Background: To secure safe school life for children with allergic diseases, especially food allergy, the School Life Management and Instruction Sheet for Allergic Diseases (SLMIS-A) have been developed by The Japanese Ministry of Education, Culture, Sports, Science, and Technology. A physician prepares SLMIS-A for children with allergic diseases who need special care at school, and schools care the children based on the document. However, occasional erroneous description in SLMIS-A causes confusion. We have developed a web application to support non-specialist physicians to prepare SLMIS-A. We investigated accuracy of the application for food allergy.

Method: Cross-sectional observational study. Data input into the application was performed based on pre-oral food challenge (OFC) questionnaire filled by caregivers of patients with egg, milk, wheat, or peanut allergy between January and August 2020. Output of the application was then compared with the actual SLMIS-A separately filled out by physicians at pediatric allergy department.

Result: A total of 94 input was performed. The consistency rate was 100% for the description of food allergy type and 90.4% for the causative food.

Conclusion: The application may enable non-specialist doctors to prepare a correct SLMIS-A for children with food allergy.

Next to hen's eggs, cow's milk is the second most frequent food allergen that causes accidental and severe allergic reactions. However, it is not generally known that more than 90% of protein drinks, which are rapidly becoming popular in the recent years, are also dairy products that are mainly composed of whey protein derived from milk. In this study, we report three cases of infants with cow's milk allergy who had immediate allergic reactions due to accidental ingestion or contact with protein drinks containing whey protein. In all three cases, the parents were not aware that the protein drinks were dairy products. The amount of milk protein in protein drinks is about six times that of cow's milk, and there have been reports of anaphylaxis in cases where tolerance has already been acquired or during oral immunotherapy. Thus, when a child with cow's milk allergy accidentally ingests a small amount of milk protein drinks, there is a risk of severe symptoms. Since there is concern that similar cases may increase in the future, we report this case with the purpose of alerting the public. We also report the results of a survey conducted on parents with children allergic to cow's milk regarding their perceptions on protein drinks.

In some regions of the Fukui prefecture, difficulties exist in accessing medical care from an allergy specialist, particularly since there is only a limited number of facilities that provide highly specialized treatment. To promote the equalization of medical care and the management of allergic diseases throughout the prefecture, online conferences are conducted monthly, on a weekday evening, via a virtual online platform. In this study, we aimed to assess the advantages and limitations of these conferences by distributing a questionnaire to 22 doctors and 5 pediatric allergy educators who participated in these conferences. Responses were received from 9 allergists, 10 non-allergists, and 4 pediatric allergy educators. Of the participating physicians, 73.7% and 26.3% reported a change in their treatment practices and hospital referrals of patients with allergies, respectively. The convenience of the virtual conferences allowed for a significant increase in the participation of female physicians who would otherwise not have managed to participate in the conventional on-site conferences. The online conferences are easy to participate for female physicians of child-care age and brought about changes in the management of medical care for allergic diseases, thereby considered potentially useful for the objective of equalizing medical care for patients with allergies.

We report two pediatric cases of eosinophilic esophagitis (EoE) that responded favorably to addition of topical steroid therapy to normal dose proton pump inhibitor (PPI) treatment according to the Japanese clinical practice guidelines for eosinophilic gastrointestinal disease in pediatric and adult patients.

Case 1 was a 14-year-old boy who had a 1.5-year history of food impaction and heartburn. He was diagnosed with EoE with maximum eosinophilic infiltration of 50/HPF on esophageal biopsy. Administration of normal dose PPI as a first-line drug failed to achieve a sufficient response. However, addition of topical steroids successfully improved not only his symptoms but also his endoscopic and pathological findings. Case 2 was a 4-year-old boy who had a history of frequent vomiting since infancy. The vomiting worsened after solid food was introduced, and he sometimes refused food. He was diagnosed with EoE with maximum eosinophilic infiltration of 83/HPF on esophageal biopsy. The vomiting disappeared by 10 weeks after starting normal dose PPI treatment, but he required concomitant treatment with topical steroids from 26 weeks of treatment because his food refusal recurred. His vomiting and food refusal improved with these treatments but recurred when the topical steroids were interrupted. After resuming the treatment, his symptoms, endoscopic findings, and pathological findings improved.

Objective: Digested soy protein, the raw material of soy-based infant formula Bonlact^® i, undergoes heat treatment and enzymatic processing, which may make it hypoallergenic. The purpose of this study is to confirm the allergenicity of Bonlact^® i.

Methods: We performed SDS-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting of digested soy protein isolate (SPI) and its raw material, non-digested SPI. Skin-prick tests (SPTs) of soybean and digested SPI, and the severity of the oral food challenge test (OFC) of tofu or soy milk and Bonlact^® i were compared in patients with soy allergy.

Results: SDS-PAGE showed lower molecular weight bands throughout the digested SPI in comparison to non-digested SPI. On immunoblotting, Gly m Bd 28K and Gly m Bd 30K specific bands were harder to detect in digested SPI in comparison to non-digested SPI. In 2 of the 3 SPTs that were performed, the diameter of the wheal of digested SPI was smaller than that of non-digested SPI. In the OFCs, Bonlact^® i induced less severe reactions in all 4 cases, and 3 cases had higher threshold protein levels in comparison to soy.

Conclusions: Bonlact^® i has a lower molecular weight and was suggested to be hypoallergenic in comparison to soy due to heat and enzymatic treatment.

In most countries, allergen labeling of food products is mandatory under the legislation. However, many studies have reported that the amplification of precautionary allergen labelling (PAL) restricts consumer behavior while infringing its purpose of protecting those with food allergy.

