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Background The PEPITES (Peanut EPIT Efficacy and Safety) trial, a 12-month randomized controlled study of children with peanut allergy and 4 to 11 years old, previously reported the safety and efficacy of epicutaneous immunotherapy (EPIT) for peanut allergy (250 μg, daily epicutaneous peanut protein; DBV712 250 μg). Objective We sought to assess interim safety and efficacy of an additional 2 years of EPIT from the ongoing (5-year treatment) PEOPLE (PEPITES Open-Label Extension) study. Methods Subjects who completed PEPITES were offered enrollment in PEOPLE. Following an additional 2 years of daily DBV712 250 μg, subjects who had received DBV712 250 μg in PEPITES underwent month-36 double-blind, placebo-controlled food challenge with an optional month-38 sustained unresponsiveness assessment. Results Of 213 eligible subjects who had received DBV712 250 μg in PEPITES, 198 (93%) entered PEOPLE, of whom 141 (71%) had assessable double-blind, placebo-controlled food challenge at month 36. At month 36, 51.8% of subjects (73 of 141) reached an eliciting dose of ≥1000 mg, compared with 40.4% (57 of 141) at month 12; 75.9% (107 of 141) demonstrated increased eliciting dose compared with baseline; and 13.5% (19 of 141) tolerated the full double-blind, placebo-controlled food challenge of 5444 mg. Median cumulative reactive dose increased from 144 to 944 mg. Eighteen subjects underwent an optional sustained unresponsiveness assessment; 14 of those (77.8%) maintained an eliciting dose of ≥1000 mg at month 38. Local patch-site skin reactions were common but decreased over time. There was no treatment-related epinephrine use in years 2 or 3. Compliance was high (96.9%), and withdrawals due to treatment-related adverse events were low (1%). Conclusions These results demonstrate that daily EPIT treatment for peanut allergy beyond 1 year leads to continued response from a well-tolerated, simple-to-use regimen.

Background Cow’s milk protein allergy (CMPA) is one of the most common food allergies in infancy. Most infants with CMPA tolerate baked milk from diagnosis and gradually acquire increased tolerance. Nevertheless, parents often display significant anxiety about this condition and a corresponding reluctance to progress with home introduction of dairy due to concerns about possible allergic reactions. Objective: To evaluate the impact on gradual home introduction of foods containing cows milk after a supervised, single low dose exposure to whole milk at time of diagnosis. Methods Infants less than 12 months old, referred with suspected IgE-mediated cow’s milk allergy were recruited to an open-label randomised, controlled trial of intervention - a single dose of fresh cow’s milk, using the validated dose of milk that would elicit reactions in 5% of CMPA subjects - the ED – vs routine care. Both groups implemented graded exposure to CM (using the 12 step MAP Milk Tolerance Induction Ladder), at Home. Parents completed food allergy quality of life and State and Trait Anxiety Inventories (STAI). Main outcome measures were milk ladder position at 6 months and 12 months post randomisation. Results: Sixty patients were recruited, 57 (95%) were followed to 6 months. By 6 months 27/37 (73%) intervention subjects had reached step 6 or above on the milk ladder compared to 10/20 (50%) control subjects (p=0.048). By 6 months 11/37 (30%) intervention subjects had reached step 12 (ie drinking unheated cow’s milk) compared to 2/20 (10%) of the controls (p=0.049). Twelve months post randomisation 31/36(86%) of the intervention group and 15/19(79%) of the control group were on step 6 or above. However, 24/37 (65%) of the intervention group were at step 12 compared to 7/20 (35%) of the control group (p=0.03). Maternal STAIs were significantly associated with their infants’ progress on the milk ladder and with changes in skin prick test and spIgE levels at 6 and 12 months. Conclusion This study demonstrates the safety and effectiveness of introduction of baked milk implemented immediately after diagnosis of cows milk allergy in a very young cohort. A supervised single dose of milk at the ED significantly accelerates this further, probably by giving parents the confidence to proceed. Maternal anxiety generally reflects infants’ progress towards completion of the milk ladder, but pre-existing high levels of maternal anxiety are associated with poorer progress.

International audience; An ion chromatography system employing a low-cost three-dimensional printed absorbance detector for indirect ultraviolet detection towards portable phosphate analysis of environmental and industrial waters has been developed. The optical detection cell was fabricated using stereolithography three-dimensional print- ing of nanocomposite material. Chromatographic analysis and detection of phos- phate were carried out using a CS5A 4 × 250 mm analytical column with indirect ultraviolet detection using a 255 nm light-emitting diode. Isocratic elution using a 0.6 mM potassium phthalate eluent combined with 1.44 mM sodium bicarbon- ate was employed at a flow rate of 0.75 ml/min. A linear calibration range of 0.5 to 30 mg/L PO43− applicable to environmental and wastewater analysis was achieved. For retention time and peak area repeatability, relative standard devi- ation values were 0.68% and 4.09%, respectively. Environmental and wastewater samples were analyzed with the optimized ion chromatography platform and the results were compared to values obtained by an accredited ion chromatograph. For the analysis of environmental samples, relative errors of

The recently published BSACI guideline for the management of egg allergy (1) , is a timely update to the 2010 guideline, with an appropriate modern emphasis on clinically based diagnosis, and promotion of tolerance. However, we challenge the recommendation, contained in the guideline, that introduction of baked egg should be delayed to 1yr of age or until 6 months post last reaction: See "Key messages" (bullet point no 19) of the guideline (1) .

