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.

/pdf/breastfeeding-and-the-use-of-human-milk-2m74a0njro.pdf

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.

/pdf/allergic-rhinitis-and-its-impact-on-asthma-aria-2008-update-13eqfzaw4u.pdf

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

Reply: To PMID 23195525.

This synopsis book reports advances and key observations that will affect the care of children with allergic and immunologic diseases now and in the near future. Reviewers for this synopsis book selected many articles that have clinical “pearls” and provide insights that are applicable for daily practice, as well as ones that challenge our previous notions and provide data that might lead to new approaches for diagnosis and treatment.

The apparent increase in atopic disease demands attention toward environmental and genetic factors and their interaction and an eye toward identifying prevention strategies. Barrier defects of the skin, reflected by genetic variants in filaggrin, are not only associated with atopic dermatitis but also with additional atopic diseases. This raises the possibility that a defective skin barrier, or immunologic changes associated with this defect, might predispose to allergen sensitization. Results of several studies support the notion that prematurity or lower birth weights might be protective against atopy, but the reason remains elusive. There are theories that obesity creates an inflammatory state that promotes atopy, as evidenced by a study from the National Health and Nutrition Survey reviewed in this supplement. An interesting novel observation was that even among lean adolescents, decreased sleep time was associated with a greater risk for atopy; fatigue is possibly being another stress on immune function. Our reviewers found a large number of studies with findings that suggest that vitamin D deficiency is related to increased atopy. Relationships were described among various studies to indicate that lower vitamin D levels or lower dietary intake is associated with more infections, more wheeze, a higher risk of atopy, and worse atopic dermatitis. Less outdoor activity, with its resulting decrease in sun exposure, …

https://pediatrics.aappublications.org/content/pediatrics/122/Supplement_4/S173.full.pdf

A Synopsis of the Synopses

Sesame Oral Desensitization Outcomes in a Pediatric Cohort

To the Editor, Common forms of sesame, namely seeds, oil, or paste (tahini), have differences in protein content and the available allergenic protein may differ (i.e., absorbed less from whole seeds compared to paste). Sesameallergic patients likely have varying thresholds of sensitivity that could result in reactions to some, but not all, forms of sesame. In a Turkish study, 26 of 44 patients (59%) with a negative oral food challenge (OFC) to sesame seed reacted to a similar dose of sesame protein in the form of tahini during an OFC (n = 22) or after consumption of tahini at home (n = 4).1 An Israeli retrospective chart review demonstrated that 78% of sesameallergic patients passed an OFC to approximately 60 intact sesame seeds (n = 51).2 These studies suggest that a substantial number of sesameallergic patients may be able to tolerate some forms of sesame (i.e., scattered seeds), but not others (i.e., tahini). Evidencebased guidance on how to advise sesameallergic patients on ingesting various forms is lacking. As a first step to understand whether there are various sesame allergy phenotypes, we sought to describe the number of patients who reported an allergic reaction to seeds, oil, and/or tahini, the reaction characteristics, and the advice provided by their allergist regarding dietary avoidance. An IRBapproved retrospective chart review was performed in pediatric patients presenting to an outpatient allergy referral clinic. A data exploration tool was used to identify charts for patients aged <18 years with an outpatient allergy encounter from 1/1/2018 to 1/31/2020 and ICD10 code Z91.018 (“Allergy to tree nuts or seeds”). Inclusion criteria for data collection were: age <18 years at time of encounter, physician diagnosis of sesame allergy, and at least one documented allergic reaction to a sesamecontaining food. Demographics, clinical and laboratory findings, and recommendations were recorded. Factors associated with allergic reaction to different forms of sesame were analyzed using Fisher's exact and Mann– Whitney tests. A result was considered statistically significant at the p < .05 level of significance. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). A total of 3394 charts matching the coding criteria were identified, 297 were randomly selected for chart review, and 66 met inclusion criteria of which 59% were male, 77% were diagnosed with sesame allergy by age 2, and 94% had other food allergies (Table 1).

Avoidance recommendations vary for sesame seeds and sesame oil for the sesame‐allergic

Sesame-allergic patients are generally advised strict food avoidance. Little data are available regarding approaches for patients who may tolerate less concentrated forms (i.e., seeds) compared to concentrated forms such as sesame paste. 

Scott H. Sicherer

Papers

Reply: To PMID 23195525.

A Synopsis of the Synopses

Sesame Oral Desensitization Outcomes in a Pediatric Cohort

Avoidance recommendations vary for sesame seeds and sesame oil for the sesame‐allergic

Understanding Sesame Allergy in the Pediatric Population