Showing papers in "Pediatric Allergy and Immunology in 2010"

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines.

Abstract: Alessandro Fiocchi, MD, Pediatric Division, Department of Child and Maternal Medicine, University of Milan Medical School at the Melloni Hospital, Milan 20129, Italy. Holger Schünemann, MD, Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1200 Main Street West Hamilton, ON L8N 3Z5, Canada. Sami L. Bahna, MD, Pediatrics & Medicine, Allergy & Immunology, Louisiana State University Health Sciences Center, Shreveport, LA 71130. Andrea Von Berg, MD, Research Institute, Children s department , Marien-Hospital, Wesel, Germany. Kirsten Beyer, MD, Charité Klinik für Pädiatrie m.S. Pneumologie und Immunologie, Augustenburger Platz 1, D-13353 Berlin, Germany. Martin Bozzola, MD, Department of Pediatrics, British Hospital-Perdriel 74-CABA-Buenos Aires, Argentina. Julia Bradsher, PhD, Food Allergy & Anaphylaxis Network, 11781 Lee Jackson Highway, Suite 160, Fairfax, VA 22033. Jan Brozek, MD, Department of Clinical Epidemiology & Biostatistics, McMaster University Health Sciences Centre, 1200 Main Street West Hamilton, ON L8N 3Z5, Canada. Enrico Compalati, MD, Allergy & Respiratory Diseases Clinic, Department of Internal Medicine. University of Genoa, 16132, Genoa, Italy. Motohiro Ebisawa, MD, Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa 228-8522, Japan. Maria Antonieta Guzman, MD, Immunology and Allergy Division, Clinical Hospital University of Chile, Santiago, Chile. Santos Dumont 999. Haiqi Li, MD, Professor of Pediatric Division, Department of Primary Child Care, Children’s Hospital, Chongqing Medical University, China, 400014. Ralf G. Heine, MD, FRACP, Department of Allergy & Immunology, Royal Children’s Hospital, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia. Paul Keith, MD, Allergy and Clinical Immunology Division, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Gideon Lack, MD, King’s College London, Asthma-UK Centre in Allergic Mechanisms of Asthma, Department of Pediatric Allergy, St Thomas’ Hospital, London SE1 7EH, United Kingdom. Massimo Landi, MD, National Pediatric Healthcare System, Italian Federation of Pediatric Medicine, Territorial Pediatric Primary Care Group, Turin, Italy. Alberto Martelli, MD, Pediatric Division, Department of Child and Maternal Medicine, University of Milan Medical School at the Melloni Hospital, Milan 20129, Italy. Fabienne Rancé, MD, Allergologie, Hôpital des Enfants, Pôle Médicochirurgical de Pédiatrie, 330 av. de Grande Bretagne, TSA 70034, 31059 Toulouse CEDEX, France. Hugh Sampson, MD, Jaffe Food Allergy Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, NY 10029-6574. Airton Stein, MD, Conceicao Hospital, Porto Alegre, Brazil. Luigi Terracciano, MD, Pediatric Division, Department of Child and Maternal Medicine, University of Milan Medical School at the Melloni Hospital, Milan 20129, Italy. Stefan Vieths, MD, Division of Allergology, Paul-EhrlichInstitut, Federal Institute for Vaccines and Biomedicines, Paul-Ehrlich-Str. 51-59, D-63225 Langen, Germany.

Effect of Probiotic Mix (Bifidobacterium Bifidum, Bifidobacterium Lactis, Lactobacillus Acidophilus) in the Primary Prevention of Eczema: A Double-Blind, Randomized, Placebo-Controlled Trial

Abstract: Controversy exists regarding the preventive effect of probiotics on the development of eczema or atopic dermatitis. We investigated whether supplementation of probiotics prevents the development of eczema in infants at high risk. In a randomized, double-blind, placebo-controlled trial, 112 pregnant women with a family history of allergic diseases received a once-daily supplement, either a mixture of Bifidobacterium bifidum BGN4, B. lactis AD011, and Lactobacillus acidophilus AD031, or placebo, starting at 4-8 wks before delivery and continuing until 6 months after delivery. Infants were exclusively breast-fed during the first 3 months, and were subsequently fed with breastmilk or cow's milk formula from 4 to 6 months of age. Clinical symptoms of the infants were monitored until 1 yr of age, when the total and specific IgE against common food allergens were measured. A total of 68 infants completed the study. The prevalence of eczema at 1 yr in the probiotic group was significantly lower than in the placebo group (18.2% vs. 40.0%, p=0.048). The cumulative incidence of eczema during the first 12 months was reduced significantly in probiotic group (36.4% vs. 62.9%, p=0.029); however, there was no difference in serum total IgE level or the sensitization against food allergens between the two groups. Prenatal and postnatal supplementation with a mixture of B. bifidum BGN4, B. lactis AD011, and L. acidophilus AD031 is an effective approach in preventing the development of eczema in infants at high risk of allergy during the first year of life.

Prebiotic oligosaccharides: in vitro evidence for gastrointestinal epithelial transfer and immunomodulatory properties.

Abstract: Eiwegger T, Stahl B, Haidl P, Schmitt J, Boehm G, Dehlink E, Urbanek R, Szepfalusi Z. Prebiotic oligosaccharides: In vitro evidence for gastrointestinal epithelial transfer and immunomodulatory properties. Pediatr Allergy Immunol 2010: 21: 1179–1188. © 2010 John Wiley & Sons A/S Prebiotic oligosaccharides are present in breast milk and evidence is pointing toward immunomodulatory properties of the acidic fraction. Recently, prebiotic supplements of infant formula [short-chain galacto (scGOS)-, long-chain fructo (lcFOS)-oligosaccharides] showed preventive effects on atopic disease development. We aimed to define the direct immunologic effects of these oligosaccharides and of human (aHMOS) and cows’ milk (aCMOS) acidic oligosaccharides and to investigate the systemic uptake of prebiotic supplements of infant formula and a specific pectin-derived acidic oligosaccharide hydrolysate (pAOS) in vitro. After assurance of LPS-free conditions (limulus assay, toll like receptor-2, -4 transfected human embryonic kidney-cells), in vitro-transfer through a CaCo-2 cell monolayer was measured using high-pH anion exchange chromatography with pulsed amperometric detection. Direct effects on proliferation, cytokine-induction of cord blood mononuclear cells and modulation of allergen-specific CD4+ T-cell cytokine profiles from allergic and non-allergic individuals were investigated. Transfer of scGOS/lcFOS and pAOS in-vitro was detected with a rate of transfer of 4–14%, depending on the molecular size and structure. AHMOS induced IFN-γ and IL-10 but not the Th-2 cytokine IL-13 at physiologic concentrations (10–100 μg/ml) in cord blood, whereas aCMOS did not induce any of these cytokines. AHMOS significantly suppressed Th-2 type cytokine-production by Ara h1-specific CD4+ T cells (CFSElow CD3+CD4+cells) from peanut allergic patients. In conclusion, human milk-derived acidic oligosaccharides may modulate postnatal allergen-specific immune responses by the suppression of Th-2-type responses in atopy-prone individuals. Moreover, there is in vitro evidence for epithelial transport of prebiotic oligosaccharides.

