Publications by authors named "Elissa M Abrams"

100 Publications

School Attendance, Asthma Risk, and COVID-19 in Children.

J Allergy Clin Immunol Pract 2021 Mar 17. Epub 2021 Mar 17.

Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.

In the face of tremendous uncertainty during the current pandemic, there is a need for clear and consistent recommendations and an understanding of the evidence in general, and for families of children with allergic conditions. A common concern of parents of children with asthma is the risk that in-person learning poses during the pandemic. This Rostrum examines the actual risk of in-person learning among children with asthma during novel coronavirus disease 2019 (COVID-19), the discrepancy between perceived and actual risk, the contributing factors to this discrepancy, and possible solutions to narrow this divide. Overall, the evidence does not support that children with asthma are at an increased risk of COVID-19 morbidity or mortality compared with children without asthma. Asthma medications do not appear to contribute to incidence or severity of COVID-19 disease. However, there is a high perceived risk of in-person learning that is partially related to how it is portrayed in the media. There is little guidance regarding transitioning asthmatic children back to school and how to properly counsel on mediation of risk. There are differences regionally and locally around school reopening, exemptions, and their implementation. To narrow the divide between perceived and actual risk, clear consistent and ongoing communication will be necessary.
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http://dx.doi.org/10.1016/j.jaip.2021.03.006DOI Listing
March 2021

The Cost-Effectiveness of Preschool Peanut Oral Immunotherapy in the Real-World Setting.

J Allergy Clin Immunol Pract 2021 Mar 18. Epub 2021 Mar 18.

Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

Background: Across North America, 1.4% to 4.5% of children and families live with peanut allergy (PA). Preschool peanut oral immunotherapy (POIT) has been shown to be safe and effective in the real-world setting.

Objective: Evaluate the cost effectiveness of preschool POIT in North America.

Methods: Markov cohort analyses and microsimulation was used to evaluate simulated preschool children with PA over an 80-year time horizon. Models incorporated the natural history of PA, comparing children treated with preschool POIT with those not receiving immunotherapy. Costs were expressed in U.S. and Canadian dollars.

Results: A preschool POIT strategy was associated with cost savings while improving quality-adjusted life-years (QALY), dominating a nonimmunotherapy approach. Over the model horizon, when all costs (and effectiveness) of PA were included from a societal perspective, a POIT versus a non-POIT approach cost $82,514 (18.51 QALY) versus $84,367 (17.75 QALY) in the United States, and $40,111 (18.83 QALY) versus $53,848 (18.26 QALY) in Canada. In microsimulations, systemic reactions to POIT were less frequent than anaphylaxis from accidental exposure without POIT (United States: 3.59, SD 3.49 vs 19.53, SD 11.71; Canada: 3.63, SD 3.54 vs 4.56, SD 3.30), epinephrine use was reduced with POIT (United States: 5.85, SD 5.73 vs 9.76, SD 5.85; Canada: 0.34, SD 0.36 vs 0.53, SD 0.38), and fatalities were rare but lower in the POIT strategy (United States: 0.00005, SD 0.0071 vs 0.00015, SD 0.012; Canada: 0.00005, SD 0.0071 vs 0.00009, SD 0.0095).

Conclusions: Preschool POIT in a real-world setting improved health and economic outcomes in the United States and Canada.
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http://dx.doi.org/10.1016/j.jaip.2021.02.058DOI Listing
March 2021

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

J Allergy Clin Immunol Pract 2021 Mar 13. Epub 2021 Mar 13.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.
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http://dx.doi.org/10.1016/j.jaip.2021.02.055DOI Listing
March 2021

COVID-19 vaccine testing & administration guidance for allergists/immunologists from the Canadian Society of Allergy and Clinical Immunology (CSACI).

Allergy Asthma Clin Immunol 2021 Mar 15;17(1):29. Epub 2021 Mar 15.

Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MN, Canada.

Background: Safe and effective vaccines provide the first hope for mitigating the devastating health and economic impacts resulting from coronavirus disease 2019 (COVID-19) and related public health orders. Recent case reports of reactions to COVID-19 vaccines have raised questions about their safety for use in individuals with allergies and those who are immunocompromised. In this document, we aim to address these concerns and provide guidance for allergists/immunologists.

Methods: Scoping review of the literature regarding COVID-19 vaccination, adverse or allergic reactions, and immunocompromise from PubMed over the term of December 2020 to present date. We filtered our search with the terms "human" and "English" and limited the search to the relevant subject age range with the term "adult." Reports resulting from these searches and relevant references cited in those reports were reviewed and cited on the basis of their relevance.

