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Two national guidelines that had previously recommended the delayed introduction of allergenic foods have been withdrawn (see the Introduction section in the Supplementary Appendix, available with the full text of this article at NEJM.org).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 influence of early exposure to allergenic foods on the subsequent development of food allergy remains uncertain. Objective We sought to determine the feasibility of the early ...introduction of multiple allergenic foods to exclusively breast-fed infants from 3 months of age and the effect on breastfeeding performance. Methods We performed a randomized controlled trial. The early introduction group (EIG) continued breastfeeding with sequential introduction of 6 allergenic foods: cow's milk, peanut, hard-boiled hen's egg, sesame, whitefish (cod), and wheat; the standard introduction group followed the UK infant feeding recommendations of exclusive breastfeeding for around 6 months with no introduction of allergenic foods before 6 months of age. Results One thousand three hundred three infants were enrolled. By 5 months of age, the median frequency of consumption of all 6 foods was 2 to 3 times per week for every food in the EIG and no consumption for every food in the standard introduction group ( P < .001 for every comparison). By 6 months of age, nonintroduction of the allergenic foods in the EIG was less than 5% for each of the 6 foods. Achievement of the stringent per-protocol consumption target for the EIG proved more difficult (42% of evaluable EIG participants). Breastfeeding rates in both groups significantly exceeded UK government data for equivalent mothers ( P < .001 at 6 and at 9 months of age). Conclusion Early introduction, before 6 months of age, of at least some amount of multiple allergenic foods appears achievable and did not affect breastfeeding. This has important implications for the evaluation of food allergy prevention strategies.
Pediatric allergic disease is a significant health concern worldwide, and the prevalence of childhood eczema, asthma, allergic rhinitis, and food allergy continues to increase. Evidence to support ...specific interventions for the prevention of eczema, asthma, and allergic rhinitis is limited, and no consensus on prevention strategies has been reached. Randomized controlled trials investigating the prevention of food allergy via oral tolerance induction and the early introduction of allergenic foods have been successful in reducing peanut and egg allergy prevalence. Infant weaning guidelines in the United Sates were recently amended to actively encourage the introduction of peanut for prevention of peanut allergy.
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 There is a paucity of literature to direct physicians in the prescribing of immunomodulators for patients with severe atopic dermatitis (AD). Objective To survey systemic agent prescribing ...practices for severe childhood AD among clinicians in the United States and Canada. Methods The TREatment of severe Atopic dermatitis in children Taskforce (TREAT), US&CANADA, a project of the Pediatric Dermatology Research Alliance (PeDRA), developed an online multiple-response survey to assess clinical practice, gather demographic information and details of systemic agent selection, and identify barriers to their use in patients with recalcitrant pediatric AD. Results In total, 133 of 290 members (45.9%) of the Society for Pediatric Dermatology completed the survey, and 115 of 133 (86.5%) used systemic treatment for severe pediatric AD. First-line drugs of choice were cyclosporine (45.2%), methotrexate (29.6%), and mycophenolate mofetil (13.0%). The most commonly used second-line agents were methotrexate (31.3%) and mycophenolate mofetil (30.4%); azathioprine was the most commonly cited third-line agent. The main factors that discouraged use of systemic agents were side-effect profiles (82.6%) and perceived risks of long-term toxicity (81.7%). Limitations Investigation of the sequence of systemic medications or combination systemic therapy was limited. Recall bias may have affected the results. Conclusion Great variation exists in prescribing practices among American and Canadian physicians using systemic agents for treatment of pediatric AD.
Correspondence to Dr Ming Lim, Children's Neurosciences, Evelina London Children's Healthcare, London SE1 7EH, UK; ming.lim@gstt.nhs.uk We read with great interest the recent publication of the ...priorities of child health research across the UK and Ireland.1 A crucial aspect of any research undertaken is the voice of the patient and their carers and in the context of the child, their parents. A robust methodology exists, established by the National Institute of Health Research (NIHR) and the James Lind Alliance (JLA) to bring patients, carers and clinicians together in Priority Setting Partnerships (PSPs).3 Briefly, a working group comprising of patient, parent and clinician representatives with the help of a wide range of stakeholders identifies research uncertainties gathered through an open platform survey and from existing national and international research recommendations. In scope uncertainties are screened against published systematic reviews and active clinical trial databases to confirm that they are unanswered and then aggregated to generate relevant research questions for interim multiple stage prioritisation before the final research priorities are identified.
