This Synopsis Book provides reviews on a diverse array of allergy and immunology topics whose authors aim to increase understanding and advance management of allergic and immunologic disorders impacting children. These insights can serve to support change or reaffirm our current clinical practice, ensuring that we are optimizing care and outcomes for our patients. Reviewers have highlighted articles that address diagnosis and management, have also identified studies that can inform on modifiable risk factors, and suggest further investigations that may lead to novel prevention strategies and therapeutic targets.
Allergic disorders affect a large number of children, with significant effects on physical health, socioeconomic impact, and quality of life. Therefore, there continues to be much interest in identifying risk factors for the development of these disorders. Several studies in this Synopsis explore potential influence of diet, environmental exposures, and early antibiotic use. Others examine types of viral infections experienced in early life and their effects on lung health and wheezing. The microbiome has been a focus for a number years, and researchers of some studies have investigated probiotic and symbiotic supplementation as a prevention approach. Two such studies reviewed in this Synopsis reveal lack of benefit of supplementation in altering the development of allergy.
Antibiotic allergies are commonly reported, but the majority of these patients are not allergic when tested. A study included in this Synopsis book describes the successful implementation of a program to screen children with penicillin allergy and directly challenge those who were identified as low-risk in the pediatric emergency department setting. Another study reported successful de-labeling of the majority of children with non–β-lactam antibiotic allergy in their cohort. These studies demonstrate that screening with risk stratification and challenges should be implemented where possible to foster antibiotic stewardship.
Atopic dermatitis affects about 15% of urban children, and persistence of disease is associated with increased risk for asthma and worse quality of life. Several studies examined the effectiveness of skin care strategies and the potential for expanding use of omalizumab, which is already approved for allergic asthma and chronic spontaneous urticaria. A newer generation high affinity, humanized monoclonal anti–immunoglobulin E antibody, ligelizumab, shows promise in a phase 2b trial for chronic spontaneous urticaria.
A major shift in food allergy management in the past 3 years has been the implementation of early introduction of peanut for infants with egg allergy and/or severe eczema to decrease risk of peanut allergy. Data from the observational Consortium for Food Allergy Research study identified additional risk factors for peanut allergy among infants, suggesting that the definition of the at-risk population may need to be refined. There are also emerging data on implementation of these guidelines. An Australian study noted that infants are being fed peanut and egg earlier in life since guidelines were changed, indicating that implementation of early feeding recommendations are reaching the wider population. However, over-implementation is a potential issue, as suggested by a US study showing evidence of screening creep (screening infants who do not fit criteria for high-risk).
Optimizing food allergy management continues to be an important area of research. Researchers of 1 study examined epitope analysis of peanut components, and those of another study provided data to support Ara h 6 component testing as approaches to improve diagnostic accuracy for peanut allergy. Several studies highlight the impact of food allergy on growth and quality of life.
A number of studies have demonstrated that oral immunotherapy (OIT) can be effective for food allergy, but there are few with long-term outcomes. One study of egg OIT showed that a majority of treated children were successful in introducing egg, and this effect lasted up to 5 years after completion of therapy. Multiple-allergen OIT was also shown that it can be safe and effective. Other approaches to treat food allergies have been explored, and one group reported on their experience with omalizumab in this context. For all children in this small cohort, omalizumab treatment resulted in improved food allergy outcomes, lending further support to expanding its indication to food allergy.
Non–immunoglobulin E–mediated food allergies also affect a number children and were the focus in several recent articles. One multicenter study describes the clinical features and natural course of disease for infants with food protein–induced allergic proctocolitis and identifies risk factors for persistence of disease. Results of a cross-sectional, population-based survey estimates food protein enterocolitis syndromes prevalence at 0.51% in US children. A longitudinal, multi-centered study demonstrates the chronic nature of eosinophilic esophagitis and the importance of assessing quality of life for patients and their families.
Many studies included in this year's Synopsis book are focused on identifying risk factors and phenotypes of asthma as well as predictors for exacerbations. Asthma control can be impacted by complex array of factors across the spectrum of biological factors, environmental factors (both allergen and nonallergen exposures), and social factors (such as housing, neighborhood conditions). Because the economic and health burden of asthma is significant, a few studies in this Synopsis book describe novel approaches to improve access to care and asthma management, including an electronic home self-monitoring application and school-based telehealth programs.
Optimizing asthma outcomes is dependent on the use of effective medications when indicated. An important area of focus that is often overlooked is ensuring proper technique for inhaler use. As one study reminds us, reviewing inhaler technique should be a regular part of asthma visits, particularly for adolescents as they are transitioning to self-management. Options for medications have significantly expanded in recent years. Two articles report on the safety and efficacy of tiotroprium as add-on therapy for children and adolescents with uncontrolled asthma regardless of phenotype, supporting its expanded indication. Another study is a post hoc analysis of phase 3 dupilumab data that demonstrate it to be effective for treating both allergic and nonallergic asthma.
Rounding out this year's Synopsis book are a number of studies that cover a diverse range of immunology topics. These include characterization of children with primary ciliary dyskinesia, identifying subgroups of children presenting with infectious diseases and other chronic illnesses (coronary heart disease, asthma) who may be at higher risk for severe infections and could benefit from immunodeficiency evaluation, and treatment outcomes for primary and secondary immunodeficiencies.
On behalf our reviewers, we hope this Supplement provides not only practical information that can be incorporated into clinical care, but also insights that will inform diagnostic and therapeutic advances, allowing us to improve the care of children with allergic and immunologic diseases. For additional information about our Section, please visit: http://www.aap.org/sections/allergy/.
Julie Wang, MD, FAAP
Editor, Best Articles Relevant to Pediatric Allergy, Asthma, and Immunology