Results: Assessment by an allergist is warranted in any individual with a suspected allergy to a COVID-19 vaccine or any of its components. Assessment by an allergist is NOT required for individuals with a history of unrelated allergies, including to allergies to foods, drugs, insect venom or environmental allergens. COVID-19 vaccines should be offered to immunocompromised patients if the benefit is deemed to outweigh any potential risks of vaccination.

Interpretation: This review provides the first Canadian guidance regarding assessment of an adolescent and adult with a suspected allergy to one of the COVID-19 vaccines currently available, or any of their known allergenic components, and for patients who are immunocompromised who require vaccination for COVID-19. As information is updated this guidance will be updated accordingly.
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http://dx.doi.org/10.1186/s13223-021-00529-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957441PMC
March 2021

Treatment of mild-to-moderate asthma in childhood and adolescence in 2021.

Lancet Respir Med 2021 Mar 12. Epub 2021 Mar 12.

Alder Hey Children's Hospital, Liverpool, UK; Division of Child Health, University of Liverpool, Liverpool, UK.

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http://dx.doi.org/10.1016/S2213-2600(21)00135-1DOI Listing
March 2021

A Cost-Effectiveness Evaluation of Hospitalizations, Fatalities, and Economic Outcomes Associated with Universal Versus Anaphylaxis Risk-Stratified COVID-19 Vaccination Strategies.

J Allergy Clin Immunol Pract 2021 Mar 9. Epub 2021 Mar 9.

Section of Allergy/Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

Background: Vaccine-associated anaphylaxis is a rare event (1.34 events/million doses; 0.00017% occurrence over 26 years). Several reports of allergic reactions concerning for anaphylaxis have been reported early into the Pfizer-BioNTech and Moderna coronavirus disease 2019 (COVID-19) vaccine campaign in the United States, Canada, and the United Kingdom.

Objective: To perform a cost-effectiveness analysis characterizing the risks of COVID-19 versus vaccine anaphylaxis, comparing universal COVID-19 vaccination versus risk-stratified vaccination approaches.

Methods: Cohort analysis models were created to evaluate the cost-effectiveness of universal vaccination versus risk-stratified vaccination (eg, contraindicated in persons with a history of any previous episode of anaphylaxis) with a threshold for cost-effective care at $10,000,000 per death prevented. In the base case, risk of anaphylaxis was estimated at 0.1%, with case-fatality estimated at 0.3%.

Results: On a population level (n = 300,000,000 simulated persons), universal vaccination was associated with a cost-savings of $503,596,316 and saved 7,607 lives, but the cost-savings was sensitive to increasing rates of vaccine-associated anaphylaxis. The universal strategy dominated at higher rates of COVID-19 infection and low rates of vaccine-associated anaphylaxis in both the health care and societal perspectives. When the risk of vaccine-associated anaphylaxis exceeded 0.8%, the risk-stratified approach to vaccination was the most cost-effective strategy. There was also an interaction between anaphylaxis risk and anaphylaxis fatality, with a risk-stratified approach becoming cost-effective as each risk increased concurrently. Stratified observation time by anaphylaxis history (15 minutes vs 30 minutes) was not cost-effective until a 1% anaphylaxis case-fatality was assumed and risk of vaccine anaphylaxis exceeded 6%.

Conclusions: This study demonstrates that unless vaccine anaphylaxis rates exceed 0.8%, a universal vaccination approach dominates a risk-stratified approach where persons with any history of anaphylaxis would be contraindicated from vaccination, with lower cost and superior health outcomes.
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http://dx.doi.org/10.1016/j.jaip.2021.02.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942189PMC
March 2021

The excess costs of childhood food allergy on Canadian families: a cross-sectional study.

Allergy Asthma Clin Immunol 2021 Mar 10;17(1):28. Epub 2021 Mar 10.

The Children's Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB, R3M 3P4, Canada.

Background: The impact of childhood food allergy on household costs has not been examined in Canada. The current study sought to examine differences in direct, indirect, and intangible costs among Canadian families with and without a food-allergic child.

Methods: Families with a child with a specialist-diagnosed food allergy (cases) were recruited from two tertiary pediatric allergy clinics in the Province of Manitoba, Canada, and matched, based on age and sex, to families without a food-allergic child (controls). Cost data for the two groups were collected via an adapted version of the Food Allergy Economic Questionnaire (FA-EcoQ). Consideration was given to income, defined as above vs. below the provincial annual median income.

