Background: Allergen avoidance is important in allergic asthma management. Nocturnal treatment with Temperature-controlled Laminar Airflow (TLA; Airsonett (R)) has been shown to provide significant reduction of exposure to allergens in the breathing zone, leading to long-term reduction in airway inflammation and improvement in quality of life. Allergic asthma patients uncontrolled on GINA step 4 were found to benefit the most. A frequently asked question from clinicians and funders is related to time to onset (TTO) of improvements for patients using TLA. Methods: Asthma Quality of Life Questionnaire (AQLQ) scores were collected in a previous study. TTO of improvements in Quality of Life was analysed for difference (TLA-placebo) in Area-under-Curve using backwards deletion from 12, 9, 6, 3 down to 1 month for the AQLQ total score, the four individual domains and specifically the sleep question. Results: Patients with uncontrolled asthma on GINA step 4 (n=87)) reported a statistically significant and clinically relevant (>= 0.5 point) improvement in total AQLQ score (0.57; p=0.009) after 3 months treatment for TLA over placebo. The shortest TTO was within 1 month for the environmental domain (0.68; p=0.016) and the sleep question (0.771; p=0.037). TTO for the emotional and symptom domains was 3 months (0.66; p=0.020 and 0.64; p=0.014 respectively) and for the activity domain 6 months (0.47; p=0.036). Conclusion: Nocturnal avoidance of allergens using TLA provided a statistically significant and clinically relevant improvement in total AQLQ score within 3 months in patients in the GINA 4 + ACT< 18 group. Questions related to sleep quality may provide the first signal of response already within a month after commencing treatment.

BACKGROUND:Obstructive respiratory disorders, such as allergic rhinitis and asthma may impair sleep quality. The aim of this study is to validate the Children's Sleep Habits Questionnaire (CSHQ) for Greek children from 6 to 14 years of age. No validated tool has been developed so far to assess sleep disturbances in Greek school-aged children. METHODS:We examined the reliability and validity of the CSHQ in a sample of children with allergic rhinitis (AR) and a non-clinical population of parents of these children as a proxy measure of children's AR quality of life (QoL) as evaluated by the Pediatric Allergic Rhinitis Quality of Life (PedARQoL) questionnaire. RESULTS:The CSHQ questionnaire Child's Form (CF) had a moderate internal consistency with a Cronbach's alpha 0.671 and Guttman split-half coefficient of 0.563 when correlated with the PedARQoL (CF). There was also a moderate intraclass correlation of ICC=0.505 between the responses to both questionnaires in the two visits. The CSHQ Parent's Form (PF) had a very good internal consistency with a Cronbach's alpha of 0.928 and Guttman split-half coefficient of 0.798. There was a high intraclass correlation of 0.643 between the responses in the two visits. CONCLUSIONS:The Greek version of the CSHQ CF, but particularly the PF has proved to be a very reliable clinical instrument, which can be used in clinical trials for assessing sleep quality in school-aged children with sleep disturbances because of obstructive airway disorders, such as AR.

Summary We describe a novel method of sampling the esophageal lining fluid in children and show that levels of eotaxin-1 and MCP-4 differentiate those children with a histological diagnosis of EoE from those without. This article is protected by copyright. All rights reserved.

BACKGROUND:Mothers of children with food allergy have increased anxiety, which may be influenced by healthcare professionals' communication of risk.OBJECTIVE:To evaluate a brief psychological intervention for reducing anxiety in mothers of children with food allergy.METHODS:Two hundred mothers of children with food allergy were recruited from allergy clinics. A computer-generated randomization list was used to allocate participants to a single-session cognitive behavioural therapy intervention including a risk communication module, or standard care. Anxiety and risk perception were assessed at 6 weeks and 1 year. Primary outcome was state anxiety at 6 weeks. Secondary outcomes included state anxiety at 1 year, risk perception at 6 weeks and 1 year, and salivary cortisol response to a simulated anaphylaxis scenario at 1 year.RESULTS:We found no significant difference in the primary outcome state anxiety at 6 weeks, with mean 31.9 (SD 10.2) intervention, 34.0 (10.2) control; mean difference 2.1 (95% CI -0.9, 5.0; P=.17). There was significantly reduced state anxiety at 6 weeks in the intervention group, in the subgroup of participants with moderate/high anxiety at enrolment (103/200, 52%), with mean 33.0 (SD 9.3) intervention, 37.8 (SD 10.0) control; mean difference 4.8 (95% CI 0.9, 8.7; P=.016; Cohen's d effect size 0.50). The psychological intervention also reduced risk perception and salivary cortisol response (P=.032; effect size 0.36).CONCLUSION:We found evidence that a brief psychological intervention which incorporates accurate risk information may impact on anxiety, risk perception and physiological stress response in mothers of children with food allergy.

