BACKGROUND:Cow's milk allergy (CMA) overdiagnosis appears to be increasing and is associated with excessive low-allergy formula prescription. We evaluated recent trends and regional variation in low-allergy formula prescribing for CMA in England, and assessed potential risk factors for higher prescribing rates. METHODS:Data on national and regional prescribing of low-allergy formulas were extracted from England's electronic prescription database using R. Region-level factors were evaluated for potential associations with regional low-allergy formula prescription rates using multivariate linear regression. Analysis of national prescribing trends covered 2007-2023, analysis of regional variation and region-level factors examined 2017-2019, prior to a re-organisation of the regional healthcare structure in England. RESULTS:Low-allergy formula prescribing increased from 6.1 to 23.3 L per birth nationally, between 2007 and 2023. Regional prescribing rate varied from 0.8 to 47.6 L per birth in 2017-2019. We found significant associations between regional low-allergy formula prescribing rate and regional prescribing rates for milk feed thickeners Gaviscon Infant and Carobel Instant (β = 0.10, p < 0.01), and for other anti-reflux medications used in young children (β = 0.89 p < 0.01). Inconsistent associations were seen with prescribing junior adrenaline auto-injectors and oral antibiotics. A model including these four variables accounted for 37% of regional variation in low-allergy formula prescribing rate. Region-level socio-economic deprivation, CMA guideline recommendations and paediatric allergy service provision were not associated with low-allergy formula prescribing. CONCLUSIONS:Low-allergy formula prescribing in England is increasing, varies significantly by region and is consistently associated with prescribing rates for milk feed thickeners and other anti-reflux medication for young children. Community prescribing behaviours may be important determinants of CMA overdiagnosis.

Background: The use of allergy tests to guide dietary exclusions for disease control in children with atopic dermatitis (AD) is controversial. We undertook a consensus exercise on how to interpret skin prick test (SPT) results and dietary history for cow’s milk, hen’s egg, wheat and soya in children <2 years old with AD. Methods: Fourteen clinicians from general practice, paediatrics, paediatric dermatology, paediatric allergy and paediatric dietetics from UK and Ireland took part in an online modified Delphi study. Over three rounds, participants gave their anonymous opinions and received individualised and group feedback. The findings were discussed in an online workshop. Results: Of 14 symptoms, 12 were identified as relevant to immediate and 7 to delayed allergy. Regarding SPTs, there was consensus over which allergens to use for wheat and soya but not cow’s milk or hen’s egg; for all study foods, wheal size was determined as 0-1 mm negative, ≥5mm sensitised , but between 2-4 mm categorisation varied by food. During the final workshop, consensus was reached on dietary advice should be given according to SPT results and dietary history. Conclusion: We attained consensus on how SPTs combined with dietary history for four common food allergens should be interpreted in young children under two years of age with AD. These pragmatic recommendations may support clinician education, consistency of decision-making and future research.

BACKGROUND:Cow's milk allergy (CMA) overdiagnosis in young children appears to be increasing and has not been well characterised. We used a clinical trial population to characterise CMA overdiagnosis and identify individual-level and primary care practice-level risk factors. METHODS:We analysed data from 1394 children born in England in 2014-2016 (BEEP trial, ISRCTN21528841). Participants underwent formal CMA diagnosis at ≤2 years. CMA overdiagnosis was defined in three separate ways: parent-reported milk reaction; primary care record of milk hypersensitivity symptoms; and primary care record of low-allergy formula prescription. RESULTS:CMA was formally diagnosed in 19 (1.4%) participants. CMA overdiagnosis was common: 16.1% had parent-reported cow's milk hypersensitivity, 11.3% primary care recorded milk hypersensitivity and 8.7% had low-allergy formula prescription. Symptoms attributed to cow's milk hypersensitivity in participants without CMA were commonly gastrointestinal and reported from a median age of 49 days. Low-allergy formula prescriptions in participants without CMA lasted a median of 10 months (interquartile range 1, 16); the estimated volume consumed was a median of 272 litres (26, 448). Risk factors for CMA overdiagnosis were high practice-based low-allergy formula prescribing in the previous year and maternal report of antibiotic prescription during pregnancy. Exclusive formula feeding from birth was associated with increased low-allergy formula prescription. There was no evidence that practice prescribing of paediatric adrenaline auto-injectors or anti-reflux medications, or maternal features such as anxiety, age, parity and socioeconomic status were associated with CMA overdiagnosis. CONCLUSION:CMA overdiagnosis is common in early infancy. Risk factors include high primary care practice-based low-allergy formula prescribing and maternal report of antibiotic prescription during pregnancy.