Results: Results from 35 matched case/control pairs revealed that while total household costs did not significantly differ between cases and controls, food-allergic families did incur higher direct costs ($12,455.69 vs. $10,078.93, p = 0.02), which were largely attributed to spending on food. In contrast, cases reported lower, but not statistically significant, total indirect costs compared to controls ($10,038.76 vs. $12,294.12, p = 0.06). Families also perceived their food-allergic child as having poorer quality of life relative to their healthy peers. Lastly, stratification of the analyses by annual income revealed several differences between the higher and lower income groups.

Conclusions: Relative to families without a food-allergic child, food-allergic families incurred higher direct costs across a number of different areas.
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http://dx.doi.org/10.1186/s13223-021-00530-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943937PMC
March 2021

An Approach to the Office-Based Practice of Food Oral Immunotherapy.

J Allergy Clin Immunol Pract 2021 Mar 5. Epub 2021 Mar 5.

Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Lebanon, NH. Electronic address:

Oral immunotherapy (OIT) provides an active treatment option for patients with food allergies. OIT may improve quality of life and raise the threshold at which a patient with food allergy may react to an allergen, but it is a rigorous therapy that requires a high degree of commitment by the clinician, patients, and families. Recent guidelines from the Canadian Society for Allergy and Clinical Immunology have provided a framework for the ethical, evidence-based, and patient-oriented clinical practice of OIT, and the European Academy of Allergy, Asthma, and Immunology guidelines have also recommended that OIT can be used as a potential treatment. The recent Food and Drug Administration approval of an OIT pharmaceutical has accelerated the adoption of OIT. This review provides a summary of the recent Canadian Society for Allergy and Clinical Immunology guidelines and a consensus of practical experience of clinicians across the United States and Canada related to patient selection, office and staff preparation, the general OIT process, OIT-related reaction management, and treatment outcomes.
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http://dx.doi.org/10.1016/j.jaip.2021.02.046DOI Listing
March 2021

Media Influence on Anxiety, Health Utility, and Health Beliefs Early in the SARS-CoV-2 Pandemic-a Survey Study.

J Gen Intern Med 2021 Feb 24. Epub 2021 Feb 24.

Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.

Background: The psychological effects from the COVID-19 pandemic and response are poorly understood.

Objective: To understand the effects of the pandemic and response on anxiety and health utility in a nationally representative sample of US adults.

Design: A de-identified, cross-sectional survey was administered at the end of April 2020. Probability weights were assigned using estimates from the 2018 American Community Survey and Integrated Public Use Microdata Series Estimates.

Participants: US adults 18-85 years of age with landline, texting-enabled cellphone, or internet access.

Intervention: Seven split-half survey blocks of 30 questions, assessing demographics, COVID-19-related health attitudes, and standardized measures of generalized self-efficacy, anxiety, depression, personality, and generic health utility.

Main Measures: State/Trait anxiety scores, EQ-5D-3L Visual Analog Scale (VAS) score, and demographic predictors of these scores.

Key Results: Among 4855 respondents, 56.7% checked COVID-19-related news several times daily, and 84.4% at least once daily. Only 65.7% desired SARS-CoV-2 vaccination for themselves, and 70.1% for their child. Mean state anxiety (S-anxiety) score was significantly higher than mean trait anxiety (T-anxiety) score (44.9, 95%CI 43.5-46.3 vs. 41.6, 95%CI 38.7-44.5; p = 0.03), with both scores significantly higher than previously published norms. In an adjusted regression model, less frequent news viewing was associated with significantly lower S-anxiety score. Mean EQ-5D-3L VAS score for the population was significantly lower vs. established US normative data (71.4 CI 67.4-75.5, std. error 2 vs. societal mean 80, std. error 0.1; p < 0.001). EQ-5D-3L VAS score was bimodal (highest with hourly and no viewing) and significantly reduced with less media viewership in an adjusted model.

Conclusions: Among a nationally representative sample, there were higher S-anxiety and lower EQ-5D-3L VAS scores compared to non-pandemic normative data, indicative of a potential detrimental acute effect of the pandemic. More frequent daily media viewership was significantly associated with higher S-anxiety but also predictive of higher health utility, as measured by EQ-5D-3L VAS scores.
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http://dx.doi.org/10.1007/s11606-020-06554-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904294PMC
February 2021

Ten tips for improving your clinical practice during the COVID-19 pandemic.

Curr Opin Pediatr 2021 Apr;33(2):260-267

Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon.

Purpose Of Review: This review provides ten tips for improving clinical practice during COVID-19 as pandemic fatigue begins to complicate personal and professional lives of clinicians.