Background: Food allergy (FA) has been shown to have an adverse impact on food allergy quality of life (FAQL). To more fully understand this impact, correlates and predictors of FAQL must be reliably measured. Coping is one such factor. In the present study (n = 200), we sought to adapt the widely used Coping Orientation to Problems Experienced (COPE) Inventory and its 15 distinct strategies to food allergy, named FA-COPE Inventory. More specifically, we propose a long (60-item) and short (30-item) version of the measure. Methods: To examine the robustness of the newly adapted FA-COPE Inventory, we tested whether the 15-factor structure of the adapted version would present good psychometrical properties, using gold standard psychometric techniques. We used Confirmatory Factor Analysis to assess model fit, McDonald's omega, and inter-item correlations to assess reliability, and Pearson's correlation to assess convergent validity with a generic coping measure and satisfaction with FA life. Results: Our results showed a good model fit (eg, CFI and TLI ≥ .94) for the 15-factor structure of the measure's long and short version. These factors also presented reliability levels aligned with the coping literature. Finally, the majority of the FA-COPE Inventory factors (eg, acceptance) were significantly associated with the generic coping measure and satisfaction with FA life. Conclusion: Both the long and short adapted FA-COPE Inventory showed a good fit to food allergy issues. These measures can help facilitate the identification of the most commonly used strategies to deal with FA. Their use can lead to a more in-depth understanding of the impact of the coping strategies and how they can help improve the quality of life of those impacted by the disease.

The COVID-19 pandemic has led to severe disruption of healthcare systems and elective planned care.1 While pandemics are infrequent, the disruption of elective care by acute respiratory viral infections is an annual occurrence, including administration of oral food challenges (OFCs) to children with suspected allergy. A major barrier to performing OFCs outside tertiary centres is the risk of adverse events including anaphylaxis.2 3 We recently reported a large series of food challenges in a COVID-19 stepdown facility,4 and here we describe our process of managing anaphylaxis in this setting. Five regional paediatric allergy clinics across Ireland jointly used a vacant COVID-19 field hospital over 6 weeks. OFCs were performed within a pod system, with each pod containing up to six patients (figure 1). Resuscitation protocols and equipment trolleys were identical to those in hospital. For anticipated anaphylaxis events, patient journey was mapped …

Background Internationally, the COVID‐19 pandemic severely curtailed access to hospital facilities for those awaiting elective/semi‐elective procedures. For allergic children in Ireland, already waiting up to 4 years for an elective oral food challenge (OFC), the restrictions signified indefinite delay. At the time of the initiative, there were approx 900 children on the Children's Health Ireland (CHI) waiting list. In July 2020, a project was facilitated by short‐term (6 weeks) access to an empty COVID stepdown facility built, in a hotel conference centre, commandeered by the Health Service Executive (HSE), Ireland. The aim of this study was to achieve the rapid roll‐out of an offsite OFC service, delivering high throughput of long waiting patients, while aligning with existing hospital policies and quality standards, international allergy guidelines and national social distancing standards. Methods The working group engaged key stakeholders to rapidly develop an offsite OFC facility. Consultant paediatric allergists, consultant paediatricians, trainees and allergy clinical nurse specialists were seconded from other duties. The facility was already equipped with hospital beds, bedside monitors (BP, pulse and oxygen saturation) and bedside oxygen. All medication and supplies had to be brought from the base hospital. Daily onsite consultant anaesthetic cover was resourced and a resuscitation room equipped. Standardized food challenge protocols were created. Access to the onsite hotel chef facilitated food preparation. A risk register was established. Results After 6 weeks of planning, the remote centre became operational on 7/9/2020, with the capacity of 27 OFC/day. 474 challenges were commenced: 465 (98%) were completed and 9 (2%) were inconclusive. 135 (29%) OFCs were positive, with 25 (5%) causing anaphylaxis. No child required advanced airway intervention. 8 children were transferred to the base hospital. The CHI allergy waiting list was reduced by almost 60% in only 24 days. Conclusions Oral food challenges remain a vital tool in the care of allergic children, with their cost saving and quality‐of‐life benefits negatively affected by a delay in their delivery. This project has shown it is possible to have huge impacts on a waiting list efficiently, effectively and safely with good planning and staff buy‐in—even in a pandemic. Adoption of new, flexible and efficient models of service delivery will be important for healthcare delivery in the post–COVID‐19 era.

The public health strategy during the SARS-CoV-2 (COVID19) pandemic of 2020-2021 led to profound changes in social behaviour, affecting not only familial but also wider social interactions. These changes may have altered viral and bacterial interchange.