Objectives To develop and validate a new allergy-specific patient-reported experience measure (PREM) for children and their parents, and to collect feedback in an integrated care setting.Design Two allergy-specific PREMs were produced using focus groups, cognitive testing, two prospective validation studies (collaboration: Royal College of Paediatrics and Child Health, Picker Institute Europe, Imperial College/London): 'Your Allergy Care', for children aged 8-16 years; 'Your Child's Allergy Care', for parents of children aged 0-7 years.Setting Community event, primary/secondary/tertiary allergy care settings.Main outcome measures Performance of PREMs in validation study; reported experience of allergy care.Participants 687 children with allergic conditions and their parents/carers.Results In total, 687 questionnaires were completed; 503/687 (253 child; 250 parent) for the final survey. In both surveys, demographic variations were not associated with differences in results. Although 71% of patients reported one or more allergic conditions (food allergy/eczema/hay fever/asthma), 62% required multiple visits before receiving final diagnosis. Overall, patient experience was good for communication with patient/ parent, competence and confidence in ability, and 73% felt looked after 'very well' and 23% 'quite well'. Areas for improvement included communication with nurseries/schools, more information on side effects, allergic conditions and allergen/irritant avoidance. Allergy care in primary/emergency care settings was associated with higher problem-scores (worse experience) than in specialist clinics.Conclusions These new PREMs will allow allergy-specific patient experience reporting for children and parents and help identification of priority areas for improvement and commissioning of care. Efforts towards better allergy care provision must be targeted at primary and emergency care settings and underpinned by improving communication between healthcare providers and the community.

AimsTo assess the impact of a service improvement initiative implementing the RCPCH asthma and allergy care pathways in children by raising awareness, providing multidisciplinary education and improving access to accurate allergy diagnosis and treatment in primary care settings for children with asthma, rhinitis, eczema, food allergies and anaphylaxis.MethodsA project board was established engaging stakeholders to allow co-production of the service and monitoring of progress. A multi-disciplinary training programme provided multidisciplinary educational workshops, supported by the development of a website providing resources for professionals and the public on the recognition of and management of common allergic problems (www.itchysneezywheezy.co.uk). One hundred and fourteen clinics were delivered, comprising 79 consultant led primary care clinics in partnership with GP’s, Community paediatric dietician’s and Community Nurse Practitioner, 7 nurse led primary care clinics and 28 nurse led community clinics in partnership with health visitors. Outcome measures were diagnostic prevalence, unscheduled care (admissions and A&E attendance), patient experience using the Paediatric Allergy Patient Reported Experience Measure (PREM) and professional confidence.Results23 multidisciplinary educational workshops were delivered to 152 professional, which increased professional confidence measured by pre and post-training questionnaires (P <0.001). 412 patients were seen at a cost saving of £17 per patient compared to hospital outpatient attendance. There was a 13% reduction in A&E attendances and a 23% reduction in admission rate with asthma and allergic conditions, the largest change in asthma admissions. 98% of parents reported high or very high levels of satisfaction with the service.ConclusionDeveloping integrated primary care specialist allergy services and education, improves confidence in community and primary care professionals, allows acquisition of allergy expertise to be developed in out of hospital settings reduces admissions and accident and emergency department attendances, with consequent cost savings whilst, delivering high levels of patient satisfaction.