Background
Recently, we have published an overview of systematic reviews in allergy epidemiology and identified asthma as the most commonly reviewed allergic disease. Building on this work, we aimed ...to investigate the quality of systematic reviews in asthma using the AMSTAR checklist and to provide a reference for future, more in‐depth assessment of the extent of previous knowledge.
Methods
We included all 307 systematic reviews indexed with asthma, including occupational asthma, and/or wheeze from our previous search in PubMed and EMBASE up to December 2014 for systematic reviews on epidemiological research on allergic diseases. Topics of the included systematic reviews were indexed and we applied the AMSTAR checklist for methodological quality to all. Statistical analyses include description of lower and upper bounds of AMSTAR scores and variation across publication time and topics.
Results
Of 43 topics catalogued, family history, birth weight, and feeding of formula were only covered once in systematic reviews published from 2011 onwards. Overall, at least one meta‐analysis was conducted for all topics except for “social determinants”, “perinatal”, “birth weight”, and “climate”. AMSTAR quality scores were significantly higher in more recently published systematic reviews, in those with meta‐analysis, and in Cochrane reviews. There was evidence of variation of quality across topics even, after accounting for these characteristics. Genetic factors in asthma development were often covered by systematic reviews with some evidence of unsubstantiated updates or repetition.
Conclusions
We present a comprehensive overview with an indexed database of published systematic reviews in asthma epidemiology including quality scores. We highlight some topics including active smoking and pets, which should be considered for future systematic reviews. We propose that our search strategy and database could be a basis for topic‐specific overviews of systematic reviews in asthma epidemiology.
Aims1) Evaluate the rate of routine childhood vaccine uptake in South London through the first year of the COVID-19 pandemic2) Identify if there is uptake variation associated with socioeconomic or ...ethnic groupsMethodsThis is a retrospective cohort study using routinely collected primary care data from the South London Lambeth DataNet database. Participants included children under 18 years registered during the study period. The pre-COVID-19 pandemic period was defined as 1st January 2016 – 31st December 2019. The early pandemic period was defined as 1st January 2020 – 31st December 2020. Demographic data and social determinants of health recorded included age, sex, ethnicity, and socioeconomic background using the index of multiple deprivation.Primary outcome was the total number of vaccine doses given per year. Secondary outcomes included comparison of uptake rates according to socioeconomic and ethnic background and by vaccine type. Subgroup analyses included evaluation of uptake for vaccines recommended during the first year of life (infant vaccinations). Infant vaccine uptake of one or more doses of the meningitis B, pneumococcal, rotavirus or 6-in-1 vaccines are shown as a percentage of registered children born during the specified year. Infant vaccine uptake of the first dose of the measles, mumps and rubella (MMR) vaccine, recommended on or after the first birthday, are shown as a percentage of registered children born during the preceding year.ResultsThere was an average of 77,613 children (0-18yrs, 51% male) registered each year over the five-year study period. 339,456 vaccine doses were given in total in 2016-20, with a trend over time toward a decreasing number given each year compared with the number of children registered table 1A.The total number of vaccine doses given in 2020 was not out of proportion with this trend. However, in 2020, there was a substantially higher number of influenza vaccines doses given 11,498 doses in 2020 vs 5742-6292 doses in 2016-19 and a lower number of human papilloma virus vaccine doses 145 doses in 2020 vs. 264-442 doses in 2016-19.The trend does not appear to change according to socioeconomic and ethnic background table 1B.Subgroup analyses of infant vaccinations showed the uptake rate of at least one dose of the following vaccines has been constant over the five-year period: 6-in-1 (87-89%), meningitis B (88-89%), and rotavirus (88-89%); but not for the pneumococcal vaccine which showed a reduction of 9% in 2020, and the MMR which showed an increase of 8% table 2. However, data from 2021 is required to fully evaluate for trends.Abstract 1029 Table 1Total vaccine doses given according to socioeconomic background and ethnicity in South London 2016 - 2020Abstract 1029 Table 2Routine infant vaccination uptake in South London 2016-2020 – children who received ≥ 1 dose† of the specified vaccine as a proportion of children born in the year specified (6-in-1; Meningitis B, Pneumococcus) or the preceding year (MMR)ConclusionDespite concerns regarding reduced uptake of routine childhood vaccinations during the pandemic, this cohort does not appear to show a disproportionate reduction in uptake, and more children received the influenza vaccine during the early pandemic time than in preceding years.These findings could help inform policy makers to improve catch-up strategies where needed. Additionally, there may be a trend of reduced vaccine uptake over recent years, which could have significant public health implications.
