1/6/11

Management of Children With Food Allergy: Current Trends and Updates

Chiang Wen Chin, BMedSci, MBBS (Nott), MRCPCH (Lon), FAMS (Singapore); A Wesley Burks, MD



INTRODUCTION

In the last two decades, the prevalence of food allergy has been on the rise.1,2 Recent obser vations that Asian immigrants in North America and Europe have equal or even increased rates of food hypersensitivity compared with their Western counterparts pose a worrying possibility that, with the urbanization and Westernization of Asia, this has resulted in the in creased prevalence of food allergy.3 The increase in food hypersensitivity expanding to areas of the world where the general awareness of food allergies is relatively low requires attention. In a recent survey in Singapore and the Philippines, the prevalence of peanut allergy appears to be low in both populations—prevalence of 0.3–0.6% in local 4- to 6-year-old children, as compared with 1.2% in the expatriate children (especially those born in the West) residing in Singapore.4 Conversely, shellfish allergy was more common in the local Singapore children (4–6 years, 1.19%) compared with expatriate children (4–6 years, 0.55%). This observation was also seen in symptomatic food allergic individuals presenting for evaluation, in which peanut sen sitization was the third most common food allergen (present in 27% of subjects) after shellfish sensitization (39% of subjects).5




CLINICAL SYMPTOMS OF FOOD ALLERGY

Different food allergens differ in their food-eliciting reaction profile as well as their prognosis (Table 1).6 Diagnosing a food allergy requires a history of symptoms and their time of onset after eating, the food or foods eaten prior to the onset of symptoms, the amount of each food eaten, and whether similar reactions have occurred on previous ingestions. Symptoms typically appear within min utes to two hours after a person has eaten the food. Symptoms of food allergy can include a tingling sensation in the mouth, swelling of the tongue and throat, rash, eczema, urticaria, vomiting, abdominal cramps, diarrhoea, wheezing, difficulty breathing, drop in blood pressure, loss of consciousness, and (very rarely) death.

DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY

There are two tests most commonly used for the diagnosis of food allergy—skin prick test and se rum specific IgE levels. These tests have excellent negative predictive values but are less than 50% in their positive predictive values.7 These diagnostic values (skin prick test or specific IgE) are helpful to the physician in deciding if a food challenge is safe or potentially harmful to the patients, based on various predictive threshold studies by various authors. Unfortunately, differences in diagnostic threshold values exist between study populations, as the age of food challenge and regional differenc es are not often comparable between the studies. Therefore, the allergist combines the available test results along with the medical history to make a food allergy diagnosis. In some cases, the allergist may deem the patient to be at high risk for food-related anaphylaxis, and the patient is advised to continue strict avoidance of the allergen and coun selled to carry an adrenaline auto-injector. In cases in which the food allergy needs to be confirmed, food challenges in the form of open challenges or double-blind food challenges to determine if the child has outgrown the food allergy should be con ducted in places that have adequate facilities to manage food-related anaphylaxis.
However, unlike other allergic diseases, food allergy is the only disorder for which there is no specific therapy available in clinical practice, with dietary avoidance as the only alternative. In fact, food-induced anaphylaxis is now the most common cause of anaphylaxis evaluated at the children’s hospital in Singapore.8
In a recent survey carried out in KK Women’s and Children’s Hospital in Singapore, a survey of 123 local Asian patients with peanut sensitiza tion revealed that 79.7% (98/123) of our patients had ingested peanuts. Of these patients, 83.7% (82/98) developed a reaction and 16.3% (16/98) did not. Of the 82 patients who reacted to peanut, 96.3% (79/82) had skin symptoms, 39.0% (32/82) respiratory, 13.4% (11/82) gastrointestinal, and 4.9% (4/82) systemic involvement. Most (41.5%; 34/82) sought treatment at primary care facilities, 19.5% (16/82) went to the emergency department, and 2.4% (2/82) required hospital admission. Only two children had an adrenaline injection during their first peanut allergic reaction. More than 56% (46/82) had accidental ingestions with peanuts, of which 43.5% (20/46) had more severe reactions and four patients developed anaphylaxis. The sever­ity of peanut reaction in this population of peanut sensitized patients is significant with almost 43% (35/82) of patients having two or more systems in volved after ingestion of peanut.9
The low use of epinephrine in the emergency care setting and the low rate of patient awareness of the correct use of the EpiPen as seen on questionnaire responses in our population of children poses a challenge to treating this potentially life-threatening scenario. As noted in other publica tions, risk of accidental ingestion in peanut-allergic patients is high, ranging from 50% to 86%.10,11 Ef forts must be made to educate our population and to increase the awareness of food allergy and its treatment, especially in the use of EpiPen in the case of anaphylaxis.
The prevalence of repeated reactions second ary to ‘accidental peanut ingestions’ after the di-agnosis of peanut allergy/sensitization was more than 56%, with half of these reactions reported to be more severe than the first symptomatic food re action. Both the clinical characteristics and peanut protein-specific allergen determination suggest a phenotype that is similar to that of European and North American patients.12 Dietary avoidance is the current standard of care, but accidental ingestions of food allergens are common because of the ubiq uitous presence of certain foods, such as peanut, milk, egg and shellfish. This problem is compound-ed by poor labelling practices in the Asia Pacific region (with the exception of Australia and Japan where labelling laws exists) and cross-contami nation during processing, which is not regulated. Furthermore, in cases of multiple food allergies, restricted diets may result in unbalanced nutrition and pose a considerable hardship to the family of a food-allergic child.
Therefore, accurate diagnosis of food allergy is of utmost importance and currently relies on oral food challenges which are not without substantial risks and should be conducted in places that have adequate facilities to manage food-related anaphy laxis. Considering the severity of food allergy as well as its increasing prevalence, improved diag nostic tests and definitive therapies are desirable. This case study and article reviews the recent de velopments in the diagnosis, management and po tential treatments for food allergy.

