Background Cow’s milk protein allergy (CMPA) is an immune-mediated reaction to milk pro- teins affecting 2.4% of children in the United Kingdom (UK). Probiotics may have a role in immune system modulation through gastrointestinal tract colonisation with a possible reduction in allergic disease. Certain neonatal units within UK use probiotic supplementation to reduce the risk of Necrotising Enterocolitis (NEC). This retrospective case controlled study aimed to establish whether routine pro- biotic supplementation for NEC had a secondary effect on the rate and tolerance acquisition in CMPA. Method Neonates born prematurely (24-32 weeks) at the Royal Devon and Exeter Hospital, between 2008-18 were investigated. Two cohorts were established: Nil exposure (2008-2013) and exposure (2013-2018) to probiotic supplementation (B. bifidum and L. acidophilus or B. bifidum, L. acidophilus and B. infantis). CMPA results were ascertained from two-year follow up data and verified by an independent paedia- tric allergist. Statistical analysis calculated rates of CMPA and the acquisition of tolerance. Results In total 722 neonates were identified; 314 (43.5%) in the intervention group (exposure), 408 (56.5%) in the control group (nil exposure). The intervention group (53.8% male) had a mean gestational age of 30+1 weeks (24-32 weeks) and mean birth weight of 1350.4g (555-3540g). Twenty one (6.7%) were diagnosed with CMPA (all non IgE-mediated) with 12 neonates acquiring to- lerance at mean age of 16 months (7-23 months). The control group (57.6% male) had a mean gestational age of 30+4 weeks (27- 32 weeks) and mean birth weight of 1448.6g (494-3002g). Seven (1.72%) were diagnosed with CMPA (all non IgE-mediated), 6 neonates acquired tolerance at a mean age of 32.5 months (7-70 months).Background Recent data suggest that the use of extensively hydrolyzed casein formula contai- ning the probiotic L.rhamnosus GG (LGG) (EHCF+LGG) reduces the incidence of other AMs and hastens the development of immune tolerance in children with IgE- mediated cow's milk allergy (CMA). To see whether formula choice for CMA treat- ment could impact the occurrence of other AMs and the time of immune tole- rance acquisition. Method Prospective open non-randomized trial on a cohort of children with a diagnosis of IgE-mediated CMA in the first year of life, already in follow-up. The patients were treated with one of the following formulas: EHCF+LGG, rice hydrolyzed formula (RHF), soy formula (SF), extensively hydrolyzed whey formula (EHWF) or amino- acid based formula (AAF). All subjects were evaluated during a 36 months follow- up. The occurence of AMs (atopic eczema, allergic urticaria, asthma and oculorhinitis) was diagnosed Immune tolerance acquisition was evaluated every 12 month by the result of oral food challenge. Results A total of 365 subjects completed the study, 73 per group. All children were from families of middle socio-economic status and lived in urban areas. At enrollment, all subjects were in stable clinical conditions without symptoms related to CMA. Demographic and anamnestic features were similar comparing the study cohorts at enrolment. Binomial regression revealed that the estimates of the incidence of the AMs are: EHCF+LGG: 0.22 (Bonferroni corrected 95%CI: 0.09 to 0.34); RHF: 0.52 (Bonferroni corrected 95%CI: 0.37 to 0.67); SF: 0.58 (Bonferroni corrected 95%CI: 0.43 to 0.72); EHWF : 0.51 (Bonferroni corrected 95%CI: 0.36 to 0.66); AAF: 0.77 (Bonferroni corrected 95%CI: 0.64 to 0.89).The incidence of the main out- come in the RHF, SF, EHWF and AAF groups vs. the EHCF+LGG group was always higher than the pre-specified absolute difference of 0.25 and significantly higher at the pre-specified alfa-level of 0.0125 (p-value <= 0.001 in all cases). The acqui- sition of immune tolerance was significantly higher in the EHCF+LGG group com-Results A total of 365 subjects completed the study, 73 per group. All children were from families of middle socio-economic status and lived in urban areas. At enrollment, all subjects were in stable clinical conditions without symptoms related to CMA. Demographic and anamnestic features were similar comparing the study cohorts at enrolment. Binomial regression revealed that the estimates of the incidence of the AMs are: EHCF+LGG: 0.22 (Bonferroni corrected 95%CI: 0.09 to 0.34); RHF: 0.52 (Bonferroni corrected 95%CI: 0.37 to 0.67); SF: 0.58 (Bonferroni corrected 95%CI: 0.43 