BACKGROUND:Prevention guidelines for infants at high risk of allergic disease recommend hydrolysed formula if formula is introduced before 6 months, but evidence is mixed. Adding specific oligosaccharides may improve outcomes.OBJECTIVE:To evaluate whether partially hydrolysed whey formula containing oligosaccharides (0.8 g/100 ml) (pHF-OS) can prevent eczema in high-risk infants [ISRCTN65195597].METHODS:We conducted a parallel-group, multicentre, randomized double-blind controlled trial of pHF-OS vs standard cow's milk formula. Infants with a family history of allergic disease were randomized (stratified by centre/maternal allergy) to active (n = 432) or control (n = 431) formula until 6 months of age if formula was introduced before 18 weeks. Primary outcome was cumulative incidence of eczema by 12 months in infants randomized at 0-4 weeks (375 pHF-OS, 383 control). Secondary outcomes were cumulative incidence of eczema by 12 or 18 months in all infants randomized, immune markers at 6 months and adverse events.RESULTS:Eczema occurred by 12 months in 84/293 (28.7%) infants allocated to pHF-OS at 0-4 weeks of age, vs 93/324 (28.7%) control (OR 0.98 95% CI 0.68, 1.40; P = 0.90), and 107/347 (30.8%) pHF-OS vs 112/370 (30.3%) control in all infants randomized (OR 0.99 95% CI 0.71, 1.37; P = 0.94). pHF-OS did not change most immune markers including total/specific IgE; however, pHF-OS reduced cow's milk-specific IgG1 (P < 0.0001) and increased regulatory T-cell and plasmacytoid dendritic cell percentages. There was no group difference in adverse events.CONCLUSION:pHF-OS does not prevent eczema in the first year in high-risk infants. The immunological changes found require confirmation in a separate cohort.

Aims Sickle cell disease (SCD) is a chronic multisystem disorder resulting in debility, organ damage, frequent hospitalisations and reduction in lifespan; affecting over 10,000 people in the UK. Since the care experience of people living with SCD in the UK is not known, this research aimed to develop a series of tools to facilitate this understanding. Methods We undertook focus group discussions to identify areas of concern in care experience in people living with SCD. This informed the development of three Patient Reported Experience Measure questionnaires, with 33–38 questions each, aimed at (a) children aged 8–15, (b) parents and carers of children with SCD and (c) adults with SCD. A fully cognitively tested pilot questionnaire survey was instituted to validate the questionnaires and gather patient and carer perspectives. Between March and October 2015 we undertook fieldwork to obtain responses from each survey group, with an aim to obtain at least 200 responses from each group. Results Key areas highlighted at the initial focus group discussions were: access to good quality primary care, A&E and psychology services; transition from paediatric to adult services and concerns regarding the physical, psychological, social and financial impact of the condition. We received a total of 736 questionnaire responses, with >200 responses from each group indicated above, with most responses from adolescents with SCD (or their parents) see Figure 1. Preliminary analysis indicated a widespread prevalence of negative thoughts and feelings when living with SCD, as indicated by >500 free text responses informing the word cloud in Figure 2. Only a third of all respondents received adequate information about treatment options and two-thirds indicated that staff in emergency departments were not fully knowledgeable in SCD. Staff delivering planned hospital care knew more about SCD than those delivering unplanned hospital care or primary care, see Figure 3. The survey validation demonstrated that the surveys functioned well and contributed to the measurement of patient experience, with little evidence of non-response and drop-out. Conclusion This is the first and the largest survey of care experience of SCD in the UK and will inform future delivery, design and commissioning of services for people with SCD.

There is conflicting evidence on the protective role of breastfeeding in relation to allergic sensitization and disease. The factors in breast milk which influence these processes are still unclear and under investigation. We know that colostrum and breast milk contain a variety of molecules which can influence immune responses in the gut-associated lymphoid tissue of a neonate. This review summarizes the evidence that variations in colostrum and breast milk composition can influence allergic outcomes in the infant, and the evidence that maternal and environmental factors can modify milk composition. Taken together, the data presented support the possibility that maternal dietary interventions may be an effective way to promote infant health through modification of breast milk composition.

Immunoglobulin A (IgA) is a predominant immunoglobulin present in human breast milk and is known to play an important role in infant gut immunity maturation. Breast milk composition varies between populations, but the environmental and maternal factors responsible for these variations are still unclear. We examined the relationship between different exposures and levels of IgA in colostrum. The objective of this study was to examine whether exposures analysed influence levels of IgA in colostrum. The present study used 294 colostrum samples from the MecMilk International cohort, collected from women residing in London, Moscow and Verona. Samples were analysed in automated Abbott Architect Analyser. We found an inverse correlation between time postpartum and colostrum total IgA level (r=−0.49, P<0.001). Adjusting for maternal parity, smoking, fresh fruit and fish consumption and allergen sensitization, multiple regression model showed that IgA levels were influenced by colostrum collection time (P<0.0001) and country of collection (P<0.01). Mode of delivery influence did not appear to be significant in univariate comparisons, once adjusted for the above maternal characteristics it showed a significant influence on total IgA (P=0.01). We conclude that the concentration of IgA in colostrum drops rapidly after birth and future studies should always consider this factor in analysis. IgA concentration varied significantly between countries, with the highest level detected in Moscow and lowest in Verona. Mode of delivery effect should be confirmed on larger cohorts. Further work is needed to determine ways to correct for IgA decline over time in colostrum, and to find the cause of variations in IgA levels between the countries.

