The Growing Problem of Pediatric Allergy: Prevalence & Prevention William J. Cochran, MD, FAAP
Department of Pediatric GI & Nutrition
Geisinger Clinic
The Growing Problem of Pediatric Allergy: Prevalence & Prevention William J. Cochran, MD, FAAP
Department of Pediatric GI & Nutrition
Geisinger Clinic
Allergy Prevalence
American Academy of Allergy, Asthma and Immunology (AAAAI). The Allergy Report: Science Based Findings on the Diagnosis & Treatment of Allergic Disorders, 1996- 2001 Affects as many as 50 million Americans
Up to 30% in some populations, particularly developed countries
In the U.S. allergies are a leading cause of chronic disease
Overall the incidence of allergies are on the rise
Food allergies are most common in infants and children
Adverse Reactions to Food Pharmacological
(Toxic) Bacterial food poisoning
Scromboid fish poisoning
Caffeine
Tyramine
Histamine
Lactase deficiency
Galactosemia
Pancreatic insufficiency Allergies:
Dermatologic
GI
Respiratory
Anaphylaxis Non Immune
Mediated Non
Pharmacological Immune
Mediated
Food Allergies
Allergy, Principles and Practice, 5th Ed., E. Middleton et al, ed. Mosby, St. Louis, 1998.
AAAAI Board of Directors. Journal of Allergy and Clinical Immunology 102 (2):173-6. 1998. In the U.S., 7 million affected by food allergies
Infants and children particularly prone to allergy
Occur in 8 percent of children less than 6 years of age
Food allergies are the leading cause of anaphylactic reactions treated in the ER in US
Approximately 100 Americans, mostly children, die annually from food-induced anaphylaxis
Peanut allergy is the most common
Acute urticaria Angioedema Atopic dermatitis Dermatitis herpetiformes Immediate GI hypersensitivity
Oral allergy syndrome Eosinophilic gastroentero- colitis Protein induced enterocolitis Acute RAD
(High risk anaphylaxis) Asthma
(Risk of anaphylaxis) Food induced hemosiderosis
Heiner syndrome IgE Mediated Mixed Mechanism Non-IgE Mediated Skin GI Respiratory Common Uncommon Adopted from HA Sampson, 2000
So, summarizing:
In each targeted organ, allergic reactions can be either IgE, non-IgE mediated or mixed. Some reactions are more common than others, and in some cases, more than one mechanism can occur (“mixed”).
This is the whole spectrum of allergic manifestations, but we’ll just highlight the more common of them, indicated by the blue color.
-Atopic Dermatitis
-Hives or urticaria
-Protein enteropathy Including protein enteritis, enterocolotis, and proctitis)
-Reactive Airway Disease—RAD
-And Asthma
In general, GI manifestations are usually cellular or non-IgE mediated and skin manifestations are usually IgE mediated.
Atopic Dermatitis
Drake et al. J Am Acad Dermatol 1992;26:485-8. The most common chronic skin disease in children.
In 80% to 90% of the cases, onset of the disease occurs before 5 to 7 years of age
Signs and symptoms
Rash: Erythematous patches with papules on the face, neck and extensor surfaces. Flexural lesions later.
Pruritis
Skin dryness, excoriations, erosions
Distress, irritability.
Trends in Prevalence of Atopic Dermatitis
*Secular trends in the UK
Eichenfield et al , 2003 Pediatrics 111: 608-16
Atopic Dermatitis: Significance
† NIH- HHS Publication No. 03-4272, Rev April 2003
‡ CDC Nat Ctr for Health Statistics Vital and Health Statistics Series, 1996, 13:134
* Moore MM - Pediatrics - 01-MAR-2004; 113(3 Pt 1): 468-74
** Burkes et al. J Pediatr 1998, 132(1):132-610 Atopic dermatitis in the U.S.
Prevalence 10-20% overall†
Affects 15 million Americans‡
17% prevalence by 6 months of age*
7 million visits per year ‡
Up to 60% of children with severe atopic dermatitis have food hypersensitivity**
Atopic Dermatitis and Quality of Life
Howlett et al. Br J Dermatol 1999;140:381-4.
Reuveni et al. Arch Pediatr Adoles Med 1999;153:249-53
Chamlin et al. Pediatrics 2004; 114(3); 607-11 In infants
Itchiness & Irritability & Altered Sleep
Pain / Colic when associated to GI allergy
Disruption of family- child interactions
In children
Disruption of daily routine
Sleep deprivation, nighttime scratching during all stages of sleep
Affects school, social interactions, personal relationships, and self-consciousness
Atopic Dermatitis: Significance
Ellis CN, Drake et al. J Am Acad Derm 2002, 46: 361-70 Healthcare Costs in the U.S.
1.6 billion (conservative)
3.8 billion (all inclusive)
Atopic Dermatitis: Significance
Leung DY - J Allergy Clin Immunol - 01-DEC-2003; 112(6 Suppl): S117 Spergel J Allergy Clin Immunology 2003; 112 (6 Suppl): S 118-27 May be the first step in the Allergy March: the relationship between allergic manifestations throughout life
Approximately 75- 80% of atopic dermatitis patients develop allergic rhinitis
More than 50% of atopic dermatitis patients develop asthma
The Allergic March
Cantani, 1999 Invest Allergol Clin Immunol 9(5)- 314-20 Atopic GI and dermal allergy Allergic asthma Lower respiratory tract (wheezing) Upper respiratory tract (rhinitis, rhino-conjunctivitis, allergic otitis media)
Increasingly, a relationship between development of atopy in early infancy is being associated with development of asthma later in life. Up to 80% of children with atopic dermatitis will eventually develop allergic rhinitis or asthma later in childhood.
Increasing Prevalence of Asthma & Atopy
Ninan et al., 1992; BMJ 304: 873-75
Diagnosis Of Food Allergy
History
Food(s) / Quantity / Timing / Reproducibility
Validated by challenge in 30-40% of cases
Skin tests
False positive results are common
Best use is as a negative predictor
RAST
Consider for those with cutaneous involvement
CAP-FEIA (Fluorescein Enzyme Immunoassay)
Food >95% PPV
Egg 7kUa/L
Milk 15 kUa/L
Peanut 14 kUa/L
Fish 20kUa/L
DIAGNOSIS OF FOOD ALLERGY
Endoscopy and biopsy
Double-blind placebo-controlled food challenges: "gold standard"
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