Objective : To seek a novel interpretation criteria for MAST Immunosystems Ⅲ, a multiplex specific IgE assay system.

 Methods : Children who volunteered to participate in the study, n=186, 6-18 years old (mean 11.6), and children with asthma on treatment, n=164, 6-18 years old (mean 10.0) were enrolled after informed consent. They answered a questionnaire including physian diagnosis of asthma, allergic rhinitis (perennial and seasonal), atopic dermatitis and food allergy and underwent spirometry, FeNO measurement, blood test for serum total IgE, white blood cell count, eosinophil% and specific IgE by MAST Immunosystems Ⅲ (MAST-33). A multivariate mathematical technique, k-means cluster analysis, was performed on the MAST-33 lumicount data.

 Results : Identified 4 sensitization clusters were 1 : Multiple with food, 2 : Inhalant allergen with pet, 3 : inhalant allergen without pet, and 4 : Low with Japanese cedar pollen. Total IgE was highest in cluster 1 as expected, but eosinophil% and FeNO were highest in cluster 2. Prevalence of asthma was very high in cluster 2. Seasonal allergic rhititis was common in cluster 1 and 3. Atopic dermatitis and food allergy were common in cluster 1.

 Conclusion : Cluster 2 may be a phenotype for asthma. Interpretation of MAST-33 results by sensitization pattern may be useful for clinical practice.

 Erythritol is a low molecular sugar alcohol. Its use in the food and confectionery industry is increasing because of its low calorie content. Here, we present a patient who developed anaphylaxis after consuming candies that contained erythritol. Our patient was a 10-year-old girl. At “8” “9” years of age, she experienced three anaphylactic episodes after consuming ice cream ; however, the cause was unclear. At 10 years of age, she experienced pharyngeal pain, dry coughing, and urticarial after playing in the park and consuming candies. Therefore she consulted our emergency outpatient department. Erythritol and sorbitol are present in candies, and the possibility of an allergic reaction to these was suspected. Skin prick tests with erythritol and sorbitol were negative, and only erythritol was positive in an intradermal test. This necessitated a single-blind food oral challenge of sorbitol and erythritol. The test was negative for sorbitol. She was administered erythritol (1.7 g in total) ; 30 minutes later, she presented with skin, and respiratory symptoms as well as anaphylaxis. Erythritol was not found to cause a reaction in a basophil activation test performed later. Recently, reports of patients with erythritol allergy have been increasing. In children, frequent consumption of erythritol-containing candies needs attention. It was useful for intake instruction of the sugar alcohol in this case.

 Objective : This study was conducted to systematically understand anxieties faced by elementary school teachers when dealing with children with food allergies and to examine its influencing factors.

 Method : Questionnaires were distributed at public elementary schools throughout Kanagawa Prefecture and 498 responses were received. Exploratory factor analysis was used for systematic understanding and logistic regression analysis was performed to determine the influencing factors.

 Results : Teachers’ “anxiety regarding dealing with children with food allergies” consisted of the following five factors : “anxiety regarding children with food allergies exhibiting allergic symptoms”, “anxiety regarding the response system and educational arrangements for children with food allergies”, “anxiety regarding managing children with food allergies”, “anxiety regarding using an EpiPen^®” and “anxiety regarding emotional aspects of children with food allergies”. The analysis of influencing factors revealed strong anxieties expressed by homeroom teachers and non-homeroom teachers, and suggested that knowledge related to food allergies and methods for handling children with food allergies may assist in easing these anxieties.

 Conclusion : Consideration must be given to training programs and support systems that take into account the multifaceted anxieties faced by teachers, especially focusing on enforcing supports for teachers with strong anxieties who are directly involved with food allergy children.