The Allergy to Peanuts imPacting Emotions And Life study (APPEAL) explored the psychosocial burden of living with self-reported peanut allergy experienced by children, teenagers, adults and caregivers in the UK and Ireland. A two-stage (quantitative survey and qualitative interview [APPEAL-1]), cross-sectional study of the psychosocial burden of peanut allergy (APPEAL-2) was conducted. Quantitative data were evaluated using descriptive statistics and qualitative data were analysed using MAXQDA software. A conceptual model specific to UK and Ireland was developed using the concepts identified during the analysis. A total of 284 adults in the UK and Ireland completed the APPEAL-1 survey and 42 individuals participated in APPEAL-2. Respondents reported that peanut allergy restricts their choices in various situations, especially with regard to choosing food when eating out (87% moderately or severely restricted), choosing where to eat (82%), special occasions (76%) and when buying food from a shop (71%). Fifty-two percent of survey participants and 40% of interview participants reported being bullied because of PA. Psychological impact of peanut allergy included feeling at least moderate levels of frustration (70%), uncertainty (79%), and stress (71%). The qualitative analysis identified three different types of coping strategies (daily monitoring or vigilance, communication and planning) and four main areas of individuals’ lives that are impacted by peanut allergy (social activities, relationships, emotions and work [adults and caregivers only]). The extent of the impact reported varied substantially between participants, with some reporting many negative consequences of living with peanut allergy and others feeling it has minimal impact on their health-related quality of life. This large survey and interview study highlight the psychosocial burden of peanut allergy for adults, teenagers, children and caregivers in the UK and Ireland. The analysis demonstrates the wide variation in level of impact of peanut allergy and the unmet need for those individuals who experience a substantial burden from living with peanut allergy.

Background: Cow’s milk protein allergy (CMPA) is one of the most common food allergies in infancy. Parents often display significant anxiety about this condition. Single dose challenges are a new method of assessing dose reactivity in food allergic children. Methods: We recruited children referred for evaluation of CMPA to a randomised, controlled trial of single dose challenge to cow’s milk, using the validated dose of milk that would elicit reactions in 5% of CMPA subjects - the ED 05 - before implementation of graded exposure to CM (using the 12 step iMAP Milk Tolerance Induction Ladder) at home. Parents completed food allergy quality of life and State and Trait Anxiety Inventories (STAI). Results: Sixty patients were recruited, 57 (95%) were followed to 6 months. By 6 months 27/37 (73%) intervention subjects had reached step 6 or above on the milk ladder compared to 10/20 (50%) control subjects (p=0.048). By 6 months 11/37 (30%) intervention subjects had reached step 12 (ie drinking unheated cow’s milk) compared to 2/20 (10%) of the controls (p=0.049). Twelve months post randomisation 31/36(86%) of the intervention group and 15/19(79%) of the control group were on step 6 or above. However, 24/37 (65%) of the intervention group were at step 12 compared to 7/20 (35%) of the control group (p=0.03). Maternal STAIs were significantly associated with their infants’ response/progress on the milk ladder and with changes in skin prick test and spIgE levels at 6 and 12 months. Conclusion: Using the 12 step iMAP milk ladder accelerates natural tolerance induction in infants under 12 months with CMPA. A supervised single dose at the ED 05 significantly accelerates this further, probably by giving parents the confidence to proceed. Maternal anxiety generally reflects infants’ progress towards tolerance but preexisting high levels of maternal anxiety are associated with poorer progress. Funding: YD was in receipt of a Clinical Research Fellowship from the National Childrens Research Centre Ireland. Declaration of Interest: AM received research funding from Aimmune Therapeutics, RvR declares consultancies for HAL Allergy BV, Citeq BV, Angany Inc, speaker fees from HAL Allergy BV, ThermoFisher Scientific, ALK and stock options from Angany Inc. ADG receives research funding and speaker fees from Aimmune Therapeutics JO’BH receives research funding, speaker fees and consultancy fees from Aimmune Thereputics, research funding and speaker fees from DBV Technologies, research funding from Johnson&Johnson, Clemens von Pirquet Foundation and Temple st Hospital Research Foundation. Ethical Approval: Ethical approval was obtained from the Clinical Research Ethics Committees of the Cork Teaching Hospitals and Crumlin Hospital. Approval was granted on 26th September 2017.

Concerns for anaphylaxis may hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunization efforts. We convened a multidisciplinary group of international experts in anaphylaxis composed of allergy, infectious disease, emergency medicine, and front-line clinicians to systematically develop recommendations regarding SARS-CoV-2 vaccine immediate allergic reactions. Medline, EMBASE, Web of Science, the World Health Organizstion (WHO) global coronavirus database, and the gray literature (inception, March 19, 2021) were systematically searched. Paired reviewers independently selected studies addressing anaphylaxis after SARS-CoV-2 vaccination, polyethylene glycol (PEG) and polysorbate allergy, and accuracy of allergy testing for SARS-CoV-2 vaccine allergy. Random effects models synthesized the data to inform recommendations based on the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, agreed upon using a modified Delphi panel. The incidence of SARS-CoV-2 vaccine anaphylaxis is 7.91 cases per million (n = 41,000,000 vaccinations; 95% confidence interval [95% CI] 4.02-15.59; 26 studies, moderate certainty), the incidence of 0.15 cases per million patient-years (95% CI 0.11-0.2), and the sensitivity for PEG skin testing is poor, although specificity is high (15 studies, very low certainty). We recommend vaccination over either no vaccination or performing SARS-CoV-2 vaccine/excipient screening allergy testing for individuals without history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient, and a shared decision-making paradigm in consultation with an allergy specialist for individuals with a history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient. We recommend further research to clarify SARS-CoV-2 vaccine/vaccine excipient testing utility in individuals potentially allergic to SARS-CoV2 vaccines or their excipients.