FUTURE TRENDS IN MANAGEMENT OF FOOD ALLERGY

An area of significant interest in recent years is the use of food oral immunotherapy (OIT) in the management of food allergy. Animal studies sug gest that the high-dose feeding of an antigen re sults in the state of non-responsiveness due to an ergy or deletion of antigen-specific T lymphocytes, whereas continuous low-dose ingestion may induce protective suppressive responses from regulatory T cells.13 Increasingly, evidence from multiple clinical trials have demonstrated that OIT induces ‘desensi tization’ and possible permanent oral tolerance. In a desensitized state, the protective effect depends on the daily, uninterrupted ingestion of the food al lergen; however, when the dosing is interrupted, the protective effect may be lost or significantly de creased. Oral tolerance, however, persists despite the discontinuation of the daily ingestion of food allergen, and the individual can tolerate exposure to the food allergen at anytime. There are a number of allergic side effects to the treatment; up to 20% of individuals may not tolerate the OIT regimen. The immunological effects of OIT include: (1) decreased skin prick tests to the food by 1 year, (2) a change in the allergen-specific response by basophils by 6 months, (3) an initial rise in allergen-specific IgE, followed by a decrease by 18–24 months, (4) an in crease in allergen-specific IgG4, and (5) changes in the Th2 (allergic) cytokines over 36 months of treat­ment. More will be learned in the next few years as we wait to see if this type of therapy is appropriate for food allergy.






