Lessons from the clinical course of IgE-mediated cow milk allergy in Israel

Cow milk and milk products are the most common food products consumed in Israel; rates of allergy to cow milk exceed those of peanuts in infants and children. The aim of the present study was to evaluate retrospectively the clinical features and natural course of immunoglobulin (Ig) E-mediated cow milk allergy (CMA) in Israel. Data of children diagnosed with CMA from 1995 to 2003, were collected regarding age at first and most recent reactions, symptoms and signs, family history of atopy, other allergic diseases, emergency department visits, hospitalizations, and treatment. Patients with transient CMA were compared to those with persistent CMA (> or =3 yr old). The study group consisted of 105 patients, 43 with transient CMA (age range: 0.48-11 yr). The remaining 62 patients (age range: 3-16.5 yr) did not achieve tolerance to cow milk during the follow-up period. No differences were found between the groups in mean age and symptoms and signs at the first allergic reaction and family history of atopy. Patients with persistent CMA had a higher rate of asthma than patients with transient CMA (61.2% vs. 18.6%, p < 0.001). Fifty patients with persistent CMA had 137 subsequent allergic reactions after diagnosis, 25% of the reactions were due to oral milk challenge at the clinic and 75% due to accidental exposure, of which 13% required an emergency department visit and 8%, hospitalization. Only 19% of the reactions were treated with epinephrine injection. In conclusion, in our experience, less than half of the children diagnosed with IgE-mediated CMA during 9 yr, outgrew it. The patients with persistent CMA have a higher prevalence of asthma compared with the general population or to children with transient CMA. The high number of recurrent allergic reactions due to accidental exposure and the low rate of epinephrine usage in these patients point to a need for better education of patients and their families.     

Latex allergy and associated risk factors in a group of Turkish patients with spina bifida

Allergic reactions to latex are common in patients with spina bifida. Its incidence varies between 28% and 67%. The aim of this study was to investigate the incidence of latex allergy and its risk factors in patients with spina bifida in Izmir, Turkey. Forty-six patients (24 male, mean age 10 years) were included in the study. A questionnaire was completed and skin prick tests with latex solution and cross-reacting foods were performed. Total IgE levels, specific IgE to common aeroallergens (Phadiotop), and latex specific IgE levels were measured. Patients with positive skin test reaction and/or who had specific IgE to latex without clinical symptoms were considered as sensitive to latex. The patients who also had clinical symptoms with latex exposure were diagnosed as allergic to latex. Latex sensitivity was found in 5/46 patients (10.8%). Only two patients had latex allergy (4.3%). Total IgE levels were higher (median 157 vs. 40 kU/L, p=0.012) and the duration of clean intermittent catheterization was longer insensitized patients when compared to non-sensitized patients (median 8 vs. 3 years, p=0.015). Specific IgE to common aeroallergens and positive skin prick test to cross-reacting foods were more prevalent in sensitized than in non-sensitized patients (p=0.02 and 0.015, respectively). The incidence of latex allergy in our group was lower than reported in the literature. This result may be due to the low number of surgical interventions. High levels of total IgE, positive Phadiotop, positive skin prick test to cross-reacting foods and the duration of clean intermittent catheterization are the risk factors for latex sensitivity in patients with spina bifida.     

