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This article covers the salient and updated themes of the Japanese Pediatric Guidelines for the Treatment and Management of Asthma (JPGL) 2020 published by the Japanese Society of Pediatric Allergy and Clinical Immunology. In the 2020 guidelines, five new clinical questions (CQs) have been added to address the 12 CQs regarding the treatment of childhood asthma. "Infant and preschool asthma" is diagnosed when young children (6 years of age) have three or more episodes of clear expiratory wheezing, which continue for more than 24 h, and symptom improvement can be observed after beta-2 agonist inhalation. In children without clear improvement, diagnostic therapeutic trial for the duration of 1 month with controller treatment can be used. Since long-term management is initiated, the treatment level is adjusted based on the current control status and the management of risk factors, with the provision for holistic care. This underscores the smooth transition of pediatric patients into adult services. There are several differences between the JPGL and the guidelines of other countries. Further evidence is obtained as the utility of the newly proposed management plans should be evaluated in the Japanese population.

Background: Cow’s milk (CM) is an increasingly common cause of severe allergic reactions, but there is uncertainty with respect to severity of reactions at low level CM exposure, as well as the reproducibility of reaction thresholds. Objective: To undertake an individual participant data (IPD) meta-analysis of studies reporting double-blind, placebo-controlled food challenges (DBPCFC) in CM, to determine the rate of anaphylaxis to low level exposures and the reproducibility of reaction thresholds. Methods: Systematic review and individual participant data (IPD) meta-analysis of studies reporting relevant data. Authors were contacted to provide additional data and/or clarifications as needed. Risk of bias was assessed using the National Institute for Clinical Excellence methodological checklists. Results: 34 studies were included, representing data from over 1000 participants. The cumulative ED01 and ED05 (cumulative doses causing objective symptoms in 1% and 5% of the at-risk allergic population) were 0.3 (95%CI 0.2-0.5) and 2.9 (95%CI 1.6-5.4) mg, respectively. At meta-analysis, 4.8% (95%CI 2.0-10.9%) and 4.8% (95%CI 0.7-27.1%) of individuals reacting to ≤5mg and ≤0.5mg of CM protein (respectively) had anaphylaxis (minimal heterogeneity, I 2 =0%). 110 individuals subsequently underwent a repeat DBPCFC: the intra-individual variation in reaction threshold was limited to a ½-log change in 80% (95%CI 65-89%) of participants. Two individuals initially tolerated 5mg CM protein but then reacted to this dose at a subsequent challenge, although neither had anaphylaxis. Conclusions: Around 5% of CM-allergic individuals reacting to an ED01 or ED05 exposure might have anaphylaxis to that dose. This equates to 5 and 24 anaphylaxis events per 10,000 patients exposed to an ED01 or ED05 dose respectively, in the broader CM-allergic population. The vast majority of these anaphylactic reactions would be at the more mild end of the spectrum of anaphylaxis severity, responding to single dose of epinephrine.

Background Cow's milk, along with hen's egg, are common causes of food allergies in children worldwide. Accidental ingestion of milk is common and often induces severe allergic reactions. Oral food challenge test (OFC) is usually performed in patients with or suspected of having a food allergy. However, the evidence of whether cow's milk OFC is useful in IgE-dependent cow's milk allergy patients to avoid total elimination is not known. Methods After setting the clinical question and outcomes, we performed a systematic review for relevant articles published from January 1, 2000 to August 31, 2019 using PubMed® and Ichushi-Web databases. Each article was then evaluated for the level of evidence. All positive results of the OFC were defined as adverse events. Results Forty articles were selected in this study. Our review revealed that cow's milk OFC was able to avoid the complete elimination of cow's milk in 66% of the patients with cow's milk allergy. We also found that adverse events occurred frequently (50.5%). Conclusions This analysis supports the recommendation of conducting cow's milk OFC to avoid complete elimination of cow's milk, however the test should be conducted with careful consideration of the patient's safety. As the methods of OFC and subjects varied among the articles selected in this study, further studies are needed to obtain higher quality evidence.