Recent Findings: COVID-19 has created unique and unexpected challenges to healthcare delivery, but has also provided opportunities for re-evaluation of practice patterns to optimize high-value practices. With ongoing uncertainty, key factors to appreciate for patient and population health include the continued touchstones of empathy and compassion, the use of effective risk communication with shared clinical decision-making when appropriate, attention to resource stewardship and vulnerable populations, importance of health literacy and need for critical assessment of media and medical literature to mitigate misinformation, and the hidden costs of the pandemic on children. Although there has been some international concern for allergic reactions to the recently approved Pfizer-BioNTech COVID-19 vaccine, neither the United States Pfizer-BioNTech or Moderna COVID-19 vaccine emergency use authorizations exclude patients without a specific allergy to a vaccine component from receiving vaccination.

Summary: Practical adjustments to practice during COVID-19 are feasible and acceptable. Experience during COVID-19 reinforces the critical need for human connection while providing care and service in every encounter.
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http://dx.doi.org/10.1097/MOP.0000000000000998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048379PMC
April 2021

Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis.

J Allergy Clin Immunol Pract 2021 Feb 4. Epub 2021 Feb 4.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, QC, Canada.

Background: Community use of epinephrine for the treatment of anaphylaxis is low. Knowledge of rates of epinephrine use in the pre-hospital setting along with identification of barriers to its use will contribute to the development of policies and guidelines.

Objectives: A search was conducted on PubMed and Embase in April 2020. Our systematic review focused on 4 domains: (1) epinephrine use in the pre-hospital setting; (2) barriers to epinephrine use in the pre-hospital setting; (3) cost evaluation and cost-effectiveness of epinephrine use; and (4) programs and strategies to improve epinephrine use during anaphylaxis.

Methods: Two meta-analyses with logit transformation were conducted to: (1) calculate the pooled estimate of the rate of epinephrine use in the pre-hospital setting among cases of anaphylaxis and (2) calculate the pooled estimate of the rate of biphasic reactions among all cases of anaphylaxis.

Results: Epinephrine use in the pre-hospital setting was significantly higher for children compared with adults (20.98% [95% confidence interval (CI): 16.38%, 26.46%] vs 7.17% [95% CI: 2.71%, 17.63%], respectively, P = .0027). The pooled estimate of biphasic reactions among all anaphylaxis cases was 3.92% (95% CI: 2.88%, 5.32%). Our main findings indicate that pre-hospital use of epinephrine in anaphylaxis remains suboptimal. Major barriers to the use of epinephrine were identified as low prescription rates of epinephrine autoinjectors and lack of stock epinephrine in schools, which was determined to be cost-effective. Finally, in reviewing programs and strategies, numerous studies have engineered effective methods to promote adequate and timely use of epinephrine.

Conclusion: The main findings of our study demonstrated that across the globe, prompt epinephrine use in cases of anaphylaxis remains suboptimal. For practical recommendations, we would suggest considering stock epinephrine in schools and food courts to increase the use of epinephrine in the community. We recommend use of pamphlets in public areas (ie, malls, food courts, etc.) to assist in recognizing anaphylaxis and after that with prompt epinephrine administration, to avoid the rare risk of fatality in anaphylaxis cases.
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http://dx.doi.org/10.1016/j.jaip.2021.01.038DOI Listing
February 2021

The COVID-19 Pandemic in 2021: Avoiding Overdiagnosis of Anaphylaxis Risk While Safely Vaccinating the World.

J Allergy Clin Immunol Pract 2021 04 30;9(4):1438-1441. Epub 2021 Jan 30.

Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH.

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http://dx.doi.org/10.1016/j.jaip.2021.01.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847187PMC
April 2021

Mothers of children with food allergies report poorer perceived life status which may be explained by limited career choices.

Allergy Asthma Clin Immunol 2021 Feb 1;17(1):12. Epub 2021 Feb 1.

Department of Food and Human Nutritional Sciences, University of Manitoba, 501G-715 McDermot Ave, Winnipeg, MB, R3E 3P4, Canada.

