Because the word abuse is too intense, often parents are not aware of their abusive act to their child, and the child also fails to recognize his/her own condition as unjust. Thus, the medical physician’s objective evaluation and proactive response to the famiy is crucial. However, such participation involves many risks, and this causes denial and trivialization to the person involved in. But denial and trivialization do not happen without awareness to the issue. It is said that 2% of the children require active support to implove their maltreatment condition. In allergic practice, most physicians would deal with the steroid phobia for atopic dermatitis. However, 80 percent of this problem can be resolved through patient education by medical personnel. On the other hand, when the parent’s prejudice is too rigid to be amended, it becomes difficult for medical personnel to handle the case alone. Experience is important in cases of patients with serious condition. Such experience can be accumulated by dealing thoroughly with familial problems in daily clinical practice. On the other hand, powerful factors that encourages notification of child abuse from the doctor are “enrichment of education for medical students” and “acknowledgement of child protection team within the hospital.” I’d like to emphasize the importance of systematic approach to this issue.

 Even nowadays, when guidelines for allergic diseases have been developed and standard medical treatments based on evidence have become available at any medical institutions nationwide, treatment refusals due to religious reasons, prejudices or other reasons, and erroneous methods of treatment that are not based on evidence are still widely spread by word-of-mouth via internet and in folk medicine. On the other hand, we also frequently encounter cases in which sufficient child care and treatment are not be provided due to poverty and the family’s lack of competence or disease awareness. As the so-called ‘worrisome cases’ require more time and consideration than general diagnosis and treatment, they are deemed troublesome and tend to be neglected and avoided. It is important to consider parents’ feelings and to try not to reject their opinions as much as possible, so that they could accept treatment. However, it is not uncommon for their opinions or feelings to be contrary to their children’s healthy growth and development, which complicates treatment. When necessary, it is important for us, healthcare professionals, to do what is best for the children in line with the ‘child first’ motto, even if it contradicts their parents’ opinions.

 Munchausen’s syndrome by proxy (MSBP) describes parental behavior that creates the appearance of or produces sicknesses in a child. Long-term follow-up is necessary because MSBP may be fatal if ignored. We need to be sensitive to this strange syndrome. It has been reported that several MSBP cases are often disguised as allergic diseases. We present the case of a nine-year-old boy who exhibited poor weight gain and vitamin B1 deficiency caused by MSBP that was disguised as various food allergies.

 In daily practice, it is difficult to diagnose MSBP and to observe patients for a long time at a single medical institution. The Child Protection Team (CPT) is helping us protect children affected by this syndrome by conducting a case conference. There is an urgent need to create an information sharing mechanism to facilitate successful multi-occupational collaboration.

 Clients in pediatric outpatient counseling unit usually consult about psychosomatic symptoms or developmental difficulties or difficulties in school life except child abuse. Through counseling, their difficulties will often decrease.

 But, despite “doing as usual”, some clients do not easily improve. Psychologists may feel “it’s not going well” in cases that cancel appointments suddenly, come late frequently, have difficulty understanding the psychologists’ explanations. Psychologists may feel they would like to “disengage from them”.

 However, this “difficulty in building relationships”, might also arise from the client’s own difficulty in building relationships. In addition, it may be difficult for some clients to provide their children proper care for treating allergies.

 Therefore, when feelings of “it’s not going well” appear, contrary to “disengaging from the clients,” it is recommended providing a more intensive treatment.

 It is recommended trying to “talk slowly, politely, and calmly”, “not be aggressive”, “be fair (not so preferential for children)”, “be a constant person”, “keep promises”, “teach that there are reliable ones” and so on.

 And we should encourage clients to overcome difficulties by setting feasible small steps that clients progress beyond, aiming to decrease difficulties even if only slightly.

 Cough is a biological defense reaction, and its pathway has physiological response and pathological reaction.

 As a pathological reaction, there are states of increased or decreased cough sensitivity, in addition these cough receptors mediated mechanisms are stimulated by mechanically or chemically, C-fiber receptors are stimulated by airway inflammation and the neuropeptides such as substance P (SP), neurokinin A (NK-A) and CGRP are released, especially it is believed that SP stimulates receptors in Aδ fibers and its impulse is transmitted via the vagal nerve afferent pathway to the medullary cough center, and causing coughing.

