journal of food allergyjournaloffoodallergy.com/journal/jfa-v1-n1.pdfdifferent ﬁ elds of food...

J FOOD ALLERGY

Official Journal of the Brazilian Society of Food Allergy

JOURNAL OF FOOD ALLERGY

January-March 2012 • Volume 1 • Number 1Printed Version ISSN 2238-0752

Katie AllenUniversity of Melbourne, Melbourne, Australia

Jaime Ramirez MayansInstituto Nacional de Pediatría, S.S, Mexico

Joseph A. BellantiGeorgetown University Medical Center, USA

Jorge Amil DiasCentro Hospitalar S. Joao, Portugal

Jorge KalilSchool of Medicine USP and Instituto Butantan, São Paulo, Brazil

Giuseppe IaconoDi Cristina Hospital, Italy

Glenn FurutaUniv. of Colorado Denver School of Medicine, USA

Olivier Goulet University of Paris 5 René Descartes, Paris, France

John Walker-SmithEmeritus Prof of Paediatric GastroenterologyUniversity of London, Londo, United Kingdom

Marcello BarcinskiFIOCRUZ, Rio de Janeiro, Brazil

Mauro Batista MoraisPaulista School of Medicine, Sao Paulo, Brazil

Simon MurchWarwick Medical School, United Kingdom

Annamaria StaianoUniversity of Naples, Federico II, Italy

Maria Del Carmen TocaUniversity of Buenos Aires, Argentina

Neil ShahGreat Ormond Street HospitalInstitue of Child Health University College London, United Kingdom

Journal of Food AllergyAddress: Visconde de Piraja, 330 / 311, 22410-001, Rio de Janeiro, Brazil

Telephone: + 55 21 2513-2161E-mail: [email protected]

Website: www.journalfoodallergy.com

EDITORIAL BOARD

Offi cial Journal of the Brazilian Society of Food Allergy - SBAA

EDITOR-IN-CHIEFProf. Aderbal SabraUniversity Unigranrio, Rio de Janeiro, Brazil

CONSULTING EDITORS

J FOOD ALLERGY

Harland WinterHarvard Medical School, USA


JFA_Issue_1_Jan_Jun_2012.indb 1JFA_Issue_1_Jan_Jun_2012.indb 1 08/11/2012 14:56:2608/11/2012 14:56:26


J FOOD ALLERGY

Volume 1, Number 1 January - March, 2012

CONTENTS

Review Article

Editor’s Comment Aderbal Sabra..............................................................................................................................................................

Atopy in children with Eosinophilic Esophagitis (EoE) and Gastroesophageal Refl ux Disease (GERD)Heather Cassell, Vincent Mukkada, Samantha A. Woodruff, Stephanie Petersburg, Zhaoxing Pan, Dan Atkins, Glenn T. Furuta, David Fleischer ...........................................................................................................

Are mothers of infants aware of the peanut and egg allergen content of foods?Jennifer Koplin, Shyamali C. Dharmage, Lyle C. Gurrin, Nicholas J. Osborne, Mimi L. K. Tang, Katrina J. Allen ...........................................................................................................................................................

Cytokines Profi les in Patients with the Spectrum of Non-IgE Food Allergy: A New Prototype of Immunological DisturbanceAderbal Sabra, Joseph Alphonso Bellanti, Selma Sabra, Barbara Zeligs, Gustavo Rodrigues, Isaac Tenório ..............................................................................................................................................................

Gastrointestinal and Behavioral Dysfunction in Children with Non-IgE-mediated Food Allergy, Ileal-Nodular-Lymphoid Hyperplasia (ILNH) and Low Th1 Function: A New Clinical-Immunologic Constellation Aderbal Sabra, Joseph A. Bellanti, Dan Hartmann, Barbara Zeligs, Selma Sabra, Ricardo Ebecken, Kalil Madi, Isaac Tenório ..........................................................................................................................................

Information for Authors ...........................................................................................................................................

Eosinophilic esophagitis in children: Basic conceptsRuben Rocha, Jorge Amil Dias ...................................................................................................................................

Original Articles

03

05

12

20

28

35

44


3

EDITOR’S COMMENT

Finally the world literature has a journal of medicine totally devoted to the study of food allergy and related sciences. Our refi ned Editorial Board with members from all over the world, all of then with a large experience in different fi elds of food allergy is signaling that JFA has come to take place and emerge as a unique journal deeply enrolled and compromised with all the sciences related to food allergy. From the bench housing the basic science to the clinical affairs JFA has compromised itself to publish papers that could cover all the fi elds of food allergy. For this reason our editorial board has a unique fashion with members dedicated to basic sciences, to others dedicated to different fi elds of the clinical aspects of food allergy. This selected group of editors will take care, as leaders in their fi elds, of the excellence and quality of our selected papers to be published in JFA. Is our goal to run for indexation, so we will start with the minimum of four issues per volume-year with all papers in accordance with the rules originated by the house of experts in NIH. Our fi rst issue, volume one number one, will appear “on line” soon, with an innovation of free access to all readers, in tree idioms: English, Portuguese and Spanish. An English edition is “in press” and will be published to be distributed to selected libraries, all over the world. Editions “on line” in Japanese, Russian and Chinese are on the way. Issue number one has fi ve articles: 1 - Atopy in children with Eosinophilic Esophagitis (EoE) and Gastroesophageal Refl ux Disease (GERD) - Heather Cassell, Vincent Mukkada, Samantha A. Woodruff, Stephanie Petersburg, Zhaoxing Pan, Dan Atkins, Glenn T. Furuta, David Fleischer Alvernon Allergy Asthma and Asthma P.C, Tucson, Arizona, (HC); Hasbro Chil-dren’s Hospital, Alpert Medical School, Brown University, Providence, RI, (VM); Department of Pediatrics, Uni-versity of Massachusetts, Worcester, MA, (SAW); Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Aurora, Colorado, (SP, GTF); Department of Pediatrics, University of Colorado Denver School of Medicine (ZP, DA, GTF, DF); Department of Pediatrics, National Jewish Health, Denver, Colorado, USA (DA, GTF, DF);2 - Gastrointestinal and Behavioral Dysfunction in Children with Non-IgE-mediated Food Allergy, Ileal-Nod-ular-Lymphoid Hyperplasia (ILNH) and Low Th1 Function: A New Clinical-Immunologic Constellation - Ad-erbal Sabra, Joseph A. Bellanti, Dan Hartmann, Barbara Zeligs, Selma Sabra, Ricardo Ebecken, Kalil Madi, Isaac Tenorio, Department of Food Allergy UNIGRANRIO, Rio de Janeiro, Brazil (AS, IT) and ICIS Immunology Service at Georgetown University, USA (AS); Department of Microbiology and Immunology and Director of ICIS at Georgetown University, USA, (JAB); Pathology Service at Georgetown University, USA, (DH); Laboratory of Immunology at Georgetown University, USA, (BZ); Pediatric Endoscopy Service HUAP-UFF, Rio de Janeiro, Brazil (SS, RE); Department of Pathology UNIGRANRIO, Rio de Janeiro, Brazil, (KM);3 - Are mothers of infants aware of the peanut and egg allergen content of foods? - Jennifer Koplin, Shyamali C. Dharmage, Lyle C. Gurrin, Nicholas J. Osborne, Mimi L. K. Tang, Katrina J. Allen Murdoch Childrens Re-search Institute (JK, SCD, LCG, NJO, MLKT, KJA), Department of Paediatrics (JK, MKT, KJA), University of Melbourne; Department of Allergy and Immunology (MLKT, KJA), Royal Children’s Hospital The Centre for Molecular, Environmental, Genetic and Analytic Epidemiology (SCD, LCG), University of Melbourne, Parkville, VIC, Australia and European Centre for Environment and Human Health (MJO), Peninsula College of Medicine and Dentistry, University of Exeter, United Kingdom;

J FOOD ALLERGY


4

EDITOR’S COMMENT - Continued

4 - Cytokines Profi les in Patients with the Spectrum of Non-IgE Food Allergy: A New Prototype of Immunologi-cal Disturbance - Aderbal Sabra, Joseph Alphonso Bellanti, Selma Sabra, Barbara Zeligs, Gustavo Rodrigues, Isaac Tenório, Department of Gastroenterology and Food Allergy, UNIGRANRIO University - School of Medicine, RJ, Brazil, (AS); Department of Immunology Center – ICISI – Georgetown University, Washington, DC, USA, (JAB); Department of Pediatrics, UNIGRANRIO University, RJ, Brazil, (SS); Department Pediatric Endoscopy, Antônio Pedro University Hospital, RJ, Brazil, (BZ); Laboratory of Immunology, Immunologic Center – ICISI – George-town University, Washington, DC, USA, (GR); Department of Pediatric Gastroenterology and Food Allergy, UNI-GRANRIO University, RJ, Brazil, (IT);5 - Eosinophilic esophagitis in children: Basic concepts - Ruben Rocha, Jorge Amil Dias - Department of Pediat-rics, Centro Hospitalar S. João, Porto, Portugal.

We are running issue number two and “call for papers” are under way to the next issues. Please send your manuscripts to JFA (www.journalfoodallergy.com), from basic science to clinical experience. All articles are wel-come, “bem vindos” and “bien venidos”. Our editorial board will appreciate to select then to be published in JFA.

Welcome to our fi rst issue.