Pediatric food allergy is associated with direct, indirect and intangible costs. However, it remains unclear if intangible costs of pediatric food allergy influence parental career choices. Using data from 63 parents whose children had been diagnosed by a pediatric allergist with food allergy, we sought to (a) establish perceived life status of families with a food allergic child, and (b) to describe any career limitations viewed as attributable to food allergy. Compared to responding parents whose children had one to two food allergies, those with three or more food allergies had significantly poorer perceived life status (ß - 0.74; 95%CI - 1.41; - 0.07; p < 0.05). Overall, 14.3% of parents (all mothers) reported career limitations due to food allergy. Two of the 7 mothers (28.6%) who reported career limitations due to their child's food allergy fell below Statistics Canada cut-off for low-income, after tax dollars (LIM-AT). One of the three mothers who had changed jobs because of their child's food allergy was below the LIM-AT. No fathers reported food allergy-related career limitations. In conclusion, mothers of children with multiple food allergies reported worse perceived life status that may be partly explained by food allergy-related career limitations.
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http://dx.doi.org/10.1186/s13223-021-00515-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7852075PMC
February 2021

Cow's milk allergy prevention.

Ann Allergy Asthma Immunol 2021 Jan 13. Epub 2021 Jan 13.

Division of Allergy and Immunology, Department of Pediatrics, Elliot and Roslyn Jaffe Food Allergy Institute, Mount Sinai Kravis Children's Hospital, New York, New York; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: Scoping review on IgE-mediated cow's milk allergy prevention.

Data Sources: Literature search of PubMed database and gray literature.

Study Selections: Peer-reviewed relevant observational and randomized controlled studies in the pediatric population in the English language were selected and reviewed.

Results: There is increasing literature supporting the role of early and ongoing cow's milk ingestion in the prevention of cow's milk allergy. The studies supporting a preventive role with early cow's milk ingestion suggest cow's milk introduction at a very early age (most within the first month of life), suggesting the possibility of a different mechanism of sensitization than other common allergens. It is possible that gut colonization and the diversity and intensity of microbial exposure may play a role in inducing cow's milk tolerance. It is also possible that vitamin D may have a role in modulating those immune functions.

Conclusion: Further research regarding the role that early cow's milk ingestion plays in the prevention of cow's milk allergy is required, and questions remain. The absolute amount required for tolerance is unclear. Studies in higher risk populations are required. However, there is an intriguing and increasingly more pervasive association between early ongoing cow's milk ingestion and cow's milk allergy prevention.
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http://dx.doi.org/10.1016/j.anai.2021.01.007DOI Listing
January 2021

Should we continue to counsel families to use hydrolyzed formulas as a means of allergy prevention in high-risk infants?

Paediatr Child Health 2020 Mar 29;25(2):79-81. Epub 2019 Jul 29.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia.

The prevalence of food allergy in North America is high, and has increased over time. As a result, focus has shifted from treatment to allergy prevention. Previous studies have suggested that hydrolyzed formula may prevent atopic dermatitis in high-risk infants. As a result, multiple international guidelines including the Canadian Paediatric Society (CPS) position statement on allergy prevention recommend the use of hydrolyzed formula as a means of allergy prevention in mothers who are not breastfeeding or using donor breastmilk. However, a recent systematic review has not supported an association between use of hydrolyzed formula and allergy prevention. In addition, studies are emerging supporting the use of early and regular cow's milk formula as a means of cow's milk allergy prevention.
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http://dx.doi.org/10.1093/pch/pxz098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757771PMC
March 2020

Beta-lactam-allergy testing appears to be inexpensive.

J Pediatr 2021 01;228:310-313

McGill University, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jpeds.2020.10.068DOI Listing
January 2021

Practical guide for evaluation and management of beta-lactam allergy: position statement from the Canadian Society of Allergy and Clinical Immunology.

Allergy Asthma Clin Immunol 2020 Nov 10;16(1):95. Epub 2020 Nov 10.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

The vast majority of individuals labelled as allergic are not deemed truly allergic upon appropriate assessment by an allergist. A label of beta-lactam allergy carries important risks for individual and public health. This article provides an overview of beta-lactam allergy, implications of erroneous beta-lactam allergy labels and the impact that can be provided by structured allergy assessment. We provide recommendations on how to stratify risk of beta-lactam allergy, beta lactam challenge protocols as well as management of patients at high risk of beta-lactam allergy.
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http://dx.doi.org/10.1186/s13223-020-00494-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653726PMC
November 2020

What the COVID-19 Pandemic Can Teach Us About Resource Stewardship and Quality in Health Care.

J Allergy Clin Immunol Pract 2021 02 27;9(2):608-612. Epub 2020 Nov 27.

Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.