 Avoidance from allergens exposure is a basic approach for treatment of allergic diseases after onset, however, both primary and secondary prevention from them have not been verified by clinical studies. Especially, infants with inflamed skin such as atopic dermatitis are susceptible to food allergy when they are restricted from taking the targeted foods. Allergen avoidance via oral route is not effective to prevent infants with atopic dermatitis from being sensitized to allergens, since percutaneous sensitization occurs through their inflamed epidermis. Healthy skin protects us from invading of allergens outside of the body. Normal epidermis consists of basal layer, prickle cell layer, granular layer and horny layer. Epidermal skin barrier is composing from various substances such as natural moisturizing factors in a horny cell, intercellular lipid in horny layer, corneodesmosomes combining horny cells and tight junctions between granular cells. Cutaneous barrier function is not intact in the epidermis of a patient with atopic dermatitis. Severity of atopic dermatitis is associated with skin barrier dysfunction and allergen sensitization. An antigen presenting cell in normal skin acts as an immunotolerance inducer, while that in inflamed skin acts as an allergen sensitizer. Prevention of atopic dermatitis and early intervention for it may be effective to prevent allergen sensitization and allergic march.

 Most food allergens are proteins contained in foods. Knowledge of food allergens is essential for understanding food allergies. By knowing the function of food allergens as a protein, physicians who care for food allergy patients can deeply diagnose and treat them. Many of the plant food allergens belong to the four protein superfamilies (prolamin, cuptin, Bet v 1 homologue and profilin), and many of the animal food allergens belong to three protein superfamilies (tropomyosin, parvalbumin and casein). Regarding the former, for example, in the case of soybean, six of the eight types of allergen components registered in WHO/IUIS are included in the four protein superfamilies. The latter is resistant to heat treatment and shows cross antigenicity to a wide variety of animals. Since chicken eggs and wheat contain a family of food allergen proteins other than the seven protein superfamilies, it is necessary to deepen their understanding by confirming the properties and functions as individual proteins.

 The “Diagnosis and Examination” chapter in the Japanese guidelines for food allergy 2017 covers history taking and immunological examinations for food allergy diagnosis. Major updates in the 2017 version includes key aspects in medical examination by interview, various methods for allergen-specific IgE antibody detection, utility of probability curves and allergen component-specific IgE. In history taking, age-dependent symptoms should be considered, especially, a special attention is necessary for breast-fed infants. For specific IgE assays, first new advancements of assay methods are described then their utilities in detail are explained. In interpreting of a probability curve, one should consider age of a patient and amount and cooking style of challenge food. Measurement of the allergen component-specific IgE antibody confers higher diagnostic accuracy. Effective use of diagnostic tests will facilitate correct diagnosis and right management of food allergy.

 The topic of oral food challenge (OFC) has been addressed in Chapter 7 of the Japanese Pediatric Guideline of Food Allergy 2016.

 In addition to detailing the guidelines, Chapter 7 defines and highlights the purpose of OFC, risk assessment, and establishment of an OFC system based on evidence. As shown in the summary, there are 5 major changes. First, the definition of OFC was updated to “OFC is a test to diagnose food allergy in suspected cases and confirm the tolerance of certain foods previously determined to be allergens by ingesting them multiple times or in a single dose”. Second, the purpose of OFC was divided into two main aspects, namely, diagnosis and confirmation of tolerance. Third, risk assessment prior to OFC was also established. Fourth, the reproducibility of the OFC results and the target dose of OFC were examined. It is also recommended that stepwise OFCs be performed regularly to ensure safety during OFC. Finally, a system for implementing OFC safely was also discussed.

 We will explain these changes and the reasons underlying them in detail.

 Background : Inhaled corticosteroids (ICS) and leukotriene receptor antagonists (LTRA) are common drugs for chronic bronchial asthma control. The aim of this systematic review (SR) is to assess the efficacy of ICS compared with LTRA as monotherapy in children with asthma.

 Methods : Randomized controlled trials (RCTs) were selected comparing efficacy of ICS with that of LTRA in children. The subjects were selected from previously published SRs of adults and children and RCTs published until March 2016. RCTs were searched from CENTRAL, MEDLINE, Embase, and the database of the Japan Medical Abstracts Society.

