Six foods commonly associated with food allergy were introduced in the diets of children at 3 months or 6 months of age. Intention-to-treat analysis showed no benefit of early introduction with ...respect to the prevalence of food allergy; a per-protocol analysis showed a difference.
The World Health Organization recommends exclusive breast-feeding of infants for their first 6 months of life.
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Two national guidelines that had previously recommended the delayed introduction of allergenic foods have been withdrawn (see the Introduction section in the Supplementary Appendix, available with the full text of this article at NEJM.org). In the 2010 United Kingdom Infant Feeding Survey, 45% of the mothers of infants 8 to 10 months of age reported avoiding giving their infant a particular food: 48% avoided nuts, 14% eggs, 10% dairy, and 6% fish.
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Fear of allergy was the most common reason for avoiding foods, followed by . . .
Background The association between atopic dermatitis (AD) and food allergy (FA) is not fully understood, although a causal relationship has been suggested. This has important implications for ...prevention and treatment. Objective We aimed to review the association between AD and FA, the effect of FA on AD severity, chronicity, and age of onset, and the temporal relationship between the two. Methods Medline and Embase were systematically searched from inception to November 2014 for studies investigating both AD and FA. Results Sixty-six studies were identified. Eighteen were population-based, 8 used high-risk cohorts, and the rest comprised patients with either established AD or FA. In population-based studies, the likelihood of food sensitization was up to 6 times higher in patients with AD versus healthy control subjects at 3 months of age (odds ratio, 6.18; 95% CI, 2.94-12.98; P < .001). Other population-based studies reported that up to 53% of subjects with AD were food sensitized, and up to 15% demonstrated signs of FA on challenge. Meanwhile, studies including only patients with established AD have reported food sensitization prevalences up to 66%, with challenge-proven FA prevalences reaching up to 81%. Sixteen studies suggested that FA is associated with a more severe AD phenotype. Six studies indicated that AD of earlier onset or increased persistence is particularly associated with FA. Finally, one study found that AD preceded the development of FA. Conclusions This systematic review confirms a strong and dose-dependent association between AD, food sensitization, and FA. AD of increased severity and chronicity is particularly associated with FA. There is also evidence that AD precedes the development of food sensitization and allergy, in keeping with a causal relationship.
Atopic dermatitis (AD) is associated with immune dysregulation, but epidemiologic data on the pattern of autoimmune comorbidity in people with AD are limited.
We sought to determine the risk of ...autoimmune conditions in people newly diagnosed with AD.
Retrospective cohort analysis (January 2009 to December 2018), using the UK-based Oxford–Royal College of General Practitioners Research and Surveillance Centre primary care database. We compared baseline prevalence and incidence after diagnosis of autoimmune conditions in 173,709 children and adults with new-onset AD and 694,836 age-, sex-, and general practitioner practice–matched controls. Outcomes were a composite of any autoimmune condition (Crohn disease, ulcerative colitis, celiac disease, pernicious anemia, type 1 diabetes, autoimmune hypothyroidism, Graves disease, psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, Sjögren syndrome, vitiligo, alopecia areata, and multiple sclerosis) and each individual autoimmune condition.
Preexisting autoimmune conditions were more common in people diagnosed with AD compared to controls (composite 5.8% vs 4.3%). Excluding people with preexisting autoimmune disease, there was an association between AD and incidence of new-onset autoimmune disease (composite adjusted hazard ratio aHR 1.28; 95% confidence interval CI 1.23-1.34). Risk was highest for more severe AD (aHR 1.99; 95% CI 1.77-2.23) than moderate AD (aHR 1.33; 95% CI 1.19-1.49) or mild AD (aHR 1.22; 95% CI 1.16-1.28). People with AD were at significantly increased risk of developing psoriatic arthritis, Sjögren syndrome, Crohn disease, vitiligo, alopecia areata, pernicious anemia, ulcerative colitis, rheumatoid arthritis, and hypothyroidism (aHR range 1.17-2.06), but not other autoimmune conditions.