to 0.72); EHWF : 0.51 (Bonferroni corrected 95%CI: 0.36 to 0.66); AAF: 0.77 (Bonferroni corrected 95%CI: 0.64 to 0.89). The incidence of the main out- come in the RHF, SF, EHWF and AAF groups vs. the EHCF+LGG group was always higher than the pre-specified absolute difference of 0.25 and significantly higher at the pre-specified alfa-level of 0.0125 (p-value <= 0.001 in all cases). The acqui- sition of immune tolerance was significantly higher in the EHCF+LGG group com- paring to the other groups. The rate of immune tolerance acquisition for EHCF+LGG groups was (95%Cl): at 12 months = 0.41 (0.30 to 0.52); at 24 months = 0.64 (0.53 to 0.75); at 36 months = 0.81 (0.72 to 0.90). Conclusion The results of the study suggest that EHCF+LGG is superior to other formulas for the prevention of AMs and for the acquisition of immune tolerance in children with CMA.Background In patients with cow's milk protein allergy (CMPA) alternative sources are recom- mended to supply the nutritional adequacy and calcium balance. Among these al- ternatives soy, rice, almond and coconut based milk alternatives can be used es- pecially after the age of two. The aim of this study was to investigate the factors affecting the choice of plant-based milk alternatives (PBMA) and their effects on nutritional status in patients with CMPA. Method The clinical characteristics, nutritional habits and three-day food consumption re- cords of 48 patients older than 2 years with the diagnosis of CMPA were evaluated. Results A total of 48 patients, [66.7% male, age 3.2 years (2.4-5.6) ] of which 54.2% had multiple food allergy were evaluated. Eighteen (37.5%) of the patients preferred PBMA however, thirteen (27.1%) patients preferred the formula, and seventeen (35.4%) of them did not consume any PBMA. There was no significant difference in z scores of body weight by age, height by age and body weight by height accor- ding to drink preference. 68.8% of the patients had a diagnosis of anaphylaxis. 81.3% of the patients were aware of PBMA and 54.2% had consumed PBMA at any time. Causes for not consuming PBMA were allergenic effects for 33.3% of patients; cost of the product for 2.6%. Soy-based and almond based milk alterna- tives were consumed by 83.3% and 16.7%, respectively. 68.6% of the patients were informed about the alternative sources by the physicians and / or dieticians while 31.4% got information from social media and / or internet. When the factors affecting the families’ decision for consuming PBMA were analyzed, it was found that the advice of doctor and / or dietician [OR 17,171 (%95 GA 1,875-1 57,255; p= 0,012)] and the presence of atopic disease [OR 18,432(%95 GA 2,098-161,965; p=0,009)] in the family were effective. PBMAs had less energy (p<0.001), lower protein content (p=0.013) and lower vi- tamin D (p<0.001) content than formulas and no significant difference was found between the formula fed children and PBMA using ones with respect to calciumPBMAs had less energy (p<0.001), lower protein content (p=0.013) and lower vi- tamin D (p<0.001) content than formulas and no significant difference was found between the formula fed children and PBMA using ones with respect to calcium and B12 contents. Conclusion Plant-based milk alternatives can be used as an alternative for the children older than 2 years of age, but patients consuming PBMA should be monitored for energy, protein and vitamin D adequacy. Doctor / dietician advice and presence of atopic disease in the family are the most effective factors in the decision to start consuming the PBMA.Background Cow's milk allergy (CMA) is the most common food allergy in young children but due to the frequently gained spontaneous tolerance, the persistence to adulthood is relatively rare. Additionally, as the mature gut mucosa of adults doesn't allow the passage of potential milk allergens, new-onset CMA in adulthood is also known to be unusual. We have aimed to present 18 patients presented with adult onset CMA. Method We have collected the data of patients admitted to our Adult Allergy Service in 2019 with symptoms related to milk hypersensitivity, whom the diagnose of adult onset milk allergy has been confirmed with clinical history and/or objective tes- ting methods. Skin prick tests with common aeroallergens, suspected food aller- gens including prick to prick to milk, together with specific IgE and component re- solved diagnostic methods (CRD) have been performed