Summary Peanut and tree nut allergies are the commonest cause of life‐threatening food‐allergic reactions and significantly affect quality of life in children and their families. Dietary nut avoidance and provision of emergency medication is currently the mainstay of treatment. Nut avoidance has consequences on both quality of life and nutrition. We review the terminology that may cause confusion and lead to unnecessary dietary restrictions. In peanut or tree nut‐allergic children, introduction of specific nuts to which the child is not allergic may improve quality of life and should be considered in patients with multiple foods allergies, vegan or ethnic‐specific diets, in whom nuts are an important source of protein. Nut‐allergic consumers do not just need to avoid foods containing nuts as an ingredient, but also contend with pre‐packed foods which frequently have precautionary allergen labelling ( PAL ) referring to possible nut contamination. Although the published rate of peanut contamination in ‘snack’ foods with PAL (see Box ) ranges from 0.9–32.4%, peanut contamination in non‐snack items with PAL is far less common. We propose that in some peanut‐allergic patients (depending on history of reactivity to trace levels of peanut, reaction severity, other medical conditions, willingness to always carry adrenaline, etc.), consideration may be given to allow the consumption of non‐snack foods containing PAL following discussion with the patient's (and their family's) specialist. More work is needed to provide consumers with clearer information on the risk of potential nut contamination in pre‐packed food. We also draw attention to the change in legislation in December 2014 that require mandatory disclosure of allergens in non‐pre‐packed foods.

BACKGROUND:Previous work has shown patients commonly misuse adrenaline autoinjectors (AAI). It is unclear whether this is due to inadequate training, or poor device design. We undertook a prospective randomized controlled trial to evaluate ability to administer adrenaline using different AAI devices.METHODS:We allocated mothers of food-allergic children prescribed an AAI for the first time to Anapen or EpiPen using a computer-generated randomization list, with optimal training according to manufacturer's instructions. After one year, participants were randomly allocated a new device (EpiPen, Anapen, new EpiPen, JEXT or Auvi-Q), without device-specific training. We assessed ability to deliver adrenaline using their AAI in a simulated anaphylaxis scenario six weeks and one year after initial training, and following device switch. Primary outcome was successful adrenaline administration at six weeks, assessed by an independent expert. Secondary outcomes were success at one year, success after switching device, and adverse events.RESULTS:We randomized 158 participants. At six weeks, 30 of 71 (42%) participants allocated to Anapen and 31 of 73 (43%) participants allocated to EpiPen were successful - RR 1.00 (95% CI 0.68-1.46). Success rates at one year were also similar, but digital injection was more common at one year with EpiPen (8/59, 14%) than Anapen (0/51, 0%, P = 0.007). When switched to a new device without specific training, success rates were higher with Auvi-Q (26/28, 93%) than other devices (39/80, 49%; P < 0.001).CONCLUSIONS:AAI device design is a major determinant of successful adrenaline administration. Success rates were low with several devices, but were high using the audio-prompt device Auvi-Q.

SummaryEosinophilic oesophagitis is an increasingly recognized allergic gastrointestinal disease, which is becoming more common. Although the average age at diagnosis is 30–50 years, it often affects very young children and carries significant long‐term morbidity. While our understanding of its pathophysiology is accumulating, the precise pathways by which the disease arises remain unclear. There are inconsistencies in its diagnosis and definition, and a drive towards international standardization is underway. Current methods for diagnosis and monitoring are relatively invasive, and controversies surround their interpretation. Management strategies are imperfect and involve burdensome long‐term dietary exclusions, or drug treatments with uncertain efficacy or serious side‐effects. It is the focus of a rapidly increasing body of research, the latest insights from which are systematically presented in this review.