Introduction In ARTEMIS, 58% of AR101-treated subjects vs. 2% of placebo-treated subjects tolerated 1000 mg peanut protein as a single dose at exit double-blind, placebo-controlled food challenge (DBPCFC; P Methods All enrolled subjects had a clinical history of peanut allergy, demonstrated sensitization to peanut (skin prick test [SPT] mean wheal diameter ≥ 3 mm and/or peanut-specific immunoglobulin E [psIgE] ≥ 0.35 kUA/L), and reacted to ≤ 300 mg peanut protein at screening DBPCFC. SPT wheal diameter (mm), psIgE (kUA/L) and psIgG4 (mgA/L) assessments were performed at screening, end of dose escalation and study completion (following 3 months at 300 mg/day). Differences between treatment groups from screening to exit were analyzed using an ANCOVA model with terms fitted for group, country and screening value. Results A total of 175 ARTEMIS subjects (AR101 n = 132, placebo n = 43) were treated. SPT wheal diameter, psIgE levels, psIgG4 levels and psIgE/IgG4 ratio are summarized in Table 1 . From baseline to exit (AR101 vs. placebo), psIgG4 levels increased (P Conclusion Exposure to AR101 was associated with immunologic changes consistent with immunomodulation: increased psIgG4, decreased peanut SPT wheal size and transient changes in psIgE levels, as reported in previous peanut oral immunotherapy trials.

Egg allergy is the most common food allergy of childhood, but it is now well established that most egg allergic infants can tolerate extensively heated egg, baked in a wheat matrix. Furthermore, ingestion of baked egg has been shown to reduce skin prick test (SPT) wheal diameter to egg white and to be associated with an increase in IgG4 antibody levels to egg proteins. Egg allergy is also an independent risk factor for the development of peanut allergy.

BackgroundFood protein-induced enterocolitis syndrome (FPIES) is a delayed type of food allergy, most often seen in infancy. We aimed to estimate its incidence, to describe common food triggers and the patient journeys of this rare but serious condition.DesignWe undertook a prospective epidemiological survey of FPIES using the British Paediatric Surveillance Unit.SettingUK and Ireland.ParticipantsA survey of all paediatricians over 13 months between January 2019 and February 2020.Main outcome measures204 cases were reported, 98 (48%) meeting case definition, giving an incidence of 0.006% for England based on 93 cases.Results98 patients reported 135 trigger foods, 27% (26 of 98) had multiple food triggers. Common food triggers included cow’s milk (24%, 33 of 135), fruits and vegetables (19%, 26 of 135), hen’s egg (16%, 22 of 135) and fish (14%, 19 of 135). In 46% (41 of 90), the initial trigger food had been ingested three or more times before diagnosis, with a median diagnostic delay of 7.9 months (3.0, 17.3). Half (50 of 98) were admitted, yet only 5% (5 of 98) received appropriate acute treatment with ondansetron. Most cases were diagnosed by an allergy specialist (74 of 98, 76%), within a median of 7.5 (3.0, 13.3) miles from home.ConclusionThe incidence of FPIES was significantly lower than expected across the whole of the British Isles. Most reports were of cases local to specialist allergy centres, with delays in diagnosis. This suggests under-recognition of FPIES in frontline clinical setting where education of healthcare professionals is required to improve recognition, earlier diagnosis and treatment.

Background Food allergy (FA) affects up to 10% of young children and 2% to 3% of adults, and appears to be increasing in prevalence across the world. The adverse and growing impact of FAs warrants that closer attention is needed to the psychological mechanisms underlying FA and quality of life, to provide benefits for both clinicians and patients. One of these psychological mechanisms, frequently present in individuals struggling with FA, is anxiety. Objective To provide an FA-specific measure to properly assess the impact of anxiety, the present research proposed the novel Food Allergy Anxiety Scale in an adult population. Methods Two studies were conducted (n = 412), and the psychometric properties of the measure were extensively assessed through several robust statistical techniques (eg, exploratory factor analysis, confirmatory factor analysis, and item response theory). Results Our findings indicated a reliable 1-factor structure, significantly associated with other constructs such as general anxiety, depression, and FA quality of life. Conclusions We are confident that the Food Allergy Anxiety Scale is a powerful tool to assess this specific role of FA within anxiety, which might lead to a better comprehension on how this psychological distress works, and consequently, the development of better strategies to reduce its impact.

Background Peanut allergy is the leading cause of food-related anaphylaxis. Current management options can negatively affect food allergy-related quality of life. We aimed to investigate the efficacy of an investigational oral biologic drug (AR101). Methods The AR101 Trial in Europe Measuring Oral Immunotherapy Success in peanut-allergic children (ARTEMIS) trial was a multicentre, double-blind, randomised, placebo-controlled phase 3 trial done at 18 hospitals in Ireland, France, Germany, Italy, Spain, Sweden, and the UK. Children and adolescents with peanut allergy, aged 4–17 years, who developed dose-limiting symptoms to 300 mg or less peanut protein (equivalent to approximately one peanut kernel) during a double-blind placebo-controlled food challenge test at study entry were enrolled. Participants were randomly assigned (3:1) to receive daily doses of either AR101 oral immunotherapy (AR101 group) or a taste-masked placebo (placebo group). All participants, investigators, and care providers were masked to treatment allocation until the study was completed. Doses were increased every 2 weeks over 6 months until a dose of 300 mg was reached and maintained for 3 months. The primary endpoint was the proportion of participants in the intention-to-treat or safety population (defined as those participants who had been randomly assigned and had received at least one dose of the assigned drug) who could consume a single dose of 1000 mg (cumulative dose 2043 mg) peanut protein without developing dose-limiting allergic symptoms at an exit double-blind placebo-controlled food challenge after 9 months of treatment. Additional endpoints included safety (ie, the frequency and severity of adverse events) and changes in food allergy-related quality of life, assessed by use of age-appropriate Food Allergy Quality of Life Questionnaires (FAQLQs) and the Food Allergy Independent Measure (FAIM). The study is registered with ClinicalTrials.gov, NCT03201003, and is completed. Findings Between June 12, 2017, and Feb 15, 2018, 227 patients were screened, of whom 175 were randomly assigned to the AR101 group (n=132) and the placebo group (n=43). All primary and secondary endpoints were met. 77 (58%) of 132 participants in the AR101 group tolerated 1000 mg peanut protein at the exit food challenge versus one (2%) of 43 participants in the placebo group (AR101–placebo treatment difference 56·0% [95% CI 44·1–65·2], p

