy had increased odds of tolerance. A higher probability of tolerance was seen with younger age of first reaction, as well as when eczema was the sole symptom of the food allergy. Children with severe reactions were less likely to have outgrown the food allergy. CONCLUSIONS. Many factors (including the type of food, age
at onset of reaction, race, and gender) may be associated with outgrowing food allergies. REVIEWER COMMENTS. Future tolerance of the food allergen(s) is one of the most frequently asked questions by caregivers of newly diagnosed children. Although this study has limitations, including the lack of oral challenge and likely recall bias, information about possible factors that may predict tolerance are described. Prospective studies investigating the natural history of food allergy will further aid the clinician in addressing the concerns of parents and would provide practitioners a larger scope of evidence with which to counsel their patients and families. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817II
Grace T. Padron, MD Vivian Hernandez-Trujillo, MD Miami, FL
Distribution of Peanut Protein in the Home Environment Brough HA, Makinson K, Penagos M, et al. J Allergy Clin Immunol. 2013;132(3):623–629 PURPOSE OF THE STUDY. The goal of this study was to assess potential routes of transfer of peanut protein into the home environment and to assess the effect that cleaning methods have on environmental peanut protein levels. STUDY POPULATION. Forty-five families were recruited from pediatric allergy clinics. METHODS. To quantify ambient household peanut levels, dust samples from all household members’ beds and the
infant’s play area were obtained by vacuuming. Wipe samples were obtained from the infant’s and parents’ eating areas, as well as other surfaces in the home. Peanut protein in the samples was measured by using enzymelinked immunosorbent assay and converted to micrograms of peanut protein per gram of dust. Peanut protein was also measured from hand wipe and saliva samples before and 3 hours after subjects ate peanut products. To measure airborne peanut protein, air samplers were placed 1 cm and 1 m above open containers of peanut products for 22 hours and over a pan of simmering peanutflavored sauce for 10 hours. In addition, air samples were obtained at and around researchers during and after they ate peanut products. Various table surfaces were spiked with peanut and then cleaned with water or detergent and sampled for residual peanut protein. RESULTS. Dust from the infant’s play area had the highest peanut protein level, followed by the parents’ bed and siblings’ beds. Correlation between concentrations in various areas of the home was high. Levels in wipe samples were lower than in dust, and the median was below the lower limit of quantification for the assay. Levels of peanut protein on a sofa cover and a pillow case increased after peanut consumption. After the items were washed twice, the level of peanut protein on the items was dramatically decreased. Peanut protein levels on hands and in saliva remained elevated 3 hours after consumption. Except for when dry roasted peanuts were being shelled, median airborne peanut protein levels were below the lower limit of quantification. After wiping the spiked table surfaces with water, there was only a small reduction in the amount of peanut protein on the surface. After vigorous detergent cleaning, there was a reduction but protein was still measurable on the wood and laminate surfaces (but not on the granite surfaces). CONCLUSIONS. Peanut protein can easily spread throughout
a home but probably not by aerosolization. It may be resistant to usual cleaning methods. REVIEWER COMMENTS. Our mothers were right, to a certain extent. We should still wash our hands and clean up after ourselves after eating. After eating peanut products, these steps will reduce but not eliminate residual peanut in the environment. This study shows that peanut can then be transferred throughout the home. The amount found would likely not trigger symptoms in an allergic patient. However, the following article in the same issue of the Journal of Allergy and Clinical Immunology by the same group indicates that environmental peanut protein is biologically active and therefore has the potential to contribute to sensitization. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817JJ
Mitchell R. Lester, MD Norwalk, CT
PEDIATRICS Volume 134, Supplement 3, November 2014
S153
and no or subjective symptoms was determined by calculating the area under the curve of the receiver-operating characteristic.
