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Assessing eczema and food allergy in young children
Linköping University, Department of Clinical and Experimental Medicine, Pediatrics . Linköping University, Faculty of Health Sciences.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Atopic disease is an increasing problem. Eczema affects 10-20% of young children, and 33-37% of children with eczema are food allergic. Among other factors, nitric oxide (NO) is thought to play a role in eczema and food allergy. Following the atopic march, pproximately 80% of children with atopic eczema will become sensitized to aeroallergens and develop asthma and/or allergic rhinitis. Skin prick test is used for investigating sensitization and is considered a safe method. However, systemic allergic reactions may appear when the test is performed. In diagnosing food allergy and for evaluating achievement of tolerance, the oral food challenge is the method of choice, and the double-blind placebocontrolled fashion is 'the gold standard'.

Skin prick test: We examined six cases of generalized allergic reactions in connection with skin prick testing in order to identify risk factors, and thereby increase safety, and we investigated the necessity of performing skin prick tests in duplicate. We found that all six children with generalized reactions were <6 months of age. When analyzing skin prick tests in duplicate, we found only 1.3% that showed diverging results, and in infants <6 months even fewer, 0.9%.

Food challenge: We developed recipes and a protocol for low-dose oral food challenge to milk and egg to be used in young children outgrowing their food allergy so as to facilitate early re-/introduction of small amounts of milk and egg. We performed 52 challenges, both open and double-blind placebo controlled. The recipes were validated for blinding. The lowdose challenge was tolerated well by the children and was easy to perform. Four children had a positive challenge outcome, all reacting to very small amounts of milk. All but two of the non-reacting children were able to introduce milk and egg into their diet.

Nitric oxide and eczema: We investigated the effect of eczema treatment on the NO levels in urine. The sum of nitrite and nitrate was measured in urinary samples from 94 infants at two visits, with an interval of 6 weeks, and the results were compared with clinical data. The levels of NO products increased significantly when the eczema improved.

The atopic march: The aim was to evaluate the atopic march in children with eczema, from referral at <2 years until 4½ years of age. We followed 123 children with eczema, 78 sensitized and 45 not sensitized to milk and/or egg, with respect to eczema severity, other allergic manifestations, development of airway sensitization, and achievement of food tolerance. The difference in severity of eczema at referral was significant when comparing food-sensitized with non-sensitized children. At follow-up, 62% were still affected by eczema, although 56% only mildly so. Tolerance was achieved in 81% of the children allergic to milk and 68% of those allergic to egg. Fifty-eight percent of the food-sensitized children and 26% of the non-sensitized children had become sensitized to aeroallergens, a significant difference. The difference in airway symptoms was not significant. Very few children were exposed to tobacco smoke in their homes.

Conclusions: Increased precautions should be considered when performing skin prick tests in infants <6 months of age. The use of a single prick, to avoid the risk of summation of reactions, is justified when performing skin prick tests. We report recipes and a protocol for standardized open and double-blind placebo-controlled low-dose food challenge in young children, enabling the introduction of small amounts of egg and milk into the diet during tolerance development. NO products in urine increases when eczema improves. This might be due to a Th2/Th1 shift induced by the eczema treatment and skin healing, and the variation in NO response may be due to individual variations in NO-induced feedback downregulation of Th1 and Th2 proliferation. The prognosis for achieving clinical tolerance is very good in children early sensitized and allergic to milk and egg, but they will become significantly more often sensitized to aeroallergens.

Place, publisher, year, edition, pages
Institutionen för molekylär och klinisk medicin , 2006.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 932
Keyword [en]
atopy, eczema, food allergy, nitric oxide, oral food challenge, skin prick test
National Category
Pediatrics
Identifiers
URN: urn:nbn:se:liu:diva-7128ISBN: 91-85497-67-3 (print)OAI: oai:DiVA.org:liu-7128DiVA: diva2:22209
Public defence
2006-01-27, Eken, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2006-09-05 Created: 2006-09-05 Last updated: 2009-08-22
List of papers
1. Skin prick tests may give generalized allergic reactions in infants
Open this publication in new window or tab >>Skin prick tests may give generalized allergic reactions in infants
2000 (English)In: Annals of Allergy, Asthma & Immunology, ISSN 1081-1206, Vol. 85, no 6, 457-460 p.Article in journal (Refereed) Published
Abstract [en]

Background: Skin prick testing, a widely used method of studying sensitization, is usually considered quick, pedagogic, and relatively inexpensive. Previous studies have shown very few negative reactions and no fatalities. In contrast, both anaphylaxis and death have been reported as a result of intracutaneous tests.

Objective: To examine detailed case studies of generalized allergic reactions in connection with skin prick testing in order to identify possible risk factors and thereby increase the safety of the test procedure.

Method: A retrospective study of medical records of six cases with generalized allergic reaction occurring during the study period 1996-1998 at the Pediatric Clinic, University Hospital of Linköping, Sweden. Data about the total number of children tested during the period were collected from the clinic's database.

Results: All six cases with generalized reactions were infants <6 months who showed positive skin prick tests to fresh food specimen. Other common features were active eczema and a family history of allergic disease. All infants received prompt treatment and recovered well. The overall rate of generalized reactions was 521 per 100,000 tested children. In the age group <6 months, the corresponding figure was 6522 per 100,000.