Background Internet search engines are increasingly being utilized as the first port of call for medical information by the public. The prevalence of allergies in developed countries has risen steadily over time. There exists significant variability in the quality of health-related information available on the web. Inaccurately diagnosed and mismanaged allergic disease has major downstream effects on patients, general practitioners, and regional allergy services. Objective This study aimed to verify whether Ireland has a relatively high rate of web-based allergy-related searches, to establish the proportion of medically accurate web pages encountered by the public, and to compare current search results localized to Dublin, Ireland with urban centers elsewhere. Methods Google Trends was used to evaluate regional interest of allergy-related search terms over a 10-year period using terms “allergy,” “allergy test,” “food allergy,” and “food intolerance.” These terms were then inputted into Google search, localizing them to cities in Ireland, the United Kingdom, and the United States. Output for each search was reviewed by two independent clinicians and deemed rational or nonevidence based, as per current best practice guidelines. Searches localized to Dublin were initially completed in 2015 and repeated in 2019 to assess for changes in the quality of search results over time. Results Ireland has a persistently high demand for web-based information relating to allergy and ranks first worldwide for “allergy test,” second for “food allergy” and “food intolerance,” and seventh for “allergy” over the specified 10-year timeframe. Results for each of the four subsearches in Dublin (2015) showed that over 60% of websites promoted nonevidence-based diagnostics. A marginal improvement in scientifically robust information was seen in 2019, but results for “allergy test” and “food intolerance” continued to promote alternative testing 57% (8/14) of the time. This strongly contrasted with results localized to Southampton and Rochester, where academic and hospital-affiliated web pages predominantly featured. Government-funded Department of Health websites did not feature in the top five results for Dublin searches “allergy testing,” “food allergy,” or “food intolerance” in either 2015 or 2019. Conclusions The Irish public demonstrates a keen interest in seeking allergy-related information on the web. The proportion of evidence-based websites encountered by the Irish public is considerably lower than that encountered by patients in other urban centers. Factors contributing to this are the lack of a specialist register for allergy in Ireland, inadequate funding for allergy centers currently in operation, and insufficient promotion by the health service of their web-based health database, which contains useful patient-oriented information on allergy. Increased funding of clinical allergology services will more meaningfully impact the health of patients if there is a parallel investment by the health service in information and communication technology consultancy to amplify their presence on the web.

BACKGROUND Internet search engines are increasingly being utilized as the first port of call for medical information by the public. The prevalence of allergies in developed countries has risen steadily over time. There exists significant variability in the quality of health-related information available on the web. Inaccurately diagnosed and mismanaged allergic disease has major downstream effects on patients, general practitioners, and regional allergy services. OBJECTIVE This study aimed to verify whether Ireland has a relatively high rate of web-based allergy-related searches, to establish the proportion of medically accurate web pages encountered by the public, and to compare current search results localized to Dublin, Ireland with urban centers elsewhere. METHODS Google Trends was used to evaluate regional interest of allergy-related search terms over a 10-year period using terms “allergy,” “allergy test,” “food allergy,” and “food intolerance.” These terms were then inputted into Google search, localizing them to cities in Ireland, the United Kingdom, and the United States. Output for each search was reviewed by two independent clinicians and deemed rational or nonevidence based, as per current best practice guidelines. Searches localized to Dublin were initially completed in 2015 and repeated in 2019 to assess for changes in the quality of search results over time. RESULTS Ireland has a persistently high demand for web-based information relating to allergy and ranks first worldwide for “allergy test,” second for “food allergy” and “food intolerance,” and seventh for “allergy” over the specified 10-year timeframe. Results for each of the four subsearches in Dublin (2015) showed that over 60% of websites promoted nonevidence-based diagnostics. A marginal improvement in scientifically robust information was seen in 2019, but results for “allergy test” and “food intolerance” continued to promote alternative testing 57% (8/14) of the time. This strongly contrasted with results localized to Southampton and Rochester, where academic and hospital-affiliated web pages predominantly featured. Government-funded Department of Health websites did not feature in the top five results for Dublin searches “allergy testing,” “food allergy,” or “food intolerance” in either 2015 or 2019. CONCLUSIONS The Irish public demonstrates a keen interest in seeking allergy-related information on the web. The proportion of evidence-based websites encountered by the Irish public is considerably lower than that encountered by patients in other urban centers. Factors contributing to this are the lack of a specialist register for allergy in Ireland, inadequate funding for allergy centers currently in operation, and insufficient promotion by the health service of their web-based health database, which contains useful patient-oriented information on allergy. Increased funding of clinical allergology services will more meaningfully impact the health of patients if there is a parallel investment by the health service in information and communication technology consultancy to amplify their presence on the web.