Evaluation of the need for routine preoperative latex allergy tests in children

BACKGROUND: Recently, there was a great increase in allergic reactions to latex and this brought relatively more concern to the latex allergy. In this prospective study we aimed to identify the frequency of latex allergy in preoperative patients, and tried to clarify whether it is necessary to perform latex allergy tests routinely in the preoperative period or not. METHODS: A total of 188 children, aged 1-14, who were admitted for various operations, were randomly included in this study and of them, 181 completed the study. Latex specific history was taken from all patients. Latex skin prick tests, challenge tests with latex gloves, total IgE and latex specific IgE measurements were performed. RESULTS: Of 181 children, two (1.1%) had positive latex skin prick tests. Latex challenge tests were negative in all children. Latex specific IgE was positive in 12 children (6.6%) as class II or higher, but no patient had allergic reactions in operations. History of repeated operations was a risk factor for latex sensitization. The risk was higher in the presence of both history of repeated operations and history of allergic disease. However, the risk was not higher in patients with the history of only allergic disease, compared to ones who had a history of neither repeated operations nor allergic disease. CONCLUSION: We conclude that routine preoperative latex allergy tests seem to be not necessary because of no allergic reactions during operation in spite of the sensitization of 6.6% detected by latex specific IgE. However, this should be investigated in larger studies.     

Parental and child factors associated with inhalant and food allergy in a population-based prospective cohort study: the Generation R Study

The prevalence of allergic diseases in children is markedly increasing to epidemic proportions. The aim of this study is to describe the presence and examine associated parental and child characteristics of allergic sensitization and physician-diagnosed allergy in Dutch children at age 10 years. This study among 5471 children was performed in a population-based prospective cohort from fetal life onwards. Allergic sensitization was measured by skin prick tests. Physician-diagnosed allergy and parental and child characteristics were collected by questionnaires. In children aged 10 years, inhalant and food allergic sensitization was present in 32.2% and 7.1%, and physician-diagnosed inhalant and food allergy in 12.4% and 2.3%. Maternal and paternal history of allergy, eczema or asthma was associated with increased risks of physician-diagnosed inhalant allergy (aOR (95% CI) 1.44 (1.23–1.70) and 1.59 (1.30–1.94), respectively), but not with food allergy. Asthma and eczema ever at age 10 years were associated with increased risks of physician-diagnosed inhalant allergy (4.60 (3.55–5.96) and 2.42 (1.94–3.03), respectively). Eczema ever at age 10 years was associated with an increased risk of physician-diagnosed food allergy (5.78, 3.04–9.52), with the highest risk of cashew (7.36, 3.20–16.94) and peanut (5.58, 3.08–10.10) food allergy.

Conclusions: We found strong effects of parental history of allergy, eczema or asthma on the presence of physician-diagnosed inhalant allergy in children at age 10 years. Eczema ever at age 10 years was a strong risk factor for the development of physician-diagnosed inhalant and food allergy.

Sublingual desensitization in children with congenital malformations and latex allergy

The frequency of latex allergy in children requiring multiple surgery ranges from 16.7% to 65%. The aim of this study was to investigate the safety and efficacy of latex desensitization in a group of 10 patients with a history of multiple surgical procedures and clinically manifested allergy to latex. We selected 10 children (female-male ratio = 5:5), aged 4-16 yr (mean +/- s.d.: 9 +/- 4), with a history of multiple surgical procedures, adverse reactions to latex and positive skin test to latex and/or specific immunoglobulin E (IgE). Latex allergy diagnosis was confirmed by specific provocation tests (cutaneous, sublingual, mucous, conjunctival tests). Rush (4-day) sublingual desensitization was performed with increasing doses of latex extract (ALK Abellò) under patients' tongue until the highest dose of 500 microg of latex. A maintenance therapy (10 drops of undiluted solution three times a week) was recommended. During the 2-yr follow-up mean values of specific IgG4 and IgE, eosinophilic cationic protein and total IgE did not show significant variations. Patients did not manifest any adverse effect during the rush phase and only two patients manifested mild local symptoms during the maintenance therapy. All the challenges showed a reduction in terms of percentage of positivity and mean scores. All the patients showed a reduction of the mean individual score (p < 0.001). Furthermore patients who needed dental examination or surgery underwent such procedures without the occurrence of symptoms. Our preliminary results show sublingual desensitization to latex can be an important therapeutic tool in the management of young allergic patients requiring multiple operations.     