Japan is one of the few countries that legally prohibits PAL by establishing methods for detecting allergens and clearly setting standards for protein content. On the other hand, many countries have failed to regulate PAL because of the lack of global consensus regarding the association between the amount of allergen intake and the risk of allergic reaction.

How much unintended allergen cross-contact is tolerable? Other countries are still searching for a risk assessment-based approach to find answers that are acceptable to all stakeholders and consumers.

Urticarial vasculitis presents urticaria-like eruptions that typically last longer than urticaria with pruritus and burning sensation and resolve with residual purpura or hyperpigmentation. It histologically shows leukocytoclastic vasculitis that affects small vessels in the upper dermis, especially postcapillary venules. It is classified into hypocomplementemic urticarial vasculitis with a decrease in serum complement titer and normocomplementemic urticarial vasculitis with a reference range of serum complement titer. Complement activation by immune complex formation due to anti-C1q antibodies is assumed to be a pathogenic mechanism of hypocomplementemic urticarial vasculitis syndrome. Most pediatric cases with cutaneous vasculitis are diagnosed with IgA vasculitis, and childhood-onset urticarial vasculitis is thought to be rare. However, there are cases of urticarial vasculitis with a certain probability. In some childhood-onset urticarial vasculitis cases, it was reported that mutations in DNASE1L3 were identified and they concurrent systemic lupus erythematosus. Urticarial vasculitis may present extracutaneous symptoms such as chronic obstructive pulmonary disease that affects their prognosis, various types of glomerulonephritis, episcleritis, and conjunctivitis. It is necessary to distinguish it from urticaria, systemic lupus erythematosus, autoinflammatory diseases, and so on.

The prevalence of food allergy in Japan is highest in infancy and decreases rapidly with age. The prevalence rate does not change significantly after adolescence. The main causative foods of immediate-type food allergy in Japan are hen's eggs, cow's milk, and wheat, but the types and ranking of these foods differ according to age groups. Recently, nut allergy in young children, especially walnut allergy, has increased rapidly. Cutaneous symptoms are highly prevalent in triggering immediate-type food allergy. Shock symptoms are also observed in approximately 10% of cases, indicating that food allergy is a very high-risk disease.

Children with food allergy in infancy develop bronchial asthma, allergic rhinitis, and atopic dermatitis at a high frequency. Thus, the risk of following the so-called "allergy march" is high.

Key points regarding the risk and prevention of immediate food allergy in childhood are as follows.

1 Risk factors of food allergy in children were family history, certain genes, skin barrier function, sunlight and vitamin D. Atopic dermatitis is the most crucial risk factor.

2 The elimination of certain foods by the mother during pregnancy and lactation to prevent the onset of childhood food allergy is not recommended because of its negative and detrimental effects on children.

3 Delayed allergenic foods for weaning foods to infants to prevent food allergy is not recommended.

4 There is insufficient evidence that exclusive breastfeeding is superior in preventing food allergy in childhood. There are some reports that cow's milk protein (standard milk) ingested with breast milk from early infancy is effective in preventing the onset of cow's milk allergy in infants.

5 There is insufficient evidence to recommend that the application of moisturizers from early infancy is effective in preventing the onset of food allergy.

Anaphylaxis is an acute, life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Majority of anaphylaxis reactions are not life-threatening; however, due to our inability to predict its severity, all anaphylaxis must be appropriately treated with intramuscular adrenaline. Adrenaline is the first-line pharmacotherapy for anaphylaxis, and diagnosis and management must occur rapidly. H1-antihistamines relieve itching but do not relieve life-threatening symptoms; therefore, like H2-receptor antagonists and glucocorticoids, they are adjunctive treatments and not appropriate as initial and lone treatments. Adrenaline auto injector is indicated for individuals who have a history or risk for anaphylaxis. They should be taught how to inject and equipped with a written anaphylaxis emergency action plan that aids them to recognize symptoms. The occurrence of unintentional injection of adrenaline from auto injectors is increasing. They need regular instructions on how to use adrenaline auto injectors correctly and safely.

Chapter 8 of "Japanese Guidelines for Food Allergy 2021" covers diagnostics and examinations for food allergy, excluding oral food challenges. Significant updates include an updated flowchart for food allergy diagnosis that is simpler and easier to understand, detailed interview points by age group, detailed description of how to interpret specific IgE antibody tests, including probability curves and ROC curves, and other tests. The other tests are also described in detail and their diagnostic significance. Since the diagnosis of allergy to each allergen is discussed in a separate chapter of the guideline, the content of this chapter is limited to a general discussion. A deep understanding of these tests allows for more accurate diagnosis and management options.

An oral food challenge (OFC) is an examination in which a single or multiple portion of a food to which a confirmed or suspected allergy has been administered is tested for the presence of triggering symptoms. An OFC is performed when it can be determined that the benefits to the patient outweigh the risks of the induced symptoms. In Japan, OFC tests are widely performed not only to confirm a diagnosis of food allergy but also to determine the threshold level of a particular allergen. The usefulness of OFC was evaluated using systematic reviews in Japanese Guidelines for Food Allergy 2021 (Guidelines). As a result, an OFC may be useful to avoid the complete elimination of eggs and milk from the diet of patients with or suspected of having food allergies. To perform the OFC more safely, a flowchart has been proposed to classify and select medical institutions that can perform OFC and determine the caseload. This review focuses on the above mentioned points and explains the implementation of OFC based on the current guidelines.