Aderbal Sabra, MD, PhDEditor-in-ChiefJournal of Food Allergy

J FOOD ALLERGY


ABSTRACT

Background: Eosinophilic esophagitis (EoE) is often confused with gastroesophageal refl ux disease (GERD). Identifi ca-tion of clinical clues that could assist in differentiating EoE from GERD would be benefi cial. Co-morbid allergic diseases occur commonly in adults and children with EoE. To date, few studies have compared the incidence of allergic diseases in children with EoE to those with GERD.Objectives: To determine the incidence of allergic diseases in children with EoE and GERD.Materials and Methods: A retrospective chart review was performed of patients who were evaluated in a multidisciplinary program caring for children with eosinophilic gastrointestinal diseases. Data regarding the presence of allergic disease (IgE-mediated food allergy, asthma, allergic rhinitis, and eczema, as well as relevant skin and serum food-specifi c-IgE testing and total serum IgE) were recorded.Results: Charts from 116 patients (ages 1-18 years) were reviewed. Patients with EoE had a signifi cantly higher per-centage of atopic diseases (IgE-mediated food allergy, asthma, allergic rhinitis, and/or eczema) compared to those with GERD (89.1% versus 50%, p=0.001). Patients with EoE had a higher percentage of allergic rhinitis (62.5% vs 35%, p=0.03), eczema (56.3% vs 30%, p=0.04), and environmental allergen sensitivity (87% vs 46%, p=0.001) (based on positive allergy tests), as well as peripheral blood eosinophilia (51% vs 11%, p=0.005) compared to those with GERD.Conclusions: A history of allergic diseases in children with common gastrointestinal symptoms aids in identifying those more likely to have EoE.

Key words: Eosinophilic Esophagitis; Gastroesophageal Refl uxJ Food Allergy. 2012; 1: (1) 05-11

INTRODUCTION

Common gastrointestinal symptoms such as vomiting, feeding intolerance, abdominal pain and dysphagia are the initial symptoms of gastroesophageal refl ux disease (GERD) and eosinophilic esophagitis (EoE) (1). While the pathophysiology of GERD is related to transient

relaxations of the lower esophageal sphincter, EoE is attributed to chronic allergic infl ammation. Although GERD and EoE are pathophysiologically distinct, the commonality of their presenting symptoms often results in children being misdiagnosed with GERD when they actually have EoE. Clinical experiences also have identifi ed a group of patients with EoE who have co-existent GERD; the pathophysiology

Journal of Food Allergy, Vol. 01 (1): 05-11, January-March - 2012

Atopy in children with Eosinophilic Esophagitis (EoE) and Gastroesophageal Refl ux Disease (GERD)Heather Cassell, Vincent Mukkada, Samantha A. Woodruff, Stephanie Petersburg, Zhaoxing Pan, Dan Atkins, Glenn T. Furuta, David Fleischer

Alvernon Allergy Asthma and Asthma P.C., Tucson, Arizona, (HC); Center for Children’s Digestive Diseases, Hasbro Children’s Hospital, Alpert Medical School, Brown University, Providence, RI, (VM); Department of Pediatrics, University of Massachusetts, Worcester, MA, (SAW); Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, Aurora, Colorado, (SP, GTF); Gas-trointestinal Eosinophilic Diseases Program, Department of Pediatrics, University of Colorado Denver School of Medicine (ZP, DA, GTF, DF); Department of Pediatrics, National Jewish Health, Denver, Colorado, USA (DA, GTF, DF)

5

ORIGINAL ARTICLE


6

Atopy in children with Eosinophilic Esophagitis

of this subgroup of patients is still not known (2,3).Therefore, an understanding of how often

allergic symptoms occur in children with EoE compared to those with the more prevalent GERD would be benefi cial. An increasing number of studies and clinical experiences have identifi ed the association of EoE with other co-morbid allergies such as IgE-mediated food allergy, asthma and eczema. To date, few studies have compared the incidence of atopic diseases in children with EoE compared to those with the more common GERD (4-8).

We hypothesize that children with EoE have an increased incidence of allergic diseases compared to those with GERD. The objective of this study was to measure the presence of allergic disease in a cohort of children evaluated in a multidisciplinary eosinophilic gastrointestinal diseases program.

MATERIAL AND METHODS

Patient SelectionA retrospective chart review was performed

of all patients evaluated in the Gastrointestinal Eosinophilic Diseases Program at Denver, Colorado from December 2007 to March 2009. A pediatric gastroenterologist and pediatric allergist evaluated all patients. Charts were reviewed to identify the presence or absence of key clinical features of allergic diseases and the results of specifi c allergy testing (skin prick testing, total IgE, allergen-specifi c IgE levels).

A diagnosis of EoE was made in children who presented with a chronic history of abdominal pain, dysphagia, food impaction, anorexia or failure to thrive, an esophageal biopsy with greater than 15 eosinophils per HPF and normal gastric and duodenal biopsies. Other causes for these fi ndings were eliminated (1). As a part of this evaluation, a number of children were found to have alternative causes of their symptoms and histopathological fi ndings. In this regard, diagnostic criteria for GERD included a clinical or pathologic response to a proton pump inhibitor (PPI) and/or a positive impedance or esophageal pH monitoring study.

Some patients had a clinico-pathological response to topical steroids or dietary exclusions but then developed heartburn or abdominal pain that was responsive to proton pump inhibition. These patients were considered to have EoE + GERD.

The presence of a systemic food reaction (generalized urticaria and/or more than one organ system involved in a reaction occurring

7


Children with EoE had a signifi cantly higher percentage of any atopic disease (IgE-mediated food allergy, asthma, allergic rhinitis, and/or eczema) compared to those with GERD (89.1% vs 50%, p=0.001; Table 2 and Figure 1). Children with EoE had a signifi cantly higher percentage of allergic rhinitis (62.5% vs 35%, p=0.03), and a higher rate of eczema (56.3% vs 30%, p=0.04) than those with GERD alone. Children with EoE + GERD also had signifi cantly higher percentages of asthma, allergic rhinitis, or eczema than children with GERD alone (p=0.01; Table 2 and Figure 1). Finally, there was a higher percentage of environmental allergen sensitivity (87% vs 46%, p=0.001) and peripheral blood eosinophilia (51% vs 11%, p=0.005; Figure 2) in children with EoE compared to those with GERD. There were no signifi cant differences in total IgE levels identifi ed among the groups.

DISCUSSION

As the worldwide incidence of EoE has increased, so has the clinical confusion differentiating EoE from GERD. This confusion is emphasized by the fact that over 33% of patients referred to our multi-disciplinary program, which focuses on eosinophilic gastrointestinal diseases (EGIDs), actually had a diagnosis other than an EGID. To begin to address this, we examined whether allergic diseases and abnormal lab values / positive skin prick tests occurred with different incidences in children with EoE and GERD. Measurements of these parameters were important to provide additional clinical features that may help distinguish between these two diseases. Results here document that the incidence of allergic diatheses, specifi cally IgE-mediated food allergy, asthma, allergic rhinitis

Diagnosis Number of Patients Median Age(range)

Percent Male

EoE 64 9.5 yrs.(2-18) 70%EoE + GERD 10 8.3 yrs.(2-16) 90%GERD 20 7.5 yrs.(2-16) 95%Other 22 5.2 yrs.(2-13) 50%

Table 1. Patient demographics.

Diagnoses Compared

Systemic Food

Reaction(p value)

Asthma(p

value)

Allergic Rhinitis

(p value)

Eczema(p

value)

Any Atopic Feature(p value)

Environmental Allergen

Sensitivity(p value)

Eosinophilia(p value)

Elevated IgE

(p value)

EoE vs. GERD

0.167 0.225 0.031* 0.040* 0.001*** 0.002** 0.005** 0.546

EoE vs. EoE+GERD

0.181 0.782 0.451 0.824 0.272 0.966 0.637 0.822

EoE vs. Other

0.015* 0.137 0.013* 0.214 0.002** 0.014* 0.004** 0.414

EoE+GERD vs. GERD

0.760 0.284 0.429 0.114 0.006** 0.058 0.150 0.571

EoE+GERD vs. Other

0.646 0.210 0.325 0.316 0.017* 0.127 0.084 0.778

GERD vs. Other

0.349 0.845 0.827 0.461 0.554 0.682 0.665 0.255

Table 2. Comparison of prevalence of allergic features in children with intestinal diseases.

*p

8


Figure 2. Analysis for allergic diseases.

Figure 1. Incidence of allergic diseases.


9


and eczema, was signifi cantly greater in children with EoE compared to those with GERD. Although peripheral eosinophilia was more common in children with EoE, we were interested to fi nd that the frequency of an elevated IgE levels, a laboratory value typically associated with EoE, was not signifi cantly different between the two groups. Our results also indicate that 50% of the pediatric GERD population had a history of an allergic disease, a value somewhat higher than suspected. Taken together, these fi ndings show that atopic disorders occur more frequently in children with EoE compared to those with GERD. This may be helpful in differentiating these two disorders, as these diagnoses are often confused.

While the overall incidence of allergic diseases, such as asthma and food allergy, is clearly increasing, the identifi cation of specifi c subsets of children who develop these diseases has not been studied extensively. Pomiecinski et al evaluated 69 adults with a history of heartburn and found that 27% had sensitization to foods as determined by skin prick testing (8). Garcia-Compean determined that atopy occurred more frequently in adults with symptoms refractory to PPI treatment (7). Dalby et al. found that food sensitization, based on skin prick testing, atopy patch testing and elevated allergen specifi c IgE levels occurred more frequently in children with EoE than those with GERD (6). Gupta et al. compared a variety of allergic features (allergic rhinitis, asthma, eczema, total IgE levels, peripheral eosinophilia, serum allergen-specifi c IgE, and skin prick testing) from 68 children with EoE to 23 with GERD, and discovered that only peripheral eosinophilia was signifi cantly greater in the EoE group (5). Finally, Aceves et al. found that children with EoE had signifi cantly more asthma and food allergy, but not allergic rhinitis, compared to children with GERD (4). Thus, while the preponderance of data suggests that patients with EoE have more allergic diatheses, not all parameters are increased when comparing to children with GERD.