Conclusion: The risk of generalized reactions after skin prick test with fresh food specimens in young children ought to be acknowledged and should lead to increased precautions when performing the test.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13929 (URN)
Available from: 2006-09-05 Created: 2006-09-05 Last updated: 2009-08-17
2. Skin prick test in duplicate: is it necessary?
Open this publication in new window or tab >>Skin prick test in duplicate: is it necessary?
2001 (English)In: Annals of Allergy, Asthma & Immunology, ISSN 1081-1206, Vol. 87, no 5, 386-389 p.Article in journal (Refereed) Published
Abstract [en]

Background: Duplicate skin prick testing has previously been recommended because of reports that accidental negative tests are common. However, duplicate tests also mean an extra allergen load, which may increase the risk of inducing a generalized reaction at the test situation, at least in the youngest infants.

Objective: To investigate whether the occurrence of both a positive and negative test result is a common feature when performing duplicate skin prick tests and can therefore justify the duplicate method.

Methods: A retrospective analysis of all skin prick tests performed in duplicate at the pediatric clinic at University Hospital in Linköping, Sweden, in 1997.

Results: Of 1,087 skin prick tests, 14 resulted in one positive and one negative test, or 1.3%. The corresponding figure in the youngest age group, (ie, <2 years of age) was 3 of 340 (0.9%).

Conclusions: Considering the risk of inducing a summation of the reactions, and thereby a generalized allergic reaction, when applying an extra allergen load on the limited surface of the small arm, we conclude that the results of this study justify using single prick test, at least in the youngest age group and probably when testing children of all ages.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13930 (URN)
Available from: 2006-09-05 Created: 2006-09-05 Last updated: 2009-08-17
3. A new model for low-dose food challenge in children with allergy to milk and egg
Open this publication in new window or tab >>A new model for low-dose food challenge in children with allergy to milk and egg
Show others...
2006 (English)In: Acta Paediatrica, ISSN 0803-5253, Vol. 95, no 9, 1133-1139 p.Article in journal (Refereed) Published
Abstract [en]

Background: Atopic eczema and food allergy are common in early childhood. Children seem to gradually develop tolerance to milk and egg, and it is a relief for families when their child can tolerate small amounts of these basic foods, even if larger doses may still cause symptoms. Aim: To develop a model for low-dose oral food challenge, facilitating re-/introduction of milk or egg. Methods: In 39 children sensitized to milk and/or egg, we performed 52 challenges using a new standardized model for low-dose oral food challenge. The recipes were validated for blinding with sensorial tests. Results: Four children challenged to milk had a positive challenge outcome. There were no significant differences with respect to family history, associated atopic manifestations, nutritional supply, eczema severity, or skin-prick test compared with the non-reacting children, but total and specific IgE values were significantly higher. All but two of the non-reacting children were able to introduce milk and egg into their diet without problems.

Conclusion: We report recipes and a protocol to be used for standardized open and double-blind placebo-controlled low-dose food challenge in young children, enabling the introduction of small amounts of egg and milk into the diet during tolerance development.

Keyword
Atopic eczema; double-blind; food allergy; food challenge; skin-prick test
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-14561 (URN)10.1080/08035250500516672 (DOI)
Available from: 2007-06-19 Created: 2007-06-19 Last updated: 2009-03-30
4. Urinary nitric oxide excretion in infants with eczema
Open this publication in new window or tab >>Urinary nitric oxide excretion in infants with eczema
Show others...
2010 (English)In: Pediatric Allergy and Immunology, ISSN 0905-6157, E-ISSN 1399-3038, Vol. 21, no 1, e229-e234 p.Article in journal (Refereed) Published
Abstract [en]

Eczema is characterized by inflammation of the skin and is commonly associated with food allergy. It has been suggested that nitric oxide (NO) is an important player in eczema, food allergy and intestinal inflammation. The aim of this study was to assess the levels of urinary NO breakdown products in infants with eczema and the effect of eczema treatment on NO levels. Ninety-four infants with eczema, 58 boys and 36 girls, with a mean age of 7.5 ± 5.2 months (mean ± s.d.) at inclusion were examined twice with an interval of 6 wk. The sum of nitrite and nitrate was measured colorimetrically in urinary samples from both visits and compared with clinical data concerning eczema severity, nutrition, gastrointestinal symptoms, asthma and skin prick positivity. The levels of NO products increased significantly from the first to the second visit: 289; 374 μm (median; IQR) vs. 457; 678 μm (median; IQR) (p < 0.001) in parallel with a significant improvement of the eczema. After eczema treatment consisting of skin care and elimination diet during the 6-wk interval between evaluations, the NO levels approached the values previously found in healthy children. The results support previous studies indicating that the homeostasis of nitrogen radicals is disturbed in childhood eczema.

Keyword
paediatric • eczema • clinical immunology • nitric oxide
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13932 (URN)10.1111/j.1399-3038.2009.00892.x (DOI)000276186200019 ()19725898 (PubMedID)
Note

Tidigare titel: Nitric oxide urinary products in infants with eczema This is the authors’ version of the following article: which has been published in final form at:Irene Devenney, Gunilla Norrman, Tony Forslund, Karin Fälth-Magnusson and Tommy Sundqvist, Urinary nitric oxide excretion in infants with eczema., 2010, Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology, (21), 1, E229-E234which has been published in final form at: http://dx.doi.org/10.1111/j.1399-3038.2009.00892.xCopyright: Wiley-Blackwell

Available from: 2006-09-05 Created: 2006-09-05 Last updated: 2017-12-13
5. Eczema in infancy and the atopic march
Open this publication in new window or tab >>Eczema in infancy and the atopic march
Manuscript (Other academic)
Identifiers
urn:nbn:se:liu:diva-13933 (URN)
Available from: 2006-09-05 Created: 2006-09-05 Last updated: 2010-01-13

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