in all patients. Results Eighteen patients (43 +16 years, 11 female) have been enrolled in our study. Three of them (2 female, ages 29+8) had symptoms consistent with adult onset Food Protein Induced Enterocolitis Syndrome (FPIES). They all had a history of child- hood type 1 CMA. Ten patients (6 female, ages 42+14) had a classic adult onset type 1 CMA diagnosed with clinical history, skin prick test and blood test positivity. The reaction with milk exposure resulted in symptoms involving skin (6/10), respiratory system (4/10), gastrointestinal system (6/10), cardiovascular (2/10). Two of them had mast cell tryptase positivity confirming anaphylaxis. In two of these cases allergy seems to havedeveloped after unnecessary milk avoidance. Five patients had intermittent symptoms suggesting a Type 1 CMA. In not all but some occasions the reaction with milk exposure resulted in symptoms involving skin (4/5), respiratory system (3/5), gastrointestinal system (3/5), car- diovascular (1/5). One of them had mast cell tryptase positivity confirming an anaphylaxis. Possible cofactors (such as exercise, fatigue, drug) have been ques- tioned but, no obvious one has been found in any of our cases. The common fea- ture among these patients with intermit’ ~ type 1 CMA was a positivity of 4-al- pha lactalbumin IgE.Background Cow’s-milk protein allergy (CMPA) is the main cause of food allergy in children younger than 3 years, a real burden for the patient and his/her family. Its gastroin- testinal manifestations are nonspecific, and the correct diagnosis remains challenging. This study aims to identify the descriptive characteristics of a children cohort diagnosed with CMPA according to the ESPGHAN guidelines. Method Twenty four children aged 8 to 39 months have been followed by a Pediatrician and an Allergist in the outpatient clinic between 2017 and 2020. Mean age was 2.2 years and 3 patients were diagnosed at 4 months of age. The most frequent symptoms that lead to the suspicion of CMPA were: Growth failure, abdominal pain, vomiting or rash caused by yogurt after food introduction. Results In the analyzed cohort 20 patients were born by c-section (a very high percentage compared to literature data, as the World Health Organization recommends a rate for c-sections between 10 and 15%). Most newborns-18 were breastfed. Atopic dermatitis, a confirmed risk factor and accompanying feature, was present in 50 % of cases. Smoking as a risk factor was identified in the parents in 50 % of diagnosed cases, in 25 % of cases both parents being smokers. During follow-up, 5 presented recurrent wheezing episodes. No allergic rhinitis or asthma cases were observed because of the short follow-up period. Recent stu- dies show that D vitamin deficit is associated with food allergy. This investigation is limited by cost and only 5 cases had vitamin D levels measured and deficit was documented in just 2 cases. It is remarkable that all the patients have received the vitamin D prophylaxis with the right doses. The mean period of diet was 12 months. 4 cases had no milk introduced because of important reactions on Oral Immunotherapy. Lack of appetite was observed in 46% of cases and 50% of children were undarwainht In aur anhart 52 % had intarrintad elaan ar nacturnal anitatianLack of appetite was observed in 46% of cases and 50% of children were underweight. In our cohort 58 % had interrupted sleep or nocturnal agitation. In 5 cases other food allergies were associated, most commonly egg and soy allergies. Conclusion Despite the relatively small cohort, the increased frequency of risk factors such as atopic dermatitis and smoking parents was documented. Proper monitoring by a multidisciplinary team including a Pediatrician, an Allergist and a Dietitian is mandatory. Malnutrition, lack of vitamin D dosing, associated allergies are all major health- care issues requiring careful medical attention and further research in focused prospective studies.Background Fish allergy is among the most prevalent forms of food allergy and is widely reco- gnized in allergen labeling law. Despite this, little is known regarding the protein isoforms which make up the allergen content of fish. A particular problematic is- sue is the diversity of consumed fish. Observed differences in clinical reactivity of different fish species make the detail of allergen composition particularly interesting. Here, we study the diversity of allergens, and