Management of nut allergy influences quality of life and anxiety in children and their mothers.

Abstract: Nut allergy is known to impact on the quality of life (QoL) and anxiety of both the allergic child and their parents, but little is known about how the management of food allergy is associated with these variables. To investigate the impact of nut allergy on QoL and anxiety in mothers and children with nut allergy in order to identify management strategies that may influence these factors. Forty-one nut allergic children (age 6-16 yrs) and their mothers completed questionnaires to assess maternal and children's QoL (PedsQL, WHOQOL-BREF, FAQL-PB), anxiety (SCAS, STAI) and perceived stress scale (PSS). Children also completed a nut allergy specific QoL questionnaire. Demographic data, details of previous reactions, test results and management plans were collected using parent-report questionnaires and hospital notes. Children with nut allergy had poorer emotional (p = 0.004), social (p = 0.043), and psychological (p = 0.006) QoL compared to healthy normative data. Maternal and child QoL and anxiety were not influenced by the severity of previous reactions. Mother and child reported lower anxiety (p = 0.043 and p < 0.001 respectively) when the child was prescribed an epinephrine auto-injector. Anxiety was not associated with whether the child carried the auto-injector or whether they strictly avoided traces of nuts in foods. Prescribing auto-injectors is associated with reduced anxiety for food allergic children and their mothers, but is not associated with improved adherence with medical management or reduced risk-taking behavior.

A systematic review of the importance of milk TGF‐β on immunological outcomes in the infant and young child

Abstract: Cytokines in milk like transforming growth factor-beta (TGF-beta) have been shown to induce oral tolerance in experimental animal studies. However, human studies are less consistent with these findings. The primary objective of this review was to conduct a systematic review of published studies on the association between TGF-beta identified in human milk and immunological outcomes in infancy and early childhood. Human prospective clinical studies were identified through MEDLINE, CAB Abstracts, Biological Abstracts and Scopus. Selection criteria included: well described populations of mothers and infants, time of milk sampling, immunological outcome measures and analytical methods of TGF-beta determination. We considered a wide range of immunological outcomes in infancy and early childhood, such as wheeze, atopy, eczema and the immunoglobulin switch. Twelve human studies were included in the review and 67% showed a positive association with TGF-beta1 or TGF-beta2 demonstrating protection against allergy-related outcomes in infancy and early childhood. High variability in concentrations of TGF-beta was noted between and within studies, some of it explained by maternal history of atopy or by consumption of probiotics. Human milk TGF-beta appears to be essential in developing and maintaining appropriate immune responses in infants and may provide protection against adverse immunological outcomes, corroborating findings from experimental animal studies. Further large clinical studies in diverse human populations are indicated to confirm these results.

High intestinal IgA associates with reduced risk of IgE-associated allergic diseases

Abstract: Development of oral tolerance and its stimulation by probiotics are still incomprehensible. Microbial stimulation of the gut may induce a subtle inflammation and induce secretion of mucosal IgA, which participates in antigen elimination. In a cohort of allergy-prone infants receiving probiotics and prebiotics or placebo we studied intestinal IgA and inflammation in the development of eczema, food allergy, asthma, and rhinitis (allergic diseases). We performed a nested unmatched case-control study of 237 infants participating in a randomized double-blind placebo-controlled allergy-prevention trial using a combination of four probiotic strains pre-natally and during 6 months form birth. We measured faecal IgA, alpha1-antitrypsin (alpha1-AT), tumour necrosis factor-alpha (TNF-alpha), and calprotectin at the age of 3 and 6 months. By age 2 yr, 124 infants had developed allergic disease or IgE-sensitization (cases) and 113 had not (controls). In infants with high faecal IgA concentration at the age of 6 months, the risk of having any allergic disease before the age of 2 yr tended to reduce [odds ratio (OR: 0.52)] and the risk for any IgE-associated (atopic) disease reduced significantly (OR: 0.49). High faecal calprotectin at the age of 6 months associated also with lower risk for IgE-associated diseases up to age 2 yr (OR: 0.49). All faecal inflammation markers (alpha1-AT, TNF-alpha, and calprotectin) correlated positively with faecal IgA (p < 0.001). Probiotics tended to augment faecal IgA (p = 0.085) and significantly increased faecal alpha1-AT (p = 0.001). High intestinal IgA in early life associates with minimal intestinal inflammation and indicates reduced risk for IgE-associated allergic diseases.

Maternal diet during pregnancy and allergic sensitization in the offspring by 5 yrs of age: a prospective cohort study.

Abstract: To examine the effect of maternal diet during pregnancy on allergic sensitization in the offspring by 5 yrs of age. The Finnish type 1 Diabetes Prediction and Prevention Nutrition Study. A population-based cohort study with 5-yr follow-up. A total of 931 children with human leukocyte antigen-conferred susceptibility to type 1 diabetes for whom maternal pregnancy food frequency questionnaire data and allergen-specific immunoglobulin E measurement at 5 yrs were available. Increasing maternal consumption of citrus fruits [odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.05-1.25] and total fruit (OR = 1.36, 95% CI = 1.09-1.70) were positively associated with sensitization to inhalant allergens, after adjustment for potential confounders. Maternal intake of vitamin D (OR = 0.56, 95% CI = 0.35-0.91) was inversely associated with sensitization to food allergens. Maternal consumption of citrus fruits during pregnancy may increase the risk to allergic sensitization in the offspring, whereas vitamin D intake may have a beneficial effect. Further studies are required to define more closely the putative effect of maternal intake of polyunsaturated fatty acids on development of allergic diseases in the offspring.