People with AD have an increased risk of multiple autoimmune conditions, especially those with more severe AD.
Background/objectives
The International Society for the Study of Vascular Anomalies (ISSVA) classification separates vascular anomalies into vascular malformations and vascular tumors. However, ...misdiagnoses and misperceptions still persist around the use of the term “hemangioma.” We assessed whether the term “haemangioma” (British spelling) was used as part of ISSVA terminology in the literature.
Methods
We searched PubMed for all English‐language publications containing the British spelling “haemangioma” in the title or from January 1, 2015 to December 31, 2016. Each paper was judged by two independent reviewers, with conflicts resolved by senior review.
Results
By the standard of the 2014 ISSVA classification, 126/195 (64.6%) publications used incorrect terminology for vascular anomalies. This was reduced to 118/195 (60.5%) when using the 2018 ISSVA classification. The most commonly misused terms were cavernous haemangioma (27.1%), haemangioma without further specification (26.3%), and hepatic/liver haemangioma (12.7%). Age was a significant predictor of accuracy of terminology (P = 0.01), with a higher accuracy in children. Correct usage also varied by the site of the vascular anomaly, being highest for lesions of the skin (76.5%) followed by muscle (58.3%), soft tissue (23.5%), bone (21.4%), viscera (7.7%), and eye (0.0%) (P = 0.02).
Conclusions
The term “haemangioma” is frequently used incorrectly by the standards of the 2014 and 2018 ISSVA classifications. Correct terminology is important as the natural history and treatment options vary depending on the type of vascular anomaly.
We live in exciting times in atopic dermatitis therapeutics, with many novel treatments in the clinical trial pipeline. Frustratingly, most of these trials are vehicle- or placebo-controlled, rather ...than head-to-head comparisons. Network meta-analyses can rank treatments against each other, even for placebo-controlled studies, aiding evidence-based guideline formulation and clinical decision-making. Treatment registries are an important additional vehicle to collect 'real-world' data on the long-term (cost) effectiveness and safety of the new drugs, outside of the stringent and short-term settings of clinical trials. As further agents enter clinical practice, the need for biomarkers of treatment response and drug safety becomes more pressing to move us towards personalized medicine and to avoid wasting healthcare resources. This review takes stock of our current treatment armamentarium for atopic dermatitis, highlights important gaps in our knowledge - including the relatively low number of studies conducted in children - and maps out how our treatment approaches for atopic dermatitis can become more targeted and holistic in the future.
Filaggrin (FLG) loss-of-function skin barrier gene mutations are associated with atopic dermatitis (AD) and transepidermal water loss (TEWL). We investigated whether FLG mutation inheritance, skin ...barrier impairment, and AD also predispose to allergic sensitization to foods. Six hundred and nineteen exclusively breastfed infants were recruited at 3 months of age and examined for AD and disease severity (SCORing Atopic Dermatitis (SCORAD)), and screened for the common FLG mutations. TEWL was measured on unaffected forearm skin. In addition, skin prick testing was performed to six study foods (cow’s milk, egg, cod, wheat, sesame, and peanut). Children with AD were significantly more likely to be sensitized (adjusted odds ratio (OR)=6.18, 95% confidence interval (CI): 2.94–12.98, P<0.001), but this effect was independent of FLG mutation carriage, TEWL, and AD phenotype (flexural vs. non-flexural). There was also a strong association between food sensitization and AD severity (adjusted ORSCORAD<20=3.91, 95% CI: 1.70–9.00, P=0.001 vs. adjusted ORSCORAD⩾20=25.60, 95% CI: 9.03–72.57, P<0.001). Equally, there was a positive association between AD and sensitization with individual foods (adjusted ORegg=9.48, 95% CI: 3.77–23.83, P<0.001; adjusted ORcow’s milk=9.11, 95% CI: 2.27–36.59, P=0.002; adjusted ORpeanut=4.09, 95% CI: 1.00–16.76, P=0.05). AD is the main skin-related risk factor for food sensitization in young infants. In exclusively breastfed children, this suggests that allergic sensitization to foods can be mediated by cutaneous antigen-presenting cells.