Background Atopic eczema is a common childhood skin problem linked with asthma, food allergy and allergic rhinitis that impairs quality of life. Objectives To determine whether advising parents to apply daily emollients in the first year can prevent eczema and/or other atopic diseases in high-risk children. Design A United Kingdom, multicentre, pragmatic, two-arm, parallel-group randomised controlled prevention trial with follow-up to 5 years. Setting Twelve secondary and four primary care centres. Participants Healthy infants (at least 37 weeks’ gestation) at high risk of developing eczema, screened and consented during the third trimester or post delivery. Interventions Infants were randomised (1 : 1) within 21 days of birth to apply emollient (Doublebase Gel®; Dermal Laboratories Ltd, Hitchin, UK or Diprobase Cream®) daily to the whole body (excluding scalp) for the first year, plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). Families were not blinded to allocation. Main outcome measures Primary outcome was eczema diagnosis in the last year at age 2 years, as defined by the UK Working Party refinement of the Hanifin and Rajka diagnostic criteria, assessed by research nurses blinded to allocation. Secondary outcomes up to age 2 years included other eczema definitions, time to onset and severity of eczema, allergic rhinitis, wheezing, allergic sensitisation, food allergy, safety (skin infections and slippages) and cost-effectiveness. Results One thousand three hundred and ninety-four newborns were randomised between November 2014 and November 2016; 693 emollient and 701 control. Adherence in the emollient group was 88% (466/532), 82% (427/519) and 74% (375/506) at 3, 6 and 12 months. At 2 years, eczema was present in 139/598 (23%) in the emollient group and 150/612 (25%) in controls (adjusted relative risk 0.95, 95% confidence interval 0.78 to 1.16; p = 0.61 and adjusted risk difference −1.2%, 95% confidence interval −5.9% to 3.6%). Other eczema definitions supported the primary analysis. Food allergy (milk, egg, peanut) was present in 41/547 (7.5%) in the emollient group versus 29/568 (5.1%) in controls (adjusted relative risk 1.47, 95% confidence interval 0.93 to 2.33). Mean number of skin infections per child in the first year was 0.23 (standard deviation 0.68) in the emollient group versus 0.15 (standard deviation 0.46) in controls; adjusted incidence rate ratio 1.55, 95% confidence interval 1.15 to 2.09. The adjusted incremental cost per percentage decrease in risk of eczema at 2 years was £5337 (£7281 unadjusted). No difference between the groups in eczema or other atopic diseases was observed during follow-up to age 5 years via parental questionnaires. Limitations Two emollient types were used which could have had different effects. The median time for starting emollients was 11 days after birth. Some contamination occurred in the control group (< 20%). Participating families were unblinded and reported on some outcomes. Conclusions We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children. Emollient use was associated with a higher risk of skin infections and a possible increase in food allergy. Emollient use is unlikely to be considered cost-effective in this context. Future research To pool similar studies in an individual patient data meta-analysis. Trial registration This trial is registered as ISRCTN21528841. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/67/12) and is published in full in Health Technology Assessment ; Vol. 28, No. 29. See the NIHR Funding and Awards website for further award information.