International study of wheezing in infants: risk factors in affluent and non-affluent countries during the first year of life

Abstract: Risk factors for wheezing during the first year of life (a major cause of respiratory morbidity worldwide) are poorly known in non-affluent countries. We studied and compared risk factors in infants living in affluent and non-affluent areas of the world. A population-based study was carried out in random samples of infants from centres in Latin America (LA) and Europe (EU). Parents answered validated questionnaires referring to the first year of their infant's life during routine health visits. Wheezing was stratified into occasional (1-2 episodes, OW) and recurrent (3 + episodes, RW). Among the 28687 infants included, the most important independent risk factors for OW and RW (both in LA and in EU) were having a cold during the first 3 months of life [OR for RW 3.12 (2.60-3.78) and 3.15 (2.51-3.97); population attributable fraction (PAF) 25.0% and 23.7%]; and attending nursery school [OR for RW 2.50 (2.04-3.08) and 3.09 (2.04-4.67); PAF 7.4% and 20.3%]. Other risk factors were as follows: male gender, smoking during pregnancy, family history of asthma/rhinitis, and infant eczema. Breast feeding for >3 months protected from RW [OR 0.8 (0.71-0.89) in LA and 0.77 (0.63-0.93) in EU]. University studies of mother protected only in LA [OR for OW 0.85 (0.76-0.95) and for RW 0.80 (0.70-0.90)]. Although most risk factors for wheezing are common in LA and EU; their public health impact may be quite different. Avoiding nursery schools and smoking in pregnancy, breastfeeding babies >3 months, and improving mother's education would have a substantial impact in lowering its prevalence worldwide.

Predictive factors for the persistence of cow's milk allergy.

Abstract: Santos A, Dias A, Pinheiro JA. Predictive factors for the persistence of cow’s milk allergy. Pediatr Allergy Immunol 2010: 21: 1127–1134. © 2010 John Wiley & Sons A/S Cow’s milk allergy (CMA) is usually transient, but recent studies have shown a later acquisition of tolerance to CM. Our aims were to characterize a population of Portuguese children with CMA and to identify predictive factors for the persistence of this food allergy. Children with CMA observed in our Paediatric Allergy Clinic between 1997 and 2006 were selected. Demographic and clinical data were collected from medical records. The group of children who tolerated CM before the age of 2 was compared with the group of children who tolerated CM beyond that age or persisted with CMA until the end of the study. Multivariate logistic regression analysis was used to investigate independent predictive factors for the persistence of CMA beyond the age of 2. In the subgroup of children with IgE-mediated CMA, the acquisition of tolerance was analysed using Cox regression. In this population of 139 children, the majority presented more than one symptom (73%) affecting more than one organ (51%), with cutaneous (81%), gastrointestinal (55%), respiratory (16%) manifestations and/or anaphylaxis (3%). Thirty-two per cent developed asthma, 20% atopic eczema, 20% rhinoconjunctivitis and 19% other food allergies over time. The acquisition of tolerance was different in the whole population versus the subgroup with IgE-mediated CMA: 34%versus 0% at the age of 2, 55%versus 22% at the age of 5 and 68%versus 43% at the age of 10. Immediate allergic symptoms, asthma and other food allergies were independent factors for the persistence of CMA beyond the age of 2. Higher maximum weal diameter on skin prick test to CM and higher maximum level of specific IgE to CM were associated with reduced likelihood of acquiring tolerance in the subgroup of children with IgE-mediated CMA. In conclusion, children with IgE-mediated CMA acquire tolerance to CM at older age. Clinical parameters and allergy tests may be helpful in defining prognosis. CM-allergic children tend to develop other atopic conditions and need specialized follow-up in the long term.

Increased serum thymic stromal lymphopoietin in children with atopic dermatitis

Abstract: The present study investigated the relationship between serum thymic stromal lymphopoietin (TSLP) levels and the presence and severity of atopic dermatitis (AD). Serum TSLP levels, blood eosinophil counts, and serum total and specific immunoglobulin E (IgE) levels were measured in 232 children. Subjects were characterized as having atopic eczema (AE; n=75), non-atopic eczema (NAE; n=70), or normal controls (n=87). Serum TSLP levels in children with AD were significantly higher than normal controls but there were no differences in children with atopic and non-atopic eczema. However, serum TSLP levels in children with AD were not significantly correlated with disease severity, blood eosinophil counts and serum total IgE levels. Our findings show an association between TSLP and AD including both AE and NAE. It is suggested that TSLP may play a contributory role in the pathogenesis of AD regardless of the presence of atopy.

Prediction of anaphylaxis during peanut food challenge: usefulness of the peanut skin prick test (SPT) and specific IgE level.

Abstract: Cutoffs (decision points) of the peanut skin prick test (SPT) and specific IgE level for predicting peanut allergy have been proposed. It is not known whether decision points indicating a significant risk of severe reactions on challenge differ from those indicating probable allergy. We aimed at determining the usefulness of allergy tests for predicting the risk of anaphylaxis on challenge following the ingestion of up to 12 g of peanut in peanut-sensitized children. Children attending the Allergy Clinic who had a positive peanut SPT and completed open-label in-hospital peanut challenges were included. The challenge protocol provided for challenges to be continued beyond initial mild reactions. Eighty-nine in-hospital peanut challenges were performed. Thirty-four were excluded as the challenge was not completed, leaving 55 for analysis. Children who completed the challenge and did not react (n = 28) or reacted without anaphylaxis (n = 6) represented the comparison group (n = 34). The study group comprised 21 children whose challenge resulted in anaphylaxis. The mean peanut SPT wheal size and specific IgE level were associated with the severity of reactions on challenge. Among the 21 children, who developed anaphylaxis, in only 3 cases was anaphylaxis the initial reaction. Unexpectedly, a history of anaphylaxis was not predictive of anaphylaxis on challenge. Anaphylaxis developed at cumulative doses of peanut ranging from 0.02 to 11.7 g. Provided that a fixed amount of peanut is ingested, available tests for peanut allergy may assist in predicting the risk of anaphylaxis during challenge in peanut-sensitized children.