CONCLUSIONS. The results of this study found that skin prick
RESULTS. Asthma was more common among adults with hazelnut allergy with objective symptoms than those with no or subjective symptoms (P 5 .03). Asthma was more common in children than adults with no or subjective symptoms of hazelnut allergy (P 5 .04). All children and most adults (97%) with subjective hazelnut allergy were sensitized to birch pollen. Sensitization to nCor a 9, rCor a 14, or both was strongly associated with hazelnut allergy with objective symptoms. IgE levels to either nCor a 9 of $1 kUA/L or rCor a 14 of $5 kUA/L in children had a sensitivity of 83% and a specificity of 93%. In adults, the combination of IgE to either nCor a 9 or rCor a 14 of $1 kUA/L had a specificity of 98%.
tests to ovomucoid and to baked egg muffin homogenized with normal saline could be helpful in deciding if eggallergic patients are ready for OFC to baked egg. A skin prick test result of ,2 mm to muffin had an 88% negative predictive value and an ovomucoid skin prick test result $11 mm had a positive predictive value of 100%. REVIEWER COMMENTS. Although it is known that 60% to 70%
of egg-allergic children can tolerate “baked egg” in their diet, it is often difficult to identify this subpopulation. Recently, ovomucoid-specific IgE levels have been shown to be useful in helping predict the outcome of OFCs to baked egg, but only when the levels are .10 kUA/L (97% positive predictive value). This study uses 2 new skin testing reagents (ovomucoid and muffin suspension) in an attempt to identify who might be able to eat baked egg. Using this approach, a 100% positive predictive value and an 88% negative predictive value have been determined. Although the majority of egg-allergic children will fall outside of these parameters, this approach could reduce the need for OFCs. Importantly, the skin response did not predict the severity of the reaction. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817GG
Heather Minto, MD Angela Hogan, MD Norfolk, VA
CONCLUSIONS. Sensitization to Cor a 9 and Cor a 14 is specific
for patients with objective symptoms in DBPCFCs to hazelnut. REVIEWER COMMENTS. IgE-specific food allergy testing has been
plagued by poor specificity, resulting in many patients being incorrectly labeled food allergic. Component testing as demonstrated in this study may improve specificity for certain foods. As the authors note, food challenges are still needed to confirm tolerance, but component testing may allow additional patients to proceed to food challenge. Patient’s sensitivities to specific components have been shown to vary regionally. When treating diverse patient populations, we must consider these possible regional variations. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817HH
Sensitization to Cor a 9 and Cor a 14 Is Highly Specific for a Hazelnut Allergy With Objective Symptoms in Dutch Children and Adults Masthoff LJ, Mattsson L, Zuidmeer-Jongejan L, et al. J Allergy Clin Immunol. 2013;132(2):393–399 PURPOSE OF THE STUDY. The goal of this study was to determine if component-resolved testing will aid in determining patients at risk for allergic reactions to hazelnut. STUDY POPULATION. A total of 161 adults and children with
sensitization ($0.35 kUA/L) to hazelnut were retrospectively recruited between 2010 and 2012 at the University Medical Center Utrecht (Utrecht, the Netherlands). METHODS. Forty children and 15 adults with objective symptoms on double-blind, placebo-controlled food challenges (DBPCFCs) and 24 adults with a convincing history of reaction were compared with 41 children and 41 adults with no symptoms on DBPCFCs. Specific IgE levels to hazelnut extract and single components were analyzed with ImmunoCAP and compared between the study groups. The diagnostic value of IgE levels for discrimination between hazelnut allergy with objective symptoms
S152
BEST ARTICLES RELEVANT TO PEDIATRIC ALLERGY AND IMMUNOLOGY
Timothy Andrews, MD James R. Banks, MD Arnold, MD
Factors Associated With Reported Food Allergy Tolerance Among US Children Gupta RS, Lau CH, Sita EE, Smith B, Greenhawt MJ. Ann Allergy Asthma Immunol. 2013;111(3):194–198.e4 PURPOSE OF THE STUDY. The goal of this study was to in-
vestigate factors associated with development of tolerance to 9 common food allergens. STUDY POPULATION. The study population included 40 000 households with children in the United States. METHODS. A randomized, cross-sectional survey was completed by eligible adult caregivers regarding a child in the home. Allergies to the 9 most frequently reported current and outgrown food allergens (milk, peanut, shellfish, tree nut, egg, fish, wheat, soy, and sesame) were analyzed. Data regarding the age of first reaction, age at which the allergy was outgrown, and severity of the reaction (mild, moderate, or severe) were obtained.