Our fi ndings do reinforce the clinical suspicion that allergic diseases occur more frequently

in children with EoE. This is important for several reasons. First, these fi ndings provide additional clinical data to support a diagnosis of EoE when evaluating children with common gastrointestinal complaints. Second, IgE has been proposed as a key molecule in the pathogenesis of EoE. In this study, elevated total IgE levels did not differ signifi cantly between children with EoE and those with GERD, whereas the presence of allergen-specifi c IgE as determined by serum allergen-specifi c IgE levels and skin prick testing was different between groups. This suggests that total IgE levels alone may not be a valuable measure of allergy in patients with EoE and reliance on allergen specifi c IgE levels may be more appropriate to assess suspected patients. Third, we show that the patients with EoE + GERD have a profi le of allergic disease that is very similar to the EoE group. This fi nding suggests that children can have both EoE and GERD, and in this situation, EoE may be the predominant condition.

A variety of other measures may help to distinguish EoE from GERD including the number of esophageal eosinophils per high powered fi eld (9), eosinophil degranulation (10), tryptase staining for mast cell identifi cation (11), esophageal fi brosis index (12,13), cytokine analysis (14) and endoscopic features (15). To date, only pH monitoring and / or a clinico-pathological response to PPI treatment are suffi cient to differentiate EoE from GERD (1). In isolation, no other clinical features, including the eosinophil enumeration or the presence of allergic features as shown here, can provide this level of diagnostic clarity.

Several issues should be considered when interpreting our fi ndings. Records reviewed were from children cared for in a tertiary care multidisciplinary allergy/GI program who were already suspected of having an allergic disease, EoE. Thus, it is not surprising that the comparison groups (GERD and others) have a high level of allergic diseases. Since children in this study were taken from this highly selected group, we anticipate that children with GERD taken from a


10


more general population would actually have much less allergic disease. Alternatively, this may be a true representation of food allergy among GERD patients since an emerging body of data suggests that chronic PPI use may predispose to allergen sensitization (2,3,16,17). This high level of allergic diseases in children with GERD also could represent the increased incidence of allergic diatheses in the general population. Also, because patients were referred to a tertiary referral center for suspicion of EoE, referral bias may have played a role in the fact that there was no statistical difference in elevated total IgE levels between the EoE and GERD groups.

In summary, our fi ndings add to a growing body of literature demonstrating that children with EoE have more allergic diseases when compared to those with GERD. While the presence of an atopic disorder is not diagnostic of EoE versus GERD, and is not part of the current diagnostic criteria for EoE, our study emphasizes that EoE patients are more likely to have an allergic disease than not and signifi cantly more likely to have an allergic disease than children with GERD. Peripheral eosinophilia, but not total IgE levels, aided in distinguishing children with EoE from those with GERD. It should be emphasized, however, that EoE is a clinico-pathological diagnosis that is made based upon current available guidelines, after the other causes of esophageal eosinophilia, including GERD, have been eliminated.

CONFLICT OF INTERESTNone declared.

ACKNOWLEDGEMENTS

This work was presented in part at the Digestive Diseases Week, Chicago 2009.

REFERENCES

1. Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, et al. Eosinophilic esophagitis: Updated consensus recommendations for children and adults. J Allergy Clin Immunol. 2011;128(1): 3-20.

2. Souza RF, Huo X, Mittal V, Schuler CM, Carmack SW, Zhang HY, et l. Gastroesophageal refl ux might cause esophagitis through a cytokine-mediated mechanism rather than caustic acid injury. Gastroenterology. 2009;137(5):1776-84.

3. Spechler SJ, Genta RM, Souza RF. Thoughts on the complex relationship between gastroesophageal refl ux disease and eosinophilic esophagitis. Am J Gastroenterol. 2007;102(6):1301-6.

4. Aceves SS, Newbury RO, Dohil R, Schwimmer J, Bastian JF. Distinguishing eosinophilic esophagitis in pediatric patients: clinical, endoscopic, and histologic features of an emerging disorder. J Clin Gastroenterol. 2007;41(3):252-6.

5. Baxi S, Gupta SK, Swigonski N, Fitzgerald JF. Clinical presentation of patients with eosinophilic infl ammation of the esophagus. Gastrointest Endosc. 2006;64(4):473-8.

6. Dalby K, Nielsen RG, Kruse-Andersen S, Fenger C, Bindslev-Jensen C, Ljungberg S, et al. Eosinophilic oesophagitis in infants and children in the region of southern Denmark: a prospective study of prevalence and clinical presentation. J Pediatr Gastroenterol Nutr. 2010;51(3):280-2.

7. García-Compeán D, González González JA, Marrufo García CA, Flores Gutiérrez JP, Barboza Quintana O, Galindo Rodríguez G, et al. Prevalence of eosinophilic esophagitis in patients with refractory gastroesophageal refl ux disease symptoms: A prospective study. Dig Liver Dis. 2011;43(3):204-8.

8. Pomiecinski F, Yang AC, Navarro-Rodrigues T, Kalil J, Castro FF. Sensitization to foods in gastroesophageal refl ux disease and its relation to eosinophils in the esophagus: is it of clinical importance? Ann Allergy Asthma Immunol. 2010;105(5):359-63.

9. Walsh SV, Antonioli DA, Goldman H, Fox VL, Bousvaros A, Leichtner AM, et al. Allergic esophagitis in children: a clinicopathological entity. Am J Surg Pathol. 1999;23(4):390-6.

10. Protheroe C, Woodruff SA, de Petris G, Mukkada V, Ochkur SI, Janarthanan S, et al. A novel histologic scoring system to evaluate mucosal biopsies from patients with eosinophilic esophagitis. Clin Gastroenterol Hepatol. 2009;7(7):749-755.

11. Dellon ES, Chen X, Miller CR, Fritchie KJ, Rubinas TC, Woosley JT, et al. Tryptase staining of mast cells may differentiate eosinophilic esophagitis from gastroesophageal refl ux disease. Am J Gastroenterol. 2011;106(2):264-71.

12. Aceves SS, Newbury RO, Dohil R, Bastian JF, Broide DH. Esophageal remodeling in pediatric eosinophilic esophagitis. J Allergy Clin Immunol. 2007;119(1):206-12.


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13. Chehade M, Sampson HA, Morotti RA, Magid MS. Esophageal subepithelial fi brosis in children with eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2007;45(3):319-28.

14. Blanchard C, Stucke EM, Rodriguez-Jimenez B, Burwinkel K, Collins MH, Ahrens A, et al. A striking local esophageal cytokine expression profi le in eosinophilic esophagitis. J Allergy Clin Immunol. 2011;127(1):208-17.

15. Straumann A, Rossi L, Simon HU, Heer P, Spichtin HP, Beglinger C. Fragility of the esophageal mucosa: a pathognomonic endoscopic sign of primary eosinophilic esophagitis? Gastrointest Endosc. 2003;57(3):407-12.

16. Untersmayr E, Bakos N, Schöll I, Kundi M, Roth-Walter F, Szalai K, et al. Anti-ulcer drugs promote IgE formation toward dietary antigens in adult patients. FASEB J. 2005;19(6):656-8.

17. Untersmayr E, Schöll I, Swoboda I, Beil WJ, Förster-Waldl E, Walter F, et al. Antacid medication

inhibits digestion of dietary proteins and causes food allergy: a fi sh allergy model in BALB/c mice. J Allergy Clin Immunol. 2003;112(3):616-23.

_______________________Submitted for publication:

July 01, 2011

_______________________Accepted:

August 31, 2011____________________Correspondence addressDr. Glenn T. Furuta13123 East 16th Ave, B290Aurora, CO 80045, USATelephone: + 1 727 777-7457Fax: + 1 720 777-7277E-mail: [email protected]


12

ABSTRACT

Background: Recent studies have suggested an association between gastrointestinal manifestations associated with de-velopmental disorders in children (1). More recent studies from our group have suggested a link between attention-def-icit-hyperactive disorder (ADHD), non-IgE mediated food allergy and ileal-lymphoid-nodular hyperplasia (ILNH) (2). Objective: In the present study, we investigated a consecutive series of children with GI diseases and a variety of be-havioral and clinical manifestations related to the central nervous system (CNS) such as migraine, anorexia, ADHD and hyperkinetic syndrome and autism associated with non-IgE mediated food allergy and have observed alterations in T-helper cell (CD4) Th1 lineages and ILNH.Materials and Methods: Twelve patients, 6 girls and 6 boys, were referred to our gastroenterology unit because of a past history of diarrhea and abdominal pain. Six patients had anorexia and failure to thrive, 4 patients had behavioral disorders including ADHD in 3 and autism in 1 and 2 patients had migraine. All patients underwent gastrointestinal, immunologi-cal, developmental and neurological studies. Immunological studies were done in all patients (Th1 and Th 2 studies) to evaluate the distribution of T-helper cells (CD4) and their subsets in the blood. Following ileocolonoscopy, the gastroin-testinal tract was studied by immunohistochemical studies performed on intestinal biopsies of ILNH lesions from 9 of 12 patients to determine CD4 and CD8 lymphocyte distribution patterns. Results: All 12 patients had food allergy, ILNH and T-helper cell lineages that displayed a decreased Th1 cytokine pat-tern, i.e.,decreased IFN-γ and IL-2 and normal Th2 cytokine pattern, i.e., IL-4, IL-5 and IL-10, respectively. Histology showed that all 9 biopsies contained moderate to severe infl ammatory infi ltrates characterized primarily by T and B lymphocytes, as well as by CD21+ dendritic cells. There were no neurological abnormalities and MRI and EEG tests were normal in all 12 patients studied.Conclusions: We have interpreted our fi ndings to indicate that ileal-lymphoid-nodular hyperplasia (ILNH) may be the hallmark lesion of the gastrointestinal tract in patients with food allergy and CNS developmental disorders and may rep-resent the tissue response linking these entities. Although the precise pathogenetic mechanism(s) of food allergy is not known with certainty, in this group of patients it is most likely related to a non-IgE mediated response as demonstrated by the lack of an elevated Th2 profi le characteristic of the IgE-mediated allergic response.