The effect of a partially hydrolysed formula based on rice protein in the treatment of infants with cow's milk protein allergy

Abstract: Reche M, Pascual C, Fiandor A, Polanco I, Rivero-Urgell M, Chifre R, Johnston S, Martin-Esteban M. The effect of a partially hydrolysed formula based on rice protein in the treatment of infants with cow’s milk protein allergy. Pediatr Allergy Immunol 2010: 21: 577–585. © 2010 John Wiley & Sons A/S Infants diagnosed with allergy to cow’s milk protein (CMP) are fed extensively hydrolysed cow’s milk formulas, modified soy formulas or even amino acid-based formulas. Hydrolysed rice protein infant formulas have become available and have been shown to be well tolerated by these infants. A prospective open, randomized clinical study to compare the clinical tolerance of a new hydrolysed rice protein formula (HRPF) with an extensively hydrolysed CMP formula (EHF) in the feeding of infants with IgE-mediated cow’s milk allergy. Ninety-two infants (46 boys and 46 girls, mean age 4.3 months, range 1.1–10.1 months) diagnosed with IgE-mediated cow’s milk allergy were enrolled in the study. Clinical tolerance to the formula products was tested. Clinical evaluation included skin prick tests with whole cow’s milk, soya and rice as well as antigens of CMP (beta-lactoglobulin, alpha-lactalbumin, casein and bovine seroalbumin), HRPF and EHF and specific IgE determinations to CMP using CAP technology. Patients were randomized to receive either an EHF based on CMP or a new HRPF. Follow-up was at 3, 6, 12, 18 and 24 months. Growth parameters were measured at each visit. One infant showed immediate allergic reaction to EHF, but no reaction was shown by any infant in the HRPF group. The number of infants who did not become tolerant to CMP during the study was not statistically different between the two groups. Measurement of IgE levels of infants allergic to CMP during the study showed no significant differences between the two formula groups. Growth parameters were in the normal range and similar between groups. In this study, the HRPF was well tolerated by infants with moderate to severe symptoms of IgE-mediated CMP allergy. Children receiving this formula showed similar growth and development of clinical tolerance to those receiving an EHF. In accordance with current guidelines, this HRPF was tolerated by more than 90% of children with CMP allergy and therefore could provide an adequate and safe alternative to CMP-hydrolysed formulas for these infants.

The natural history of allergic rhinitis in childhood

Abstract: The distinction between 'seasonal' and 'perennial' allergic rhinitis (AR) is not always adequate. The 'Allergic Rhinitis and its Impact on Asthma' (ARIA) work group suggested a new classification for AR based on severity and duration of symptoms. Our primary aim was to describe the natural history and burden of AR according to the new ARIA criteria in a population-based birth cohort study of children up to 13 yr. We defined symptoms as 'severe' (impairment of daily activities) or 'mild' (no impairment) and 'persistent' (duration > 1 month) or 'intermittent' (

Reduced IFN‐γ‐ and enhanced IL‐4‐producing CD4+ cord blood T cells are associated with a higher risk for atopic dermatitis during the first 2 yr of life

Abstract: The aim of this study was to analyse whether altered cytokine production by cord blood (CB) T cells is of relevance regarding the development of allergic diseases during the first 2 yr of life independent from known or suspected risk factors for allergy. Within an ongoing birth cohort study (Life style - Immune System - Allergy; LISA) the cytokine production of PMA/ionomycin-stimulated CB cells was measured by intracellular cytokine staining. Data of 98 children from Leipzig and Munich with complete information on cytokine production at birth and allergic outcomes during the first 2 yr were analysed. Statistical analysis was performed using a regression model adjusted for gender, month of birth, parental history of atopy, parental education, exposure to environmental tobacco smoke, maternal smoking during pregnancy, renovation activities during pregnancy, pet ownership and study centre. During the first 2 yr of life, 17.3% of the children developed a physician-diagnosed atopic dermatitis. Children with reduced frequencies of interferon-gamma (IFN-gamma)-producing CD4(+) T cells in the CB (1st quartile) had a higher risk to develop atopic dermatitis (adjusted OR 5.16, 95% CI: 1.04-25.6). Furthermore, a high percentage of interleukin (IL)-4-producing T cells in CB in children from the Leipzig cohort were associated with an increased risk for atopic dermatitis (adjusted OR 8.92, 95% CI: 1.40-56.93 for the 90th percentile). CD8(+) cytokine-producing CB T cells had no relation to increased risk for atopic dermatitis. Low amounts of IFN-gamma and high amounts of IL-4-producing T cells at birth may enhance the risk of subsequent development of atopic dermatitis.

Changes in faecal microbiota of infants with cow’s milk protein allergy – a Spanish prospective case–control 6‐month follow‐up study

Abstract: Major differences have been found in gut microbiota between healthy and allergic children, and a possible association between allergy and altered microbiota patterns have been postulated. The main object of the study was to compare the faecal microbiota between healthy and cow's milk protein allergy (CMPA) infants at the baseline immediately after the diagnosis, and to evaluate the changes in the faecal microbiota after 6 months of treatment of CMPA infants fed on extensively cow's milk protein hydrolyzed formulae without pre- or probiotics, compared with healthy children fed on standard milk formulae. The population comprised 92 infants aged 2-12 months who were non-allergic (n=46) or diagnosed with IgE-mediated CMPA (n=46). At baseline and at 6 months, faecal samples were collected into sterile plastic tubes, immediately placed into anaerobic jars and processed within 2 h of their collection. Weighed faeces samples were diluted from 10(-1) to 10(-7) and cultured in selective media for total count of aerobes, anaerobes, enterobacteria, bifidobacteria, lactobacilli, clostridia and yeasts. Samples from non-allergic and allergic infants were compared at baseline and at 6 months using appropriate statistical tests, considering p<0.05 to be significant. In comparison with healthy infants, CMPA infants had higher total bacteria and anaerobic counts and a lower yeast count at baseline, finding no difference in the proportions of each bacterial group between groups. After 6 months, CMPA infants showed higher anaerobic and lactobacilli counts, a higher proportion of lactobacilli, a lower count and proportion of bifidobacteria, and lower proportions of enterobacteria and yeasts. Comparison of faecal samples from CMPA infants between baseline and at 6 months showed an increase in count and proportion of lactobacilli and a decrease in counts and proportions of enterobacteria and bifidobacteria. Differences in the composition of gut microbiota between CMPA and healthy infants may influence in the development of or protection from this allergy.

Food allergy knowledge, attitudes, and beliefs of parents with food-allergic children in the United States.