India is a low-middle income country with a population of 1.4 billion and home to one quarter of the world's children. Exclusive breastfeeding until 6 months and continued breastfeeding until at least 2 years as per global recommendations are common practice. The Indian government and associated organisations have strived to protect breastfeeding, which is important in a country with high under-5 mortality, malnutrition and stunting. Allergic disease is under-recognised in India, but despite the absence of a dedicated allergy medical specialty, awareness of allergy is increasing among healthcare practitioners and in the general population. In high-income countries, overdiagnosis of allergy has become recognised as an issue in recent years. Allergy healthcare professionals have also attracted criticism for close relationships with the formula industry, which appear to have contributed to excessive use of specialised formula products and undermining of breastfeeding. Specialised formula has been used unnecessarily for preventing allergy, based on fraudulent and selectively reported science; and for managing normal infant symptoms which are mislabelled as milk allergy. This forms part of a broader formula industry corporate strategy to widen the boundaries of illness in order to expand sales and markets. In India, allergic disease management is hindered by limited understanding of the disease entity among practitioners, low access to diagnostics, limited healthcare resources, high exposure to air pollution and a large, diverse population. Data specific to India on allergic disease prevalence and interpreting allergy diagnostics are incomplete. The knowledge gaps mean allergy management in India is often extrapolated from guidance developed in high-income countries with low breastfeeding rates. As the allergy specialty develops in India, local guidance and practice will need to recognise the threat that current allergy practice poses to India's normative infant feeding culture, and ensure that breastfeeding continues to be supported at all levels.

BACKGROUND:Excessive use of specialized formula for cow's milk allergy was reported in England, but complete analysis has not been undertaken and trends in other countries are unknown. Some specialized formula products, especially amino-acid formula (AAF), have high free sugars content. We evaluated specialized formula trends in countries with public databases documenting national prescription rates.METHODS:Cross-sectional analysis of national prescription databases in the United Kingdom, Norway and Australia. Outcomes were volume and cost of specialized formula, and proportion of infants prescribed specialized formula. Expected volumes assumed 1% cow's milk allergy incidence and similar formula feeding rates between infants with and without milk allergy.RESULTS:Prescribed volumes of specialized formula for infants rose 2.8-fold in England from 2007 to 2018, with similar trends in other regions of the United Kingdom. Volumes rose 2.2-fold in Norway from 2009 to 2020 and 3.2-fold in Australia from 2001 to 2012. In 2020, total volumes were 9.7- to 12.6-fold greater than expected in England, 8.3- to 15.6-fold greater than expected in Norway and 3.3- to 4.5-fold greater than expected in Australia, where prescribing restrictions were introduced in 2012. In Norway, the proportion of infants prescribed specialized formula increased from 2.2% in 2009 to 6.9% in 2020, or 11.2- to 13.3-fold greater than expected. In 2020, specialized formula for infants cost US$117 (103 euro) per birth in England, US$93 (82 euro) in Norway and US$27 (23 euro) in Australia. Soya formula prescriptions exceeded expected volumes 5.5- to 6.4-fold in England in 1994 and subsequently declined, co-incident with public health concerns regarding soya formula safety. In 2020, 30%-50% of prescribed specialized formula across the three countries was AAF.CONCLUSIONS:In England, Norway and Australia, specialized formula prescriptions increased in the early 21st century and exceeded expected levels. Unnecessary specialized formula use may make a significant contribution to free sugars consumption in young children.