Background: This study was aimed at evaluating the efficacy and safety of oral immunotherapy (OIT) in children with severe cow's milk allergy. Methods: The subjects comprised 28 children (aged 3–12 years) with allergic symptoms that were induced by ≤ 10 mL of cow's milk in an oral food challenge test (OFC). The subjects were randomly allocated to the treatment group (n = 14) and control group (n = 14); the former received rush immunotherapy for 2 weeks, followed by a gradual increase of cow's milk volume to 100 mL for 1 year, and the latter completely eliminated cow's milk for 1 year. Both groups underwent an OFC with 100 mL of cow's milk after 1 year. Results: The treatment group had significantly higher rates of a negative OFC [7/14 (50%) vs. 0/14 (0%), p 100 mL). Conclusions: The effect of immunotherapy was 50%, but the incidence of adverse events was not low. Further studies focusing on safety is necessary to standardize OIT for cow's milk allergy.

Background: There are no validated quantitative tools for assessing asthma exacerbation, which may cause significant variation in determining the severity of exacerbation across caregivers. A modified Pulmonary Index Score (mPIS) has been proposed as a quantitative indicator of the severity of childhood asthma exacerbation. However, the utility of mPIS as a treatment decision-making tool has not been investigated. Objective: The aim of the present study was to clarify the utility of therapeutic strategies based on mPIS in children hospitalized for asthma exacerbation. Methods: This was a case-control study of patients admitted to our hospital between 2010 and 2015. In addition to the conventional therapy based on Japanese guidelines, treatment adaptation by using mPIS began in 2013. Children admitted after 2013 were regarded as being in the case group and those before 2012 were the control group. The length of the hospital stay and the duration of continuous isoproterenol inhalation therapy (CIT) were compared as clinical outcomes. Results: The targeted number of patients was 346 (182 cases and 164 controls). The mean ± standard error age was 3.5 ± 0.2 years in the case group and 3.4 ± 0.2 years in the control group. Male patients constituted 64.3% of the case group and 60.4% of the control group. The mean ± standard error length of hospital stay was significantly shortened in the case group (8.1 ± 0.2 days versus 9.6 ± 0.2 days, p < 0.001). The mean ± standard error duration of CIT was also shortened in the case group (2.3 ± 0.1 days versus 3.9 ± 0.3 days, p < 0.001). Conclusion: An mPIS-based therapeutic strategy may have reduced the length of hospital stay by enabling timely adjustments to clinical interventions and enabling caregivers to perform a more-accurate assessment of asthma exacerbation.

A semi-micro column HPLC-fluorescence method for routine determination of thiol derivatives such as homocysteine (Hcy), cysteine (Cys) and cysteamine (CA) is described. The thiol derivatives labeled with ammonium-7-fluorobenzo-2-oxa-1,3-diazole-4-sulfonate (SBD-F) were isocratically separated within 12 min on a semi-micro ODS column (Daisopak-SP-120-5-ODS-BP) with a mixture of 25 mm acetate buffer (pH 2.00) and CH3CN as a mobile phase. The purity and similarity of SBD-thiols by a multi-wavelength fluorescence detector were more than 92.3 and 96.7%. The detection limits of Hcy, Cys and CA at a signal-to-noise ratio of 3 were 0.16, 0.47 and 0.03 µm, respectively. Furthermore validation parameters such as accuracy, precision and robustness of the proposed method showed satisfactory results. Almost 850 plasma sample injections (range 572–1076, n = 3) for a column could be performed without differences in retention time and peak heights of labels. As an application of the proposed method, the determination of thiol derivatives in normal human plasma (n = 103) was demonstrated. The correlation coefficients between Hcy vs Cys and Hcy vs CA were 0.38 and −0.35, respectively. Copyright © 2009 John Wiley & Sons, Ltd.