Abstract: Parents of food-allergic children are responsible for risk assessment and management of their child's condition. Such practices are likely informed by parental knowledge, attitudes, and beliefs of food allergy. Our objective was to characterize food allergy knowledge and perceptions among parents with food-allergic children. Parents were recruited nationally between January 2008 and 2009 to complete the validated, web-based Chicago Food Allergy Research Survey for Parents of Children with Food Allergy. Findings were analyzed to provide composite/itemized knowledge scores, describe attitudes and beliefs, and examine the effects of participant characteristics on response. A sample of 2945 parents was obtained. Participants had an average knowledge score of 75% correct (range 19-100%). Strengths were observed in each content domain; e.g., 95% of participants accurately identified the signs of a milk-induced reaction. Weaknesses were limited to items assessing food allergy triggers/environmental risks and perceptions of susceptibility/prevalence; e.g., 52% of parents incorrectly believed young children are at higher risk for fatal anaphylaxis than adolescents. Parental attitudes/beliefs were diverse, although 85% agreed children should carry an EpiPen at school and 91% felt schools should have staff trained in food allergy. One in four parents reported food allergy caused a strain on their marriage/relationship, and 40% reported experiencing hostility from other parents when trying to accommodate their child's food allergy. In conclusion, parents in our study exhibited solid baseline knowledge although several important misconceptions were identified. While a broad spectrum of parental perceptions was observed, a large proportion of parents reported that their child's food allergy had an adverse impact on personal relationships and also agreed on certain policies to address food allergy in schools.

Allergic rhinitis in the child and associated comorbidities

Abstract: Sih T, Mion O. Allergic rhinitis in the child and associated comorbidities. Pediatr Allergy Immunol 2010: 21: e107–e113. © 2009 John Wiley & Sons A/S Allergic rhinitis (AR) typically presents after the second year of life, but the exact prevalence in early life is unknown. AR affects 10–30% of the population, with the greatest frequency found in children and adolescents. It appears that the prevalence has increased in the pediatric population. As the childs’ immune system develops between the 1st and 4th yr of life, those with an atopic predisposition begin to express allergic disease with a clear Th2 response to allergen exposure, resulting in symptoms. In pediatric AR, two or more seasons of pollen exposure are generally needed for sensitization, so allergy testing to seasonal allergens (trees, grasses, and weeds) should be conducted after the age of 2 or 3 years. Sensitization to perennial allergens (animals, dust mites, and cockroaches) may manifest several months after exposure. Classification of AR includes measurement of frequency and duration of symptoms. Intermittent AR is defined as symptoms for <4 days/wk or <4 consecutive weeks. Persistent AR is defined as occurring for more than 4 days/wk and more than 4 consecutive weeks. AR is associated with impairments in quality of life, sleep disorders, emotional problems, and impairment in activities such as work and school productivity and social functioning. AR can also be graded in severity – either mild or moderate/severe. There are comorbidities associated with AR. The chronic effects of the inflammatory process affect lungs, ears, growth, and others. AR can induce medical complications, learning problems and sleep-related complaints, such as obstructive sleep apnea syndrome and chronic and acute sinusitis, acute otitis media, serous otitis media, and aggravation of adenoidal hypertrophy and asthma.

Probiotics and prebiotics in atopic dermatitis: review of the theoretical background and clinical evidence

Abstract: The prevalence of atopic dermatitis (AD) has risen over the past decades, especially in western societies. According to the revised hygiene hypothesis this increase is caused by a changed intestinal colonization pattern during infancy, which has an impact on the immune system. Manipulating the intestinal microflora with pro-, pre- or synbiotics is an innovative way to prevent or treat AD. This review provides an overview of the theoretical basis for using probiotics and prebiotics in AD and presents the current evidence from randomized controlled trials (RCTs) regarding prevention and treatment of AD and food allergy in children with pro-, pre- and synbiotics. Seven RCTs on prevention and 12 RCTs on treatment were found by searching the Pubmed, Embase and Cochrane databases. Results of these trials are conflicting. In conclusion, at this moment there is not enough evidence to support the use of pro-, pre- or synbiotics for prevention or treatment of AD in children in clinical practice.

Allergic sensitization is associated with rhinovirus-, but not other virus-, induced wheezing in children.

Abstract: Jartti T, Kuusipalo H, Vuorinen T, Soderlund-Venermo M, Allander T, Waris M, Hartiala J, Ruuskanen O. Allergic sensitization is associated with rhinovirus-, but not other virus-, induced wheezing in children. Pediatr Allergy Immunol 2010: 21: 1008–1014. © 2010 John Wiley & Sons A/S Background: Data on the link between atopy and viral wheeze are limited. Aim: To evaluate the association between IgE sensitization and viral infection in wheezing children. Methods: This is an observational study in hospitalized wheezing children (n = 247; median age 1.6 ; interquartile range 1.1, 2.9). Eighteen respiratory viral infections were studied using all available methods. A specific immunoglobulin E (IgE) sensitization for common food and aeroallergens and other atopy-related variables including total IgE, blood and nasal eosinophils, exhaled nitric oxide, eczema and atopic eczema, parental allergy and asthma, number of wheezing episodes, positive asthma predictive index or asthma and use of inhaled corticosteroid were correlated with specific viral etiology. Results: Atopy was closely associated with sole rhinovirus etiology (n = 58) but not with sole respiratory syncytial virus, sole enterovirus, sole human bocavirus, sole other virus, mixed viral, or virus negative etiology. The number of sensitizations was particularly associated with sole rhinovirus etiology (odds ratio 4.59; 95% confidence interval 1.78, 11.8; adjusted to age and sex), followed by aeroallergen sensitization (respectively; 4.18; 2.00, 8.72), total IgE level (2.06; 1.32, 3.21), food allergen sensitization (2.02; 1.08, 3.78), and nasal eosinophil count (1.52; 1.08, 2.13). Conclusions: According to our data, allergic sensitization is positively linked to rhinovirus-, but not other virus-, associated wheezing and calls attention for studies to test rhinovirus-associated wheezing as a part of asthma risk indices.

Development of atopic dermatitis in the DARC birth cohort

Abstract: Atopic dermatitis (AD) is a chronic, relapsing,itchy, inflammatory, skin disease, which usuallyappears in the first years of life. There is no gold-standard for the diagnosis of AD; it is based onclinical criteria combined with disease history,and the most common diagnostic tool is derivedfrom Hanifin and Rajka in 1980 (1). The etiologyof AD is complex, where epidermal barrier (2)and filaggrin defects (3) and two subsets ofimmune hyperreactivity, i.e., an IgE mediated(extrinsic) and a non-IgE mediated (intrinsic)form, are involved.The role of sensitization in children with AD isunclear, but both atopic predisposition and earlysensitization is known to influence onset (4, 5),duration (6, 7) and severity (5, 8). Food allergy isreported to be associated with AD (9–12),however only few studies have addressed thecausal relationship (13–16). The aim of this studywas to describe the relapsing pattern of AD inchildren during the first 6 yr of life in a popula-tion-based cohort with focus on sensitization andprognosis.