Latex allergy risk assessment in children and adolescents with type I diabetes mellitus

An increased frequency of allergic reactions to latex has been reported in specific populations with chronic latex exposure. However, relevance of latex allergy to children and adolescents with type I diabetes mellitus (DM1) has not been studied yet. The aim of the studty is to assess latex allergy risk in children and adolescents with DM1. Thirty-nine children with DM1 and 35 controls were enrolled. In a case-control study, we applied to all subjects a standard questionnaire, and specific Immunoglobulin E (IgE) concentrations for latex, common aeroallergens, and food-allergens were measured in serum samples. Latex exposure rates by means of medical procedures, operations, and latex glove usage were not different between DM1 and controls. Symptoms due to latex exposure were not determined in both groups. Three (7.7%) subjects in DM1 tested positive for latex-specific antibodies (LSIE), whereas no subject in controls. Diabetics that tested positive for latex-specific antibodies had the disease for three, 5 and 8 years. Nine (23.1%) of diabetics, and two (5.7%) of controls were atopic (p = 0.04). In our investigation, we found that children and adolescents with DM1 are not a risk group for latex allergy, and LSIE in children with DM1 was not accompanied by symptoms of latex allergy, or, presumably, increased risk of latex anaphylaxis.     

Latex allergy in children : Diagnosis and management

Latex allergy is an increasingly common condition, in both children and health care workers who provide care for them. Subpopulations at particular risk include children with spina bifida, children undergoing multiple surgical procedures, and health care workers in the operating theatre. Chemical additives in latex gloves can cause an irritant or allergic contact dermatitis. Latex proteins are responsible for most of the immediate IgE-mediated hypersensitivity allergic reactions. Symptoms range from rhinitis, conjunctivitis and urticaria to anaphylaxis and death. A latexdirected history is the primary method of identifying latex sensitivity, although both skin and serum testing is available and increasingly accurate. (Latex avoidance should be used in all individuals with a positive skin or blood test or a positive history). The most important preventive measure for patients with or at risk for latex allergy is minimizing direct patient exposure to latex products, most notably latex gloves. Recent operating room studies indicate simple preventive measures can dramatically reduce intraoperative reactions. Preoperative prophylaxis with antihistamines and steroids have not been shown to be necessary or effective. Treatment of an allergic reaction begins with immediate removal of any identified source of latex in direct patient contact. Treatment is similar to anaphylaxis from other causes, and may require the use of epinephrine. Everyone caring for the patient at risk for latex allergy must be involved in making their medical environment safe.     

The pattern of sesame sensitivity among infants and children

Recently, we found sesame to be a major cause of severe IgE-mediated food allergic reactions among infants and young children in Israel. The purpose of this study was to describe the different patterns of sesame sensitivity. We have identified three subgroups among our patients (n = 32). Group I (n = 23, M/F; 14/9) consisted of cases with IgE-mediated sesame allergy. The mean age of the first allergic reaction was 11.7 months. Although the main clinical manifestation was urticaria/angiedema (n = 14, 60%), anaphylaxis was the presenting symptom in seven (30%) patients; all of them were younger than 1 year. Sixteen (70%) were found to be allergic to other foods, and other atopic diseases were identified in 18 (78%) patients. Three patients 'outgrew' their allergy within 1–2 years. Group II (n = 2) included cases in whom sesame allergy was ruled out based on a negative skin prick test (SPT) together with a negative open oral challenge. Group III (n = 7) consisted of patients that were found to be SPT positive for sesame as part of a screening for other food allergies. Although sesame products have become fashionable in westernized countries, early exposure may cause sesame to share eventually the same 'noteriety and fate' as peanut – a major cause of severe food allergic reactions.     

