There are few investigations from the patient's point of view on the school lunch program for children with food allergies. We interviewed the parents of children with food allergies about the menu of the lunches provided by the school between August and September, 2010. On the basis of diagnosis made at our allergy clinic, 183 participants excluded either hen eggs, milk, or wheat from the menu of their school lunches. All the participants were attending kindergarten (n=46), nursery (n=51), or elementary school (n=86) in Aichi Prefecture in which school lunches were provided. Among the children attending a nursery, 35% (n=18) were provided school lunches with a substitute menu and 88% (n=45) were provided a menu with the allergenic food excluded. Sixty-one percent of the children (n=31) did not have to bring their own lunch box. Half of the children attending kindergarten were supplied nutritionally adequate lunches, and the other half had to bring their own lunch almost every day. Only 14% (n=12) of the schoolchildren did not have to bring their own lunch box. The frequency of children carrying their own lunch boxes was associated with exclusion of multiple foods, exclusion of wheat, and the limitations of the central kitchen facility, especially in the elementary schools.
School lunches for the children with food allergies seemed to be insufficient in Aichi prefecture. Social education to improve the situation might be needed through the comparison with advanced areas.

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In order to clarify conditions of asthma control, evaluate JPAC and its relation to personal asthma management and identify issues for nursing support, a self-administered questionnaire was given to guardians of children diagnosed with bronchial asthma, residing in Hokkaido and requiring regular visits to the hospital, between February and April of 2010. Analysis of the 403 valid replies determined that 24.8% of respondents had "total control", 38.5% had "good control", and 36.7% had "inadequate control". As for the self-management and self-control of asthma, half of respondents stated they forgot to take their medicines, 60% of guardians smoked, 20% kept pets, and slightly less than 20% used PEF. As for awareness of the degree of severity of their children's illness, 90% claimed that their condition was "mild", and more than 80% held to the belief that their children's conditions would either be cured or improve over time. This represents a large gap between the objective severity of illness and guardians' recognition thereof. The task for nursing, then, is to lay the foundations for independent maintenance of health grounded in, and guided by, independent indicators of severity.

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In 2011, we conducted a survey of the treatment of childhood asthma in clinics and hospitals in Nara prefecture, using the same case-study questionnaire that we used in our 2005 and 2007 studies. The survey was conducted from June 1^st to July 31^st, 2011, and 86 doctors completed the questionnaire. In this survey, 22% of the doctors were members of the Japanese Society of Allergology, 26% were members of the Japanese Society of Pediatric Allergy and Clinical Immunology, 67% were members of the Japan Pediatric Society, and 22% were members of the Japanese Society of Internal Medicine. In this case study, model case 1 was infantile atopic asthma with 3 episodes of wheezing during the past 3 months. In this case, the most selected medication for long-term medication was a leukotriene antagonist (74%) and the second was anti-allergic drugs (26%). The regular use of beta2-agonist combined with inhaled disodium cromoglycate (DSCG) was selected by 6% of the doctors in 2011, which was less than in 2005 (40%). Model case 2 was atopic asthma in childhood treated with theophylline and an antihistamine, which had more than one episode of wheezing during the past month. In this case, the most selected medication for long-term medication was inhaled corticosteroids (64%) and the second was leukotriene antagonist (57%), which was increased significantly from the survey in 2007. The regular use of beta2-agonist combined with inhaled DSCG was selected by 22% of the doctors in 2011, which was less than in 2007 (63%). Comparison of the medications used with the 2 model cases in 2011, 2007 and 2005, showed the use of beta2-agonist in combination with inhaled DSCG was decreased and the use of leukotriene antagonist was increased.

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A 1-year-7-month old boy was referred to our hospital suspected of nutritional rickets. He had received a diagnosis of food allergy by a dermatologist at 4 months old. The mother had eliminated egg, cow's milk, and wheat from her diet so that the proteins could not being passed through the breastmilk. He had taken an elimination diet in which egg, cow's milk, and wheat were removed. Around at 1 year old, urticaria had developed and he had gotten fretful after fish intake. As IgE antibodies against fish had showed positive, fish intake had been restricted. At the first visit, radiographic images of lower legs showed little rickets changes. Blood examinations revealed the marked elevation of levels of alkaline phosphatase and parathyroid hormone, while serum concentrations of calcium and phosphate were within normal range. At 1 year 8 months old, he suddenly showed a drastic drop in running ability and blood exam revealed the low level of 25(OH)D, which led to the definitive diagnosis of vitamin D deficiency rickets. Restriction of fish that are the main sources of vitamin D with breast-feeding would cause vitamin D deficiency rickets though he had gotten enough sun exposure. This case indicated that we should take note of rickets even without any symptoms in a food allergy patient who need restriction diet.

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Recent advances in the treatment of asthma have contributed greatly to the control of patient's symptoms and improvement of quality of life. Therefore, pharmacological therapies would only be paid attention to, and it should be easy to forget guidance of the environment control. In particular, it is likely that the spread of inhaled corticosteroids have led to such a situation. Failure to avoid from exposure with inhalant allergens such as dust mites and non specific factors including cigarette smoke and other air pollutions involved in the exacerbation of asthma results in severe or refractory asthma. Also anti-asthmatic drugs more than necessary could be prescribed in order to obtain good control. The Japanese Pediatric Guidelines for the Treatment and Management of asthma 2012 indicates that the basic idea of long-term management of asthma in children is not composed only of drug therapy, and environment controls and educational activities should be carried out as well. Chapter 4 entitled "Risk factors and its prevention", comments on risk factors of the onset and exacerbation of asthma, and recommends the methods of prevention of asthma.

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[in Japanese]

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[in Japanese]

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Most patients with food allergy will develop tolerance to food allergen.
Most patients with egg, cow's milk, wheat and soy bean allergy are likely to develop tolerance while the patients with buckwheat, peanut, tree nuts, crustacea and fish allergy are unlikely to develop tolerance. The patients who have allergy to more than one food, the other allergy such as asthma or atopic dermatitis, the past history of anaphylaxis shock are unlikely to develop tolerance. In laboratory test specific IgE level to food allergen seems to be predictive of allergy outcome.

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[in Japanese]

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