ROLE OF PRIMARY PREVENTION OF FOOD ALLERGY: WEANING IN INFANTS

Weaning guidelines have been revised in recent years with a reversal in policy advice in several countries with respect to the optimal timing of complementary food introduction in infants.14 There is insufficient evidence for delaying introduction of solid foods, including potentially allergenic foods, beyond 4–6 months of age, even in infants at risk of developing allergic disease.15–17 The premise for this is that restricting developmentally appropriate solid food variety beyond age 6 months can lead to inadequate nutrient intake, growth deficits, and feeding problems (such as oral food aversion). If the patient develops an allergic reaction, appropriate review by a specialist physician to help in the di agnostic workup and advice for food elimination or reintroduction is advised.
There is consistent evidence that breastfeed ing for at least 4 months, compared with feeding formula made with intact cow milk protein, pre vents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood.18 In studies of infants at high risk for atopy and who are not exclusively breastfed for 4–6 months, there is modest evidence that atopic dermatitis may be prevented in more subjects by the use of hydrolysed formulas compared with formula made with intact cow milk protein. However, no significant differ ence for asthma, allergic rhinitis and food allergy outcomes were noted.19 Comparative studies of the various hydrolysed formulas presently available also indicate that not all formulas have the same protective benefit.20
Some supporting evidence for the above guideline changes is the worrying observation that the prevalence of peanut allergy in children in the UK and North America has doubled over 10 years and approximates 1.8% and 1.2%, respectively.21,22 This occurred despite avoidance of peanuts in preg-nancy and early life in an attempt to prevent peanut allergy for the last two decades. Moreover, recent epidemiological work has shown that peanut al lergy was some 10 times less common in Jewish populations living in Israel where regular exposure to peanut-containing foods in early life is the norm, compared with Jewish origin populations in the UK where peanut ingestion is far less common.23 This has led to the suggestion that early oral exposure to food allergens may be important to induce oral tolerance to foods.
In light of the present evidence available, it is postulated that a ‘window of opportunity’ for the introduction of different food allergens ex ists. This timing may differ between allergens, in a small subset of individuals at risk of developing food allergy, and is influenced by additional envi ronmental and genetic factors. Hence, we would advise that a general cautionary attitude needs be adopted and further studies are needed before a blanket recommendation of weaning strategies to the general population can be implemented to the at-risk population. Preferably, these studies will be of a prospective interventional design in at-risk and non-at-risk populations and in children with diverse genetic and cultural backgrounds
About the Authors
Dr Chiang is Consultant at the Allergy and Immunology Service, Department of Paediatrics, KK Women’s and Children’s Hospi tal, Singapore. Dr Burks is Professor at the Division of Pediatric Allergy and Immunology, Duke University Medical Center in the United States.
Acknowledgement
This paper was made possible through a collaboration between KK Women’s and Children’s Hospital (KKH) and the Journal of Paediatrics, Obstetrics and Gynaecology. KKH is the largest medical facility in Singapore which provides specialized care for women, babies and children.

REFERENCES

  1. Grundy J, Matthews S, Bateman B, et al. Rising prevalence of allergy to peanut in children: data from 2 sequential cohorts. J Allergy Clin Immunol 2002;110:784–789.
  2. Kagan RS, Joseph L, Dufresne C, et al. Preva lence of peanut allergy in primary-school children in Montreal, Canada. J Allergy Clin Immunol 2003;112:1223–1228.
  3. Cataldo F, Accomando S, Fragapane ML, et al. Are food intolerances and allergies increasing in immigrant children coming from developing coun tries? Pediatr Allergy Immunol 2006;17:364–369.
  4. Shek LP, Cabrera-Morales EA, Soh SE, et al. A population-based questionnaire survey on the prevalence of peanut, tree nut, and shellfish allergy in 2 Asian populations. J Allergy Clin Immunol 2010;126:324–331, 331.
  5. Chiang WC, Kidon MI, Liew WK, et al. The changing face of food hypersensitivity in an Asian community. Clin Exp Allergy 2007;37:1055–1061.
  6. Lee BW, Aw M, Chiang WC, et al. Academy of Medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy. Singapore Med J 2010;51:599–607.
  7. Sampson HA. Food allergy – accurately iden tifying clinical reactivity. Allergy 2005;60(suppl 79):19–24.
  8. Liew WK, Chiang WC, Goh A, et al. Changing face of paediatric anaphylaxis. Poster presented at: 8th Asia Pacific Congress of Allergy, Asthma and Clinical Immunology; 6–9 November 2010; Singapore.
  9. Chiang WC, Goh SH, Liew WK, et al. Clinical characteristics in children with peanut allergy. Poster presented at: 29th Congress of the European Academy of Allergy and Clinical Immunology; 5–9 June 2010; London, UK.
  10. Hourihane JO, Kilburn SA, Dean P, et al. Clinical characteristics of peanut allergy. Clin Exp Allergy 1997;27:634–639.
  11. Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998;102:e6.
  12. Chiang WC, Pons L, Kidon MI, et al. Serological and clinical characteristics of children with peanut sensitization in an Asian community. Pediatr Allergy Immunol 2010;21:e429–e438.
  13. Chehade M, Mayer L. Oral tolerance and its relation to food hypersensitivities. J Allergy Clin Immunol 2005;115:3–12.
  14. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydro lyzed formulas. Pediatrics 2008;121:183–191.
  15. Fiocchi A, Assa’ad A, Bahna S. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 2006;97:10–20.
  16. Host A, Koletzko B, Dreborg S, et al. Dietary products used in infants for treatment and preven tion of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediat ric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child 1999;81:80–84.
  17. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydro lyzed formulas. Pediatrics 2008;121:183–191.
  18. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2006;(3):CD000133.
  19. von Berg A, Filipiak-Pittroff B, Kramer U, et al. Preventive effect of hydrolyzed infant formulas persists until age 6 years: long-term results from the German Infant Nutritional Intervention Study (GINI). J Allergy Clin Immunol 2008;121:1442–1447.
  20. Osborn DA, Sinn J. Formulas containing hydro lysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006;(4):CD003664.
  21. Hourihane JO, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol 2007;119:1197–1202.
  22. Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study. J Allergy Clin Immunol 2003;112:1203–1207.
  23. Du TG, Katz Y, Sasieni P, et al. Early consump tion of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122:984–991.