Key words: Behavioral dysfunction; Non-IgE mediated food allergy; Ileal-nodular-lymphoid hyperplasiaJ Food Allergy. 2012; 1: (1) 12-19

Gastrointestinal and Behavioral Dysfunction in Children with Non-IgE-mediated Food Allergy, Ileal-Nodular-Lymphoid Hy-perplasia (ILNH) and Low Th1 Function: A New Clinical-Im-munologic Constellation Aderbal Sabra, Joseph A. Bellanti, Dan Hartmann, Barbara Zeligs, Selma Sabra, Ricardo Ebeck-en, Kalil Madi, Isaac Tenorio

Department of Food Allergy UNIGRANRIO, Rio de Janeiro, Brazil (AS, IT) and ICIS Immunology Service at Georgetown University, USA (AS); Department of Microbiology and Immunology and Director of ICIS at Georgetown University, USA, (JAB); Pathology Service at Georgetown University, USA, (DH); Laboratory of Im-munology at Georgetown University, USA, (BZ); Pediatric Endoscopy Service HUAP-UFF, Rio de Janeiro, Brazil (SS, RE); Department of Pathology UNIGRANRIO, Rio de Janeiro, Brazil, (KM)


ORIGINAL ARTICLE


13

Gastrointestinal and Behavioral Dysfunction in Children with Non-IgE-mediated

INTRODUCTION

In addition to the involvement of the skin, gastrointestinal and respiratory tracts as the classic target organs of immunologically-mediated injury (IMI) resulting from allergic infl ammation, a congeries of scientifi c and clinical evidence is now accumulating to suggest that the central nervous system (CNS) may be yet another organ in which IMI occurs (1). Although considerable progress has been made in the fi eld of IgE-mediated food allergy, several recent studies have suggested that in a large number of patients with food allergy non-IgE-mechanisms may also be involved (3) whose precise pathogenetic pathway(s), nonetheless, continues to be unclear. Over the past several years a major investigative effort of our clinical and laboratory studies (4-6) has been directed to the analysis of immunologic mechanism(s) involved in the pathogenesis of a wide variety of clinical entities in children with food allergy who present with gastrointestinal symptoms, mainly chronic diarrhea, abdominal pain and failure to thrive (FTT) and which are associated with neurological and behavioral clinical manifestations (4-6). These studies have demonstrated distinct patterns of cytokine profi les which are associated with specifi c disease entities and which suggest that the study of these might not only help to elucidate pathogenetic mechanisms but which may also offer a sensitive predictive marker to identify children at risk to the development of these diseases. The present report describes the results of studies which have demonstrated distinct patterns of cytokine profi les in a variety of developmental CNS disorders in children who also present with gastrointestinal dysfunction and food allergy.

MATERIALS AND METHODS

Twelve children referred to our pediatric gastroenterology clinic with intestinal symptoms (diarrhea and abdominal pain) and neurological and behavioral manifestation (migraine, ADHD, overactivity and anorexia) were investigated (Table 1). Clinical and laboratory investigations Histories and physical examinations were performed on all subjects and a family history

of allergy was obtained. The diagnosis of FA was made on the basis of DBPCFC and skin testing to identify the offending allergens (7). The criteria used for improvement in each of the major categories of disease following dietary restriction of identifi ed offending foods and institution of a hypoallergic diet consisted of the following:

1. ADHD: decrease of hyperactivity and improvement in cognitive function as determined by history and questionnaires developed for the study;2. Autism: improvement in well-being, more communicative and improvement in gastrointestinal symptoms;3. Anorexia and FTT: improved appetite and gain of weight;4. Migraine: cessation of headaches.

DBPCFC test: The DBPCFC was performed in all 12 patients and consisted of the following two phases: Phase 1: a dietary elimination of the offending food that resulted in clinical improvement. Phase 2: a challenge diet containing the offending food(s) which resulted in recurrence of symptoms using the DBPCFC as described by Bock SA (7). The symptoms which were assessed were those involving the GI tract and consisted of abdominal pain and diarrhea. These were used in all 12 patients to evaluate the clinical improvement after dietary restriction and their recrudescence after DBPCFC. The selected food allergens used were those responsible for the most likely causative antigen, for each given patient, according to history and skin prick test results. In phase 1 all 12 patients were placed, for a period of at least 90 days, on an amino-acid based formula as the sole source of protein. During this period the intestinal symptom of diarrhea and abdominal pain had dissipated. In phase 2, after 90 days, we perform the DBPCFC and neither patient nor observer knew the nature of the protein or substance used in the test. All 12 patients were hospitalized during the fi rst 7 days of challenge to evaluate the development of any acute adverse reactions. None of the 12 patients developed any reactions during hospitalization. Considering that all patients were non-IgE, the


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DBPCFC was continued for 21 day in our outpatient clinic to detect any delayed reactions. Gastrointestinal studies were performed on all subjects for protein- losing enteropathies as evidenced by elevated α-1-anti-trypsin concentrations in stool (α-1-ATS) and jejunal biopsies were performed to evaluate the presence of chronic enteropathy (8). After bowel preparation, ileocolonoscopy was performed under sedation. Mucosal biopsies were taken from the ileum, cecum and rectum. Upper GI endoscopy was also performed after ileocolonoscopy and biopsies were taken from the antrum of the stomach. All biopsy specimens were formalin-fi xed and underwent light microscopy studies and immunohistochemical studies were performed to determine the prevalence of CD4 and CD8 populations. All ileocolonoendoscopies were recorded by video or still images and compared with those from previous normal and abnormal studies performed in age-matched children. In addition to these studies, we also evaluated the distribution of T-helper (CD4) cells and their subsets in the blood of normal patients and in patients with food allergy using a modifi cation of the method of Prussin and Metcalfe (9). Purifi ed peripheral blood mononuclear cells ( PBMC) were isolated using HISTOPAQUE -1077 Sigma and were frozen in 10% DMSO @ -70 C. Prior to staining, PBMC were thawed and co-cultured for 18 hours, after which they were stimulated for 3.5 hours

with 20 ng/ml phorbol myristate (PMA) and 1 μM ionomycin in the presence of 10 μg/ml of brefeldin. Unstimulated controls were incubated with brefeldin alone. Cells were fi xed with 4% paraformaldehyde, frozen at -70 C until they were stained using specifi c monoclonal antibodies for surface markers, i.e., CD3, CD4 and CD8, and cytokine characteristics, i.e., Th1-associated INF-γ, Il-2 and Th2-associated IL-4, IL-5, and IL-10. The stained cells were evaluated on a FACSCAlibur fl ow cytometer (Becton Dickinson Immunocytometer Systems, Palo Alto, CA) using CELLQUES software. The assay measures two T-helper (CD4) lineages based upon measurement of cytokine profi les characteristic of each lineage: 1) a Th1 interferon gamma (IFN-γ)-dependent pathway; and 2) a Th 2 interleukin 4 (IL-4) dependent pathway. Formalin- fi xed biopsie samples of ileum, colon and the stomach and jejunum were prepared and assessed by a pathologist. All tissues were examined by immunohistochemical methods for distribution of lymphocyte subpopulations. Five micron-thick tissue sections were deparaffi nized and incubated with monoclonal mouse antibodies (Dako Corporation, Carpinteria, CA) raised against the following human leukocyte markers: CD3, CD4, CD5, CD8, CD20, and CD21. The fi rst four antibodies characterize human T cells, whereas CD20 characterizes B cells and CD21, both B and follicular dendritic cells. The sections were washed and stained with biotinylated anti-mouse antibodies,

Table 1. Clinical and Laboratory Findings in Study Group Children with GI Disorders, Behavioral and Neurological Abnormalities*.Pt. # Sex Age (yrs) Diagnosis IgE Eos% CD4 CD8 CD4/CD81 M 2 6/12 ADHD 88 6 1516 866 1.72 M 2 8/12 ADHD 9 4 1140 926 1.23 M 7 5/12 ADHD 18 5 1376 966 1.44 M 2 4/12 Autism 2.3 0 2085 1063 1.95 F 10 8/12 Anorexia+FTT ** 72 1 1023 602 1.76 F 1 2/12 Anorexia+FTT 6 2 1972 686 2.97 F 1 2/12 Anorexia+FTT 37 3 4438 4183 1.18 F 5 11/12 Anorexia+FTT 3.2 1 1135 428 2.69 F 4 6/12 Anorexia+FTT 6.3 4 1272 652 1.910 F 1 8/12 Anorexia+FTT 6 4 3822 948 411 M 8 11/12 Migraine 103 6 6732 4580 1.512 M 9 9/12 Migraine 21 3 778 520 1.5

*All 12 patients where Caucasian; **Failure to thrive (FTT)


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followed by streptavidin-peroxidase conjugates (Cell Marque, Austin, TX). Following the addition of substrate, the cells were counterstained with hematoxylin, cover-slipped, and visualized by light microscopy. A hematologic counter was used to evaluate the cell numbers. Neurological and psychiatric assessments were performed by consultant staff. Magnetic-resonance imaging (MRI) and electroencephalography (EEG) were performed under sedation. Thyroid function, serum long-chains fatty acids and aminoacid chromatography were also performed. Antiendomyseal and antigliadin antibodies were done. Stool samples were analyzed for alpha-1- antitrypsin, cultured for C. jejuni, salmonella, shigella, Y enterocolitica, E.coli (ET, EP, E agg, EH, EI) and Clostridium and B fragilis and assessed for ova and parasites.

Ethical approval and consent The study protocol was reviewed and approved by the Institutional Review Boards of Georgetown University, Washington, DC and the Universidade do Grande Rio, Rio de Janeiro, Brazil and parents gave informed consent.

RESULTS

Clinical and laboratory investigations in all 12 patients demonstrated a positive family history of allergy, an elevation of α-1-ATS, a small bowel biopsy appearance of chronic enteropathy (Figure 1a) in the absence of specifi c antibodies and a normal stool examination for infection and parasites. With these fi ndings the diagnosis of FA was considered (10,11). The DBPCFC established the diagnosis of FA which was corroborated by the high prevalence of positive skin tests to common food allergens which were eliminated from the diet (Table 2). The results of the dietary elimination and DBPCFC were discussed with the parents when the code was broken. All 12 patients relapsed with abdominal pain and diarrhea during the 21 day study period. In all situations the relapses were coincident with the presence of the suspected offending dietary allergen. When the patients were placed on the amino-acid based diet all symptoms dissipated once again.