Background The prevalence of food allergy in adolescents varies with estimates of 2.3–4.5% in different populations (1,2). This group are a vulnerable population. They are at greater risk of fatal anaphylaxis and fatal asthmatic episodes. In Ireland, they have a potential further risk in that most have not had an opportunity to see an allergist through childhood due to extremely limited access. Aims To examine the presence of risk factors for poorly controlled allergic disease identifiable in adolescent patients on the routine waiting list (WL) in the allergy department. Methods Adolescents attending their first allergy clinic appointment who were on the routine outpatient WL were included between September- December 2017. Clinical data pertaining to each adolescent’s allergic disease was collected at this appointment. A scoring system was utilised to numerically grade the cause for concern for each adolescent after review in clinic. A 1A point was awarded for each major concern identified and a 1B point was awarded for each moderate concern identified. Results Data was collected on 17 adolescents over the 3-month period. The primary reason for referral in all patients was investigation of food allergy. Ten were referred by GPs, 5 by general paediatricians and 2 by dermatologists. 15/17 adolescents had between 1–3 criteria for major concern; uncontrolled asthma (n=6), recurrent reactions while on the WL (n=11), anaphylaxis while on WL (n=3), no AAI prescribed (n=4). 14/17 had criteria for moderate concern; not carrying a prescribed in date AAI (n=9), poorly controlled allergic rhinitis (n=10), social isolation (n=3). The highest score was 3A+1B in 2 adolescents. Conclusion This study shows that adolescents are at significant risk of allergic reactions, uncontrolled asthma and recurrent food reactions prior to review by a specialist allergist. 10/17 (59%) had a reaction while on the WL. Three cases were anaphylaxis. This study has prompted design of a specific information leaflet for GPs referring adolescents to the allergy clinic as well as review of criteria for urgent review in clinic. References Pereira B, Venter C, Grundy J, Clayton CB, Arshad SH, Dean T. Prevalence of sensitization to food allergens, reported adverse reaction to foods, food avoidance, and food hypersensitivity among teenagers. J Allergy Clin Immunol 2005;116(4):884–92. Sasaki M, Koplin JJ, Dharmage SC, Field MJ, Sawyer SM, McWilliam V, et al. Prevalence of clinic-defined food allergy in early adolescence: The SchoolNuts study. J Allergy Clin Immunol 2018 Jan;141(1):391–398.e4.

Background Non-allergic Chronic Urticaria (CU), which includes both Chronic Spontaneous Urticaria (CSU) and Chronic Inducible Urticaria (CIU), is a condition characterised by wheals, erythema and pruritus. It is often associated with angioedema. CSU/CIU are often misinterpreted as an allergic condition by both families and healthcare professionals leading to unnecessary investigations, unwarranted therapeutics, and a high referral burden on paediatric allergy specialists. The aim of this study was to define the demographics of cases of chronic urticaria referred to an Irish allergy clinic and to explore diagnostic and treatment patterns at a primary care level. Finally, this study aimed to determine the specialist management strategy as compared to the current British Society for Allergy and Clinical Immunology (BSACI) guidelines. Methods A retrospective audit of medical records of all children seen by the Allergy service at Our Lady’s Children’s Hospital Crumlin (OLCHC) with a diagnosis of Chronic Spontaneous Urticaria or Chronic Inducible Urticaria between January 2014 - December 2017 was conducted. Results A total of 97 children were included. Both genders were equally affected (Males n=48) and the most common age of onset of CU was –-5 years (n=44). Of the 97 children reviewed, the majority (71%) presented through primary care referral (n=69). At the primary care level, only 10% of children (n=10) were appropriately diagnosed with CU. The most common pre-referral misdiagnosis was allergy (n=32), followed by no diagnosis (n=12). While 65% of children (n=63) were started on an antihistamine, only 32% (n=28) received a second-generation H1 antihistamine by the primary care provider. Five cases inappropriately were prescribed oral or topical corticosteroids. Once reviewed by the specialist allergy service at OLCHC, 100% of the children were prescribed second-generation H1 antihistamines, primarily cetirizine (n=64), and no children were treated with corticosteroids. Following the first allergy consult, 70% of children saw resolution of symptoms and were discharged (n=67). Conclusion This audit demonstrates that recognition and appropriate treatment of Chronic Spontaneous and Chronic Inducible Urticaria are key targets for primary care education in order to achieve prompt resolution of symptoms and reduced referral burden on specialist services.

