Intro: Please stay tuned to the end of this program or see the show notes for important information regarding today's speakers and the content of this podcast.

Gerry Lee, MD: Hello, everyone, and welcome to another episode of Allergy Talk, a roundup of the latest in the field of allergy and immunology by the American College of Allergy, Asthma, and Immunology. For today's episode, we will be reviewing articles from Allergy Watch, a bi-monthly publication which provides research summaries to college members for the major journals in allergy and immunology.

And you can also earn CME credit by listening to this podcast. For information about CME, or to read archived issues of Allergy Watch, head over to college.acaai.org/publications/AllergyWatch. And make sure you check out the ACAAI community on DocMatter where we can continue the discussion about these articles.

Well, hello again. My name is Gerry Lee. I'm an Associate Professor at Emory University, an Assistant Editor of Allergy Watch. And once again, I am joined by the Editor in Chief of Allergy Watch, Dr. Stan Fineman. for listening.

Stanley M. Fineman, MD: Hi, everybody, and thanks for having me. I am current Editor In Chief of Allergy Watch. I'm past president of the college, and I'm a adjunct faculty at Emory.

Host: And we're really excited to be joined by another Assistant Editor for Allergy Watch in the third chair, Dr. Sarah Spreit. Sarah, much for joining us. Tell the listeners about yourself.

Sarah Spriet, MD: Hi, everyone, and thanks for having me. I'm Dr. Sarah Spriet. I am Clinical Allergist Immunologist at A.T. Augusta Military Medical Center in Northern Virginia, and I'm also the newly appointed Associate Program Director for the training program at Walter Reed.

Host: Well, I'm really excited. We got a bunch of great articles today. Stan, why don't you kick us off? I think there's so much information that continues to comes out about prevention of food allergy. I think you have one more piece of information for us.

Stanley M. Fineman, MD: So the study I'm going to present is from the Annals of Allergy that was published last year. And it's entitled, The Protective Effect of Moderate Maternal Peanut Consumption on Peanut Sensitization and Allergy. And it was from the authors from Israel and what they did was they analyzed data from the LEAP study. We all remember the LEAP study that was published in 2015 in the New England Journal where they assigned infants who had eczema and egg allergy or both to avoid peanuts until they were 60 months of age.

And as we all know, the children who ingesting peanuts, tended not to develop peanut allergy and those that had the avoidance were the ones who did develop allergy. And so, what they did is they said, well, let's use this data in the control group. These are the control group was the group that was assigned to the avoidance, the infants who had avoidance of peanut ingestion. And they asked the moms of these children, did they consume peanut or not?

So the mothers self-reported peanut consumption during pregnancy, and they were classified as either having more than five grams per week of a peanut, less than five grams per week, or none at all. In other words, this is mothers who said they didn't consume, while they were, pregnant or nursing. Cause they also looked at the nursing activity, they also asked that as well. So, then they analyzed the children. Of course, everybody was analyzed at 60 months. That was part of the LEAP trial. And they looked at rates of peanut sensitization. And 10 percent of the infants of mothers with low peanut consumption, that was the ones who had less than five grams per week compared to 25.8 percent of the high peanut ingestion and 25 percent of no peanut consumption. And of course they looked at rates of peanut allergy with positive oral challenges. And again, it was much lower in the mothers who had low peanut consumption, less than five grams a week, whereas it was 19 or 18 percent, respectively, of the ones who had high consumption or didn't have any consumption at all.

So the moderate peanut consumption during the breastfeeding, was associated with a lower frequency of the peanut allergy outcomes. That is either developing allergy or having the food challenge. And the factors that contributed to it, include the factors associated with both adverse events included the no peanut consumption while breastfeeding. That was an odds ratio of three. Certain ethnicity factors was also an odds ratio of three. And then they also looked at scoring the atopic dermatitis, the score ad, over 40 and that was a 2.78. So for the at risk infants, the moderate maternal consumption of peanuts during breastfeeding, less than five grams a week, was associated with lower rates of peanut allergy and sensitization.