 There is other mechanism via smooth muscle contraction in pathological cough reaction, and each of which is independent.

 Prolonged cough is thought to be due to either pathway of two pathological responses or merger of both pathways.

 On the other hand, TRPV1 cloned as a capsaicin receptor is expressed in sensory nerve specific (C fiber, Aδ fiber).

 Our study showed that TRPV1 was distributed in all respiratory organs and co-localized with SP, NK-A and CGRP.

 It is suggest that TRPV1 is involved in cough and airway contraction because these neuropeptides are released from it by stimulation, in addition it is thought that its activation could be more hypersensitive due to airway inflammation.

 Airway secretion is essential for the maintenance of normal respiration, but hypersecretion gives rise to various negative effects, including impaired mucociliary clearance, which leads to prolonged cough. Asthmatic patients with chronic cough and sputum are known to exhibit poor disease control and more frequent exacerbations. For those patients, essential treatments to control airway inflammation are insufficient, and strategies that directly target airway secretion are also important. Treatment for hypersecretion includes ①suppression of mucin production, ②inhibition of mucin secretion, and ③promotion of mucociliary clearance.

 The studies on coughing have mainly been dependent on subjective reporting, the measurement of the sensitivity of the cough reflex, and the quality of life (QOL) in relation to cough. The subjective reporting of symptoms and QOL by parents of children tends to be imprecise and may be influenced by various factors, including the environment, clinical setting, and even the personality of the parents. One of the serious problems is that cough mainly occurs at night, and may not be perceived by either the patients or their parents, thus, the recall of symptoms that occur overnight is poor. We recently developed an original objective method to measure overnight cough in pediatric patients using a cough monitor, which is simple, safe and effort-independent. The aims of the present study were to classify the cough severity and to evaluate a characteristic pattern of cough frequency in children with prolonged cough using our objective cough monitoring system. We want to demonstrate that the nocturnal cough data obtained by objective cough monitoring represents a new step in the treatment of childhood chronic cough.

 Pediatricians often encounter a child with persistent cough in the daily practice. There are numerous causes of persistent cough. However, many of them are just a series of recurrent “cold.” Especially in a young child who has newly joined a nursery or kindergarten. On the other hand, there are serious contagious diseases such as pertussis and tuberculosis, which requires intervention as soon as possible. Thus, it is critical to determine whether the cough really needs to be treated. Therefore, a systematic approach to the diagnosis of a persistent cough is indicated in the clinical guidelines. Generally, there is so-called a pointer, which leads to a specific diagnosis. Thorough history taking, physical examination, chest X-ray, lung function tests, should be performed efficiently. However, there are non-specific coughs without any clues besides a persistent cough. These non-specific coughs may be treated as asthma or infection. However, they often get well in the natural course, with or without medication. Thus, use of medicine should be as judicious as it could be.

 Lower respiratory symptoms appear from various reasons. In some cases, it’s difficult to diagnose the reason for wheezing. We describe a previously healthy 13-month-old boy who wheezed for over a month. He was taken to a clinic where he was initially diagnosed and treated for bronchial asthma. However, the symptoms persisted for over a month. Computed tomography revealed a foreign body shaped like a stag beetle lodged in his esophagus. Edema around the foreign body had caused tracheal compression. Endoscopy under general anesthesia resulted in the extraction of a plastic seal with a 2.3-cm diameter that was shaped a stag beetle. Children who swallow a foreign body in the absence of a witness can remain undiagnosed for long periods. Symptoms of foreign body ingestion include respiratory symptoms such as wheezing and coughing. The possibility of an ingested esophageal foreign body should be considered when young children present with wheezing symptoms.