Clinical & Experimental AllergyVolume 52, Issue 1 p. 29-32 CLINICAL QUESTIONFree Access Dietary management of breastfed children with food allergy Hilary Allen, Hilary Allen National Heart and Lung Institute, Imperial College London, London, UKSearch for more papers by this authorRobert J. Boyle, Corresponding Author Robert J. Boyle r.boyle@imperial.ac.uk orcid.org/0000-0002-4913-7580 National Heart and Lung Institute, Imperial College London, London, UK Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK Correspondence Robert J. Boyle, National Heart and Lung Institute, Imperial College London, Norfolk Place, Wright Fleming Building, London W2 1PG, England. Email: r.boyle@imperial.ac.ukSearch for more papers by this author Hilary Allen, Hilary Allen National Heart and Lung Institute, Imperial College London, London, UKSearch for more papers by this authorRobert J. Boyle, Corresponding Author Robert J. Boyle r.boyle@imperial.ac.uk orcid.org/0000-0002-4913-7580 National Heart and Lung Institute, Imperial College London, London, UK Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK Correspondence Robert J. Boyle, National Heart and Lung Institute, Imperial College London, Norfolk Place, Wright Fleming Building, London W2 1PG, England. Email: r.boyle@imperial.ac.ukSearch for more papers by this author First published: 03 January 2022 https://doi.org/10.1111/cea.14073AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Key Messages Breastfeeding women's diet can influence their child, usually through non-allergic mechanisms such as flavour sensing. Children with food allergies do not usually react to maternal allergen ingestion during breastfeeding. When healthcare practitioners advise maternal dietary restriction, this can harm mother and undermine breastfeeding. 1 INTRODUCTION Scientific publications from the early 20th century onwards have reported maternal ingestion of specific foods triggering acute allergic reactions such as rashes and vomiting in breastfed, food allergic infants.1 Early reports focussed on vegetables, milk, egg, codfish and chocolate; and while opinions varied at the time, these particular foods were thought to trigger allergies.1 In some cases, vegetables and fish were also considered to cause non-allergic symptoms in the infant through breastmilk.1 The role of maternal dietary restriction in managing food allergy continues to be the subject of debate in the 21st century. In this Clinical Question article, we will discuss the evidence for maternal dietary proteins triggering allergic reactions in breastfed, food allergic children and suggest an approach for the practical management of these children, taking account of the potential risks and benefits of maternal exclusion diets. Case history: A 6-month-old, breastfed child with mild eczema has an acute reaction to her first direct exposure to cow's milk and a strongly positive skin prick test to commercial milk extract. Should mother be advised to exclude milk from her diet? In order to address this question, we need to understand first whether maternal dietary restriction is likely to be effective, that is, whether maternal food allergen ingestion is likely to trigger symptoms in this child with probable cow's milk allergy. Second, we need to understand whether advice by healthcare practitioners to restrict the maternal diet is likely to be safe. 2 CAN MATERNAL FOOD ALLERGEN INGESTION TRIGGER ACUTE OR CHRONIC SYMPTOMS IN BREASTFED CHILDREN WITH FOOD ALLERGIES? In clinical practice, lactating mothers commonly report observations of a relationship between their own ingestion of specific foods and symptoms of crying, gastrointestinal disturbance or eczema in their child. For healthcare practitioners, differentiating between a causal association and normal infant behaviour in a breastfed child with food allergies poses a diagnostic challenge.2 Controlled studies have suggested that infants do have behavioural responses to specific maternal dietary exposures through flavour sensing.3 A number of case reports and case series document acute or delayed reactions to breastmilk in food allergic infants, but blinded challenge studies suggest that the prevalence of such reactions associated with documented allergy to a relevant food in mother's diet is low.4 Mechanistic studies show that food allergens ingested by lactating women often become detectable in breastmilk.2 However, detectable food allergen levels in breastmilk are in the range of nanograms per ml, meaning that infant ingestion of typical threshold doses for triggering acute reactions is almost impossible.2 This leaves some uncertainty about whether maternal dietary restriction should be advised for preventing food allergic children from reacting to maternal dietary exposures. Acute or delayed allergic reactions in an exclusively breastfed infant are rare, and although proctocolitis can occur in breastfed infants, this is not always caused by a specific, identifiable food allergy.4 Similarly, the evidence that eczema can be managed via maternal dietary restriction is not strong.5 One of the few double-blind clinical trials in this field evaluated 37 infants, and an improvement in eczema was identified in 6 infants when mothers excluded egg and cow's milk, which relapsed on re-introduction, while