So the authors state that they figure that this really paints a unique picture of interplay between environment and oral exposure to peanut, and then Iris Attani, who was the Allergy Watch, editor who, commented on this, said in her comment, unsurprisingly, no maternal peanut consumption was associated with both sensitization and allergy.

So, conclusion there is that moderate peanut consumption is probably what we should be recommending for our moms.

Host: You know, this is so tough. I mean, I can imagine a mom reading this study and then like weighing out the peanut every week. I mean, people are terrified about peanut allergy. Part of this is, I think this is just self-report questionnaire and, you'll wonder, is it really anything to do with the consumption itself or this is just a marker of exposure? I mean, what do you think, Sarah?

Sarah Spriet, MD: Yeah, I'm with you. I think it's really hard to pin that down and it's interesting, certainly intriguing, but it's hard to give specific guidance to the mom who is really invested in this question, based on this.

Host: You tell the mom anything when they ask you?

Dr Sarah Spriet: I say, at this point, modifying your diet is not recommended. Certainly getting some element of exposure is thought to be protective, but I don't think we have enough data to give specific guidance at this point.

Host: I like that. I'm very political about it too because I don't have any evidence. Even this, I don't think is solid evidence to say don't eat it, too much, but eat a little bit. I'm not sure I could even say that. I don't understand. do you have a talking point for parents when they were asking about how much peanut they should eat?

Stanley M. Fineman, MD: I agree with what Sarah said about not restricting your diet, and I do encourage them to have it in the house. The authors do talk about the dual allergen exposure hypothesis. That we all know about the potential transcutaneous exposure to allergens, even in the absence of oral tolerance.

So, that still hasn't been worked out completely. But I would certainly encourage moms to eat peanuts in their diet. And, as you said, it was self-reported data. So, the difference between less than five or greater than five, I mean, it's hard to tell, but, I think we still have a lot to learn,

 The nice thing, of course, in this study is the fact that they're analyzing children from the LEAP study, but they were in the control group. So we're trying to learn more so we can advise our moms better.

Host: Yeah. I think it's still, an open question, but I welcome this research because let me tell you, the parents are definitely asking us. So Sarah, you have a really interesting article, how we should be approaching venom allergy testing. So I'd love to hear what you've learned.

Sarah Spriet, MD: Yeah, and this is an area of interest for me. You know, in the military, we work up a lot of people with the question of venom allergy, primarily because it does have duty implications. And so we do good amount of venom skin testing. And so this certainly piqued my interest when I saw it in the Annals last year.

The title of this article is Hymenoptera Venom Skin Testing. Adopting an Accelerated Test Protocol, and it was written by Wong, et al. And what these authors did, and these investigators, they did a retrospective chart review and looked at the safety outcomes and the demographics for patients who were worked up for possible venom allergy at four different military medical centers.

And two of those centers were using an accelerated intradermal skin test protocol, and so they were starting at either the 0.1 microgram per milliliter or the 1 microgram per milliliter concentration, and they compared the patient demographics and safety outcomes to two centers that were using the standard Intradermal Skin Test Protocol that starts with .001 or .01 microgram per milliliter.

And there's a lot of numbers to sort through when you're reading the results of this study, but in, In essence, they found that for those who underwent the standard protocol, 1.5 percent of them had some adverse reaction during their testing. Now, at least one of those patients was noted to have hives, and this was a patient who was suffering from chronic hives.

As opposed to the accelerated protocol, there were no adverse effects. This article was reviewed by Dr. Iris Otani as well, and she commented on the fact that only seven patients had a history of severe sting reactions of the 134 that were analyzed, and so that certainly could limit our generalizability of this study.

But I think for those of us who are doing intradermal skin testing on a regular basis, this is definitely intriguing, especially, these authors found that there was some reduction in the time spent during testing, certainly the discomfort, if you're not doing as many intradermal skin tests. And, this is valuable.

I'm not sure if it's ready for primetime yet, but it certainly adds to the body of evidence that's demonstrating some potential benefits from a more accelerated intradermal skin test protocol.