Source :
http://www.mims.com/Page.aspx?menuid=PublicationTopic&PubGroup=JPOG&Publication=JPOG&Issue=2010-12&Topic=Management+of+Children+With+Food+Allergy:+Current+Trends+and+Updates&PubGroupCountry=HK,%20ID,%20MY,%20PH,%20SG,%20TH,%20TW,%20VN&HT=8af3b118475f538ccaff52d3ad836000

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1/6/11

Management of Children With Food Allergy: Current Trends and Updates

Chiang Wen Chin, BMedSci, MBBS (Nott), MRCPCH (Lon), FAMS (Singapore); A Wesley Burks, MD



INTRODUCTION

In the last two decades, the prevalence of food allergy has been on the rise.1,2 Recent obser vations that Asian immigrants in North America and Europe have equal or even increased rates of food hypersensitivity compared with their Western counterparts pose a worrying possibility that, with the urbanization and Westernization of Asia, this has resulted in the in creased prevalence of food allergy.3 The increase in food hypersensitivity expanding to areas of the world where the general awareness of food allergies is relatively low requires attention. In a recent survey in Singapore and the Philippines, the prevalence of peanut allergy appears to be low in both populations—prevalence of 0.3–0.6% in local 4- to 6-year-old children, as compared with 1.2% in the expatriate children (especially those born in the West) residing in Singapore.4 Conversely, shellfish allergy was more common in the local Singapore children (4–6 years, 1.19%) compared with expatriate children (4–6 years, 0.55%). This observation was also seen in symptomatic food allergic individuals presenting for evaluation, in which peanut sen sitization was the third most common food allergen (present in 27% of subjects) after shellfish sensitization (39% of subjects).5




CLINICAL SYMPTOMS OF FOOD ALLERGY

Different food allergens differ in their food-eliciting reaction profile as well as their prognosis (Table 1).6 Diagnosing a food allergy requires a history of symptoms and their time of onset after eating, the food or foods eaten prior to the onset of symptoms, the amount of each food eaten, and whether similar reactions have occurred on previous ingestions. Symptoms typically appear within min utes to two hours after a person has eaten the food. Symptoms of food allergy can include a tingling sensation in the mouth, swelling of the tongue and throat, rash, eczema, urticaria, vomiting, abdominal cramps, diarrhoea, wheezing, difficulty breathing, drop in blood pressure, loss of consciousness, and (very rarely) death.

DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY

There are two tests most commonly used for the diagnosis of food allergy—skin prick test and se rum specific IgE levels. These tests have excellent negative predictive values but are less than 50% in their positive predictive values.7 These diagnostic values (skin prick test or specific IgE) are helpful to the physician in deciding if a food challenge is safe or potentially harmful to the patients, based on various predictive threshold studies by various authors. Unfortunately, differences in diagnostic threshold values exist between study populations, as the age of food challenge and regional differenc es are not often comparable between the studies. Therefore, the allergist combines the available test results along with the medical history to make a food allergy diagnosis. In some cases, the allergist may deem the patient to be at high risk for food-related anaphylaxis, and the patient is advised to continue strict avoidance of the allergen and coun selled to carry an adrenaline auto-injector. In cases in which the food allergy needs to be confirmed, food challenges in the form of open challenges or double-blind food challenges to determine if the child has outgrown the food allergy should be con ducted in places that have adequate facilities to manage food-related anaphylaxis.
However, unlike other allergic diseases, food allergy is the only disorder for which there is no specific therapy available in clinical practice, with dietary avoidance as the only alternative. In fact, food-induced anaphylaxis is now the most common cause of anaphylaxis evaluated at the children’s hospital in Singapore.8
In a recent survey carried out in KK Women’s and Children’s Hospital in Singapore, a survey of 123 local Asian patients with peanut sensitiza tion revealed that 79.7% (98/123) of our patients had ingested peanuts. Of these patients, 83.7% (82/98) developed a reaction and 16.3% (16/98) did not. Of the 82 patients who reacted to peanut, 96.3% (79/82) had skin symptoms, 39.0% (32/82) respiratory, 13.4% (11/82) gastrointestinal, and 4.9% (4/82) systemic involvement. Most (41.5%; 34/82) sought treatment at primary care facilities, 19.5% (16/82) went to the emergency department, and 2.4% (2/82) required hospital admission. Only two children had an adrenaline injection during their first peanut allergic reaction. More than 56% (46/82) had accidental ingestions with peanuts, of which 43.5% (20/46) had more severe reactions and four patients developed anaphylaxis. The sever­ity of peanut reaction in this population of peanut sensitized patients is significant with almost 43% (35/82) of patients having two or more systems in volved after ingestion of peanut.9
The low use of epinephrine in the emergency care setting and the low rate of patient awareness of the correct use of the EpiPen as seen on questionnaire responses in our population of children poses a challenge to treating this potentially life-threatening scenario. As noted in other publica tions, risk of accidental ingestion in peanut-allergic patients is high, ranging from 50% to 86%.10,11 Ef forts must be made to educate our population and to increase the awareness of food allergy and its treatment, especially in the use of EpiPen in the case of anaphylaxis.
The prevalence of repeated reactions second ary to ‘accidental peanut ingestions’ after the di-agnosis of peanut allergy/sensitization was more than 56%, with half of these reactions reported to be more severe than the first symptomatic food re action. Both the clinical characteristics and peanut protein-specific allergen determination suggest a phenotype that is similar to that of European and North American patients.12 Dietary avoidance is the current standard of care, but accidental ingestions of food allergens are common because of the ubiq uitous presence of certain foods, such as peanut, milk, egg and shellfish. This problem is compound-ed by poor labelling practices in the Asia Pacific region (with the exception of Australia and Japan where labelling laws exists) and cross-contami nation during processing, which is not regulated. Furthermore, in cases of multiple food allergies, restricted diets may result in unbalanced nutrition and pose a considerable hardship to the family of a food-allergic child.
Therefore, accurate diagnosis of food allergy is of utmost importance and currently relies on oral food challenges which are not without substantial risks and should be conducted in places that have adequate facilities to manage food-related anaphy laxis. Considering the severity of food allergy as well as its increasing prevalence, improved diag nostic tests and definitive therapies are desirable. This case study and article reviews the recent de velopments in the diagnosis, management and po tential treatments for food allergy.