dietary manipulation was not helpful for most participants.6 Studies in this field have often failed to identify a significant association between specific food allergy in the child and apparent response to maternal exclusion of the same food. So, the evidence for advising maternal dietary restriction when their child has a diagnosed food allergy is low-level evidence, relying largely on case reports and small case series.4 3 CAN HEALTHCARE PRACTITIONERS SAFELY ADVISE MATERNAL DIETARY EXCLUSION OF FOOD ALLERGENS WHEN A CHILD IS DIAGNOSED WITH FOOD ALLERGY? Guidelines widely recommend this practice, but the advice is controversial, with some reporting that maternal dietary restrictions can undermine breastfeeding.2, 7 In the absence of stronger evidence, healthcare practitioners need to carefully consider the risks and benefits of advising maternal dietary restrictions (Figure 1). FIGURE 1Open in figure viewerPowerPoint Potential benefits and harms of healthcare professional advice for a woman breastfeeding a food allergic children to restrict her diet Possible reasons to advise dietary exclusions include safeguarding against accidental, direct exposure of the child to the food allergen when the mother or family members continue to consume the food. Anecdotal evidence suggests benefit of maternal dietary restriction for some children with chronic symptoms associated with food allergy, such as eczema.4 Eczema is the most burdensome skin condition worldwide, with a high prevalence during the first 2 years of life8 and limited non-pharmacological options for management. Some families may feel that maternal dietary restriction is safer than using medical products such as skin creams, wash products and topical anti-inflammatories. Offering a solution by restricting the maternal diet may empower families, giving them a sense of control and potentially increasing confidence that they can safely breastfeed their child. However, exclusion diets can be difficult to adhere to, symptoms may persist leading to ever more restrictive diets and families advised to use maternal dietary exclusion may suffer adverse nutritional, emotional and economic outcomes. Women using dietary exclusions to manage food allergy in their child were reported in one study to have increased depression and anxiety symptoms, and over three-quarters of mothers reported weight loss and two-thirds a reduction in breastmilk supply.9 Larger and more representative studies are needed to better understand the impact of dietary exclusions on breastfeeding women; however, these preliminary findings of adverse effects are supported by anecdotal reports of such diets undermining confidence in breastfeeding.7 4 PROPOSAL FOR AN APPROACH WHICH MINIMIZES RISK OF HARMING MOTHER AND CHILD WHILE SUPPORTING MATERNAL AUTONOMY IN DECISION-MAKING The potential harms of advising maternal dietary restriction are magnified when the child's diagnosis of food allergy is uncertain. Maternal dietary restrictions may also be used to manage symptoms which are not food allergy, although the science underpinning this practice is largely derived from case reports and case series. A possible solution to minimize the risks in this area is to view the role of the healthcare practitioner as one of offering support to mothers who notice an issue in their child, ensuring that any elimination diet is done safely, minimizing risk of harming both mother and child and ensuring maternal autonomy in decision-making (Figure 2). The risks of environmental or accidental exposure to the child when family members continue eating the food allergen should be discussed, facilitating a risk assessment and helping family members to make an informed decision on the best approach for their personal circumstances, particularly when there may be other children in the household who would benefit from eating the relevant food allergen. Supporting, rather than actively advising, maternal dietary exclusion may be a more appropriate approach unless there is objective evidence that a child reacts to maternally ingested allergens, as described in previous case reports and series.4 FIGURE 2Open in figure viewerPowerPoint Proposed approach for safely supporting women breastfeeding a food allergic child Case Resolution: The healthcare practitioner should be careful not to promote maternal dietary restriction as a solution to this child's eczema, if mother has not already noticed a relationship between her diet and her child's eczema. However, if mother has noticed a clear relationship between her own dietary intake and her child's eczema and wishes to restrict her diet, the healthcare practitioner's role is to support her and minimize the risk of adverse nutritional consequences for her or her child. 