 Anaphylactic symptoms and psychogenic reaction are sometimes difficult to distinguish. An 11-year-old boy with no history of allergies presented to the emergency department with dyspnea after eating one-eighth of an apple. He was diagnosed with anaphylaxis (An) and given intramuscular adrenaline injection and other anaphylactic treatments. Subsequently, he was referred to our hospital for further examination. With open oral food challenge, dyspnea developed after eating one-eighth of an apple. Upon determining that he was suffering from An, he was administered intramuscular adrenaline. Thirty minutes later, he lapsed into hyperventilation, and was treated with bag rebreathing. As we suspected the possibility of a psychogenic reaction, we interviewed the patient about his daily life, through which his hectic lifestyle was revealed. Subsequent blind oral food challenge to apple was negative ; therefore, we strongly suspected the manifestation of a psychogenic reaction. Findings from an interview with his mother conducted by a clinical psychologist strongly indicated that he might have been experiencing emotional conflicts, stress and frustrations with his family relationships, cramming in school, and participating in sports activities. He was given counseling, which resolved the symptoms, suggesting that potential involvement of psychogenic factors should be considered in anaphylactic-like conditions in adolescent patients.

 Recently, erythritol has been increasingly consumed as a diet food, and accordingly, pediatric cases of immediate hypersensitivity reactions to erythritol have been reported. We herein report another case of erythritol hypersensitivity characterized by allergic symptoms and signs not only to food products but also to the dry syrup formulation of the anti-influenza medicine TAMIFLU^®. The present patient was a nine-year-old girl who had a two-year history of immediate allergic symptoms and signs, such as eyelid edema, uriticaria, and dyspnea, after the intake of low-calorie jelly, gum, or powdered green tea ice cream. She also developed similar symptoms and signs when she took TAMIFLU^® dry syrup. Because erythritol was the only component common to those food products and the medicine that induced hypersensitivity reactions, we suspected erythritol as the causative agent. A skin prick test with a sweetener containing 99% erythritol was negative ; however, upon oral challenge with 1 g of erythritol, she developed eyelid edema and uriticaria on the face and trunk, leading to a diagnosis of erythritol allergy. Given that erythritol is included in various sweets and drugs, we should be alert for this clinical entity in children.

 PURPOSE : This study aimed to clarify the relationships between parenting stress, as recognized by mothers of young children with asthma, and family functioning and social background.

 METHODS : Participants were mothers of young children with asthma. The children were between 1 and 6 years old and all had a history of asthma or asthmatic bronchitis for more than 6 months. The participants were recruited from hospitals and a self-help group. The mothers were asked to complete a questionnaire about demographics, asthma condition, family functioning, and parenting stress and to return it to a researcher.

 RESULTS : Fifty-one participants returned the questionnaire (85.0% recovery rate). Of the children, 47.0% had poorly controlled asthma and 35.3% had moderate to severe asthma. Approximately 15.7% of the mothers were at high risk for parenting stress, and 41.2% scored above the cutoff level for declining family functioning. Multiple regression analysis revealed that advanced maternal age, high maternal educational attainment, children with severe asthma, and declining family functioning in the roles and affective involvement categories were correlated with the worsening of parental stress.

 CONCLUSION : Older and more educated mothers of children with asthma tended to feel stress. This result indicates the possibility that reducing parenting stress in these mothers could be achieved by relieving severe asthma and improving role and affective involvement in family functioning.

 Objective : To evaluate the effectiveness of washing with soap in fall-winter as treatment for eczema in children with atopic dermatitis (AD).

 Methods : We conducted a nonrandomized intervention trial. We enrolled children with AD whose eczema was controlled with regular steroid ointment application on less than 1 of 3 days. For 4 weeks, participants washed their upper and lower limbs on one side with soap and on the other side without soap. The primary outcome was the difference between the soap and non-soap sides in the absolute change in EASI scores from baseline to week 4.

 Results : Of 30 participants, 4 withdrew ; the remaining 26 were analyzed. For the soap and non-soap sides, the primary outcome was −0.10±0.4 and −0.03±0.3, respectively (p=0.48), the mean POEM score was 1.4±1.6 and 1.4±1.6, respectively (p=0.95), and the total frequency of additional steroid ointment applications was 7.7±11.1 and 7.7±12.6 times, respectively (p=1.0). Participants were categorized according to self-assessments of the usefulness of soap. Four, 17, and 5 were assigned to soap-effective, invariant, and non-soap-effective groups.

 Conclusion : For children with controlled AD, washing with soap was not effective for treating eczema in the fall-winter.