Neurologic testing revealed no abnormal fi ndings in any of the 12 patients and MRI scans and EEGs were normal. In all 12 subjects, serum antiendomyseal-antigliadin antibody studies were negative and common enteric pathogens were not identifi ed by culture, microscopy or serologic examination. The endoscopic fi ndings are shown in Table 3 together with the histological diagnosis. The terminal ileum was seen in all cases and the most striking feature was that all patients had the characteristic nodularity of ILNH (Figure 1b). Four patients had lymphoid-nodular hyperplasia of the cecum and the colon and the remaining 8 patients had no colonic or rectal abnormalities at endoscopy. The histological fi ndings of reactive lymphoid follicular hyperplasia were present in all the ileal biopsies (Figure1 c). Although the cecum and rectum appeared normal on colonoscopic inspection, microscopic examination of biopsies of these tissues revealed evidence of chronic infl ammation characterized by heavy infi ltration of mononuclear cells. Immuno-histo-pathologic characterization of the chronic infl ammatory infi ltrates found in the jejunum, ileum, cecum and rectum revealed a predominance of CD4 over CD8. In most cases, there was a predominant bias towards T-lymphocytes demonstrating the helper (CD4) phenotype, as compared to the cytotoxic/suppressor ( CD8+) T cells. There were many B-lymphoctyes present in the infl ammatory infi ltrates as shown by the CD 19 surface positivity. In some cases, CD21+ large dendritic cells were also observed (Figure 1d). The results of immunologic studies performed on peripheral blood lymphocytes of all patients to evaluate the distribution of T-helper cell and their subset Th1 and Th2 lineages are shown in Table 4. It can be seen that the mean values of Th1-associated cytokines (i.e., INF-γ,IL-2 ) were signifi cantly lower than control values, (p

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DISCUSSION

In the present study, we describe a pattern of immunological disturbance in patients with FA and behavioral and neurological disorders. In previous studies, such disorders as migraine, infantile colic, abdominal epilepsy, constipation, allergic tension-fatigue syndrome, ADHD, anorexia, hyperkinetic syndrome and autism have been correlated with FA (1,2,12-19). For more than a century such symptoms and syndromes have engaged the attention of physicians but more anecdotal data has been produced than facts. Studies by Egger et al (12,13) and more recently a report by A.J. Wakefi eld et al (1,20) have introduced strong data to support our hypothesis that FA is the pivotal causative factor that produces the lesions in the terminal ileum that consist of greatly enlarged lymphoid nodules containing large collections of lymphocytes in the gastrointestinal lymphoid tissues adjacent to Peyer’s patches (21). (Figure 1b). We have interpreted our fi ndings to indicate that the ILNH may be the hallmark lesion of patients with ADHD and other developmental disorders (2). The gastrointestinal lesion, we hypothesize, allows the entry of food antigens across the infl amed mucosa of the bowel as a result of the reactive infl ammatory response in the gastrointestinal tract. Our fi ndings of a pattern of lymphocyte dysfunction of the Th1 and Th2 subsets with a predominance of CD4+ cells which displayed a decreased Th1 cytokine pattern and normal Th2 cytokine pattern in patients with FA is consistent

Table 2. Results of Skin Prick Tests to Common Food Allergens in the Study Population.Food Allergen Negative 1+ 2+ 3+Cows milk 4 4 4 0Beef 5 3 4 0Goats milk 5 3 3 1Egg white 5 0 6 1Egg yolk 9 3 0 0Corn 7 0 5 0Wheat 7 2 2 1White fi sh 8 3 1 0Turkey 9 2 1 0Chicken 9 2 1 0Soy 11 0 1 0Rice 10 2 0 0

Figure 1. A photomicrograph of a jejunal biopsy of a pa-tient with food allergy showing villous atrophy and lym-phocytic infi ltration of the lamina propria characteristric of chronic enteropathy (Figure 1a). Endoscopic appear-ance of the terminal ileum of a patient with food allergy showing the characteristic nodular appearance of ileal lymphoid-nodular hyperplasia (ILNH) (Figure 1b). A photomicrograph of a biopsy of the superfi cial area of an ILNH lesion from the patient shown in Figure 1b showing the characteristic histological fi ndings of reactive lym-phoid follicular hyperplasia (Figure 1c). A photomicro-graph of the same biopsy specimen in Figure 1c showing positive CD21 specifi c streptavidin-immunoperoxidase staining within large dendritic cells (Figure 1d).


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children with non-IgE-mediated food allergy, ileal-nodular-lymphoid hyperplasia (ILNH) and low Th1 function. They also provide a basis for continued study of the role of the gastrointestinal immune system in the pathogenesis of immunologically-mediated CNS disorders.

CONFLICT OF INTEREST

None declared.

REFERENCES

1. Wakefi eld AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, et al. Ileal-lymphoid-nodular hyperplasia, non-specifi c colitis, and pervasive developmental disorder in children. Lancet. 1998 Feb 28;351(9103):637-41. Retraction in: Lancet. 2010 Feb 6;375(9713):445. Partial retraction in:

with our hypothesis and provide the fi rst strong data to support an immunological basis for non-IgE mediated FA in this group of patients. The presence of ILNH and intestinal infl ammation and the absence of detectable neurological abnormalities in study subjects are consistent with an exogenous infl uence upon cerebral function. The presence of the immunological disturbance and the diagnosis of non-IgE mediated FA correlates well with the improvement of patients following a hypoallergenic diet (10, 22-27). After the removal of the offending allergen(s) all children achieved behavioral and neurological improvement. The recrudescence of symptoms following reintroduction of the offending food antigen suggests a reversible element related to diet. The results of theses studies lend further support for consideration of the brain as a target organ of immune injury and for an association of gastrointestinal and behavioral dysfunction in

Table 4. Cytokine Profi les of Patients and Controls*.Pt. # Age (yrs) Diagnosis IFN-γ IL-2 IL-4 IL-10 IL-51 2 6/12 ADHD 1.3 4.2 1.3 0.1 0.12 2 8/12 ADHD 4.6 3.2 0.5 0.2 .23 7 5/12 ADHD 3.8 12 3.1 0.1 0.34 2 4/12 Autism 1.2 4.5 0.1 0 05 10 8/12 Anorexia+FTT** 5.6 6.5 3.4 0.3 0.26 1 2/12 Anorexia+FTT 1.1 2.5 2.3 0.3 07 1 2/12 Anorexia+FTT 7.5 4 1 0.1 38 5 11/12 Anorexia+FTT 1.4 3.6 0.1 0 ND***9 4 6/12 Anorexia+FTT 0.9 4.2 0.5 0.1 0.210 1 8/12 Anorexia+FTT 1.6 3.7 0.6 0.1 ND11 8 11/12 Migraine 3.6 11 2 0.1 0.312 9 2/12 Migraine 0.9 2.3 1.4 0 0Mean±SD 2.8±2 5.1±3 1.4±1 0.12±0.1 0.4±0.7Controls**** Adults Normal 9±3 19±13 1.3±1 ND NDControls***** Adults Normal 17±5 53±16 5±3 ND 0.8±0.4

* Results expressed as % of stimulated cells producing cytokines - % of unstimulated cells; ** Failure to thrive (FTT); *** Not determined; **** Laboratory controls; ***** Literature control

Table 3. Frequency and Anatomic Location of ILNH in the Study Population.Anatomic Location ILNH-Positive ILNH- NegativeIleum 12 0Cecum 4 8Colon 4 8Rectum 0 12


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Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Valentine A, Davies SE, Walker-Smith JA. Lancet. 2004 Mar 6;363(9411):750.

2. Sabra A, Bellanti JA, Colón AR: Ileal-lymphoid-nodular hyperplasia, non-specifi c colitis, and pervasive developmental disorder in children. Lancet. 1998 Jul 18;352(9123):234-5.

3. Sampson HA. Food allergy: from biology toward therapy. Hosp Pract 2000; 35: 67-83.

4. Sabra A, Hartman D, Zeligs BJ et al. Linkage of ileal-lymphoid-nodular hyperplasia (ILNH), food allergy and CNS developmental disorders: evidence for a non-IgE association. Ann Allergy Asthma Immunol 1999;82:81-82

5. Sabra A, Zeligs J, Hartmann D, et al. Celiac disease: A possible clinical model of Th1-mediated non IgE food allergy. Ann Allergy Asthma Immunol. 1999;82:81-82.

6. Sabra A, Hartman D, Bellanti JA, Zeligs BJ. Heterogeneity of cytokine profi les in food allergy and possible clinical signifi cance. Ann Allergy Asthma Immunol. 2001;86:90.

7. Bock SA. In vivo diagnosis: skin testing and oral challenges procedures. In Food Allergy by Metcalfe D, Sampson H and Simon RA, (2nd ed.), Blackwell Science,USA. 1997; pp. 151-166.

8. Iyngkaran N, Yadav M, Boey CG, Lam KL. Severity and extent of upper small bowel mucosal damage in cow’s milk protein-sensitive enteropathy. J Pediatr Gastroenterol Nutr. 1988 Sep-Oct;7(5):667-74.

9. Prussin C, Metcalfe DD. Detection of intracytoplasmic cytokine using fl ow cytometry and directly conjugated anti-cytokine antibodies. J Immunol Methods. 1995 Dec 15;188(1):117-28.

10. Sabra A, Del Castillo R, Sabra S, Madi K. Food Allergy. Themes of Pediatrics # 59, Ed. Nestle, Rio. 1995; pp. 1-56.

11. Walker-Smith JA. Food sensitive enteropathies. Clin Gastroenterol. 1986 Jan;15(1):55-69.

12. Egger J, Stolla A, McEwen LM. Controlled trial of hyposensitisation in children with food-induced hyperkinetic syndrome. Lancet. 1992 May 9;339(8802):1150-3.