 Results : Twenty RCTs were identified. Patients with ages 2 to 18 years were enrolled. The severity of asthma was classified as moderate-to-severe by the Japanese Pediatric Guidelines for the Treatment and Management of Asthma. We evaluated seven outcomes, including the number of patients who required at least one systemic corticosteroid administration for asthma exacerbation, number of patients who required hospital admission for asthma exacerbation, improvement in lung function, and adverse effects. The number of patients who required systemic corticosteroid administration for asthma exacerbation was significantly higher in the group treated with LTRA, compared with ICS treatment.

 Conclusion : Patients over 2 years old with moderate-to-severe asthma treated with LTRA were more likely to develop asthma exacerbation and require systemic corticosteroids than those treated with ICS.

 Background : A systemic review (SR) was performed to compare the effect of pMDIs with spacers to that of nebulizers in the delivery of short-acting beta2-agonists (SABAs) in the treatment of acute asthma exacerbation.

 Methods : Randomized controlled trials (RCTs) comparing the pMDI with spacers and nebulizers used for the inhalations of SABAs in patients under 20 years of age with acute asthma exacerbation in the emergency department (ED) were selected. The primary outcome was hospital admission after multiple inhalations of SABAs.

 Results : A total of 26 RCTs (30 references) were selected from a previous SR, and none were selected from an additional search. The primary outcome was analyzed from nine studies (363 children), and the risk ratio of the using pMDI with spacers to that using nebulizers was 0.71 (95% confidence interval 0.47～1.08, p=0.11). The time spent in the ED was significantly shorter using spacers than using nebulizers. The rise in pulse rate (% baseline) and frequency of tremors were significantly lower using spacers than using nebulizers.

 Conclusion : The effect of multiple inhalations of SABAs using pMDI with spacers was not different from that of inhalations using nebulizers in children with acute asthma. Further studies using a Japanese usual dose of SABAs in a Japanese population are required.

 A systematic review (SR) was conducted to determine whether increased inhaled corticosteroids (ICS) dosages are useful for acute exacerbation of bronchial asthma in children. Randomized controlled trials (RCTs) were conducted to compare increased and stable daily dosages of ICS for asthma exacerbation in children. RCTs in children were selected from a previously published SR of adults and children. Databases (MEDLINE, Embase, and CENTRAL) were searched for RCTs published until March 2016. RCTs reported in Japanese were searched from a database of the Japan Medical Abstracts Society. One RCT was selected from a previously published SR in children and adults, while a second RCT was selected from an additional search. Both trials used beclomethasone (BDP) as the ICS. One study was a single-center, crossover study conducted in New Zealand, while the other was a multicenter, parallel-group study in the United States. None of the RCTs reported in Japanese were included in this study. The increased dosages of ICS did not reduce the risk of asthma exacerbations that required rescue systemic corticosteroids. Only RCTs that used BUD were found. Therefore, till date, there is limited evidence to support the recommendation of increasing the ICS dosage for asthma exacerbation in children.

 Background : Systemic corticosteroids play a central role in the treatment of bronchial asthma exacerbations in children.

 Objective : To evaluate the effectiveness of systemic corticosteroids for prevention of relapse following acute exacerbations of asthma in children.

 Methods : Randomized controlled trials comparing systemic corticosteroids with placebo for the treatment of bronchial asthma exacerbations in children were searched, and the results of the selected studies were included in a meta-analysis.

 Results : Ten studies were selected. There was no significant difference in the incidence of hospitalization after the intervention between the corticosteroid and placebo groups (relative risk [RR], 0.81 ; 95% confidence interval [CI], 0.42-1.60 ; p=0.55). Significantly fewer patients needed additional treatment after interventions with corticosteroids than with placebo (RR, 0.48 ; 95%CI, 0.33-0.70 ; p=0.0001), but only two studies with a very limited number of patients were eligible for this analysis.

 Conclusion : Treatment with systemic corticosteroids may be beneficial for the prevention of relapse following acute exacerbations of asthma in children. However, because the number of studies included in this systematic review was very limited, further investigations are needed to confirm the effectiveness of systemic corticosteroids.