 Allergic conjunctivitis disease are conjunctival inflammatory diseases caused by type Ⅰ allergic reactions. In this review, we will describe mainly allergic conjunctivitis diseases seen in children. Allergic conjunctivitis diseases can be classified into four categories as follows : allergic conjunctivitis (seasonal/perennial), atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Atopic keratoconjunctivitis and vernal keratoconjunctivitis are severe diseases in children and are accompanied with conjunctival proliferation. In cases with severe allergic conjunctivitis disease, anti-allergic ophthalmic solution is used in combination with immunosuppressive and steroid ophthalmic solution. During treatment with steroids, it is necessary to pay attention to the onset of glaucoma due to elevated intraocular pressure as a side effect of steroid. Measurement of serum and tear antigen-specific IgE can be effective for diagnosis of allergic conjunctivitis diseases. Specific immunotherapy using the identified antigen can be effective in reduction of symptoms in the future.

 In the 2016 Japanese Pediatric Guidelines for Food Allergy, food-dependent exercise-induced anaphylaxis (FDEIA) was defined as anaphylaxis that is provoked by a combination of specific food ingestion and physical exercise, and excluded cases with past history of immediate food allergy (i. e., after oral immunotherapy).

 FDEIA is IgE-dependent, and can be associated with several factors other than food and exercise. FDEIA occurs rarely and first onset is generally between the ages of 10 and 30 years. The main causative foods are wheat and crustaceans. FDEIA tends to occur during vigorous exercise, such as running and ball games, and within 2 hours of eating the causative food.

 The causative food can be identified by investigating the clinical history and performing an allergy test. In addition, further provocation tests may be required to confirm diagnosis. Provocation tests have a low success rate, which can be improved by administering acetylsalicylic acid (ASA) prior to test. However, ASA may induce severe symptoms, and its use is therefore not recommended in a first provocation test.

 Consumption of the causative food should be avoided for 2 hours prior to physical exercise. However, the quality of life of the patient should not be impaired by inappropriate meal and exercise restrictions.

 Oral allergy syndrome is an IgE mediated immediate food allergy of which reaction is localized to the oral mucous membrane. In this chapter, it is defined as pollen-food allergy syndrome (PFAS) which affects patients with pollen allergy. The common causative foods include fresh fruits, vegetables, and legumes and allergens include Bet v 1 homologs and profilin, which show cross-antigenicity with pollens. Thorough history taking and identifying antigen-specific IgE antibodies can help achieve a definitive diagnosis. To identify specific IgE antibodies, a prick-prick test using fresh vegetables and fruits is superior to measuring antigen-specific IgE antibodies in the blood. An elimination diet is the basis of treatment ; however, many heat-treated foods can be orally ingested.

 Since 30～50% of patients with latex allergy are reported to have hypersensitive reactions to fruits and vegetables, these cases are also referred to as latex-fruit syndrome.

 Non-Immunoglobulin E (IgE)-mediated gastrointestinal food allergies in neonates and infants and the related diseases are described in Chapter 12 of the new guideline, the 2016 Japanese Pediatric Guideline for Food Allergy (JPGFA). Herein, the modifications from the previous guideline, the JPGFA2012, and the new information added have been explained. In particular, the JPGFA2016 contains more pages than JPGFA2012 that describe eosinophilic gastrointestinal disorders and gluten-sensitive enteropathy as subsections of chapter 12.

 Patients with food allergies and their families must be vigilant about food allergen avoidance every day. The burden of avoidance and fear of an accidental exposure can increase anxiety and result in reduced quality of life. Physicians are required not only to support them but also to create safe social systems, especially at schools. The Ministry of Education, Culture, Sports, Science and Technology has published guidelines for the management of food allergies in schools. A key to its success is to work in cooperation with schools to form an effective partnership. The first step is to share accurate information about patients. The “Certificate for School Life Management” is mandatory at schools, and the “Certificate for Nursery Life Management” is required at nurseries. Despite the best avoidance efforts, accidents can and do happen. Hence, training should be imparted by a healthcare professional regarding treatment protocols, including the use of an epinephrine auto-injector.