13. Egger J, Carter CM, Wilson J, Turner MW, Soothill JF. Is migraine food allergy? A double-blind controlled trial of oligoantigenic diet treatment. Lancet. 1983 Oct 15;2(8355):865-9.

14. Hewson P, Oberklaid F, Menahem S. Infant colic, distress, and crying. Clin Pediatr (Phila). 1987 Feb;26(2):69-76.

15. Senanayake N. ‘Eating epilepsy’--a reappraisal. Epilepsy Res. 1990 Jan-Feb;5(1):74-9.

16. Sabra A, Bellanti JA, Rais JM, Castro HJ, de Inocencio JM, Sabra S. IgE and non-IgE food allergy. Ann Allergy Asthma Immunol. 2003 Jun;90(6 Suppl 3):71-6.

17. Bellanti JA, Malka-Rais J, Castro HJ, de Inocencio JM, Sabra A. Developmental immunology: clinical application to allergy-immunology. Ann Allergy Asthma Immunol. 2003 Jun;90(6 Suppl 3):2-6.

18. Pastorello EA, Pravettoni V, Incorvaia C, Bellanti JA. Food allergy: an update. Allergy. 1999;54(Suppl 58):43-5.

19. Turunen S, Karttunen TJ, Kokkonen J. Lymphoid nodular hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr. 2004 Nov;145(5):606-11.

20. Wakefi eld AJ, Montgomery SM. Measles virus as a risk for infl ammatory bowel disease: an unusually tolerant approach. Am J Gastroenterol. 2000 Jun;95(6):1389-92.

21. Eigenmann PA. T lymphocytes in food allergy: overview of an intricate network of circulating and organ-resident cells. Pediatr Allergy Immunol. 2002 Jun;13(3):162-71.

22. Halpern GM, Scott JR. Non-IgE antibody mediated mechanisms in food allergy. Ann Allergy. 1987 Jan;58(1):14-27.


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23. Lessof MH, Kemeny DM. Non-IgE-mediated reactions to food: how much is allergic? Ann Allergy. 1987 Nov;59(5 Pt 2):90-2.

24. Zanussi C. Food allergy treatment. Clinics in Immunology and Allergy 1982;2:221-239.

25. Hauer AC, Breese EJ, Walker-Smith JA, MacDonald TT. The frequency of cells secreting interferon-gamma and interleukin-4, -5, and -10 in the blood and duodenal mucosa of children with cow’s milk hypersensitivity. Pediatr Res. 1997 Nov;42(5):629-38.

26. Sampson HA. Food allergy. JAMA. 1997 Dec 10;278(22):1888-94.

27. Bellanti JA, Zeligs BJ, Malka-Rais J, Sabra A. Abnormalities of Th1 function in non-IgE food allergy, celiac disease, and ileal lymphonodular hyperplasia: a new relationship? Ann Allergy Asthma Immunol. 2003 Jun;90(6 Suppl 3):84-9.


June 01, 2011

_______________________Accepted:

August 31, 2011

____________________Correspondence addressDr. Aderbal SabraRua Visconde Pirajá, 330 sala 310Ipanema, 22410-001, Rio de Janeiro, RJFax: + 55 21 2267-0645E-mail: [email protected]


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Allergen content of foods

ABSTRACT

Background: Research into risk factors for food allergy has focused on the role of timing of fi rst exposure to allergenic foods on the subsequent development of food allergy. This research requires the collection of accurate questionnaire-based data on allergen exposure, which in turn requires accurate parental knowledge of the dietary allergen content of foods.Objective: To assess knowledge of egg and peanut content in maternal and infant diets among a population-recruited sample of mothers of 12 month old infants in Melbourne, Australia.Materials and Methods: Mothers of 12-month-old infants without an existing diagnosis of peanut or egg allergy who at-tended council-run immunisation sessions were invited to participate in the study (n=78 participated, 96% response rate). Participants completed a questionnaire requiring them to identify whether or not a number of foods in their own diet and their infant’s diets usually contain peanut or egg. Data on maternal and infant food avoidance was also collected.Results: Each of the peanut-containing and peanut-free foods were correctly identifi ed by more than 80% of participants. By contrast, mothers tended to over-report the egg content of foods, with three of the seven egg-free foods thought to contain egg by at least 30% of participants. The majority of mothers (71%) had not yet introduced peanut into their child’s diet by 12 months of age and around one quarter of these had avoided peanut because of concern about the possi-ble development of peanut allergy. Peanut avoidance during pregnancy was reported by 18% (95% CI 10-28) of mothers, while 13% (95% CI 9-27) avoided peanut while breastfeeding. More than 50% of mothers who had not yet introduced peanut into their infants diet were also avoiding foods with precautionary labeling (“may contain traces of nuts”).Conclusions: Maternal awareness of the peanut content of foods in their own diets and in the diets of their infants was high, possibly refl ecting high levels of concern regarding exposure of their children to peanut.

Key words: mothers; peanut hypersensitivity; egg hypersensitivity; food hypersensitivityJ Food Allergy. 2012; 1: (1) 20-27

INTRODUCTION

Peanut and egg are among the most common causes of food allergic reactions resulting in hospital visits in children under the age of 5 (1). We recently reported that up to 3% of 1 year old infants in

Melbourne, Australia have oral food challenge-confi rmed peanut allergy, while almost 9% are allergic to raw egg, although the majority of these infants can tolerate small amounts of egg in baked goods (2).


Are mothers of infants aware of the peanut and egg allergen content of foods?Jennifer Koplin, Shyamali C. Dharmage, Lyle C. Gurrin, Nicholas J. Osborne, Mimi L. K. Tang, Katrina J. Allen

Murdoch Childrens Research Institute (JK, SCD, LCG, NJO, MLKT, KJA), Department of Paediatrics (JK, MKT, KJA), University of Melbourne; Department of Allergy and Immunology (MLKT, KJA), Royal Children’s Hos-pital Th e Centre for Molecular, Environmental, Genetic and Analytic Epidemiology (SCD, LCG), University of Melbourne, Parkville, VIC, Australia and European Centre for Environment and Human Health (MJO), Penin-sula College of Medicine and Dentistry, University of Exeter, United Kingdom

ORIGINAL ARTICLE


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Recent research into risk factors for food allergy has focused on the role of timing of introduction of foods on the subsequent development of food allergy (3-5). To investigate the association between timing of introduction of foods and the development of allergy to these foods, valid parental data regarding dietary exposures in early life are important. This in turn requires an understanding of whether parental knowledge of the dietary allergen content of foods is accurate. The implications of inaccurate exposure measurements for the analysis of data from epidemiological studies are well documented, especially the likelihood of bias in estimated measures of association between exposures (e.g. timing of introduction of food) and outcome (e.g. the risk of disease). Some studies of allergen knowledge have been reported in families of children with food allergy, who will have received education in this regard (6,7). We were unable to identify any studies evaluating allergen knowledge in the general population who are most relevant to population-based studies of the role of timing of allergen introduction in the development of food allergy. We therefore assessed knowledge of egg and peanut content in maternal and infant diets among a population-recruited sample of mothers of 12 month old infants in Melbourne, Australia. We also explored maternal attitudes towards precautionary labelling on packaged foods. Current legislation in Australia and New Zealand states that all ingredients derived from commonly allergenic sources (including peanuts, tree nuts, eggs, cow’s milk, soy, fi sh, crustacea, sesame seeds and cereals with gluten) must be clearly labeled (8). Similar legislation exists in the US and Europe. However, use of shared processing equipment and facilities could result in cross-contact of foods intended to be free of the allergen, which has led to the use of precautionary labelling such as “may contain traces of [allergen]” by manufacturers. There is currently no information in the Australia New Zealand Food Standards Code (Standard 1.2.3) pertaining to the use of this type of “may contain” precautionary

statement. Use of precautionary labeling in Australia is widespread (9), however there have been no previous studies investigating the impact of this type of labeling on food choices of mothers of non-allergic infants.

MATERIALS AND METHODS

Inclusion criteria Mothers of infants without an existing diagnosis of peanut or egg allergy who attended council-run immunisation sessions in fi ve local government areas (LGA) around Melbourne for their child’s 12 month immunisation were eligible for recruitment. We excluded parents of infants who were diagnosed as peanut or egg allergic as it is likely they would have increased knowledge of food allergens compared with the general population. Only 3 mothers (3.7% of those approached) were excluded from participation in the Food Knowledge Study because of known food allergy in the infant.

Sampling frame The sampling frame for this study was designed to capture participants from a range of backgrounds. Five local government areas were selected for recruitment based on the Index of Relative Socio-economic Advantage and Disadvantage fi gures for residents in each local government area (calculated using data from the 2001 census by the Australian Bureau of Statistics (10)). To do this, the 31 local government areas in greater Metropolitan Melbourne were ranked according to this index and then divided into quintiles. One centre from each quintile was selected for attendance. The Index of Relative Socio-economic Advantage and Disadvantage is a continuum of advantage (high values) to disadvantage (low values) which is derived from Census variables related to both advantage and disadvantage, like household with low income and people with a tertiary education. Although centres were selected based on this index and not on educational status alone, because of the way in


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which the index was derived the areas selected also covered areas with residents of both low and high levels of education.

Questionnaires The questionnaire was designed to be able to be completed within the 15 minute post-immunisation waiting period to improve compliance and reduce burden on participants. The questionnaire was initially piloted in 5 adults with young children to assess clarity of the questions and length of time taken to complete the survey. The pilot survey was deemed to take too long to complete and was therefore shortened to increase compliance. Questionnaires were administered on the day by a single researcher. Mothers were provided with a list of foods, which was derived from information regarding egg and peanut avoidance provided to parents of children with food allergy by the Royal Children’s Hospital Department of Allergy and Immunology. Input was also sought from a dietician at the Royal Children’s Hospital. Mothers were initially asked whether they or their child had ever eaten each food on the list. For those foods that were part of either their own diet or their child’s diet they were then asked to identify whether or not each food usually contains peanut or egg. Mothers were also asked whether their child had eaten foods containing egg and peanut, the age at which egg and peanut had been introduced into the diet, whether they had delayed the introduction of egg and peanut because they were concerned about food allergy in their child and if so, whether they also avoided foods labelled “may contain traces” of peanut/egg. Data on family history of allergy and allergic symptoms in the child was also collected.