RESULTS. Of the total 38 840 final surveys regarding children submitted, 8.3% of children had current food allergies, whereas 3.2% had outgrown food allergies. The data showed an average age of 3.6 years for the first reaction to any food. However, the mean age of the first reaction was younger for milk, egg, and soy reactions. Overall, the mean age for outgrowing food allergy was 5.4 years, although a younger mean age of tolerance was reported for milk, wheat, egg, and soy. Significantly higher frequency of tolerance was seen in milk, egg, or soy allergy, in contrast to those with shellfish, tree nut, and peanut allergies. Factors such as gender and race also influenced odds of tolerance, with boys having a higher tolerance rate than girls and a higher number of white versus black children reporting tolerance. Children with multiple food allergies showed significantly lower odds of developing tolerance, whereas those with a single food allergy had increased odds of tolerance. A higher probability of tolerance was seen with younger age of first reaction, as well as when eczema was the sole symptom of the food allergy. Children with severe reactions were less likely to have outgrown the food allergy. CONCLUSIONS. Many factors (including the type of food, age
at onset of reaction, race, and gender) may be associated with outgrowing food allergies. REVIEWER COMMENTS. Future tolerance of the food allergen(s) is one of the most frequently asked questions by caregivers of newly diagnosed children. Although this study has limitations, including the lack of oral challenge and likely recall bias, information about possible factors that may predict tolerance are described. Prospective studies investigating the natural history of food allergy will further aid the clinician in addressing the concerns of parents and would provide practitioners a larger scope of evidence with which to counsel their patients and families. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817II
Grace T. Padron, MD Vivian Hernandez-Trujillo, MD Miami, FL
Distribution of Peanut Protein in the Home Environment Brough HA, Makinson K, Penagos M, et al. J Allergy Clin Immunol. 2013;132(3):623–629 PURPOSE OF THE STUDY. The goal of this study was to assess potential routes of transfer of peanut protein into the home environment and to assess the effect that cleaning methods have on environmental peanut protein levels. STUDY POPULATION. Forty-five families were recruited from pediatric allergy clinics. METHODS. To quantify ambient household peanut levels, dust samples from all household members’ beds and the
infant’s play area were obtained by vacuuming. Wipe samples were obtained from the infant’s and parents’ eating areas, as well as other surfaces in the home. Peanut protein in the samples was measured by using enzymelinked immunosorbent assay and converted to micrograms of peanut protein per gram of dust. Peanut protein was also measured from hand wipe and saliva samples before and 3 hours after subjects ate peanut products. To measure airborne peanut protein, air samplers were placed 1 cm and 1 m above open containers of peanut products for 22 hours and over a pan of simmering peanutflavored sauce for 10 hours. In addition, air samples were obtained at and around researchers during and after they ate peanut products. Various table surfaces were spiked with peanut and then cleaned with water or detergent and sampled for residual peanut protein. RESULTS. Dust from the infant’s play area had the highest peanut protein level, followed by the parents’ bed and siblings’ beds. Correlation between concentrations in various areas of the home was high. Levels in wipe samples were lower than in dust, and the median was below the lower limit of quantification for the assay. Levels of peanut protein on a sofa cover and a pillow case increased after peanut consumption. After the items were washed twice, the level of peanut protein on the items was dramatically decreased. Peanut protein levels on hands and in saliva remained elevated 3 hours after consumption. Except for when dry roasted peanuts were being shelled, median airborne peanut protein levels were below the lower limit of quantification. After wiping the spiked table surfaces with water, there was only a small reduction in the amount of peanut protein on the surface. After vigorous detergent cleaning, there was a reduction but protein was still measurable on the wood and laminate surfaces (but not on the granite surfaces). CONCLUSIONS. Peanut protein can easily spread throughout
a home but probably not by aerosolization. It may be resistant to usual cleaning methods. REVIEWER COMMENTS. Our mothers were right, to a certain extent. We should still wash our hands and clean up after ourselves after eating. After eating peanut products, these steps will reduce but not eliminate residual peanut in the environment. This study shows that peanut can then be transferred throughout the home. The amount found would likely not trigger symptoms in an allergic patient. However, the following article in the same issue of the Journal of Allergy and Clinical Immunology by the same group indicates that environmental peanut protein is biologically active and therefore has the potential to contribute to sensitization. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2014–1817JJ
Mitchell R. Lester, MD Norwalk, CT
PEDIATRICS Volume 134, Supplement 3, November 2014
S153