The coronavirus disease 2019 pandemic has forever changed how we view health care service delivery. Although there are undoubtedly some unintended consequences that will result from current health care service reallocation, it provides a unique opportunity to consider how to deliver quality care currently, and after the pandemic. In the context of lessons learned, moving forward some of what was previously routine could remain reserved for more exceptional circumstances. To determine what is "routine," what is "essential," and what is "exceptional," it is necessary to view medical decisions within the paradigm of high-quality care. The Institute for Healthcare Improvement definition of the dimensions of quality is based on whether the care is safe, effective, patient-centered, timely, efficient, and equitable. This type of stewardship has been applied to many interventions already deemed unnecessary by organizations such as the Choosing Wisely initiative, but the coronavirus disease 2019 pandemic provides a lens from which to consider other aspects of care. The following will provide examples from Allergy/Immunology that outline how we can reconsider what quality means in the post-coronavirus disease health care system.
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http://dx.doi.org/10.1016/j.jaip.2020.11.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691847PMC
February 2021

A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition: Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology.

J Allergy Clin Immunol Pract 2021 Jan 26;9(1):22-43.e4. Epub 2020 Nov 26.

Section of Allergy & Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo. Electronic address:

Recently published data from high-impact randomized controlled trials indicate the strong potential of strategies to prevent the development of food allergy in high-risk individuals, but guidance in the United States at present is limited to a policy for only the prevention of peanut allergy, despite other data being available and several other countries advocating early egg and peanut introduction. Eczema is considered the highest risk factor for developing IgE-mediated food allergy, but children without risk factors still develop food allergy. To prevent peanut and/or egg allergy, both peanut and egg should be introduced around 6 months of life, but not before 4 months. Screening before introduction is not required, but may be preferred by some families. Other allergens should be introduced around this time as well. Upon introducing complementary foods, infants should be fed a diverse diet, because this may help foster prevention of food allergy. There is no protective benefit from the use of hydrolyzed formula in the first year of life against food allergy or food sensitization. Maternal exclusion of common allergens during pregnancy and/or lactation as a means to prevent food allergy is not recommended. Although exclusive breast-feeding is universally recommended for all mothers, there is no specific association between exclusive breast-feeding and the primary prevention of any specific food allergy.
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http://dx.doi.org/10.1016/j.jaip.2020.11.002DOI Listing
January 2021

First Real-World Effectiveness Analysis of Preschool Peanut Oral Immunotherapy.

J Allergy Clin Immunol Pract 2021 Mar 19;9(3):1349-1356.e1. Epub 2020 Nov 19.

British Columbia Children's Hospital, Vancouver, BC, Canada; Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

Background: We previously described safety of preschool peanut oral immunotherapy (P-OIT) in a real-world setting; 0.4% of patients experienced a severe reaction, and 4.1% received epinephrine, during build-up.

Objective: To determine the effectiveness of preschool P-OIT after 1 year of maintenance.

Methods: Preschoolers (9-70 months) with at least 1 objective reaction to peanut (during baseline oral food challenge (OFC) or P-OIT build-up) received a follow-up OFC to cumulative 4000 mg protein after 1 year on 300 mg peanut daily maintenance. Effectiveness of desensitization was defined as proportion of patients with a negative follow-up OFC. Symptoms and treatment at follow-up OFC were recorded.

Results: Of the 117 patients who successfully completed 1 year of P-OIT and subsequently underwent a cumulative 4000-mg follow-up OFC, 92 (78.6%) had a negative OFC and 115 (98.3%) tolerated a cumulative dose of greater than or equal to 1000 mg. For the 25 (21.4%) who reacted, their threshold increased by 3376 mg (95% CI, 2884-3868) from baseline to follow-up; 17 (14.5%) patients experienced grade 1 reactions, 7 (6.00%) grade 2, and 1 (0.85%) grade 3. Two patients (1.71%) received epinephrine associated with P-OIT, and 1 (0.85%) went to the emergency department.

Conclusions: Our data demonstrate that real-world preschool P-OIT is effective after 1 year of maintenance for those who received a follow-up OFC. For those who reacted, their threshold increased sufficiently to protect against accidental exposures. P-OIT should be considered for preschoolers as an alternative to current recommendations to avoid peanut.
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http://dx.doi.org/10.1016/j.jaip.2020.10.045DOI Listing
March 2021

L’asthme et la COVID-19.

CMAJ 2020 11;192(44):E1388

Section d'allergie et immunologie clinique, Département de pédiatrie (Abrams), Université du Manitoba; Section de médecine hospitalière pédiatrique et Département de pédiatrie et de santé infantile ('t Jong), Université du Manitoba; Institut de recherche en santé des enfants du Manitoba (Abrams, 't Jong), Winnipeg, Man.; Divisions d'allergie et immunologie (Abrams) et de pneumologie (Yang), Département de pédiatrie, Université de la Colombie-Britannique, Vancouver, C.-B.; Institut de recherche de l'Hôpital pour enfants de la Colombie-Britannique (Yang), Vancouver, C.-B.