Intrauterine exposure to polycyclic aromatic hydrocarbons, fine particulate matter and early wheeze. Prospective birth cohort study in 4‐year olds

Abstract: The main goal of the study was to determine the relationship between prenatal exposure to polycyclic aromatic hydrocarbons (PAHs) measured by PAH-DNA adducts in umbilical cord blood and early wheeze. The level of PAH-DNA adducts in the cord blood is assumed to reflect the cumulative dose of PAHs absorbed by the foetus over the prenatal period. The effect of prenatal PAH exposure on respiratory health measured by the incidence rate ratio (IRR) for the number of wheezing days in the subsequent 4 yr follow-up was adjusted for potential confounding factors such as personal prenatal exposure to fine particulate matter (PM2.5), environmental tobacco smoke (ETS), gender of child, maternal characteristics (age, education and atopy), parity and mould/ dampness in the home. The study sample includes 339 newborns of nonsmoking mothers 18–35 yr of age and free from chronic diseases, who were recruited from ambulatory prenatal clinics in the first or second trimester of pregnancy. The number of wheezing days during the first 2 yr of life was positively associated with prenatal level of PAH-DNA adducts (IRR = 1.69, 95%CI = 1.52–1.88), prenatal particulate matter (PM2.5) level dichotomized by the median (IRR = 1.38; 95%CI: 1.25–1.51), maternal atopy (IRR = 1.43; 95%CI: 1.29–1.58), mouldy/ damp house (IRR = 1.43; 95%CI: 1.27–1.61). The level of maternal education and maternal age at delivery was inversely associated with the IRRs for wheeze. The significant association between frequency of wheeze and the level of prenatal environmental hazards (PAHs and PM2.5) was not observed at ages 3 or 4 yrs. Although the frequency of wheezing at ages 3 or 4 was no longer associated with prenatal exposure to PAHs and PM2.5, its occurrence depended on the presence of wheezing in the first 2 yr of life, which nearly tripled the risk of wheezing in later life. In conclusion, the findings may suggest that driving force for early wheezing (<24 months of age) is different to those leading to later onset of wheeze. As we reported no synergistic effects between prenatal PAH (measured by PAH-DNA adducts) and PM2.5 exposures on early wheeze, this suggests the two exposures may exert independent effects via different biological mechanism on wheeze.

Polycyclic aromatic hydrocarbon metabolite levels and pediatric allergy and asthma in an inner-city cohort

Abstract: Exposure to polycyclic aromatic hydrocarbons (PAH) has been associated with allergic sensitization and asthma. We hypothesized that increased urinary PAH metabolites are associated with allergy or asthma among children age 5 yrs in an inner-city birth cohort. As part of an ongoing prospective birth cohort under the auspices of the Columbia Center for Children's Environmental Health (CCCEH), urine was collected from 5-yr-old children (n = 222) of Dominican American and African American mothers in Northern Manhattan and South Bronx of New York City. Twenty-four PAH metabolites were measured in these specimens, and their levels (unadjusted and specific gravity corrected) were evaluated with IgE levels and asthma outcomes. Ten metabolites were detected in urine from all children. Concentrations ranged higher than those in representative samples of US children ages 6-11 in the National Health and Nutrition Examination Survey (NHANES). Among CCCEH children, compared with African Americans, the Dominican children had higher 2-hydroxynaphthalene but lower 9-hydroxyfluorene and 4-hydroxyphenanthrene concentrations. Increased 3-hydroxyfluorene and 3-hydroxyphenanthrene levels were associated with higher anti-mouse IgE levels (p < 0.05). These plus 2-hydroxynaphthalene, 2-hydroxyflourene and 1-hydroxyphenanthrene concentrations were associated with higher anti-mouse IgE levels on multivariate analyzes. Increased 2-hydroxyphenanthrene, 3-hydroxyphenanthrene and 4-hydroxyphenanthrene levels were associated with higher anti-cat IgE levels (p < 0.05) in univariate, but not multivariate, analyzes. Levels of PAH metabolites were not associated with respiratory symptoms. Measures of PAH metabolites suggest considerable exposure in an urban pediatric population, and possible associations with allergic sensitization to mouse.

Safety of anti-IgE treatment with omalizumab in children with seasonal allergic rhinitis undergoing specific immunotherapy simultaneously.

Abstract: Kamin W, Kopp MV, Erdnuess F, Schauer U, Zielen S, Wahn U. Safety of anti-IgE treatment with omalizumab in children with seasonal allergic rhinitis undergoing specific immunotherapy simultaneously. Pediatr Allergy Immunol 2010: 21: e160–e165. © 2009 John Wiley & Sons A/S Introduction Seasonal allergic rhinitis (SAR) affects at least 10–25% of the Caucasian race and about 40% of patients are children. Standard treatment of SAR is specific immunotherapy (SIT), but anti-allergic drugs can significantly enhance efficacy of SIT. One candidate is the humanized monoclonal anti-IgE antibody omalizumab. Material and Methods Randomized, double-blind, placebo-controlled, multi-centre trial in Germany. A total of 221 children were randomly assigned to four different groups and treated with SIT (either grass or birch pollen), starting at least 14 wk before the local birch pollen season. After the 12-wk SIT titration phase, either anti-IgE (omalizumab) or placebo (NaCl 0.9%) therapy was added. This combination therapy with SIT and anti-IgE or placebo lasted 24 wk. To record local reactions and adverse events (AE), the injection site was examined by a clinician 20 min after application of study medication. Further, patients stated any AE and the use of rescue medication by means of a diary 3 days after every injection. Finally, any AE or serious adverse event (SAE) reported by the patients was specified on a standard form by clinicians. Overall tolerance was judged by the doctors according to the patient’s diaries. To test differences between the groups, we used either the two-sided Wilcoxon rank-sum test or the two-sided chi-square test. Results Tolerability of SIT and omalizumab treatment was good (82% of patients). Only some AE with possible causal relationship to treatment occurred slightly more often in the verum groups, i.e. local reactions (16.8 vs. 12.3%) and gastrointestinal (2.7 vs. 0.9%) and ear symptoms (1.8 vs. 0%). Most AE (93.4% in omalizumab and 87.2% in placebo group) were judged by the patients as mild to moderate. SAE were restricted to four patients with asthma in the placebo group, two subjects with headache in the verum group and three patients with infections (two in verum and one in placebo group). Only the cases of asthma were judged to be possibly related to study medication. Further, redness and swelling at the SIT injection site appeared significantly more often in the placebo group which suggests a positive effect of omalizumab on local reaction induced by SIT. Conclusion Omalizumab represents an important clinical advance in the management of allergic diseases and can be considered to be safe in children.