Comparison of Allergic Reactions to Intravenous and Intramuscular Pegaspargase in Children with Acute Lymphoblastic Leukemia

Pegaspargase (PEG) is a standard component of therapy for pediatric acute lymphoblastic leukemia (ALL). Because PEG preparations are bacterially derived, they are highly immunogenic. PEG has traditionally been delivered intramuscularly (IM), but over the last several years, more PEG has been given intravenously (IV) in order to provide a less painful and more convenient means of delivery. However, there are limited data comparing allergic reactions between IV and IM PEG recipients, especially in a large cohort of patients. We reviewed the charts of pediatric ALL patients diagnosed from 2006 to 2011 who received PEG at our institution and compared the incidence, time to onset of symptoms, reaction grade, and hospitalization rate for patients who had allergic reactions to PEG. Of 318 evaluable patients, 159 received IV and 159 received IM PEG. Thirty-one (19.5%) IV patients had an allergic reaction, compared to 17 (10.7%) IM patients (P = .028). Time to onset of symptoms was ≤ 30 minutes for 26 of 27 evaluable IV patients (96.3%) versus only two of 11 evaluable IM patients (18.2%; P < .001). Four of 31 IV patients (12.9%) and six of 17 IM patients (35.5%) required hospitalization (P = .134). There is increased incidence of allergy in patients who received IV PEG compared to IM. Grade of reaction was similar between IV and IM, but allergic reactions to IV PEG had a more rapid onset. While the risk of allergy may be increased, IV delivery appears to have an acceptable safety profile for administration in ALL patients.     

Spina bifida outcome: a 25-year prospective

BACKGROUND: Open spina bifida is the most complex congenital abnormality compatible with long-term survival. This report outlines the 20- to 25-year outcome for our original cohort of patients with a myelomeningocele treated in a nonselective, prospective manner. METHODS: Of the initial 118 children, 71 patients were available for our most recent review. Nineteen patients have been lost to follow-up and 28 patients have died. Data were collected on: motor level, shunt status, education/employment, seizure history, mobility, bladder/bowel continence, tethered cord, scoliosis, latex allergy, posterior cervical decompression, tracheostomy and/or gastrostomy tube. RESULTS: Mortality (24%) continues to climb into young adulthood. Eighty-six percent of the cohort have cerebrospinal fluid diversion, with 95% having undergone at least one shunt revision. Thirty-two percent have undergone a tethered cord release, with 97% having an improvement or stabilization in their preoperative symptoms. Forty-nine percent have scoliosis, with 43% eventually requiring a spinal fusion. Sixteen patients (23%) have had at least one seizure. Eighty-five percent are attending or have graduated from high school and/or college. More than 80% of young adults have social bladder continence. Approximately 1/3 of patients are allergic to latex, with 6 patients having experienced a life-threatening reaction. CONCLUSION: At least 75% of children born with a myelomeningocele can be expected to reach their early adult years. Late deterioration is common. One of the greatest challenges in medicine today is establishing a network of care for these adults with spina bifida.     

Weekly dosing of carboplatin increases risk of allergy in children

BACKGROUND: Carboplatin (CBDCA) has been used increasingly to treat pediatric low-grade gliomas. Allergic reactions to CBDCA have been reported in 2% to 30% of children. The reason for this high incidence of allergy is unclear. METHODS: To determine the risk factors for CBDCA allergy, an historic cohort study was conducted for all children who received the drug during a 6-year period at the Lucile Salter Packard Children's Hospital at Stanford. The patients' medical records were reviewed for data on age, tumor type, CBDCA dose schedule, total number of doses, cumulative dosage, dose per treatment, other chemotherapy administered, and allergic reaction. RESULTS: Fifty-four children (mean age 7.2 years, 35 boys) were identified. Six children (11.1%) had an allergic reaction to CBDCA. All reactors had low-grade gliomas treated with weekly CBDCA and vincristine, with a dosage per treatment <500 mg/m2. Overall, six (75%) of eight children administered weekly CBDCA, 6 (46.2%) of 13 children with brain tumors, and 6 (40%) of 15 administered CBDCA dosage <500 mg/m2 manifested allergic reactions. Patients receiving more than five doses had significant risk for CBDCA allergy (relative risk [RR] = 11.8; 95% confidence interval [CI]: 1.5-94.1). Using logistic regression with multiple variables, weekly dose schedule was the most predictive covariate for allergic reaction (P < 0.000 1), and other factors were unrelated or redundant. CONCLUSIONS: Children with low-grade gliomas receiving CBDCA weekly are at significantly increased risk for CBDCA allergy. The repetitive, weekly dosing schedule of CBDCA appears to be a key risk factor for allergic reaction in brain tumor patients. The high frequency of allergy with weekly CBDCA warrants further consideration when planning future trials.     

