Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

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Breastfeeding and the Use of Human Milk

Allergic rhinitis is a symptomatic disorder of the nose induced after allergen exposure by an IgE-mediated inflammation of the membranes lining the nose. It is a global health problem that causes major illness and disability worldwide. Over 600 million patients from all countries, all ethnic groups and of all ages suffer from allergic rhinitis. It affects social life, sleep, school and work and its economic impact is substantial. Risk factors for allergic rhinitis are well identified. Indoor and outdoor allergens as well as occupational agents cause rhinitis and other allergic diseases. The role of indoor and outdoor pollution is probably very important, but has yet to be fully understood both for the occurrence of the disease and its manifestations.

In 1999, during the Allergic Rhinitis and its Impact on Asthma (ARIA) WHO workshop, the expert panel proposed a new classification for allergic rhinitis which was subdivided into 'intermittent' or 'persistent' disease.

This classification is now validated. The diagnosis of allergic rhinitis is often quite easy, but in some cases it may cause problems and many patients are still under-diagnosed, often because they do not perceive the symptoms of rhinitis as a disease impairing their social life, school and work.

The management of allergic rhinitis is well established and the ARIA expert panel based its recommendations on evidence using an extensive review of the literature available up to December 1999. The statements of evidence for the development of these guidelines followed WHO rules and were based on those of Shekelle et al. A large number of papers have been published since 2000 and are extensively reviewed in the 2008 Update using the same evidence-based system. Recommendations for the management of allergic rhinitis are similar in both the ARIA workshop report and the 2008 Update. In the future, the GRADE approach will be used, but is not yet available.

Another important aspect of the ARIA guidelines was to consider co-morbidities. Both allergic rhinitis and asthma are systemic inflammatory conditions and often co-exist in the same patients. In the 2008 Update, these links have been confirmed.

The ARIA document is not intended to be a standard-of-care document for individual countries. It is provided as a basis for physicians, health care professionals and organizations involved in the treatment of allergic rhinitis and asthma in various countries to facilitate the development of relevant local standard-of-care documents for patients.

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Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen)

Authors Jan L. Brozek, MD, PhD – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada Jean Bousquet, MD, PhD – Service des Maladies Respiratoires, Hopital Arnaud de Villeneuve, Montpellier, France, INSERM, CESP U1018, Respiratory and Environmental Epidemiology Team, France, and WHO Collaborating Center for Rhinitis and Asthma Carlos E. Baena-Cagnani, MD – Faculty of Medicine, Catholic University of Cordoba, Cordoba, Argentina Sergio Bonini, MD – Institute of Neurobiology and Molecular Medicine – CNR, Rome, Italy and Department of Medicine, Second University of Naples, Naples, Italy G. Walter Canonica, MD – Allergy & Respiratory Diseases, DIMI, Department of Internal Medicine, University of Genoa, Genoa, Italy Thomas B. Casale, MD – Division of Allergy and Immunology, Department of Medicine, Creighton University, Omaha, Nebraska, USA Roy Gerth van Wijk, MD, PhD – Section of Allergology, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands Ken Ohta, MD, PhD – Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan Torsten Zuberbier, MD – Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany Holger J. Schunemann, MD, PhD, MSc – Department of Clinical Epidemiology & Biostatistics and Medicine, McMaster University, Hamilton, Canada

/pdf/allergic-rhinitis-and-its-impact-on-asthma-20b4c7y0pr.pdf

Allergic Rhinitis and Its Impact on Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

The innate immune system relies on its capacity to rapidly detect invading pathogenic microbes as foreign and to eliminate them. The discovery of Toll-like receptors (TLRs) provided a class of membrane receptors that sense extracellular microbes and trigger antipathogen signaling cascades. More recently, intracellular microbial sensors have been identified, including NOD-like receptors (NLRs). Some of the NLRs also sense nonmicrobial danger signals and form large cytoplasmic complexes called inflammasomes that link the sensing of microbial products and metabolic stress to the proteolytic activation of the proinflammatory cytokines IL-1β and IL-18. The NALP3 inflammasome has been associated with several autoinflammatory conditions including gout. Likewise, the NALP3 inflammasome is a crucial element in the adjuvant effect of aluminum and can direct a humoral adaptive immune response. In this review, we discuss the role of NLRs, and in particular the inflammasomes, in the recognition of microbial and danger components and the role they play in health and disease.

https://www.um.es/biomybiotec/web/Seminarios/2009/papers/Pablo_Pelegrín_Annu%20Rev%20Immunol%202009%20Martinon-1.pdf

The Inflammasomes: Guardians of the Body

Erratum to: Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement (vol 9, 33, 2016)

Pertussis Vaccines Among Children with Milk Allergy J. D. Kattan, A. L. Cox, A. Nowak-Wegrzyn, G. Gimenez, L. Bardina, H. A. Sampson, S. H. Sicherer; Mt. Sinai School of Medicine, New York, NY. RATIONALE:Vaccines containing diphtheria, tetanus, and acellular pertussis are processed in medium containing casamino acids derived from cow’s milk; several milk allergic children have reported allergic reactions following administration of these vaccines. METHODS: This was a chart review of patients seen in our practice who had reported allergic reactions after receiving tetanus vaccines (primary or booster doses) from September 2007 to March 2010. An inhibition-ELISA was performed to determine the presence of milk protein in the vaccines. RESULTS:We identified seven patients (5 male, 2 female; median age 11 years; range: 5-17), who reported convincing allergic reactions to tetanus vaccines. Six patients had prior allergic reactions to cow’s milk, including severe reactions (5) and or reactions to trace exposures (4); one was diagnosed with milk allergy based on serologic testing. All patients had elevated milk specific IgE levels documented within 2 years of their reactions to the vaccine: 59, 96, and 5 patients >100 kUA/L. Each reported symptoms consistent with a diagnosis of anaphylaxis promptly after receiving the vaccine. Symptoms included: wheezing (5/7), urticaria (5/7), sneezing/nasal congestion (3/7), angioedema (3/7), and repetitive cough (2/7). Treatments included antihistamines (5/7), epinephrine (3/7), inhaled beta-agonists (3/7), and corticosteroids (2/7). Assays were performed on 2 different lots of the tetanus, diphtheria, and acellular pertussis vaccine, confirming the presence of milk protein in one lot (30 ng/mL). CONCLUSIONS: Vaccines containing tetanus, diphtheria, and acellular pertussis derived from broths containing casamino acids may present a risk to persons with severe milk allergy.

Allergic Reactions to Diphtheria, Tetanus, and Acellular Pertussis Vaccines Among Children with Milk Allergy

Eysink PE, Bottema BJ, ter Riet G, Aalberse RC, Stapel SO, Bindels PJ. Pediatr Allergy Immunol . 2004;15:394–400 

To identify patterns of clinical history associated with extreme (high or low) probabilities of allergic sensitization in coughing children to restrict allergy testing to those with an intermediate probability of sensitization.

A total of 752 children in the Netherlands, aged 1 to 4 years, visiting their general …

https://pediatrics.aappublications.org/content/pediatrics/116/Supplement_2/559.2.full.pdf

Scott H. Sicherer

Papers

Erratum to: Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement (vol 9, 33, 2016)

Allergic Reactions to Diphtheria, Tetanus, and Acellular Pertussis Vaccines Among Children with Milk Allergy

Coughing In Pre-School Children in General Practice: When Are RAST’s for Inhalation Allergy Indicated?

Elimination Diets and Oral Food Challenges

Peanut Allergen Exposure through Kissing (Saliva): Assessment and Intervention