In acute-based research (p=0.02), neonatal research (p=0.01), studies funded by non-profit organisations (p=0.0006) or pharmaceutical companies (p=0.04), and manuscript where the corresponding ...authors with hospital affiliations (p=0.04), ethnicity was less likely to be reported. Table 1 Characteristics of the included manuscripts Reporting of ethnicity (N=140) Ethnicity data available within the main manuscript, n (%) 46 (32.9) Ethnicity data available, n (%) (ethnicity data found either in the manuscript, supplemental information or referenced in another publication) 55 (39.3) Only Caucasian ethnicity reported, n (%) 21 (15) Differences between papers that did and did not report ethnicity Ethnicity included (n=55) Ethnicity not included (n=85) P value Mean age (SD) 10.2 (5.3) 8.7 (6.9) 0.2 Mean percentage of male sex (SD) 48.6 (15.6) 53.2 (17.1) 0.12 Mean number of participants (SD) 1357.7 (2593.8) 530.4 (1780.1) 0.03 Multicentre or one centre Multicentre (n=76), n (%) 39 (51.3) 37 (48.7) 0.001 One centre (n=64), n (%) 16 (25) 48 (75) UK only or international collaboration UK only (n=103), n (%) 36 (35) 67(65) 0.08 International collaboration (n=37), n (%) 19 (51.4) 18 (48.6) Subspecialties of paediatric research Neonatal research (n=19), n (%) 4 (21.1) 15 (78.9) 0.08 Obesity-related (n=18), n (%) 7 (38.9) 11 (61.1) 0.9 Nutrition/physical activity (n=21), n (%) 6 (28.6) 15 (71.4) 0.3 Psychiatry and psychology (n=18), n (%) 13 (72.2) 5 (27.8) 0.0002 Infectious disease and allergy (n=17), n (%) 8 (47.1) 9 (52.9) 0.5 Funding source Government/large national institution (n=68), n (%) 30 (44.1) 38 (55.9) 0.3 University/hospital charity funded (n=21), n (%) 13 (61.9) 8 (38.1) 0.9 Non-profit organisations (n=20), n (%) 1 (5) 19 (95) 0.0006 Pharmaceutical (n=23), n (%) 8 (34.8) 15 (65.2) 0.005 No funding declared (n=8), n (%) 1 (12.5) 7 (87.5) 0.1 Acute or community Acute: research mostly in hospital setting (n=33), n (%) 7 (21.2) 26 (78.8) 0.02 Community: research mostly in community setting (n=107), n (%) 48 (44.9) 59 (55.1) Investigative medicinal product used (n=45), n (%) 21 (46.7) 24 (53.3) 0.2 2019 mean impact factor (SD) 9.67 (16.5) 7.5 (15.4) 0.4 Published in journals* Yes (n=20), n (%) 12 (60) 8 (40) 0.04 No (n=120), n (%) 43 (35.8) 77 (64.2) Institution type of the corresponding author University (n=110), n (%) 44 (40) 66 (60) 0.7 Hospital (n=21), n (%) 4 (19) 17 (81) 0.04 Pharmaceutical (n=7), n (%) 5 (71.4) 2 (28.6) 0.05 Government/large national institution (n=2), n (%) 2 (100) 0 (0) 0.07 P value in bold denotes statistical significance. *Includes publication in the following journals: The 1993 NIH Revitalization Act mandating race and ethnicity reporting in research it funds3 is likely to have contributed to the improved reporting in the USA compared with the UK, with NIH funded study reporting in 90.3% of publications.5 However, Rees et al 2 reported a relative increase in reporting over the past decade well after legislative introduction, and as the NIH only funds a proportion of paediatric research within the USA, other factors are likely contributing to this improvement.3 The UK National Institute for Health Research (NIHR) has developed an ethnicity framework in 2020 aiming to broaden participation, as well as creating a toolkit following on from the INCLUDE project.6 The framework provides questions to guide both funders and research groups through promoting inclusion of underserved groups and tackling barriers to inclusion. Competing interests ML receives grants from Boston Children’s Hospital Research Funds, Great Ormond Street Hospital Charity and Great Ormond Street Hospital/Guy’s and St Thomas’ Trust/St Mary’s Hospital Charity; has received consultation fees from CSL Behring, Novartis, Octapharma and Roche; has received travel grants from Merck Serono; and was awarded educational grants to organise meetings by Novartis, Biogen Idec, Merck Serono and Bayer.
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