Myelomeningocele, avocados, and rubber tree plants

Infants with myelomeningocele and the nurses who care for them have something in common. Both are at higher risk than the general population for developing latex allergies. This article provides a review of the literature regarding latex production, latex allergic responses in children and adults, types of latex allergic reactions, and prevention of latex allergies.     

Natural rubber latex sensitisation and allergy in patients with spina bifida, urogenital disorders and oesophageal atresia compared with a normal paediatric population.

BACKGROUND: Natural rubber latex (NRL) contains proteins which, after repeated contact with latex products and an allergic predisposition (atopy), can lead to sensitisation (specific IgE against NRL proteins) or allergy (type 1 allergy with symptoms from urticaria to allergic shock). Spina bifida patients are known to be a high risk group for latex allergy and sensitisation due to numerous operations beginning soon after birth. In the study presented here we compared spina bifida patients with patients who also underwent repeated operations beginning soon after birth (urological malformations) or underwent surgery once in the neonatal period but had numerous anaesthesias because of repeated treatment with a bougie (oesophageal atresia). In this setting the influence of surgery and anaesthesia on NRL-sensitisation was investigated. MATERIALS AND METHODS: We investigated the prevalence of NRL-specific IgE (> 0.35 kU/l, ImmunoCAP system, Pharmacia) in a normal paediatric population (neither atopic nor having undergone surgery) (group I), spina bifida patients (group II), children with urogenital malformations (group III) and children with oesophago-tracheal malformations (group IV). RESULTS: The highest rate of NRL-sensitised patients was found in the spina bifida group (II) (48 %), followed by groups III and IV with 17 % each, compared to 4 % for the control group. NRL-allergic reactions were noted only in the patients with spina bifida and the urological malformation group (18 % in group II, 8 % in Group III). Apart from atopy the number of operations could be identified as a risk factor for the development of NRL-sensitisation and allergy (group II, III). The prevalence of latex allergy was lower after repeated anaesthesia (group IV) than after repeated surgery. CONCLUSIONS: In addition to the known high risk group of spina bifida patients, other patients with congenital malformations and early surgery also have a significant risk for latex sensitisation. When treating patients with malformations requiring repeated surgery, prophylactic measures similar to those for spina bifida patients should be considered.     

Association of MBL2 polymorphism with asthma after bronchiolitis in infancy

Background: Mannose‐binding lectin (MBL) is a component of innate immunity and has been linked with the pathogenesis of asthma. The aim of the present study was to evaluate the association of MBL genotypes with preschool asthma and allergy in children with bronchiolitis in early infancy. Methods: In all, 205 infants were hospitalized for bronchiolitis at <6 months of age. Asthma and allergy were studied from a total of 166 children at 6.4 years (mean). A total of 141 (85%) frozen whole blood samples were available for MBL genotyping and MBL2 gene mutations were determined on pyrosequencing for detection of three single‐nucleotide polymorphisms. Results: Ninety‐five children (67.4%) had the wild‐type MBL genotype A/A and 46 had A/O or O/O genotypes. Asthma was present in 16 children (11.3%) at 5–7 years of age. Nine children (19.6%) with non‐AA genotype had asthma (vs 7.4% of those with genotype AA, P= 0.03). The result remained significant after adjustment for age, gender and atopy. There were no significant associations between MBL genotypes and asthma at any age before the study. Atopic dermatitis, allergic rhinitis or paternal and/or maternal asthma had no significant associations with MBL genotypes. Conclusions: The variant non‐A/A MBL genotype is associated with asthma after bronchiolitis in infancy, but not earlier than at 5–7 years of age.     