The Enquiring About Tolerance (EAT) study was a randomized trial of the early introduction of allergenic solids into the infant diet from 3 months of age. The intervention effect did not reach ...statistical significance in the intention-to-treat analysis of the primary outcome.
We sought to determine whether infants at high risk of developing a food allergy benefited from early introduction.
A secondary intention-to-treat analysis was performed of 3 groups: nonwhite infants; infants with visible eczema at enrollment, with severity determined by SCORAD; and infants with enrollment food sensitization (specific IgE ≥0.1 kU/L).
Among infants with sensitization to 1 or more foods at enrollment (≥0.1 kU/L), early introduction group (EIG) infants developed significantly less food allergy to 1 or more foods than standard introduction group (SIG) infants (SIG, 34.2%; EIG, 19.2%; P = .03), and among infants with sensitization to egg at enrollment, EIG infants developed less egg allergy (SIG, 48.6%; EIG, 20.0%; P = .01). Similarly, among infants with moderate SCORAD (15-<40) at enrollment, EIG infants developed significantly less food allergy to 1 or more foods (SIG, 46.7%; EIG, 22.6%; P = .048) and less egg allergy (SIG, 43.3%; EIG, 16.1%; P = .02).
Early introduction was effective in preventing the development of food allergy in specific groups of infants at high risk of developing food allergy: those sensitized to egg or to any food at enrollment and those with eczema of increasing severity at enrollment. This efficacy occurred despite low adherence to the early introduction regimen. This has significant implications for the new national infant feeding recommendations that are emerging around the world.
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Background
Psychological and educational interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. This is an ...update of the original Cochrane review.
Objectives
To assess the effect of psychological and educational interventions for atopic eczema in children.
Search methods
We updated our searches of the following databases to January 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 12), MEDLINE (from 1946), EMBASE (from 1974), OpenGrey, and PsycINFO (from 1806). We also searched six trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs).
Selection criteria
Randomised controlled trials of psychological or educational interventions, or both, used to assist children and their carers in managing atopic eczema.
Data collection and analysis
Three authors independently applied eligibility criteria, assessed trial quality, and extracted data. A lack of comparable data prevented data synthesis, and we were unable to conduct meta‐analysis because there were insufficient data.
Main results
We included 10 RCTs, of which 5 were new to this update; all interventions were adjuncts to conventional therapy and were delivered in primary‐ and secondary‐care settings. There were 2003 participants in the 9 educational interventions and 44 participants in the 1 psychological study. Some included studies had methodological weaknesses; for example, we judged four studies to have high risk of detection bias, attrition bias, or other bias. Our primary outcomes were participant‐rated global assessment, reduction in disease severity (reported as objective SCORAD (SCORing Atopic Dermatitis)), and improvement in sleep and quality of life. No study reported participant‐rated global assessment or improvement of sleep.
The largest and most robust study (n = 992) demonstrated significant reduction in disease severity and improvement in quality of life, in both nurse‐ and dermatologist‐led intervention groups. It provided six standardised, age‐appropriate group education sessions. Statistically significant improvements in objective severity using the SCORAD clinical tool were recorded for all intervention groups when compared with controls. Improvements in objective severity (intervention minus no intervention) by age group were as follows: age 3 months to 7 years = 4.2, 95% confidence interval (CI) 1.7 to 6.8; age 8 to 12 years = 6.7, 95% CI 2.1 to 11.2; and age 13 to 18 years = 9.9, 95% CI 4.3 to 15.5. In three of five studies, which could not be combined because of their heterogeneity, the objective SCORAD measure was statistically significantly better in the intervention group compared with the usual care groups. However, in all of the above studies, the confidence interval limits do not exceed the minimum clinically important difference of 8.2 for objective SCORAD.
The largest study measured quality of life using the German 'Quality of life in parents of children with atopic dermatitis' questionnaire, a validated tool with five subscales. Parents of children under seven years had significantly better improvements in the intervention group on all five subscales. Parents of children aged 8 to 12 years experienced significantly better improvements in the intervention group on 3 of the 5 subscales.
