The patient was a 6-year-old girl who had two episodes of frequent vomiting approximately 3 hours after eating school lunch. On both occasions, the only symptoms were vomiting and fatigue, which improved the next day. Cashew nuts were common to the items consumed. She had never eaten cashew nuts before the first episode. The patient was receiving treatment for bronchial asthma. Her brother also had a food allergy, while her parents had hay fever. Prick test of cashew nuts and cashew nuts-specific IgE test yielded negative results. Also, an oral food challenge test with cashew nuts induced vomiting 2 hours after ingestion. She was diagnosed with food protein-induced enterocolitis syndrome (FPIES) caused by cashew nuts. In recent years, the consumption of cashew nuts has been increasing, and this has been accompanied by an increase in IgE-related allergies. However, reports of FPIES by cashew nuts are rare. Since cashew nuts are occasionally served in school lunches, they may induce an allergy in school-age children.

In recent years, the approach to pediatric food allergies (FA) has changed because of a paradigm shift wherein earlier exposure to allergens is deemed more beneficial. Guidelines have been developed and nursery schools are required to respond to FA in a directed and more cautious manner.

While dealing with pediatric FA, it is important for local medical specialists to understand the current practices and response measures, establish an efficient and coordinated system with the frontliners, and explore areas of improvement.

A questionnaire was distributed prior to the workshop, and a survey was conducted to know the status of dealing with FA among nursery school children and the incidence of accidental ingestion of food allergens. The results of the survey and the effectiveness of the workshop will be discussed.

Most accidental ingestion of food allergens occurred during snack time. However, the number of children with FA has decreased over the past three years, especially among those ≤ 1 year. The number of incidents of accidental ingestion of food allergens decreased from an average of 20.6 incidents/year to 7 incidents/year and 8 incidents/year in the 5 years before and after the start of the workshop.

These results suggest that by incorporating food allergy workshops for all nursery schools in Kasugai City, it was possible to reduce the incidence of accidental ingestion.

Objective: This study aimed to clarify the current status of tree nuts in a comprehensive analysis of pediatric anaphylaxis cases.

Methods: The Aichi Medical Association surveyed pediatric anaphylaxis cases aged under 15 years from 87 secondary and 25 tertiary emergency care hospitals in Aichi Prefecture (population 7.5 million), Japan.

Results: Of the 2,480 food-induced anaphylaxis cases identified between April 2017 and March 2021, 308 were tree-nut-induced. The cases per year was 40, 74, 94, and 100 in 2017, 2018, 2019, and 2020, respectively. Egg and milk were the most frequent among food triggers in 2017, while the greatest proportional increase was observed in tree nuts from 6.0% in 2017, ranking fourth, to 18.8% in 2020, ranking first. Tree nuts were the first-ranking causative food in the 1, 2- and 3-6-year-old groups in 2020. Overall, 189 (61.8%) cases were admitted to the hospital, of which three were admitted to the intensive care unit. A total of 147 were treated with adrenaline, and 55 cases included previously prescribed adrenaline auto-injectors. Walnut (45.5%) accounted for the highest incidence among tree nuts, followed by cashew (20.1%), macadamia, and pistachio.

Conclusions: The proportion of tree nuts in food-induced anaphylaxis has increased.

The laceration caused by adrenaline auto-injector (AAI) use is the adverse event that could occur when AAIs are used. Here, we experienced a case of the laceration caused by AAI use at the medical settings in a 2-year-old boy. The patient had egg allergy and was prescribed AAI. He experienced an oral food challenge test and started to intake programmed boiled egg. One day, he developed anaphylaxis after intaking the same amount of egg. He and his caregivers visited emergency room without using AAI because they could not decide to use it. His mother asked the doctor to use AAI by herself under the medical staff's supervision and the doctor accepted her wish. Then, the doctor held patient's legs and his mother used AAI, but the patient moved his legs. AAI was removed smoothly from patient's thigh and his symptoms recovered quickly. However, the patient incurred a 10cm-long laceration, which resulted in scar.

