Allergic diseases in children: A continuing challenge for the Allergist-Immunologist

Within the pages of this issue of the Proceedings, several articles delve into an eclectic array of topics surrounding allergic diseases in children, shedding light on the multifaceted challenges faced by the allergist/immunologist. As we navigate the intricate landscape of these allergic disorders, ranging from respiratory syncytial virus (RSV) and COVID-19 infection to the more common allergic manifestations of asthma, urticaria/atopic dermatitis, and food allergy, it becomes increasingly apparent that these conditions not only underscore the diverse manifestations of allergic diseases in children but also will continue to present an ongoing and dynamic challenge for the allergist/immunologist.

Two articles in this issue address viral respiratory illnesses associated with widespread morbidity in children. Ferrante et al.¹ report on the global health disparities in managing RSV infection in infants and children, and offer novel strategies for preventing bronchiolitis and postbronchiolitis recurrent wheezing in low- and middle-income countries. The authors conducted a systematic literature review across PubMed data bases of RSV infection and the socioeconomic impact of bronchiolitis and postbronchiolitic recurrent wheezing in low- and middle-income countries, and stress the importance of addressing linkages between malnutrition and disease susceptibility because of the known relationships between undernutrition and greater vulnerability to infectious diseases, including RSV infection.

In a separate infectious disease–related report, Rudsenske and Perkins² conducted a retrospective review of pediatric patients by using an anonymized data base that allows querying via the International Classification of Diseases, Tenth Revision codes from the University of Mississippi Medical Center's Research Data Warehouse. The authors identified 5261 patients with confirmed COVID-19 ages 0–21 and then divided this population into atopic and non-atopic cohorts. The authors found increased hospitalizations, length of stay, and intensive care in the atopic population, and similar outcomes in mortality and the development of multisystem inflammatory syndrome in children.

Moving next to chronic urticaria, Keller et al.³ performed a meta-analysis to clarify the prognostic role of evaluating total immunoglobulin E (IgE) levels in patients with chronic spontaneous urticaria as a predictive marker of therapeutic effectiveness to omalizumab. Based on analysis of the three studies that met study criteria, the authors report higher mean IgE values in responders than non-responders and propose considering baseline total IgE as a predictive therapeutic biomarker of omalizumab.

In transitioning to pediatric asthma, Navalpakam et al.⁴ sought to determine the impact of frequent systemic steroid bursts on the immune function of children with asthma living in the inner-city. Children ages 3–18 years and with asthma were divided into two study groups, group 1 (≥2 systemic steroid bursts/year) and group 2, a control group (0–1 systemic steroid bursts/year). The authors found that inner-city children with asthma who received frequent steroid bursts did not have a significantly different immune profile from those who did not. In recognizing the significance of these findings for pediatric patients with asthma, this paper was selected for this issue’s For the Patient section entitled ‘Impact of steroids on immune profiles of children with asthma living in the inner-city. This segment, found in the final pages of the print version of this issue and also available online, comprises a one-page article synopsis presented in an easily understandable format designed to assist patients in comprehending the content of the full article.

In continuing with the theme of pediatric asthma, Bernstein et al.⁵ sought to determine the sequential and chronological relationships between atopic dermatitis and asthma for children in an under-resourced community. Because atopic dermatitis is believed to lead to asthma development as part of the “atopic march,” the progression from atopic dermatitis to asthma in the under-resourced, urban community of Sun Valley, Colorado, was examined by assessing Medicaid data for the years 2016 to 2019 for a diagnosis of atopic dermatitis or asthma in children 6 and 7 years old. The authors report that correlations between atopic dermatitis and asthma diagnoses were significant only with respect to atopic dermatitis at age 6 years compared with asthma 1 year later at age 7 years.

In continuing with the theme of atopic dermatitis, Park et al.⁶ sought to assess factors influencing the quality of life (QoL) in children with atopic dermatitis in Korea. The authors report finding that children with poor QoL were more sensitized to inhalant allergens and had more exacerbating factors, which included inhalation allergen–related exacerbating factors, even after adjusting for age, total IgE, body mass index, and severity, and use of moisturizer. They found fair concordance between animal sensitization and an exacerbating factor, including dog and cat. This study showed that impaired QoL in children with atopic dermatitis is associated with inhalant allergen sensitization and inhalant allergen–related exacerbation factors. The authors suggest that inhalation-related exacerbation factors, including animal allergens, might be addressed to improve atopic dermatitis management in children.

In moving forward to food allergy, the next three papers address the topics of food allergens and oral immunotherapy (OIT). Among food allergens, lipid transfer proteins (LTP) are common in the Mediterranean region. Kazancioglu et al.⁷ aimed to investigate co-sensitization patterns and cluster relationships between LTP allergen molecules across a broad panel of allergen-specific sensitization patterns and clinical outcomes in eastern Mediterranean children. Among 496 children evaluated for multiple sensitizations, the authors report that 21% of children with multiple food and/or pollen sensitizations were found to have LTP sensitization and that almost half reported clinical reactivity. In addition, they found a correlation between clinical reactivity, LTP molecule positivity, and increasing age.

Because OIT can place psychological burdens on patients and their parents, stemming from the required preparations and the occurrence of repeated adverse reactions, Shin et al.⁸ investigated changes in QoL and psychological burden in parents of children receiving OIT for food allergy. Parents were asked to fill out the Korean versions of the Food Allergy Quality of Life–Parental Burden, the Food Allergy Quality of Life–Parental Form, the Beck Anxiety Inventory, and the Patient Health Questionnaire–9 for depression before initiating OIT, after 2 months of updosing, and after the end of the updosing phase. Their results suggest that OIT improves parental burden and QoL in parents of children with food allergy.

This issue’s Patient-Oriented Problem Solving (POPS) case presentation explores the evaluation and treatment of a 5-year-old boy who presents to an allergist after anaphylaxis to sunflower seed butter. The POPS case presentation is a recurring feature of the Proceedings written by an allergy/immunology fellow-in-training from one of the U.S. allergy/immunology training programs.^9–18 The POPS series aims to provide an innovative and practical learning experience for the allergist/immunologist in training by using a didactic format of clinical presentation and deductive reasoning. In this issue’s POPS, Baloh and Hsu¹⁹ from the Harvard Medical School and Brigham and Women’s Hospital (Boston, MA), lead the reader through this learning process, illustrating how established OIT protocols for peanut, milk, and egg can be extrapolated to other foods, including sunflower seed. In agreement with the report by Shin et al.,⁸ both the patient and his parents reported significantly decreased anxiety about sunflower cross-contamination.

In summary, the collection of articles found within the pages of this issue probes an array of topics surrounding allergic diseases in children that continue to challenge the allergist/immunologist and provide further insight into the intersecting crossroads of infection, inflammation, and allergic disease that afflict patients whom the allergist/immunologist serves. The articles exemplify how the complexities of allergic disease pathogenesis and development continue to challenge the allergist/immunologist. In keeping with the overall mission of the Proceedings, which is to distribute timely information with regard to advancements in the knowledge and practice of allergy, asthma, and immunology to clinicians entrusted with the care of patients, we hope that the articles found within this issue will continue to foster enhanced patient management and outcomes. On behalf of the Editorial Board, we hope that you are able to make practical use of the diverse literature offered in this issue of the Proceedings.