Statistical methods Population prevalence was estimated as the observed proportion with 95% confi dence intervals calculated by assuming that the observation

proportion follows a binomial distribution. Stata software (release 11.0; Stata Corp, College Station, USA) was used for all analyses.

Ethics approval Ethics approval was obtained from the University of Melbourne Health Sciences Human Ethics Sub-Committee (ref. no. 0827592).

RESULTS

Participation rate and demographics of study participants Of 81 eligible mothers approached, 78 agreed to participate (response rate 96%). Demographics and family and personal history of allergy among the infants included in the study are shown in Table-1.Peanut and egg consumption among participating infants and mothers during pregnancy The majority of infants participating in the study (94%; 95% CI 86-98) had consumed egg or egg-containing products by 12 months of age while only 29% (95% CI 20-41) had consumed peanut or peanut-containing products. Of those who had not yet introduced peanut, 6% ( 95% CI 0, 12.1) thought the child might have an allergy to peanut while 26% (95% CI 14, 39) thought early introduction of peanuts could cause the child to develop an allergy. Approximately half (53%, 95% CI 39-67) of mothers who had not yet introduced peanuts stated that they had also avoided products labeled “may contain traces of peanuts”. Only 9% (95% CI 3.7, 17.6) of mothers stated that they never read the labels of foods that they purchased for their child while 46% (95% CI 34.8, 57.8) sometimes read labels and 45% (95% CI 34, 57) read the labels every time they purchased a new food. Peanut avoidance during pregnancy was reported by 18% (95% CI 10-28) of mothers, 13% (95% CI 9-27) avoided peanut while breastfeeding and 6% (95% CI 2-14) avoided egg during pregnancy and breastfeeding.


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Maternal knowledge of egg and peanut content of foods in both infant and their own diet Most of the foods containing peanut and egg as well as the peanut-free foods were correctly identifi ed by more than 90% of those participants reporting that these foods formed part of their own diet or their infant’s diet (Table-2). The exceptions were sweet biscuits/cookies (containing egg) and plain chocolate (peanut-free). Three of the egg-free foods, namely savory crackers, rice crackers and dry pasta, were misclassifi ed by more than 30% of participants reporting that these foods formed part of their own diets. As expected, infant diets contained fewer of the listed foods compared with maternal diets.

DISCUSSION

Mothers of 12-month-old infants in this study had a surprisingly high level of knowledge of which foods contain peanut in their own diet as well as in their child’s diet. A further surprise was how many

mothers who had not yet introduced peanut into their infant’s diet were reading labels and avoiding even traces of peanuts despite the fact that in Australia there is a fairly ubiquitous use of precautionary labeling (9) and complex labeling laws that do not require mandatory labeling of foods which may be subject to trace contamination with peanut. These results suggest that mothers of infants have a high regard for exposure of their children to allergens and that infant food labeling is of signifi cant importance to consumers, irrespective of allergy status. Of the peanut-free foods, plain chocolate was the food most often thought to contain peanut. It is possible that this refl ects confusion about the meaning of “may contain traces of peanuts” or other similar precautionary labelling, which is found on a large proportion of chocolate products (9,11). The only egg-containing foods which were not identifi ed as containing egg by at least 90% of participants were sweet biscuits. This may be explained by the fact that while some varieties of sweet biscuits such as Arnott’s Teddy BearTM biscuits (the example used in this questionnaire) do

Table 1. Demographics and family and personal history of allergies among the infants included in the study (n=78).History of allergy in child’s immediate family %Any allergies†

Parents 44.9 (33.6, 56.2)Siblings 43.9 (28.0, 59.8)*

Egg allergyParents 1.3 (0.03, 6.9)Siblings* 2.4 (0.06, 12.9)*

Peanut allergyParents 1.3 (0.03, 6.9)Siblings* 4.9 (0.06, 16.5)*

History of allergy in the childEczema 35.1 (24.5, 46.8)Reaction to any foods 20.5 (11.3, 29.7)

Demographic factorsAny siblings 55.1 (43.4, 66.4)Sex (% male) 50.0 (38.2, 61.8)Parent completing survey has tertiary education 69.2 (57.8, 79.2)

* Percentage of those infants with at least one sibling † Parent report of asthma, eczema, hay fever or food allergy


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contain egg, other similar biscuits such as Arnott’s MarieTM biscuits are egg-free. To obtain accurate information on egg consumption, questionnaires should therefore clearly distinguish between egg-containing and egg-free biscuits. There were also some egg-free foods, namely dry pasta (spaghetti), rice crackers and savory crackers, which were thought by a signifi cant portion of mothers to contain egg. It is therefore possible that maternal report of consumption of egg-containing products may overestimate the amount of egg consumed. An unexpectedly high percentage of mothers (53%) who were avoiding peanuts in their child’s diet also avoided foods with the precautionary labelling “may contain traces of peanut”, despite the fact that the majority of these products are unlikely to contain detectable levels of peanut (12) and that the frequent use of this labelling is likely to restrict food choices. This may refl ect confusion about what this labelling means. There is currently no information in the Australia New Zealand Food Standards Code pertaining to the use of this type of “may contain” precautionary statement.

The high level of awareness of the peanut content of foods among mothers of infants may in part be due to concern about food allergies. The majority of mothers (71%) had not yet introduced peanut into their child’s diet by 12 months of age and around one quarter of these had avoided peanut because of concern about the possible development of peanut allergy. This is contrary to infant feeding guidelines current at the time of conducting this study, which stated that there is no evidence to support delaying the introduction of potentially allergenic foods for allergy prevention (13). It is possible that parents were not aware of these new guidelines as these were introduced only a short period of time before this study commenced. Some guidelines had previously recommended avoidance of peanuts until after 3 years of age for children at high risk of peanut allergy (14). Interestingly, between 10-20% of mothers also avoided peanuts during pregnancy and while breastfeeding, a practice which is no longer recommended for allergy prevention (13). We were unable to identify any previous studies examining allergen knowledge in the general population.

Mother’s diet Child’s dietAte food (n) Answered

correctly (%)Ate food (n) Answered correctly

(%)Peanut containing foods

DrumstickTM or CornettoTM ice-cream

61 100.0 8 100.0

“SnickersTM” chocolate bar 55 100.0 1 100.0“PicnicTM” chocolate bar 53 100.0 1 100.0Satay sauce 64 98.4 6 100.0Pad Thai 46 93.5 1 100.0Kellogg’s Crunchy Nut Cornfl akesTM

26 92.3 1 100.0

Summer RollTM/Nougat Honey Log barTM

52 92.3 1 100.0

Peanut free foodsFruit-fl avoured icy pole 63 100.0 24 100.0Plain cornfl akes 43 93.0 12 100.0Plain chocolate e.g. Cadbury Dairy MilkTM

75 84.0 20 90.0

Table 2a. Proportion of participants who correctly identifi ed the peanut content of each food in their own diet or their child’s diet.


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Table 2b. Proportion of participants who correctly identifi ed the egg content of each food in their own diet or their child’s diet.

Mother’s diet Child’s dietAte food (n) Answered

correctly (%)Ate food (n) Answered

correctly (%)Egg containing foods

Pavlova 54 100.0 8 100.0Cakes e.g. sponge cake 77 100.0 69 100.0Meringues 45 100.0 7 100.0Quiche 69 98.6 35 97.1Omelettes 71 98.6 43 97.7Mayonnaise 63 98.4 17 100.0Muffi ns (sweet) 77 97.4 54 96.3Custard 57 96.5 49 94.0Pancakes 73 95.9 38 97.4Crumbed/battered foods e.g. chicken schnitzel

68 91.2 46 95.7

Fresh pasta e.g. ravioli 76 90.0 53 92.5Sweet biscuits (e.g. Arnott’s Teddy BearsTM)

72 80.6 52 76.9

Egg free foodsPotato chips/French fries 75 97.3 47 97.9Popcorn 68 97.1 8 87.5Vinegar-based salad dressing e.g. French dressing

66 90.9 7 87.5

Rice crackers 70 68.6 45 75.6Savory crackers e.g. Arnott’s SaladaTM crackers

76 63.2 52 63.5

Dry pasta (spaghetti) 76 38.2 64 40.6Baby cereals e.g. HeinzTM rice cereal

- - 70 92.9


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The strengths of this study include the high response rate, which minimizes the possibility of participation bias. The limitations include a relatively high proportion of tertiary educated parents, who may be more likely to read labels and may have a greater awareness of the allergen content of foods, and the lack of information on parents with little or no knowledge of the English language. Our fi ndings may not be generalizable to other countries with different food labeling practices and regulations. The list of foods included in the questionnaire was designed to include the major peanut- and egg-containing foods consumed by infants at 12 months. However, it is likely that some infants will have consumed foods containing peanut and egg that are not on the list. Furthermore, some categories were quite broad, for example “sweet biscuits” and “dry pasta” and could have included both egg-containing and egg-free versions. In these cases, an example was always provided to aid in answering the question.

CONCLUSIONS

Mothers were able to correctly identify whether or not the majority of foods in their own diets and in the diets of their infants contained peanut, suggesting that questionnaire-based data regarding current maternal and infant peanut consumption is likely to be accurate. Questionnaires measuring maternal and infant egg exposure may overestimate egg consumption, as several egg-free foods were commonly thought to contain egg. Researchers should therefore ensure that clarifi cation is provided regarding the egg content of foods when collecting questionnaire-based data.

CONFLICT OF INTEREST

None declared.