Clinical outcome and IL-17, IL-23, IL-27 and FOXP3 expression in peripheral blood mononuclear cells of pollen-allergic children during sublingual immunotherapy.

Abstract: Induction of allergen-specific, tolerogenic, IL-10 and/or TGF-β-producing T-regulatory (Treg) cells that express transcription factor FOXP3 is considered as one of the key mechanisms of allergen-specific immunotherapy. However, little is known of the induction of FOXP3 expression in children during sublingual immunotherapy (SLIT). Recently, also, a novel subgroup of T-helper (Th) cells, the Th17 cells, secreting predominantly IL-17 (IL-17A), was identified. The expressions of IL-17 or the Th17-regulating cytokines IL-23 and IL-27 during SLIT are currently completely unexplored. This randomized, placebo-controlled dose-response study was performed to analyze the effects of SLIT on FOXP3, IL-17, IL-23, and IL-27 expressions in peripheral blood mononuclear cells (PBMC) of children with allergic rhinitis and their associations with clinical outcome. Thirty children were included: ten received SLIT with a glycerinated mixture of birch, hazel and alder with a cumulative weekly dose of 24,000 SQ-U, 10 with dose 200,000 SQ-U/wk, and ten received placebo. Cytokine and FOXP3 mRNA expressions in allergen-, purified protein derivative-stimulated and non-stimulated PBMC were determined at 0, 1 and 2 yr of SLIT by real-time RT-PCR (TaqMan). Symptoms and medications were recorded using diary cards. Allergen-induced IL-17 mRNA expression was significantly increased in the study subjects with elevated combined Symptom Medication Score (SMS) after 2 yr. There was also a significant positive correlation between the allergen-induced IL-17 and SMS in whole study group (r = 0.38, p = 0.039) and especially the 200,000 SQ-U dose-treated group (r = 0.74, p = 0.027) at 2 yr. Allergen-induced FOXP3 mRNA expression was significantly increased in the 200,000 SQ-U dose-treated children after two study years as compared with baseline (p = 0.016) and placebo-treated children (p = 0.028). The changes in FOXP3 mRNA expression positively correlated with IL-10 and TGF-β mRNAs during SLIT in whole study population. Increased allergen-induced IL-17 responses during SLIT are associated with elevated SMS. Increased tolerogenic, allergen-specific Treg responses are also observed in children during SLIT.

Confirmed association between neonatal phototherapy or neonatal icterus and risk of childhood asthma.

Abstract: We have previously demonstrated an association between neonatal phototherapy and/or neonatal icterus and risk of hospitalization for childhood asthma. This study included children who were prescribed anti-asthmatic medication on a population basis to study exposures during the foetal and neonatal period and risk of childhood asthma. The Swedish Medical Birth Register was linked to the Swedish Prescribed Drug Register. Perinatal data for singleton children who were prescribed anti-asthmatic medication (n = 61,256) were compared with corresponding data for all singleton children born in Sweden from 1 January 1990 to 30 June 2003 and surviving to 1 July 2005 (n = 1,338,319). Mantel-Haenszel's odds ratios were calculated after adjustment for various known confounders. Being the first-born child, maternal age above 44 yr, involuntary childlessness for more than 1 yr, maternal smoking during pregnancy, maternal diabetes mellitus of any kind, pre-eclampsia, caesarean section, and instrumental vaginal delivery were all associated with an increased prescription of anti-asthmatic medication during childhood. Preterm birth, low birth weight, being small for gestational age, respiratory problems, mechanical ventilation, and sepsis and/or pneumonia were also associated with increased drug prescriptions. Neonatal phototherapy and/or icterus were risk determinants for children who developed asthma before the age of 12. After controlling for confounders, the odds ratio for phototherapy and/or icterus remained at 1.30 (95% confidence interval 1.16-1.47). In conclusion, this large population-based study confirms an association between some maternal and perinatal factors and childhood asthma, including neonatal phototherapy and/or icterus.

Five-grass pollen 300IR SLIT tablets: efficacy and safety in children and adolescents

Abstract: The efficacy and safety of five-grass pollen 300IR sublingual immunotherapy (SLIT) tablets (Stallergenes SA, France) have previously been demonstrated in paediatric patients. This report presents additional data concerning efficacy at pollen peak, efficacy and safety according to age, nasal and ocular symptoms, use of rescue medication, satisfaction with treatment and compliance. Children (5-11 yr) and adolescents (12-17 yr) with grass pollen-allergic rhinoconjunctivitis were included in a multinational, randomized, double-blind, placebo-controlled study and received either a 300IR five-grass pollen tablet or placebo daily in a pre- (4 months) and co-seasonal protocol. The severity of six symptoms (sneezing, rhinorrhoea, nasal congestion, nasal and ocular pruritis, and tearing) was scored, and rescue medication use was recorded daily during the pollen season. Patient satisfaction was recorded at the season end. A total of 161 children and 117 adolescents were evaluated (n = 267). 300IR SLIT was effective over the whole season (p = 0.0010) and at the pollen peak (p = 0.0009). The adjusted mean difference between 300IR and placebo groups was significant for both nasal (p = 0.0183) and ocular (p < 0.0001) symptoms. Rescue medication use was statistically lower in the SLIT group during the pollen season and at the pollen peak (both p < 0.05). More patients in the SLIT group were satisfied with their treatment compared to placebo (83.2% vs. 68.1%, p = 0.0030), and compliance was high (SLIT 93.9% of patients were compliant, placebo 94.8% of patients were compliant). SLIT was well tolerated by children and adolescents. 300IR five-grass pollen tablets are effective and safe during the pollen season and at the pollen peak in children and adolescents with grass pollen rhinoconjunctivitis.