Background Allergic diseases are prevalent in ASD children, with a frequency equivalent to that in the general population.1,2Unfortunately, owing to their impaired expressive language, aberrant behaviours and lower tolerance to diagnostic measures compared with typically developing children European Academy of Allergy and Clinical Immunology and British Society of Allergy and Clinical immunology. Methodology Retrospective and prospective data collection from clinical notes from children attending department of Allergy and immunology, Our Lady Children Hospital Crumlin from August 2017 till November 2017. Results Out of 20 children recruited, 18 were eligible, 15boys (84%) and 3 girls (16%).Half of them had been diagnosed with Autism and other half with ASD. Main reason of referral was food allergy (88%), Skin Prick Test was indicated in 88% of children but was performed only in 8(45%) children. In non autistic children in our centre we can perform skin test on almost every child our doing 1300 skin prick test annually. Food challenge was performed only in one child out of 9 indicated, while in non autistic children we perfom 240 food challenges per year which represents 99% of cases if food challenge indicated. Allergic Diagnosis was confirmed in 8(45%) children, refuted in 2(11%) children, inconclusive in 8(45%) mainly because of lack of information from SPT and blood test (38%) or due to failure to challenge (38%).Home food introduction was advised in 8(45%) children was not successful in 5(62%), while at initial level only in 3(38%) children over period of 6 months to 2 years. Ninety percent of Non autistic children in one of our local audit tolerated baked egg at home introduction successfully. Associated atopic features with food allergy were Eczema (66%), Asthma (33%) and Allergic Rhinitis (11%). Conclusions Diagnosing Food allergy in children with Autism is difficult because of behavioural issues and their restricted food patterns, because of these reasons they are mostly under diagnosed and not properly managed. More resources will be required to achieve this goal. Recommendations Regular follow up with detailed feeding history and restricted patterns Early dietician and psychology input may help. References Jyonouchi H. Food allergy and ASD is there a link? Curr. Allergy Asthma Rep. 9, 194–201 (2009). Jyonouchi H, Geng L, Cushing-Ruby A, Quraishi H. Impact of innate immunity in a subset of children with ASD: a case control study. J. Neuroinflammation 5, 52 (2008).

Introduction Food allergy has become an increasingly common condition in the paediatric community over recent decades1. Many of these patients are at risk of developing anaphylaxis following exposure to food allergens. Adrenaline Auto-Injector (AAI) devices are prescribed to these patients to be used in the event of anaphylaxis following accidental exposure. Guidance The Irish Food Allergy Network (IFAN) recommends that patients who are prescribed AAIs should carry two AAIs at all times. For school-going children, it is recommended that two AAIs should be stored in their school in the event of accidental exposure2. Aims To evaluate parental compliance with carriage of AAI devices according to guidelines. To review parental confidence on when and how to use AAIs. Methodology A one-page questionnaire was compiled, which was approved by Tallaght University Hospital Clinical Audit Committee. We invited parents of children attending the paediatric allergy outpatient and day-ward services who had been prescribed AAI devices to complete this questionnaire anonymously and return it to clinical staff. This audit was carried out from October 2018 to January 2019 in five outpatient and four day-ward clinics each month. Data was compiled in a spreadsheet and interpreted. Results 53 parents completed our questionnaire. Patients ranged from nine months to sixteen years of age. 71% (n=38) reported carrying AAI devices. Of these, 66% (n=35) carried two devices. 88% (n=47) reported that their AAIs were within date. Of those without devices, 15% (n=8) reported AAIs were left in the car while another 11% (n=6) stated their AAIs were left at home. Regarding confidence in AAI training, 75% (n=40) of parents surveyed felt confident in knowing when an AAI should be given, giving a score of 4 or 5 on a scale of 1 to 5. 86% (n=46) were confident in knowing how to administer an AAI device. Conclusion Our audit shows that 1 in 3 patients who were prescribed AAIs did not carry the recommended two devices with them when attending our outpatient services. Only 75% of patients and parents felt confident in knowing when they should give an AAI. This audit highlights the importance of taking the time to educate and re-educate patients and parents. Emphasis should be made on the importance of carrying AAIs at all times. References Ben-Shoshan M et al, Curr Allergy Asthma Rep (2012)12:346. https://doi.org/10.1007/s11882–012–0274–3 IFAN[Internet], Food Allergy in School. Cork Irl. 2017(cited Jan 2019) http://ifan.ie/childcare-schools/Save

Background The prevalence of food allergy amongst young children in the developed world is estimated to be 5%. Recently published data demonstrates that early introduction of food allergens prevents food allergy1. There remains much controversy over whether these foods should be introduced with or without prior allergy skin testing. On one hand, access to such testing, is universally delayed due to limited resources. On the other hand, introduction without testing may trigger an allergic reaction. New UK and Australian guidance have advised introduction of peanut and egg at 6 months without testing. To date, no life-threatening reactions have been reported related to the introduction of these allergenic foods. However, it remains unclear whether other major allergens such as sesame, could be introduced in this way. Sesame allergy affects approx. 0.1% of the population but is more prevalent in areas with high consumption such as the Middle East where it is the second commonest cause of anaphylaxis in Israeli children2. The aim of this cases series is to highlight three cases of sesame anaphylaxis in infants under one year. The sesame was introduced at home without prior testing. Methods A retrospective chart review was undertaken of known cases of sesame anaphylaxis in infants, admitted to our tertiary Paediatric Hospital. Results Our patients ranged in age from 6 to 8 months and all presented via the Emergency Department. They all received tahini-containing hummus in the home setting for the first time prior to presentation. Patient one developed perioral erythema, facial flushing, angioedema, tongue swelling and profuse vomiting, he was administered adrenaline by ambulance personnel. Patient two became immediately distressed, developed stridor with facial and lip swelling, vomiting and diarrhea. He received two doses of adrenaline pre-hospital. Patient three developed immediate perioral urticaria spreading to his neck. He became pale and lethargic and vomited. This patient did not receive adrenaline but was managed with antihistamines and oral corticosteroids. All three infants showed subsequent positive SPT to sesame (ranging from 4–6 mm) with negative testing for chickpea. Conclusion Early introduction of peanut is now taking place worldwide with no reported cases to date of anaphylaxis. Here we present 3 cases of sesame anaphylaxis from just one institution. This case series highlights that early introduction of food allergens is likely to have differential risk profiles, with sesame seed introduction likely to carry a higher risk if introduced to all infants without prior screening.