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http://dx.doi.org/10.1503/cmaj.200617-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647481PMC
November 2020

Pediatric asthma and COVID-19: The known, the unknown, and the controversial.

Pediatr Pulmonol 2020 12 22;55(12):3573-3578. Epub 2020 Oct 22.

Pediatric Respirology, Alder Hey Children's Hospital, Liverpool, UK.

The novel coronavirus disease-2019 (COVID-19), caused by the pathogen severe acute respiratory syndrome-CoV-2, is causing a global pandemic, with over 26.9 million cases and 880,000 deaths as of September 6, 2020. While there has been speculation and observational research about the impact of COVID-19 on asthma, much remains unknown. The goal of this article is to provide a scoping review on pediatric asthma and COVID-19 and summarize what we do and do not know from the first wave of the pandemic.
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http://dx.doi.org/10.1002/ppul.25117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675412PMC
December 2020

High anxiety and health-related quality of life in families with children with food allergy during coronavirus disease 2019.

Ann Allergy Asthma Immunol 2021 01 18;126(1):83-88.e1. Epub 2020 Sep 18.

Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; The Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada.

Background: Food allergy has a known effect on quality of life (QoL), but this has not been extensively studied during the coronavirus disease 2019 pandemic.

Objective: To characterize the levels of anxiety of mothers of children aged 0 to 8 years with food allergy compared with families of children without a food allergy and the health-related QoL among children with food allergy during the coronavirus disease 2019 pandemic.

Methods: In a mixed-methods study, Canadian mothers of children aged 0 to 8 years with (cases) and without (controls) food allergy provided demographic data and completed age-appropriate anxiety questionnaires between April 14, 2020, and April 28, 2020. The cases also provided food allergy-related data and completed the Food Allergy Quality of Life Questionnaire. In-depth interviews were subsequently conducted with purposefully selected cases.

Results: In a total of 580 participants, 5.5% were cases and 94.5% were controls. For mothers of children aged 0 to 1.5 years, anxiety levels did not differ between cases and controls. For mothers of children aged 1.5 to 8 years, anxiety levels were higher in cases vs controls (P < .05). Among the cases, neither overall nor domain-specific Food Allergy Quality of Life Questionnaire scores differed between age groups (0-3 vs 4-7 years), even after adjustment for confounding variables, including childcare during the pandemic. Qualitatively, the following 3 themes were identified: unexpected challenges of food shopping; less food-related food anxiety during the pandemic; and differences and delays in food allergy testing and therapy.

Conclusion: Mothers of children with food allergy reported high anxiety and poor health-related QoL. Yet, qualitatively, day-to-day food allergy management was better during the pandemic.
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http://dx.doi.org/10.1016/j.anai.2020.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498414PMC
January 2021

Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge.

J Allergy Clin Immunol Pract 2021 Feb 6;9(2):916-921. Epub 2020 Sep 6.

Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada.

Background: Serum sickness-like reactions (SSLRs) are defined by the presence of rash (primarily urticaria) and joint complaints (arthralgia/arthritis) that are believed to occur due to a non-IgE-mediated response to medications. However, similar reactions can occur due to viral infections, and it can be difficult to distinguish between the two. This may lead to unnecessary avoidance of the culprit antibiotic.

Objective: We aimed to evaluate children presenting with suspected SSLRs through a graded oral challenge (GOC).

Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy (β-lactam or other antibiotics) and a clinical presentation compatible with SSLR were recruited for the study between March 2013 and February 2020. A standardized survey with questions on treatment, symptoms, and associated factors was completed, and a GOC (10% and subsequently 90% of the oral antibiotic dose) was conducted. Patients with a negative GOC were contacted annually to query on subsequent antibiotic use.

Results: Among 75 patients presenting with suspected SSLRs, the median age was 2.0 years and 46.7% were males. Most reactions were attributed to amoxicillin. Among the 75 patients, 2.7% reacted immediately (within 1 hour) to a GOC and 4.0% had a nonimmediate reaction. Of the 43 patients successfully contacted, 20 reported subsequent culprit antibiotic use of whom 25.0% had a subsequent mild reaction (macular/papular rash).