5 CONCLUSION Breastfed children respond to maternal dietary intake of specific foods, but most of this is not allergy. Studies suggest that reproducible allergic reactions to food antigens in breastmilk are rare, and the evidence that maternal dietary restrictions benefit associated symptoms such as eczema is weak. We therefore suggest that the best person to decide on dietary elimination is the mother herself based on her knowledge and observations of her child, and the role of healthcare practitioners is to support women's decisions. When healthcare practitioners promote the concept that maternal dietary restrictions are an important part of food allergy management, this risks causing harmful adverse effects without benefitting the allergic child. REFERENCES 1Shannon WR. Demonstration of food proteins in human breast milk by anaphylactic experiments on guinea-pigs: their probable relationship to certain diseases of the nursing infant. A preliminary report. JAMA Pediatr. 1921; 22(3): 223- 231. CASGoogle Scholar 2Munblit D, Perkin MR, Palmer DJ, Allen KJ, Boyle RJ. Assessment of evidence about common infant symptoms and cow's milk allergy. JAMA Pediatr. 2020; 174(6): 599. CrossrefPubMedWeb of Science®Google Scholar 3Mennella Julie A., Beauchamp Gary K. The transfer of alcohol to human milk. N Engl J Med. 1991; 325(14): 981- 985. doi:10.1056/nejm199110033251401CrossrefCASPubMedWeb of Science®Google Scholar 4Rajani PS, Martin H, Groetch M, Järvinen KM. Presentation and management of food allergy in breastfed infants and risks of maternal elimination diets. J Allergy Clin Immunol Pract. 2020; 8(1): 52- 67. CrossrefPubMedWeb of Science®Google Scholar 5Roberts K, Gilbertson A, Dawson S, Turner N, Ridd MJ. Test-guided dietary exclusions for treating established Atopic Dermatitis in children: A Systematic Review. Clin Exp Allergy. 2021. doi:10.1111/cea.14072Wiley Online LibraryWeb of Science®Google Scholar 6Cant AJ, Bailes JA, Marsden RA, Hewitt D. Effect of maternal dietary exclusion on breast fed infants with eczema: two controlled studies. BMJ. 1986; 293(6541): 231- 233. CrossrefCASPubMedGoogle Scholar 7van Tulleken C. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers. BMJ. 2018; 363: k5056. CrossrefGoogle Scholar 8de Lusignan S, Alexander H, Broderick C, et al. The epidemiology of eczema in children and adults in England: a population-based study using primary care data. Clin Exp Allergy. 2021; 51(3): 471- 482. Wiley Online LibraryPubMedWeb of Science®Google Scholar 9Yilmaz O, Kacar AS, Gogebakan E, et al. The relationship between dietary elimination and maternal psychopathology in breastfeeding mothers of infants with food allergy. Pediatr Allergy Immunol. 2021. doi:10.1111/pai.13670PubMedWeb of Science®Google Scholar Volume52, Issue1January 2022Pages 29-32 FiguresReferencesRelatedInformation

BACKGROUND:The effectiveness of emollients for preventing atopic dermatitis/eczema is controversial. The Barrier Enhancement for Eczema Prevention trial evaluated the effects of daily emollients during the first year of life on atopic dermatitis and atopic conditions to age 5 years.METHODS:1394 term infants with a family history of atopic disease were randomized (1:1) to daily emollient plus standard skin-care advice (693 emollient group) or standard skin-care advice alone (701 controls). Long-term follow-up at ages 3, 4 and 5 years was via parental questionnaires. Main outcomes were parental report of a clinical diagnosis of atopic dermatitis and food allergy.RESULTS:Parents reported more frequent moisturizer application in the emollient group through to 5 years. A clinical diagnosis of atopic dermatitis between 12 and 60 months was reported for 188/608 (31%) in the emollient group and 178/631 (28%) in the control group (adjusted relative risk 1.10, 95% confidence interval 0.93 to 1.30). Although more parents in the emollient group reported food reactions in the previous year at 3 and 4 years, cumulative incidence of doctor-diagnosed food allergy by 5 years was similar between groups (92/609 [15%] emollients and 87/632 [14%] controls, adjusted relative risk 1.11, 95% confidence interval 0.84 to 1.45). Findings were similar for cumulative incidence of asthma and hay fever.CONCLUSIONS:Daily emollient application during the first year of life does not prevent atopic dermatitis, food allergy, asthma or hay fever.

BACKGROUND:There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy. METHODS:Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback. FINDINGS:Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula. INTERPRETATION:These new milk allergy recommendations from non-conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines.