FUTURE TRENDS IN MANAGEMENT OF FOOD ALLERGY

An area of significant interest in recent years is the use of food oral immunotherapy (OIT) in the management of food allergy. Animal studies sug gest that the high-dose feeding of an antigen re sults in the state of non-responsiveness due to an ergy or deletion of antigen-specific T lymphocytes, whereas continuous low-dose ingestion may induce protective suppressive responses from regulatory T cells.13 Increasingly, evidence from multiple clinical trials have demonstrated that OIT induces ‘desensi tization’ and possible permanent oral tolerance. In a desensitized state, the protective effect depends on the daily, uninterrupted ingestion of the food al lergen; however, when the dosing is interrupted, the protective effect may be lost or significantly de creased. Oral tolerance, however, persists despite the discontinuation of the daily ingestion of food allergen, and the individual can tolerate exposure to the food allergen at anytime. There are a number of allergic side effects to the treatment; up to 20% of individuals may not tolerate the OIT regimen. The immunological effects of OIT include: (1) decreased skin prick tests to the food by 1 year, (2) a change in the allergen-specific response by basophils by 6 months, (3) an initial rise in allergen-specific IgE, followed by a decrease by 18–24 months, (4) an in crease in allergen-specific IgG4, and (5) changes in the Th2 (allergic) cytokines over 36 months of treat­ment. More will be learned in the next few years as we wait to see if this type of therapy is appropriate for food allergy.






ROLE OF PRIMARY PREVENTION OF FOOD ALLERGY: WEANING IN INFANTS

Weaning guidelines have been revised in recent years with a reversal in policy advice in several countries with respect to the optimal timing of complementary food introduction in infants.14 There is insufficient evidence for delaying introduction of solid foods, including potentially allergenic foods, beyond 4–6 months of age, even in infants at risk of developing allergic disease.15–17 The premise for this is that restricting developmentally appropriate solid food variety beyond age 6 months can lead to inadequate nutrient intake, growth deficits, and feeding problems (such as oral food aversion). If the patient develops an allergic reaction, appropriate review by a specialist physician to help in the di agnostic workup and advice for food elimination or reintroduction is advised.
There is consistent evidence that breastfeed ing for at least 4 months, compared with feeding formula made with intact cow milk protein, pre vents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood.18 In studies of infants at high risk for atopy and who are not exclusively breastfed for 4–6 months, there is modest evidence that atopic dermatitis may be prevented in more subjects by the use of hydrolysed formulas compared with formula made with intact cow milk protein. However, no significant differ ence for asthma, allergic rhinitis and food allergy outcomes were noted.19 Comparative studies of the various hydrolysed formulas presently available also indicate that not all formulas have the same protective benefit.20
Some supporting evidence for the above guideline changes is the worrying observation that the prevalence of peanut allergy in children in the UK and North America has doubled over 10 years and approximates 1.8% and 1.2%, respectively.21,22 This occurred despite avoidance of peanuts in preg-nancy and early life in an attempt to prevent peanut allergy for the last two decades. Moreover, recent epidemiological work has shown that peanut al lergy was some 10 times less common in Jewish populations living in Israel where regular exposure to peanut-containing foods in early life is the norm, compared with Jewish origin populations in the UK where peanut ingestion is far less common.23 This has led to the suggestion that early oral exposure to food allergens may be important to induce oral tolerance to foods.
In light of the present evidence available, it is postulated that a ‘window of opportunity’ for the introduction of different food allergens ex ists. This timing may differ between allergens, in a small subset of individuals at risk of developing food allergy, and is influenced by additional envi ronmental and genetic factors. Hence, we would advise that a general cautionary attitude needs be adopted and further studies are needed before a blanket recommendation of weaning strategies to the general population can be implemented to the at-risk population. Preferably, these studies will be of a prospective interventional design in at-risk and non-at-risk populations and in children with diverse genetic and cultural backgrounds
About the Authors
Dr Chiang is Consultant at the Allergy and Immunology Service, Department of Paediatrics, KK Women’s and Children’s Hospi tal, Singapore. Dr Burks is Professor at the Division of Pediatric Allergy and Immunology, Duke University Medical Center in the United States.
Acknowledgement
This paper was made possible through a collaboration between KK Women’s and Children’s Hospital (KKH) and the Journal of Paediatrics, Obstetrics and Gynaecology. KKH is the largest medical facility in Singapore which provides specialized care for women, babies and children.