Stanley M. Fineman, MD: So, Sarah, this is an interesting study because I recall when hymenopteric skin testings first started, I guess that's the benefit of, having some years in the field. But back in the early 80s is when it came out we were very scared of hymenoptera venom testing. You know, we were worried about anaphylaxis and things like that.

And they basically started this protocol. So, I would love to see our practice parameter guidelines, pick up on these types of studies that, could make it more efficient and less painful and certainly still accurate for our patients, but, I'm glad you brought this up.

Host: I'm the odd man here because I don't do skin testing for venom. I think on a previous podcast, I confessed to Dr. Fineman that I rely heavily on his practice to help out my patients. You know, there was a previous study that was discussing blood testing first. And then, validating the rest, some negatives with skin testing if needed, so I have very little experience of it, but overall with y'all's experience, how often are you seeing systemics or reactions? Are you seeing stuff like this where maybe it's questionable or you see, oh yeah, it was definitely the venom. What's your thoughts?

Sarah Spriet, MD: In my practice, I've not had a systemic reaction to skin testing, period.

Stanley M. Fineman, MD: Neither have I, you know, we may have some large locals, but, nothing systemic. And, with starting immunotherapy, obviously we've had some reactions to that. But, what you bring up, Gerry, is a problem. The hymenoptera extract is extremely expensive and it's not compensated that well.

And, I think that a lot of practices are doing in vitro testing for IgE sensitivity to the venoms. And certainly it's valid and it's a good way to do it, but, I think we need to get guidance from our practice parameter group or guidelines that can analyze these types of rapid protocols or rapid skin test, accelerated skin test protocols, compare them to the in vitro and give us some good guidance of what should we do with our patients.

Host: I think absolutely there is a role for skin testing, you know, certainly we would trust a negative skin test over a blood test, but, but moving that along obviously is a great option. So I'm looking forward as well to further modifications to the recommendations if the evidence supports it. So I got one more article, that I think isn't allergy per se, but it's a commonthing we encounter in clinic, and that's Sinusitis!

Pediatric Sinusitis. I mean, we see snotty noses continuously. And when a child meets criteria for sinusitis, clearly, especially if the child's suffering, there's a lot of questions whether, antibiotics are indicated, what antibiotics to give. So this article was published in JAMA. First author was Timothy Savage, and it was entitled Treatment Failure and Adverse Events After Amoxicillin Clavulanic acid vs. Amoxicillin for Pediatric Acute Sinusitis. And there's some interesting statistics. In the intro, there's like 4.9 million prescriptions for pediatric sinusitis a year and only 68 to 72% of cases actually have a positive culture. Though antibiotics are prescribed 85% of the time. So, you know, some interesting numbers there.

I've always followed the IDSA criteria. It's like ancient now it's like 2012. But for both adult and pediatric acute sinusitis, IDSA, infectious Disease Society of America recommended Augmentin first line. And, the reasons for that was that they were seeing epidemiological evidence for increased H. flu, which over 65 percent of H. flu isolates make beta lactamase, more accela, they all express beta lactamase. And that they were seeing a lot of this H. flu and mroe accela in isolates, in culture over time. They attributed that to the increased use of, pneumococcal conjugate vaccine, which decreased strep pneumo isolates. And even though previous studies did show that there wasn't really much of a difference between amoxicillin and amoxiclav, the IDSA was always concerned because those studies were done in the pre pneumococcal conjugate vaccine era. So maybe that's not relevant. So that's what these authors decided to do.

Like, okay, now that we have PCV13 out for years, let's repeat the study and see what they show. So this is an analysis of a claims database called MarketScan. They looked at pediatric patients with the ICD 10 code of acute sinusitis for a three year period. They got a either amox or amoxclav.

Obviously, they did the usual exclusions. You know, you couldn't have had, like, some sort of existing sinus disease or recent antibiotics or some sort of infection at the same time. And basically, they looked at treatment failure. So, in the two weeks after receiving the antibiotic, if you got a new antibiotic or you went to the ER or got hospitalized if you had some sort of complication, they list all these horrible complications like meningitis, orbital cellulitis, osteo, getting some sort of neurosurgery or rhinoscopy.