Immune regulatory cytokines in the milk of lactating women from farming and urban environments

Abstract: Peroni DG, Pescollderungg L, Piacentini GL, Rigotti E, Maselli M, Watschinger K, Piazza M, Pigozzi R, Boner AL. Immune regulatory cytokines in the milk of lactating women from farming and urban environments. Pediatr Allergy Immunol 2010: 21: 977–982. © 2010 John Wiley & Sons A/S Children living on farms have fewer allergies. It is unclear whether breastfeeding in different environments contributes to preventing allergies by exposing offspring to different cytokines that can modulate immune responses. The aim of this study was to quantify and compare levels of Transforming Growth Factor-β1 (TGF-β1) and Interleukin-10 (IL-10) in the colostrum and mature milk of mothers living in towns at sea level (references) and mothers on farms. Milk samples were collected within 3 days postpartum (colostrum) and at the first month of the baby’s life (mature milk). Sixty-nine reference mothers and 45 farm mothers participated in the study. TGF-β1 concentrations were significantly higher both in the colostrum (p < 0.05) and in mature milk (p < 0.05) of farm mothers. In the reference mothers, a significant decrease in TGF-β1 concentrations was observed between colostrum (650, range 0–8000 pg/ml) and mature milk (250, range 0–8000 pg/ml) (p < 0.05). In farm mothers, TGF-β1 concentrations were 1102 pg/ml (range 0–14,500) in colostrum and remained high in mature milk (821 pg/ml, range 0–14,650). IL-10 concentrations were higher in the mature milk of farm mothers (p < 0.05). No significant differences in IL-10 were observed between colostrum and mature milk in the control group (15 pg/ml, range 0–1800, and 0 pg/ml, range 0–230) or in farm mothers (9.5 pg/ml, range 0–1775, and 14.2 pg/ml, range 0–930), respectively. Exposure to a farm environment is associated with higher concentrations of TGF-β1 and IL-10 in breast milk when compared to exposure to an urban environment. Higher cytokine concentrations in breast milk may influence early modulation of the development of an immune response, leading to a reduced prevalence of allergy-related diseases in farm children.

Exposure to traffic exhaust and night cough during early childhood: the CCAAPS birth cohort

Abstract: Though studies have investigated the association between air pollution and respiratory health outcomes in children, few have focused on night cough. The study objective was to simultaneously evaluate family factors (i.e., race, gender, maternal and paternal asthma, and breastfeeding), health (allergen sensitization and wheezing symptoms), home factors (dog, cat, mold, endotoxin, and dust mite), and other environmental exposures (traffic exhaust and second-hand tobacco smoke) for associations with recurrent dry night cough (RNC) during early childhood. A structural equation model with repeat measures was developed assessing RNC at ages one, two, and three. The prevalence of RNC was relatively large and similar at ages, one, two, and three at 21.6%, 17.3%, and 21.1%, respectively. Children exposed to the highest tertile of traffic exhaust had an estimated 45% increase in risk of RNC compared with children less exposed (adjusted OR 1.45, 95% CI: 1.09, 1.94). Also, wheezing was associated with a 76% higher risk of RNC (adjusted OR 1.76, 95% CI: 1.36, 2.26). A protective trend for breastfeeding was found with a 27% reduction in risk associated with breastfeeding (adjusted OR 0.73, 95% CI: 0.53, 1.01). No other factors were significant. These results suggest that traffic exhaust exposure may be a risk factor for night cough in young children.

Filaggrin gene variants and atopic diseases in early childhood assessed longitudinally from birth.

Abstract: Copenhagen Prospective Study on Asthma in Childhood (COPSAC) was one of the discovery cohorts of the association between eczema and variants in the filaggrin coding gene (FLG). Here, we study the FLG-associated risk of asthma symptoms in early life and describe the temporal relationship in the development of the different FLG-associated atopic outcomes: asthma, sensitization and eczema, assessed longitudinally from birth. A high-risk cohort of 411 children was assessed in a prospective clinical study from birth to school-age. Asthma, acute severe asthma exacerbations, sensitization and eczema were diagnosed prospectively by the investigators. FLG variants R501X and Del4 were determined in 382 Caucasians. Filaggrin variants increased risk of developing recurrent wheeze, asthma and asthma exacerbations (hazard ratio 1.82 [1.06-3.12], p = 0.03), which was expressed within the first 1.5 yr of life. Children with filaggrin variants had a marked and persistent increase in acute severe asthma exacerbations from 1 yr of age (incidence ratio 2.40 [1.19-4.81], p = 0.01) and increased risk of asthma by age 5 (odds ratio 2.62 [1.12-6.11], p = 0.03). FLG variants increased the risk of eczema, manifesting fully in the first year of life (point prevalence ratio for age 0-5 was 1.75 [1.29-2.37]; p-value = 0.0003) contrasting the increased risk of specific sensitization by age 4 (odds ratio 3.52 [1.72-7.25], p = 0.0007) but not age 1.5. This study describes a FLG-associated pattern of atopic diseases characterized by the early onset of asthma symptoms and eczema and later development of sensitization. The association of filaggrin variants with asthma suggests skin barrier dysfunction as a novel, and potentially modifiable, mechanism driving early childhood asthma.

Non-surgical treatment of adenoidal hypertrophy: the role of treating IgE-mediated inflammation.

Abstract: Adenoidal hypertrophy (AH) and adenotonsillar hypertrophy are common disorders in the pediatric population and can cause symptoms such as mouth breathing, nasal congestion, hyponasal speech, snoring, and obstructive sleep apnea (OSA), as well as chronic sinusitis and recurrent otitis media. More serious long-term sequelae, typically secondary to OSA, include neurocognitive abnormalities (e.g. behavioral and learning difficulties, poor attention span, hyperactivity, below average intelligence quotient); cardiovascular morbidity (e.g. decreased right ventricular ejection fraction, left ventricular hypertrophy, elevated diastolic blood pressure); and growth failure. Adenoidectomy (with tonsillectomy in cases of adenotonsillar hypertrophy) is the typical management strategy for patients with AH. Potential complications have prompted the investigation of non-surgical alternatives. Evidence of a pathophysiologic link between AH and allergy suggests a possible role for intranasal corticosteroids (INS) in the management of patients with AH. This article reviews the epidemiology and pathophysiology of AH with a particular focus on evidence of its association with allergy and allergic rhinitis. Current treatment options are briefly considered with discussion on the rationale and evidence for the use of INS.