Medical staffs have few opportunities where they actually experience AAI use. This might be a rare incident, but it is important to educate medical staffs continuously through appropriate education, such as simulation education so that they are familiar with the management of AAI use.

Effective allergen immunotherapy has been studied for more than a millennium and since that time researchers have been working to improve efficacy and reduce the side effects. The mechanism of allergen immunotherapy is to induce regulatory T (T_reg) cells and reduce T helper (Th) 2 cells to induce class switching from IgE to IgG and induce blocking antibodies to inhibit IgE allergen binding. Modification of allergens and routes of treatment has been performed. Among them, many researchers were interested in peptide immunotherapy. Since T cell epitope peptide has no IgE epitope, it is unable to bind IgE, but rather induces T_reg and reduces Th2 cells, respectively, and therefore, considered an ideal therapy. Results from cellular and animal model studies have been successful, however in clinical studies, T cell peptide immunotherapy has failed to show efficacy and caused side effects, because of the high effective rate of placebo and the development of IgE against T-cell epitope peptides. Currently, the modifications of IgE-allergen binding by blocking antibodies are necessary for successful allergen immunotherapy.

Cedar (Cryptomeria japonica) pollinosis is one of the most common allergic diseases in Japan. Cedar pollen contains several allergens, including gibberellin-regulated protein (GRP). GRPs are widely conserved proteins in plants and have been reported as fruit allergens, including Pru p 7, which was identified in peach fruit, causing mainly oral symptoms and in some cases systemic allergic symptoms.

We recently reported that one of the causes of fruit allergy in cypress pollinosis patients is the development of pollen-food allergy syndrome (PFAS) caused by GRPs, Cup s 7 from European cypress (Cupressus sempervirens) pollen and Cry j 7 Japanese cedar (C. japonica) pollen.

In this paper, we review the allergen studies of GRP, including PFAS.

Chapter 12 of the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2020 describes the management of asthma in daily life, focusing on school and preschool life, exercise, vaccination, and disaster. If special consideration is required in school, preschool, or extracurricular activities, the instruction table for school life management and cooperation with parents and school is referred for appropriate action. Exercise-induced asthma (EIA) is a phenomenon in which wheezing and dyspnea occur temporarily during or after exercise in patient with asthma. The stakeholders should properly understand EIA and cooperate to eradicate EIA from school children. Vaccination can be administered in asthmatic as well as healthy children. When an asthmatic child is planned for general anesthesia or surgery, asthma should be controlled as much as possible, as needed. To prevent unforeseen circumstances such as natural disasters, some action plans should be devised. Brochures are available for use before occurring emergencies.

Since its first edition in 2000, each revision of the Japanese Pediatric Guidelines for the Treatment and Management of Asthma has progressed in response to the final statement on future issues in the previous editions. This year, 9 issues were listed, and examples of future research questions were also provided.

1) Further development as an EBM guideline and more evidence "from Japan" should be obtained; 2) Diagnostic criteria and treatment guidelines for infantile asthma should be clarified; 3) For better transitional care, more evidence on asthma in adolescents and young adults is needed, 4) Criteria for selection and discontinuation of biologics should be clarified; 5) Positioning of allergen immunotherapy in asthma treatment; 6) Development of better biomarkers for treatment selection and elucidation of asthma pathophysiology; 7) Comprehensive asthma care including comorbid allergic diseases such as allergic rhinitis; 8) The need for a comprehensive asthma care system; 9) Establishment of comprehensive treatment scheme of asthma and comorbid allergic diseases such as allergic rhinitis. 8) Further research on respiratory infections that are closely related to the onset and exacerbation of asthma, and a 'novel' concept of infection control in asthma care, which was highlighted by the COVID-19 pandemic, and 9) Further promotion of equalization of asthma care based on the Basic Law on Allergic Disease Control and Prevention.