IMPORTANCE: There are currently no approved treatments for peanut allergy. OBJECTIVE: To assess the efficacy and adverse events of epicutaneous immunotherapy with a peanut patch among peanut-allergic children. DESIGN, SETTING, AND PARTICIPANTS: Phase 3, randomized, double-blind, placebo-controlled trial conducted at 31 sites in 5 countries between January 8, 2016, and August 18, 2017. Participants included peanut-allergic children (aged 4-11 years [n = 356] without a history of a severe anaphylactic reaction) developing objective symptoms during a double-blind, placebo-controlled food challenge at an eliciting dose of 300 mg or less of peanut protein. INTERVENTIONS: Daily treatment with peanut patch containing either 250 μg of peanut protein (n = 238) or placebo (n = 118) for 12 months. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage difference in responders between the peanut patch and placebo patch based on eliciting dose (highest dose at which objective signs/symptoms of an immediate hypersensitivity reaction developed) determined by food challenges at baseline and month 12. Participants with baseline eliciting dose of 10 mg or less were responders if the posttreatment eliciting dose was 300 mg or more; participants with baseline eliciting dose greater than 10 to 300 mg were responders if the posttreatment eliciting dose was 1000 mg or more. A threshold of 15% or more on the lower bound of a 95% CI around responder rate difference was prespecified to determine a positive trial result. Adverse event evaluation included collection of treatment-emergent adverse events (TEAEs). RESULTS: Among 356 participants randomized (median age, 7 years; 61.2% male), 89.9% completed the trial; the mean treatment adherence was 98.5%. The responder rate was 35.3% with peanut-patch treatment vs 13.6% with placebo (difference, 21.7% [95% CI, 12.4%-29.8%; P

Ventriculo-peritoneal shunts are used extensively for the management of hydrocephalus and frequently present with complications such as shunt blockage and infection. Cerebrospinal fluid (CSF) eosinophilia and allergic responses to the shunt itself are rare, poorly understood but increasingly recognised complications. Here, the authors describe a child who required multiple shunt revision surgeries due to extensive scalp tenderness overlying the shunt tubing and persistent severe headaches despite having a normal working shunt and no CSF infection or eosinophilia. Histological investigation of excised tissue during the last shunt revision demonstrated fibrosis with scar tissue and chronic inflammatory infiltrate with foreign body giant cells and few abortive granulomata. This was felt to represent a foreign body reaction to the shunt. A hypoallergenic ‘extracted' shunt was trialled (extracted Delta® valve and extracted ventricular and peritoneal catheters; Medtronic) and the child has had no further shunt revisions and is currently asymptomatic 1 year after the insertion.

Over the last two decades, the prevalence of peanut and tree nut allergy has increased throughout the western world. Adverse reactions to these foods account for over 50% of all deaths resulting from food-related anaphylaxis. Until recently, evidence suggested that all peanut and tree nut allergy were permanent. It is now known that about 20% and 10%, respectively, of young patients outgrow peanut and tree nut allergies. Achieving tolerance is associated with increasing circulating T regulatory cells and reduced production of allergen-specific IgE. Reliable predictors of resolution are not yet available. A direct correlation between skin test weal size and allergen-specific IgE, at the time of diagnosis and likelihood of resolution, has been reported. Resolution of peanut or tree nut allergy cannot be determined conclusively by either allergen-specific IgE analysis or by skin prick testing. Oral food challenge is the gold standard for determining resolution of food allergy. Food challenges should only be undertaken in a clinical setting fully equipped to deal with a potential severe adverse reaction. Approximately 8% of patients who outgrow peanut allergy may suffer a recurrence, but recurrent tree nut allergy has not been reported to date. Infrequent ingestion of peanut may be related to the re-emergence of allergy. Induction of tolerance through oral immunotherapy or sublingual immunotherapy is now being actively studied, but remains experimental. Studies have reported short-term desensitization to peanut, but ongoing follow-up will determine whether tolerance is achieved long term.

Results 66% of GPs report that they always or almost always take a focussed FA history for patients presenting with urticaria. Significantly more histories were taken for urticaria than for feeding problems (p=0.007), eczema (p=0.025) or asthma (p

Results When HR IgE FHS were categorized by eczema severity, those with severe AD were more likely to have HR IgE to cow’s milk (x2 11.3, P < 0.001), egg (x2 6.5, P < 0.05) and peanut (x2 25.4, P < 0.0001) compared to those with mild to moderate AD. Those ≤ 2 years with severe AD were more likely to have multiple HR IgE FHS compared to those with mild to moderate AD for all combinations: cow’s milk and egg (x2 18.62, P < 0.0001); peanut and egg: (x2 24.72, P < 0.0001); cow’s milk and peanut (x2 16.37, P < 0.0001); cow’s milk, egg and peanut (x2 20.01, P < 0.0001).