Bibliographic updates

May 2017


Claude Molina et Jacques Gayraud

1. The gap in anaphylaxis diagnosis and management by French physicians.
2. Long term consequences of therapeutic intervention in a developing child: early-life antibiotic use and food allergy
3. Early life antibiotic use and the risk of asthma and asthma exacerbations in children
4. Controlled trial of early egg intake to prevent egg allergy
5. A Clinical trial of intra-dermal and intra-muscular seasonal influenza vaccination in patients with atopic dermatitis


I. The gaps in anaphylaxis diagnosis and management by French physicians
G. Pouessel,et al Ped.Allergy Immunol 2017 28 April 288-306.

The aim of the current study was to assess physicians’ knowledge regarding diagnosis and management of anaphylaxis in children and then to identify causes for the deficiencies. The authors conducted a survey using a two-part questionnaire. In the first part, the questions were based on a clinical scenario involving a 2-year-old child with a peanut allergy: skills on anaphylaxis diagnosis and management were evaluated; in the second part, factors associated with correct diagnosis and management were assessed.           

Diagnosis of anaphylaxis, evaluation of the severity of the adverse reactions, and the use of adrenaline were insufficient for the majority of the physicians. Only 19% of the participants had an optimal management step by step from diagnosis to referral to an allergist; 31% of them completed the correct diagnosis and the appropriate treatment with intramuscular adrenaline. Pediatric specialty and CME on food allergy were associated with a better diagnosis, a more frequent use of adrenaline, and a better five-step management.

II. Long term consequences of therapeutic intervention in a developing child: early-life antibiotic use and food allergy
J.M.Hascouet & coll : Bulletin Acad.Med April 2017 (in press)
A.G. Hirsch & al. Clin.Exp.Allergy 2017 47 2 236-244.

Some perinatal treatments appear to have adverse consequences at adulthood. For example, treatment with broad spectrum antibiotics or for prolonged periods of time, in pregnant mothers or neonates, leads to microbiota alteration which has been associated with an increased risk of allergy and obesity later on. Of note, feeding with mothers’ milk allows restoration of physiologic microbiota.                          

Non-steroidal anti-inflammatory drugs such as ibuprofen use in vulnerable infants with a gender sensibility towards girls might increase the risk of programmed low nephron endowment and premature glomerulosclerosis.

Likewise antibiotic use is associated with food allergy in a longitudinal data on 30 060 children up to age 7 years from Geisinger Clinic’s electronic health records in US. There were 484 milk allergy, 598 food allergy and 3652 other allergy cases

The acknowledgement of the long term effects of perinatal care may allow modulating it to reduce adverse consequences at adulthood.    

III. Early life antibiotic use and the risk of asthma and asthma exacerbations in children

F Ahmadizar, Ped.Allergy.Immunol.2017 Accepted manuscript online: 19 April 2017

The aim of this study was to assess the association between use of antibiotic during the first three years of life and the risk of developing childhood asthma and the occurrence of asthma exacerbations.

Data from four large childhood cohorts were used; two population-based cohorts to study the risk of developing asthma: Generation R (n=7,393, the Netherlands) and SEATON (n=891, Scotland, UK), and two asthma cohorts to assess the risk of asthma exacerbations: PACMAN (n=668, the Netherlands) and BREATHE (n=806, Scotland, UK). Odds ratios (ORs) were derived from logistic regression analysis within each database followed by pooling the results using a fixed or random-effect model.                               

Results : Antibiotic use in early life was associated with an increased risk of asthma in an analysis of the Generation R and SEATON data. There was no association between antibiotic use in early life and risk of asthma exacerbations later in life in an analysis of the PACMAN and BREATHE.

Conclusion : Children treated with antibiotic in the first three years of life are more likely to develop asthma, but there is no evidence that the exposure to antibiotic is associated with increased risk of asthma exacerbations.

 

IV. Controlled trial of early egg intake to prevent egg allergy

D.J.Palmer et al JACI 2017 May 139 5 1600-1607
J.Bellach et al JACI 2017 May 139 5 1591-1599


Two studies, the 1st in Australia, the 2nd in Germany, sought to determine whether regular consumption of egg protein from age 4 to 6 months reduce the risk of IgE mediated allergy in infants at 12 months or not.

-  In the 1st study the infants who had hereditary risk, (atopic mother) but without eczema, receive daily pasteurized raw whole egg powder (n = 407) or a color-matched rice powder (n = 413) to age 10 months. All followed an egg-free diet and cooked egg was introduced to both groups at age 10 months. The primary outcome was IgE-mediated egg allergy defined by a positive pasteurized raw egg challenge and egg sensitization at age 12 months.                    

There was no difference between groups in the percentage of infants with IgE-mediated egg allergy. A higher proportion of participants in the egg group confirmed allergic reaction (25 of 407 [6.1%] compared with 6 of 413 [1.5%]). Egg-specific IgG4 levels were substantially higher in the egg group at 12 months.                                                

The authors found no evidence that regular egg intake from age 4 to 6 months alter the risk of egg allergy by age 1 year.                             

-  In the 2nd German study with similar methods, 406 infants, 4 to 6 months old , were randomized and received egg white powder until 12 months ; the primary outcome being sensitization to hen’s egg, and the secondary outcome hen’s allergy confirmed by food challenge. Among 406 screened, 23infants (5.7%) had hen's egg–specific IgE before randomization. Of the 383 non sensitized infants (56.7% male), 184 were randomized to egg white powder and 199 to placebo. At 12 months of age, 5.6% of the children in the egg group were hen's egg sensitized versus 2.6% in the placebo group and 2.1% had egg allergy versus 0,6 in placebo.     So the conclusion is the same as the 1st study. In contrast, it might be dangerous to undertake such investigations, without precaution considering that many 4- to 6-month old infants were already allergic to hen's egg.

V. A Clinical trial of intra-dermal and intra-muscular seasonal influenza vaccination in patients with atopic dermatitis
D.Y.M. Leunge JACI 2017 may 139 5 1575-1582   

The primary objective of this study was to compare antibody responses to intradermal vaccination in participants with moderate/severe AD with those in nonatopic participants. Secondary objectives were to evaluate the effect of route of administration, Staphylococcus aureus skin colonization, and disease severity on vaccine response.                                                        

This was an open-label study conducted in the 2012-2013 influenza season at 5 US clinical sites. A total of 360 participants with moderate/severe AD or nonatopic subjects were assessed for eligibility, 347 of whom received intradermal or intramuscular vaccination per label and were followed for 28 days after vaccination. The primary outcome was the difference in the proportion of participants achieving seroprotection (hemagglutination-inhibition antibody titer ≥1:40 on day 28 after vaccination).              

Seroprotection rates for influenza B, H1N1, and H3N2 were not different (1) between participants with AD and nonatopic participants receiving intradermal vaccination and (2) between AD participants receiving intradermal and intramuscular vaccination.                      

After intradermal, but not intramuscular, vaccination, participants with AD with S aureus colonization experienced (1) lower seroprotection and seroconversion rates and lower hemagglutination-inhibition antibody titer geometric mean fold increase against influenza B and (2) lower seroconversion rates against influenza H1N1 than noncolonized participants with AD.                                     

Conclusion: Participants with AD colonized with S aureus exhibited a reduced immune response to influenza vaccination compared with noncolonized participants after intradermal but not intramuscular vaccination. Because most patients with AD are colonized with S aureus, intramuscular influenza vaccination should be given preference in these patient.


Your comments and questions are welcome at the following addresses:

Claude Molina                         
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Jacques Gayraud
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Last updated 28 June 2017