ASCIA guidelines for prevention of anaphylaxis in schools,pre‐schools and childcare: 2015 update

The aim of these guidelines is to assist staff in school and childcare settings to plan and implement appropriate risk minimisation strategies, taking into consideration the needs of the allergic child, the likely effectiveness of measures and the practicality of implementation. Although these guidelines include risk minimisation strategies for allergic reactions to insect stings or bites, latex and medication, the major focus relates to food allergy. This is due to the higher relative prevalence of food allergy in childhood (compared with other allergic triggers) and the higher likelihood of accidental exposure in these settings. Care of the allergic child in the school, pre‐school or childcare settings requires accurate information obtained from parents and carers, staff training in the recognition and management of acute allergic reactions, planning for unexpected reactions (including in those not previously identified as being at risk), age appropriate education of children with severe allergies and their peers, and implementation of practical strategies to reduce the risk of accidental exposure to known allergic triggers. Strategy development also needs to take into account local or regional established legislative or procedural guidelines and the possibility that the first episode of anaphylaxis may occur outside the home. Food bans are not recommended as the primary risk minimisation strategy due to difficulties in implementation and lack of proven effectiveness.     

Latex allergy and sensitization in children with spina bifida

BACKGROUND: The purpose of this study was to investigate the prevalence rate of latex sensitization and latex allergy among children with spina bifida and to evaluate risk factors for natural rubber latex hypersensitivity. METHODS: A total of 34 children between 2.5 and 17 years of age participated in the study. Participants completed a questionnaire and underwent skin prick tests with latex, common aeroallergens and food allergens as well as measurements of specific IgE to latex and food allergens (RAST CAP). RESULTS: The prevalence of latex sensitization and latex allergy was estimated to be 32.4 and 18.8%, respectively. The most common reported clinical manifestation of latex allergy was urticaria. Three out of six symptomatic patients reported anaphylactic reactions. CONCLUSION: We found that major risk factors for latex sensitization were atopy and a history of numerous operations.     

Natural rubber latex allergy: prevalence and risk factors in patients with spina bifida compared with atopic children and controls

Type 1 allergy against natural rubber latex is an increasing problem in health care workers and children with spina bifida or urogenital malformations. The aim of our study was to evaluate the prevalence of latex IgE antibodies and cross-reacting fruit antibodies in patients with spina bifida compared with atopic and non-atopic controls. Risk factors for sensitization should be determined. Sera of 148 patients with spina bifida and 98 controls (44 with atopy) were screened for IgE antibodies against latex, banana and kiwi by fluorescence enzyme immunoassay (CAP system). Atopies, allergic symptoms after latex contacts and the number of operations were compiled by a questionnaire. Patients with spina bifida developed latex IgE antibodies (≥0.7 kU/l) more frequently (40.5%) than atopic children (11.4%) or healthy controls (1.9%). All 18 symptomatic patients belonged to the spina bifida group and had high values of latex antibodies. The risk for developing latex antibodies increases with the number of operations. There was no difference in the history of atopic diseases and in a screening test of IgE antibodies against inhalative allergens between latex sensitized and not sensitized children with spina bifida. Antibodies against banana were more frequent in the latex sensitized children with spina bifida. (18.3% vs 3.4%, P = 0.002). Conclusion The high prevalence of latex antibodies in children with spina bifida justifies a primary prophylaxis by avoiding latex contacts, especially during anaesthesia and surgery, a correlation between the number of operations and the development of latex antibodies exists. Received: 30 March 1996 and in revised form: 19 March 1997 / Accepted: 20 March 1997     

Erwinia asparaginase after allergy to E. coli asparaginase in children with acute lymphoblastic leukemia

Background

Escherichia coli asparaginase is an important component of treatment for childhood acute lymphoblastic leukemia (ALL); however, hypersensitivity develops in up to 30% of patients. We assessed the nadir enzyme activity and tolerability of Erwinia asparaginase, an alternative preparation, in E. coli asparaginase‐allergic patients.