The popularization of the Japanese Pediatric Guideline for the Treatment and Management of Bronchial Asthma (JPGL) has enabled standardization of the approach to pediatric bronchial asthma. This has resulted in the appropriate use of basic anti-asthmatic drugs for children. In chapter 14 of the JPGL 2020, the principal therapeutic agents for pediatric bronchial asthma are listed. These medications have remained almost unchanged over recent years except for updates on the information on biologics since JPGL 2017. In particular, the age of insurance coverage for use of mepolizumab has been lowered to at least 6 years and dupilumab has been newly approved for use in children over 12 years old. In addition, fluticasone propionate/formoterol fumarate hydrate has become available for children over 6 years of age. As with JPGL 2017, the table in chapter 14 was prepared based on the information obtained from the Pharmaceuticals and Medical Devices Agency. The contraindications and adverse reactions of these drugs are described separately. This article presents a brief discussion of the principal anti-asthmatic agents listed in chapter 14, by quoting the interpretations provided in the main text of JPGL 2020.

The Japanese Guidelines for Food allergy (JGFA) 2021 has been revised five years after the previous edition and is based on the policy of Medical Information Network Distribution Service. The JGFA was developed by a three-tiered organizing committee. The committee finalized the scope of the JGFA and selected four clinical questions (CQ) on oral immunotherapy and oral food challenge test based on the key clinical issues. Systematic reviews on two CQs on oral immunotherapy were conducted by referring to the relevant Cochrane review, and those on two CQs on oral food challenge test were conducted including observational studies. The results were reviewed by each outcome, and the total body of evidence was evaluated along with the bias. The recommendations were determined by a confidential ballot of all committee members. Each recommendation on the JGFA is included with a commentary.

1. A food allergy is defined as "a phenomenon in which adverse reactions are caused through antigen-specific immunological mechanisms after exposure to a given food".

2. Allergens involved in food allergy might be non-food, the intrusion routes of them vary.

3. Food allergies are immunologically classified into IgE-mediated reactions and non-IgE-mediated reactions. Based on the time course, it is divided into immediate reactions and non-immediate reactions. Most of the IgE-mediated reactions cause immediate reaction, but it is not always the case.

4. Symptoms provoked by food allergy include skin, mucosal, respiratory, gastrointestinal, nervous and cardiac organs.

5. Anaphylaxis is defined as "severe hypersensitivity reaction that may cause a life-threatening risk with systemic symptoms induced at several organs". Anaphylaxis shock is that accompanied by reduced blood pressure or incontinence.

The chapter on "Food Allergens" in the Japanese Guidelines for Food Allergy 2021 was written to organize the knowledge required for an overview of food allergens. First, general knowledge of allergens was mentioned, including the fact that the majority of food allergens are proteins, knowledge of allergen epitopes and mechanisms of allergen reduction. Next, the confusingly used terms cross-antigenicity and clinical cross-reactivity were explained, noting that cross-antigenicity does not necessarily mean clinical cross-reactivity and the extent to which clinical cross-reactivity occurs between foods that exhibit cross-antigenicity. Four protein superfamilies containing most plant food allergens, prolamin, cupin, Bet v 1 homolog [pathogenesis-related protein: PR-10], and profilin, and three protein superfamilies containing most animal food allergens, tropomyosin, parvalbumin, and casein, are described.

Since food is a beneficial foreign substance for organisms, oral tolerance is induced and suppresses an excessive immune response. Such failure of oral tolerance is considered a pathogenic mechanism of food allergies. Sensitization to food allergens is induced by multiple exposure routes, including intrauterine sensitization, transcutaneous sensitization, transintestinal sensitization, respiratory tract sensitization, and their role in the development of food allergies has garnered attention.

In terms of IgE-dependent allergies, IgEs are cross-linked via the binding of multiple allergen-specific IgE on mast cells and allergens, inducing the degranulation of chemical mediators and the production of lipid mediators, etc. Regarding the pathology of non-IgE-dependent allergies, specific lymphocytes are thought to play an essential role in the pathology; however, the details thereof remain unclarified.

Many patients with immediate-type food allergies in their childhood acquire tolerance as they grow. The development of digestive tract digestive functions, physicochemical defense mechanisms, and oral tolerance mechanisms due to growth are considered mechanisms of acquiring tolerance to food allergy. On the other hand, allergen immunotherapy induces desensitization and/or sustained unresponsiveness, suppressing symptoms.