Clinical & Experimental AllergyVolume 51, Issue 3 p. 495-498 RESEARCH LETTER A cost-analysis of outpatient paediatric penicillin allergy de-labelling using telemedicine Hilary I Allen, Corresponding Author hilary.allen@nuigalway.ie orcid.org/0000-0002-7013-0308 Department of Paediatrics, University Hospital Galway, Galway, Ireland School of Medicine, National University of Ireland, Galway, Ireland Correspondence Hilary I Allen, Department of Paediatrics, University Hospital Galway, Galway, Ireland. Email: hilary.allen@nuigalway.ieSearch for more papers by this authorPaddy Gillespie, School of Business and Economics, National University of Ireland, Galway, IrelandSearch for more papers by this authorMarta Vazquez-Ortiz, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, UKSearch for more papers by this authorAndrew W Murphy, Department of General Practice &, HRB Clinical Trial Network Primary Care Ireland, National University of Ireland, Galway, IrelandSearch for more papers by this authorEdina M Moylett, Department of Paediatrics, University Hospital Galway, Galway, Ireland Department of Paediatrics, National University of Ireland, Galway, IrelandSearch for more papers by this author Hilary I Allen, Corresponding Author hilary.allen@nuigalway.ie orcid.org/0000-0002-7013-0308 Department of Paediatrics, University Hospital Galway, Galway, Ireland School of Medicine, National University of Ireland, Galway, Ireland Correspondence Hilary I Allen, Department of Paediatrics, University Hospital Galway, Galway, Ireland. Email: hilary.allen@nuigalway.ieSearch for more papers by this authorPaddy Gillespie, School of Business and Economics, National University of Ireland, Galway, IrelandSearch for more papers by this authorMarta Vazquez-Ortiz, Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, UKSearch for more papers by this authorAndrew W Murphy, Department of General Practice &, HRB Clinical Trial Network Primary Care Ireland, National University of Ireland, Galway, IrelandSearch for more papers by this authorEdina M Moylett, Department of Paediatrics, University Hospital Galway, Galway, Ireland Department of Paediatrics, National University of Ireland, Galway, IrelandSearch for more papers by this author First published: 10 November 2020 https://doi.org/10.1111/cea.13782 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Volume51, Issue3March 2021Pages 495-498 RelatedInformation

Up to 5% of children are inappropriately labeled “penicillin-allergic,” commonly in the context of a viral rash, leading to the use of alternative antibiotics and poorer health outcomes.1 Investigating these mostly “low probability” patients poses a significant burden on allergy services.

Background and aims Up to 5% of children report a reaction to a beta-lactam antibiotic. This is commonly a rash which occurs in the setting of a viral illness. These children are often labelled with a drug allergy. Previous studies on drug allergy in children have involved skin prick testing, intradermal testing and graded dose challenges in the hospital setting. This study was conducted to explore the diagnosis of drug allergy in a selected low-risk cohort of ‘beta-lactam allergy labelled’ children, using risk stratified, single dose, oral beta-lactam challenges, potentially reproducible in primary care. Methods Children aged 1–16 yrs. old from primary, secondary and tertiary care in the Connacht area were invited; recruitment is ongoing; a target of 100 patients has been set. Participants are screened via a detailed telephone consultation using a non-standardised questionnaire to ensure they meet the inclusion criteria: single, non-immediate (>1 hour) skin rash or other symptoms compatible with an allergic reaction after beta-lactam including urticaria or angioedema occurring > 1 hour and persisting > 12 hours. Exclusion criteria are: immediate allergic reaction < 1 hour; or > 1 hour but resolving within 12 hours; cardiorespiratory involvement; multiple antibiotic allergy, atypical/severe drug reaction or IV beta-lactams and insufficiently controlled asthma. Eligible candidates attend an outpatient visit, are confirmed as clinically well, including pre-challenge temperature and cardio-respiratory exam. A single, age-appropriate dose of the causative beta-lactam is administered. Visual assessment is performed every 30 minutes for 2 hours; adverse events recorded and managed accordingly. A 5-day beta-lactam course is prescribed to negative challenge participants. Delayed hypersensitivity and parental satisfaction is assessed via follow up phone-call 6 days post-challenge. Study approval by the hospital clinical research ethics committee was obtained. Results To date, 76 children (16 months to 15 years) have been enrolled; 59 have undergone pre-challenge screening; with skin rash being the main indication (53/59, 90%). Six/seventy-six (8%) were excluded, one withdrew; 17 children are from secondary care, 55 from primary care, 4 self-referrals. Twenty-five children have completed the challenge (24 amoxicillin, 1 flucloxacillin) with no reactions. Parents reported high satisfaction with the challenge process and confidence in using a beta-lactam antibiotic in the future. Conclusion This study demonstrates that performing a streamlined, single dose, oral challenge to low risk patients in an outpatient setting is feasible, safe and acceptable to participants. This method may be reproducible in primary care.