Patients and Methods

Between 2000 and 2002, 215 children with newly diagnosed ALL were enrolled on Dana‐Farber Cancer Institute ALL Consortium Protocol 00‐01 and were to receive 30 weekly doses of intramuscular E. coli asparaginase. If E. coli asparaginase allergy developed, patients were switched to twice‐weekly intramuscular Erwinia asparaginase (25,000 IU/m²). Nadir serum asparaginase activity (NSAA) was measured every 3 weeks.

Results

Forty‐two patients (20%) developed E. coli asparaginase allergy and switched to Erwinia. Of 38 patients with evaluable samples, 34 (89%) Erwinia‐treated patients had at least one therapeutic NSAA (≥0.1 IU/ml). The median NSAA was 0.247 IU/ml 3 days and 0.077 IU/ml 4 days after an Erwinia dose. Associated toxicities included allergy in 14 (33%) and pancreatitis in 3 patients (7%). At a median follow‐up of 5.4 years, event‐free survival (±standard error) of the 42 patients who switched to Erwinia was 86 ± 5% compared with 81 ± 3% for the 170 patients without E. coli asparaginase allergy (P = 0.55).

Conclusions

Twice‐weekly Erwinia asparaginase was well tolerated and achieved a therapeutically effective NSAA in most E. coli asparaginase‐allergic patients. Development of E. coli allergy and subsequent treatment with twice‐weekly Erwinia did not adversely impact event‐free survival. Erwinia asparaginase should be considered for E. coli asparaginase‐allergic patients. Pediatr Blood Cancer 2010;54:199–205. © 2009 Wiley‐Liss, Inc.     

Contribution of pulmonary hemodynamics on manifestation of allergic asthma in patients with congenital heart disease

The purpose of this study was to determine whether pulmonary hemodynamic abnormalities relate to manifestations of allergic asthma. In 448 patients with congenital heart disease the relationships between asthma and age or pulmonary arterial blood (PA) flow were studied. Asthma (allergic and non-allergic) was more common in 39 (19%) of 201 patients with high PA flow, compared with the incidence in those with normal PA flow (6/117, 5%; P < 0.001) and reduced PA flow (1/130, 1%; P < 0.05). In the high PA flow group, the frequency of asthma declined significantly (P < 0.01) with age, from 25–26% in the 6 month-5 year patient group to 5% in the 6–12 year old patients. The frequency of asthma, including allergic type, was significantly (P < 0.01) greater in patients with pulmonary hypertension (15/24, 63%) than in those without (10/77, 13%) at the age of 6 months to 1 year. Asthma in the high PA flow group was associated with other allergic diseases in 30 (77%) of 39 patients, including food allergy in nine (23%), atopic dermatitis in 14 (36%), allergic rhinitis in seven (18%) and abnormally high total IgE levels in 14 (36%). These findings suggest that high pulmonary flow or pulmonary hypertension enhances the manifestation of allergic disease, particularly asthma.     

The R.U.B.B.E.R. tool: Screening children for latex allergy

The pediatric nurse practitioner may encounter IgE-mediated allergic reactions to natural latex rubber not only in patients with spina bifida but also in the general pediatric population. The R.U.B.B.E.R. screening tool is a short research-based questionnaire that elicits unrecognized past allergic reactions to latex and identifies children at risk for this condition. Management strategies include patient identification, referral for allergy evaluation, patient and family education about avoiding latex, and design of a latex-safe practice environment.