REFERENCES

  1. Grundy J, Matthews S, Bateman B, et al. Rising prevalence of allergy to peanut in children: data from 2 sequential cohorts. J Allergy Clin Immunol 2002;110:784–789.
  2. Kagan RS, Joseph L, Dufresne C, et al. Preva lence of peanut allergy in primary-school children in Montreal, Canada. J Allergy Clin Immunol 2003;112:1223–1228.
  3. Cataldo F, Accomando S, Fragapane ML, et al. Are food intolerances and allergies increasing in immigrant children coming from developing coun tries? Pediatr Allergy Immunol 2006;17:364–369.
  4. Shek LP, Cabrera-Morales EA, Soh SE, et al. A population-based questionnaire survey on the prevalence of peanut, tree nut, and shellfish allergy in 2 Asian populations. J Allergy Clin Immunol 2010;126:324–331, 331.
  5. Chiang WC, Kidon MI, Liew WK, et al. The changing face of food hypersensitivity in an Asian community. Clin Exp Allergy 2007;37:1055–1061.
  6. Lee BW, Aw M, Chiang WC, et al. Academy of Medicine, Singapore-Ministry of Health clinical practice guidelines: management of food allergy. Singapore Med J 2010;51:599–607.
  7. Sampson HA. Food allergy – accurately iden tifying clinical reactivity. Allergy 2005;60(suppl 79):19–24.
  8. Liew WK, Chiang WC, Goh A, et al. Changing face of paediatric anaphylaxis. Poster presented at: 8th Asia Pacific Congress of Allergy, Asthma and Clinical Immunology; 6–9 November 2010; Singapore.
  9. Chiang WC, Goh SH, Liew WK, et al. Clinical characteristics in children with peanut allergy. Poster presented at: 29th Congress of the European Academy of Allergy and Clinical Immunology; 5–9 June 2010; London, UK.
  10. Hourihane JO, Kilburn SA, Dean P, et al. Clinical characteristics of peanut allergy. Clin Exp Allergy 1997;27:634–639.
  11. Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics 1998;102:e6.
  12. Chiang WC, Pons L, Kidon MI, et al. Serological and clinical characteristics of children with peanut sensitization in an Asian community. Pediatr Allergy Immunol 2010;21:e429–e438.
  13. Chehade M, Mayer L. Oral tolerance and its relation to food hypersensitivities. J Allergy Clin Immunol 2005;115:3–12.
  14. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydro lyzed formulas. Pediatrics 2008;121:183–191.
  15. Fiocchi A, Assa’ad A, Bahna S. Food allergy and the introduction of solid foods to infants: a consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 2006;97:10–20.
  16. Host A, Koletzko B, Dreborg S, et al. Dietary products used in infants for treatment and preven tion of food allergy. Joint Statement of the European Society for Paediatric Allergology and Clinical Immunology (ESPACI) Committee on Hypoallergenic Formulas and the European Society for Paediat ric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition. Arch Dis Child 1999;81:80–84.
  17. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydro lyzed formulas. Pediatrics 2008;121:183–191.
  18. Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2006;(3):CD000133.
  19. von Berg A, Filipiak-Pittroff B, Kramer U, et al. Preventive effect of hydrolyzed infant formulas persists until age 6 years: long-term results from the German Infant Nutritional Intervention Study (GINI). J Allergy Clin Immunol 2008;121:1442–1447.
  20. Osborn DA, Sinn J. Formulas containing hydro lysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev 2006;(4):CD003664.
  21. Hourihane JO, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol 2007;119:1197–1202.
  22. Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study. J Allergy Clin Immunol 2003;112:1203–1207.
  23. Du TG, Katz Y, Sasieni P, et al. Early consump tion of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122:984–991.

Source :
http://www.mims.com/Page.aspx?menuid=PublicationTopic&PubGroup=JPOG&Publication=JPOG&Issue=2010-12&Topic=Management+of+Children+With+Food+Allergy:+Current+Trends+and+Updates&PubGroupCountry=HK,%20ID,%20MY,%20PH,%20SG,%20TH,%20TW,%20VN&HT=8af3b118475f538ccaff52d3ad836000

regards, taniafdi ^_^
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