Acknowledgements

Liz Rogers, dietician at the Royal Children’s Hospital Department of Nutrition and Food Services, provided input into the development of the questionnaire. We

express our gratitude to the mothers who participated in this research.

REFERENCES

1. Ross MP, Ferguson M, Street D, Klontz K, Schroeder T, Luccioli S. Analysis of food-allergic and anaphylactic events in the National Electronic Injury Surveillance System. J Allergy Clin Immunol. 2008;121(1):166-71.

2. Osborne NJ, Koplin JJ, Martin PE, Gurrin LC, Lowe AJ, Matheson MC, et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. J Allergy Clin Immunol. 2011;127(3):668-76.e1-2.

3. Koplin JJ, Osborne NJ, Wake M, Martin PE, Gurrin LC, Robinson MN, et al. Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol. 2010;126(4):807-13.

4. Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki SJ, Fisher HR, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol. 2008;122(5):984-91.

5. Fox AT, Sasieni P, du Toit G, Syed H, Lack G. Household peanut consumption as a risk factor for the development of peanut allergy. J Allergy Clin Immunol. 2009;123(2):417-23.

6. Joshi P, Mofi di S, Sicherer SH. Interpretation of commercial food ingredient labels by parents of food-allergic children. J Allergy Clin Immunol. 2002;109(6):1019-21.

7. Weber TK, Speridião Pda G, Sdepanian VL, Neto UF, de Morais MB.The performance of parents of children receiving cow’s milk free diets at identifi cation of commercial food products with and without cow’s milk. J Pediatr (Rio J). 2007;83(5):459-64.

8. Food Standards Australia New Zealand. Standard 1.2.3 — mandatory warning and advisory statements and declarations. Canberra 2002 [cited 2010 May]; Available from: http://www.foodstandards.gov.au/_srcfi les/Standard_1_2_3_Warning_Statements_v103.pdf.

9. Koplin JJ, Osborne NJ, Allen KJ. Prevalence of allergen avoidance advisory statements on packaged processed foods in a supermarket. Med J Aust. 2010;193(7):426-7.

10. Australian Bureau of Statistics 2033.0.55.001 - Socio-economic Indexes for Areas (SEIFA). 2001 [cited 2011 3rd March]; Available from: http://www.abs.gov.au/AUSSTATS/[email protected]/Lookup/2033.0.55.001Main+Features12001?OpenDocument.


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11. Pieretti MM, Chung D, Pacenza R, Slotkin T, Sicherer SH. Audit of manufactured products: use of allergen advisory labels and identifi cation of labeling ambiguities. J Allergy Clin Immunol. 2009;124(2):337-41.

12. Hefl e SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol. 2007;120(1):171-6.

13. Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-91.

14. [No authors listed] American Academy of Pediatrics. Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106(2 Pt 1):346-9.


July 01, 2011

_______________________Accepted:

August 31, 2011

____________________Correspondence addressDr. Katrina J AllenDepartment of Allergy and ImmunologyThe Royal Children’s HospitalFlemington Road, Parkville 3052Victoria, AustraliaFax: + 61 3 9345-4848Email: [email protected]


ABSTRACT

Objective: The purpose of this study is to investigate possible mechanisms of the allergic reaction in patients with non-IgE Food Allergy characterized by normal expression of TH2 cytokines and normal IgE.Materials and Methods: Eighteen patients with allergic manifestation to several foods entered into the study: 4 patients had a diagnosis of Celiac Disease (CD), 4 had Breast Milk Colitis (BMC), 4 patients had a diagnosis of Attention Defi -cit Hyperactive Disorder (ADHD) and Autism and 6 patients had Cow´s Milk Enterophaty with anorexia and failure to thrive (FTT).The immunologic studies which were performed in all patients included evaluation of the distribution of T-helper CD4 cells and their subsets in the blood. The assay measures two T-helper CD4 lineages based upon measurement of cytokine profi les characteristic of each lineage: Th1-associated INF-γ, Il-2 and Th2-associated IL-4 and IL-5.Results: In patients with Celiac Disease was observed a decrease of CD4/CD8 and an increased TH1 cytokines IFN-γ and IL-2. In patients with breast milk colitis the CD4/CD8 ratios was normal, but Th1 cytokines was also elevated mainly IFN-γ. In remaining studied patients the TH1 cytokines profi les were normal or decreased.Conclusions: In the present study, we observed a new prototype of immunological disturbance in patients with Food Al-lergy and Coeliac Desease, Breast Milk Colitis, Cow´s Milk Enterophaty and Behavioral Disorders. The fi ndings of el-evated TH1 cytokine profi les in Celiac Disease and Breast Milk Colitis, eg: INF-γ, IL-2 have been previously described, however, the decreased TH1 cytokine profi les haven’t been described. Our fi nding of decreased TH1 cytokine profi les in these groups may represent a new abnormal immunological alteration in these developmental disorders.

Key words: celiac disease; autistic disorder; anorexia; failure to thriveJ Food Allergy. 2012; 1: (1) 28-34

INTRODUCTION

Food allergy (FA) is commonly defi ned as an abnormal immunologic reaction to ingested food proteins in certain genetically predisposed individuals. This immunologic reaction is responsible for a wide variety of symptoms and clinical manifestations

expressed in several organs and systems, eg: skin, respiratory tract, gastrointestinal tract and central nervous system (CNS) (1-3). Although classically defi ned as an immunologically-mediated disorder related to Type 1 IgE-mediated injury, it is now clear that there are non-IgE mechanisms involved in the pathogenesis of FA.


Cytokines Profi les in Patients with the Spectrum of Non-IgE Food Allergy: A New Prototype of Immunological DisturbanceAderbal Sabra, Joseph Alphonso Bellanti, Selma Sabra, Barbara Zeligs, Gustavo Rodrigues, Isaac Tenório

Department of Gastroenterology and Food Allergy, UNIGRANRIO University - School of Medicine, RJ, Brazil, (AS); Department of Immunology Center – ICISI – Georgetown University, Washington, DC, USA, (JAB); De-partment of Pediatrics, UNIGRANRIO University, RJ, Brazil, (SS); Department Pediatric Endoscopy, Antônio Pedro University Hospital, RJ, Brazil, (BZ); Laboratory of Immunology, Immunologic Center – ICISI – George-town University, Washington, DC, USA, (GR); Department of Pediatric Gastroenterology and Food Allergy, UNIGRANRIO University, RJ, Brazil, (IT)

28

ORIGINAL ARTICLE


29

Cytokines Profi les in Patients with the Spectrum of Non-IgE Food AllergyCytokines Profi les in Patients with the Spectrum of Non-IgE Food Allergy

FA is common world wide condition, affecting 6-8% of infants in the fi rst 3 years of life, but predominantly in the fi rst 2 years (4-7). A recent 5-year follow-up study by Sicherer et al. (8) observed that the prevalence and severity of FA are increasing in the past 2 decades (8). Although the hygiene hypothesis has been proposed as an explanation for the increase in prevalence of all allergic diseases, additional factors are likely involved (9-11). On the other hand, since the incidence of FA is known to decline with advancing age, immunologic maturation (12,13) may play an important role. Although any food protein may provoke FA, not more than 10 foods are responsible for the vast majority of food allergic reactions. Cow milk, egg, soy, wheat, peanut, tree nut, fi sh, shellfi sh, beef and chicken are the main allergens related with FA (6,14,15). The evaluation of FA depends upon taking a detailed medical history, establishing whether a food-induced allergic reaction has occurred, ascertaining which food was involved, and identifying what allergic mechanism was possibly triggered. Based in the laboratory evaluation of IgE all the cases of FA are today divided into two major groups: 1) IgE-mediated FA and 2) non-IgE-mediated or cell mediated FA (Table-1). Appropriate diagnostic studies, including skin testing and the double-blind placebo-controlled food challenge (DBPCFC), are the mainstays of diagnosis (1,15). The principal therapy remains the identifi cation and elimination of the offending food from the diet (16). The IgE-mediated allergic reaction is the best classically understood mechanism to explain FA. This immunologic reaction involves the participation of helper Th2 CD4+T cells with a predominant production of cytokines IL-4 and IL-5 which lead to a stimulation of B lymphocytes to produce IgE. Most if not all of the clinical manifestations are linked to the high levels of IgE in peripheral blood (17). Although it is known that the non-IgE-mediated disorders are classically characterized by normal levels of IgE, there is a paucity of information to

explain this group of FA reactions and more research is needed in this area (17,18). In a previous study we have reported Th1 activity in a group of patients with Th1-mediated non IgE food allergy (19). The purpose of the present study is to investigate possible mechanisms of the allergic reaction in a larger number of patients with non-IgE FA characterized by depletion or high production of TH1 cytokines with normal expression of TH2 cytokines and normal IgE.

MATERIAL ANS METHODS

Eighteen patients who presented with allergic manifestation to several foods and who had normal levels of serum IgE and negative RASTs to food and inhalant allergens were entered into the study. Eight patients came from our GI clinic population; 4 had a diagnosis of Celiac Disease (CD); and 4 had Breast Milk Colitis (BMC). Ten additional children were referred to our clinic with intestinal symptoms and neurological and behavioral manifestations (ADHD, overactivity and anorexia) and failure to thrive; 4 patients had a diagnosis of Attention Defi cit Hyperactive Disorder (ADHD) and Autism and 6 with anorexia and failure to thrive (FTT) (Table-2). CD was diagnosed by clinical symptoms and elevated anti-gliadin, anti-endomysial and anti-transglutaminase tissue antibodies with biopsy proven CD (19-22). The 4 patients with CD were placed in a gluten-free diet. In phase 2, following challenge of these 4 subjects with gliadin there was a relapse of symptoms. BMC was diagnosed by the clinical manifestation of blood stool in exclusively breast feed babies. Stool work-up for parasites and infectious was negative (1). The diagnosis of FA was established by clinical symptoms and DBPCFC (6,23). The DBPCFC was performed in all 18 patients and consisted of the following two phases; Phase 1: a dietary elimination of the offending food that resulted

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