Authors' conclusions
This update has incorporated five new RCTs using educational interventions as an adjunct to conventional treatment for children with atopic eczema. We did not identify any further studies using psychological interventions. The inclusion of new studies has not substantially altered the conclusions from the original review. The educational studies in both the original review and this update lack detail about intervention design and do not use a complex interventions framework. Few use an explicit theoretical base, and the components of each intervention are not sufficiently well described to allow replication. A relative lack of rigorously designed trials provides limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of atopic eczema in children. However, there is some evidence from included paediatric studies using different educational intervention delivery models (multiprofessional eczema interventions and nurse‐led clinics) that these may lead to improvements in disease severity and quality of life. Educational and psychological interventions require further development using a complex interventions framework. Comparative evaluation is needed to examine their impact on eczema severity, quality of life, psychological distress, and cost‐effectiveness. There is also a need for comparison of educational interventions with stand‐alone psychosocial self‐help.
Living in a hard water area is associated with an increased risk of atopic dermatitis (AD). Greater skin barrier impairment after exposure to surfactants in wash products, combined with the high ...calcium levels of hard water and/or high chlorine levels, is a compelling mechanism for this increase. The purpose of this study was to investigate this mechanism in individuals with and without a predisposition to skin barrier impairment. We recruited 80 participants: healthy control subjects and AD patients with and without FLG mutations. The skin of each participant was washed with sodium lauryl sulfate in water of varying hardness levels and chlorine concentrations, rinsed, and covered with chambers to determine the effects of surfactant residues. Sites washed with hard water had significantly increased sodium lauryl sulfate deposits. These deposits increased transepidermal water loss and caused irritation, particularly in AD patients carrying FLG mutations. A clear effect of chlorine was not observed. Water softening by ion-exchange mitigated the negative effects of hard water. Barrier impairment resulting from the interaction between hard water and surfactants is a contributory factor to the development of AD. Installation of a water softener in early life may be able to prevent AD development. An intervention study is required to test this hypothesis.
Bathing babies less frequently and intensively in the first six months of life may prevent eczema, but this has not yet been definitively tested in a randomised controlled trial. Such a trial would ...require evidence-based support to help parents engage with a minimal bathing routine. The present study reports the development of this support.
We adopted a four-stage design process: (i) Pregnant women and their families (n = 31) were interviewed to ascertain key barriers and facilitators towards following the minimal bathing intervention. (ii) These barriers and facilitators were mapped to behaviour change techniques, focussing on the intervention types of education, persuasion and environmental restructuring, alongside appropriate modes of delivery, and prototype intervention materials were developed. (iii) We iteratively refined these materials in a workshop with multidisciplinary experts and Patient and Public Involvement and Engagement (PPIE) representatives (n = 13) and an (iv) intervention walkthrough with families (n = 5). The design process was informed by the Behaviour Change Wheel, Theoretical framework of acceptability and the Template for intervention description and replication.
Social influences and motivational factors are likely to influence both uptake and adherence to the intervention. Anticipated emotional reward from participating in research for the benefit of others was indicated to be a strong facilitator for intervention uptake. Alternatives to bathing, having fun with the baby and the night-time routine, alongside family support, were notable facilitators suggested to aid adherence to the intervention. Barriers included hygiene concerns and anticipated negative social appraisal. Barriers and facilitators were mapped to thirty-six behaviour change techniques, focussing on the intervention types of education, persuasion and environmental restructuring, all of which were embedded into the package of support. The prototype intervention materials received positive feedback from the expert workshop and study walkthrough with families. The final package of support comprises printed and digital prompts and cues, a study booklet, video, and digital tool for self-monitoring.
The intervention design process incorporated the 'real world' views and experiences of families, experts and PPIE representatives, alongside criteria for designing behavioural interventions. The effectiveness of the package of support will be tested in a feasibility trial and embedded process evaluation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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