Conclusions: This is the first and largest pediatric study to assess SSLR using a GOC. Our findings suggest that using a GOC is safe and appropriate for differentiating between β-lactam-induced SSLR and viral exanthem in this population.
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http://dx.doi.org/10.1016/j.jaip.2020.08.047DOI Listing
February 2021

Increasing Awareness of the Low Risk of Severe Reaction at Infant Peanut Introduction: Implications During COVID-19 and Beyond.

J Allergy Clin Immunol Pract 2020 Nov - Dec;8(10):3259-3260. Epub 2020 Sep 4.

Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.08.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7473022PMC
November 2020

Mitigating Misinformation and Changing the Social Narrative.

J Allergy Clin Immunol Pract 2020 Nov - Dec;8(10):3261-3263. Epub 2020 Aug 18.

Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.

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http://dx.doi.org/10.1016/j.jaip.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434362PMC
August 2020

Prevalence of Physician-Reported Food Allergy in Canadian Children.

J Allergy Clin Immunol Pract 2021 Jan 6;9(1):193-199. Epub 2020 Aug 6.

Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada. Electronic address:

Background: Food allergy prevalence data have largely been derived from self-report, and estimates vary.

Objective: Determine the prevalence of physician-reported food allergy in children using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPSSN).

Methods: This was a retrospective cohort study using the CPCSSN repository, Canada's only primary care practice-based surveillance system. Machine learning algorithms were applied to assess for food allergy documentation. Demographic information, chronic diseases of interest, prescribed medications, and health behaviors from the CPCSSN repository were identified.

Results: The prevalence of physician-reported food allergy in Canadian children was 2.53% (95% CI, 2.48%-2.59%). The most common food allergies documented were peanut (0.8% of children), tree nut (0.6%), cow's milk (0.4%), egg (0.3%), fruit (0.2%), finned fish (0.2%), and shellfish (0.2%). Among children with food allergy, only 33.7% had an epinephrine autoinjector prescription. In logistic regression analysis, children with food allergy were more likely to have an atopic comorbidity (odds ratio [OR], 2.20; 95% CI, 2.06-2.35) and less likely to be obese than children without food allergies (OR, 0.84; 95% CI, 0.78-0.90). In the age- and sex-adjusted models, patients with food allergy were significantly more likely to have a psychiatric morbidity, specifically: attention deficit/hyperactivity disorder (OR, 1.81; 95% CI, 1.66-1.96), autism (OR, 1.89; 95% CI, 1.63-2.19), and depression (OR, 1.17; 95% CI, 1.02-1.35).

Conclusions: Our study is the first to estimate national physician-reported prevalence of food allergy, and demonstrates a lower rate than that based on self-report. Further studies into the association of food allergy and psychiatric comorbidities (attention deficit/hyperactivity disorder, autism, depression) and the association of food allergy and obesity are needed.
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http://dx.doi.org/10.1016/j.jaip.2020.07.039DOI Listing
January 2021

COVID-19, asthma, and return to school.

Lancet Respir Med 2020 09 6;8(9):847-849. Epub 2020 Aug 6.

Clinical Pharmacology Unit, Faculty of Medicine and Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal; Department of Pediatrics, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.

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http://dx.doi.org/10.1016/S2213-2600(20)30353-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833054PMC
September 2020

"I want to really crack this nut": an analysis of parent-perceived policy needs surrounding food allergy.

BMC Public Health 2020 Aug 1;20(1):1194. Epub 2020 Aug 1.

University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB, R3E 3P4, Canada.

Background: In Canada, anaphylaxis-level food allergy constitutes a legal disability. Yet, no nationwide policies exist to support families. We sought to understand what parents of children with food allergy perceive as the most pressing food allergy-related policy concerns in Canada.

Methods: Between March-June 2019, we interviewed 23 families whose food allergic children (N = 28mean age 7.9 years) attending an allergy clinic in Winnipeg, Canada. Interviews were audio-recorded, transcribed and analyzed using content analysis.

Results: Over 40% of children had multiple food allergies, representing most of Health Canada's priority allergens. We identified four themes: (1) High prevalence. High priority?. (2) Food labels can be misleading, (3) Costs and creative ideas, and (4) Do we have to just deal with the status quo around allergies?

Conclusion: Food allergy ought to be a national policy priority, to improve the process for precautionary labelling, to improve funding, educational tools access to care, and knowledge of current allergy guidelines.
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http://dx.doi.org/10.1186/s12889-020-09309-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395383PMC
August 2020

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change.

J Allergy Clin Immunol Pract 2020 10 25;8(9):2851-2857. Epub 2020 Jul 25.

Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.
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http://dx.doi.org/10.1016/j.jaip.2020.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382335PMC
October 2020