My goodness, I hope I never see that. But again, they looked at everything. And, obviously, they looked at adverse events and, they had some confounders they adjusted for. They adjusted for age, what childhood chronic conditions there were, where they lived, rural or region, the specialty of the doctor, as well as the setting outpatient or ED.

And, you know, they were able to find, uh, 320,000 patients. to look at the data. And interestingly, if they look at just overall treatment failure for either amox or amoxclav, amoxclav is a 1.7 percent treatment failure and amox, 1.8%. Not really statistically different. Now, for those who did have a treatment failure, that serious failure, and they define serious failure as going like the ED or getting hospitalized.

That was 0.01%. So in pediatric acute sinusitis, that's not very common. And if they did have a treatment failure for the 1.7 to 1.8%, they just did an outpatient change of antibiotics. Usually there wasn't any serious harm, they just sort of switched out the antibiotics. Now, on the flip side, if you look at adverse events.

There were more adverse events if you use amoxclav. GI symptoms had an odds ratio of 1.15 and yeast infection 1.33. Huge, but slightly elevated. So, taken together, it does seem like they've repeated some of the previous work that was done in the pre-PCV13 era, and even now that people are using pneumococcal conjugate vaccine that may modify Strep pneumo, amoxicillin still seems to work for acute sinusitis, though, maybe some of these kids don't probably need the antibiotic anyways. I mean, we can, that's another conversation, but, I think that in general, kids probably do very well when you treat them with amox for ear infections, so I can't imagine it being much different to sinusitis. So I do believe the results. I'm not sure, if y'all did a go to for AmoxClav like IDSA or did you routinely do Amox? What did you do in your, pediatric patients?

Sarah Spriet, MD: I'm pediatric trained, so, it was always amox first, and if they weren't getting the response that I was looking for in that initial 48, 72 hours, or if they've been on amoxicillin within the last month, you know, I might alter my approach in that case, but yes, I'm in the amoxicillin first camp.

Stanley M. Fineman, MD: So when I was seeing children with sinusitis, I usually gave them amoxicillin clavulanic, as a first choice, mainly from the ENT literature that's really in adults. It's not really in kids. But I think this is very compelling.

And of course the kids are gonna like the amoxicillin a lot better than the amoxicillin clavulanic that tastes terrible. But one of the things I was a little surprised about was that the risk ratio for the GI symptoms wasn't that high, there wasn't that difference, and I think we see more than a risk ratio of 1.15 difference, slightly more, but not a lot, but I think we generally see more people complaining of GI complaints with the amoxicillin clav than we do with amoxicillin. And this study was done in JAMA. And that's one of the beauties of Allergy Watch is the fact that, we're looking at relevant articles for our practices from all kinds of journals. So I'm glad that you picked this to talk about Gerry.

Host: Well, you know, we have to thank the reviewer, Sham Joshi, who also makes a statement, in Allergy Watch that, again, this is another piece of information when caregivers or adolescents talk about risk benefit, especially if they were used to amoxiclav in the past. There's a little piece of information if you wanted to give a reassurance.

And I always appreciate that. So, I agree, I find it valuable to keep up to date, even though I really should be monitoring big things in my practice, Allergy Watch does reign it in. Well, I hope you enjoyed also the articles that we reviewed. If you enjoyed this podcast, please rate us on iTunes.

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The ACAAI is presenting this podcast for educational purposes only. It is not medical advice or intended to replace the judgment of a licensed physician. The college is not responsible for any claims related to the procedures, professionals, products, or methods discussed in the podcast, and it does not approve or endorse any products, professional services, or methods that might be referenced.

Today's speakers have the following disclosures. Drs. Lee and Dr. Spreit have nothing to disclose. Dr. Fineman has been a speaker for Takeda and has done research for A. Immune, DBVU, and BioQuest.