isoforms thereof, in two of the most highly-consumed fish species, salmon and trout. Method Samples of fillet, rack (vertebrae), brain and liver of salmon (Salmo salar) and rain- bow trout (Oncorhynchus mykiss) were extracted, reduced, alkylated and digested prior to data-dependent mass spectrometry analysis. Data were analyzed by com- parison to salmon and trout sequence databases. Relative quantitation was per- formed using a top N label-free workflow with normalization by protein concentra- tion of extracts. Results Proteomic analysis allowed the identification and relative quantitation of all puta- tive salmon and trout allergens (8-parvalbumin, enolase, aldolase, tropomyosin, collagen-a, creatine kinase, triosephosphate isomerase, pyruvate kinase and vitellogenin) listed on IUIS and Allergen Online from a total of 6821 identified sal- mon and trout protein groups. Trout homologues of allergens were also identified. In many cases, multiple isoform of allergens were present. Further detailed analy- sis of B-parvalbumin, aldolase and enolase revealed the presence of tissue-speci- fic isoforms. Relative quantity of allergens in trout and salmon demonstrate diffe- rences at both the total allergen level, and isoform level. Conclusion The molecular composition of fish allergens is more complex than appears at first glance. Multiple isoforms of many fish allergens are expressed, though not all of these are present in commonly consumed tissue (fillet). Although sequences of trout and salmon allergens are similar, differences exist in expression level and tissue specificity. Marked difference in expression profile demonstrate that even hetween hiahlv-related sneries sich as salmon and trout direct seciience cam-Background The association between IgE-mediated food allergy and eosinophilic esophagitis (EoE) is known. The risk of immediate reactions in EoE is well documented. However, the association of EoE in patients with pre-existing IgE-mediated cow's milk allergy (CMA) is less explored. Our objective was evaluate the time between symptom onset and EoE diagnosis in patients with mediated CMA IgE mediated and its clinical characteristics. Method Medical records’ review of patients diagnosed with CMA who developed EoE. Demographic, clinical, peripheral eosinophilia, gastrointestinal symptoms, sensiti- zation profile, endoscopic pattern and associated allergic diseases were evaluated. Results The number of patients evaluated were 10, of which 7 were men (70%), with a mean age of 12.9 years. On average, the age at onset of EoE symptoms was 6 years old, diagnosed at 8 years old and onset of CMA symptoms at 5 months old. We observed high levels of milk-specific IgE: 76.1 kU / L (29.3-100). On average, peripheral eosinophilia was 806.9 cells/mm? (420-1330). Atopic manifestations, such as asthma and rhinitis, were present in 80% of pa- tients and atopic dermatitis in 20%. There was family history of EoE in one case. The main symptoms were: need of fluids during eating (50%), dysphagia (40%), prolonged eating (30%), choking (30%) and vomiting (30%). The diagnosis of EoE was possible through the active search of symptoms, since most patients presented compensatory behaviors of dysphagia. Multiple sensitization to milk and other food, as egg, soy and wheat, were observed, with the respective numbers: 46.1%, 23%, 23%.The main symptoms were: need of fluids during eating (50%), dysphagia (40%), prolonged eating (30%), choking (30%) and vomiting (30%). The diagnosis of EoE was possible through the active search of symptoms, since most patients presented compensatory behaviors of dysphagia. Multiple sensitization to milk and other food, as egg, soy and wheat, were observed, with the respective numbers: 46.1%, 23%, 23%. The predominant endoscopic pattern was inflammatory; longitudinal striae being the most frequent finding (38.5%). The evolution to the fibrostenotic pattern oc- curred in only 1 case (7.7%). Conclusion The delay in the diagnosis of EoE may be due to nonspecific symptoms and dys- phagia compensation mechanisms. Therefore, proactive investigation allows early suspicion and confirmation of the disease, which could prevent further com- plication of the disease (stenosis). Demographics data | Results Male gender (%) 70 Current age (average, years) 12,9 Age of onset of symptoms of EoE | 6 Age of diagnosis (average, years) | 8 APLV symptoms start age | 5Background Prevalence of food sensitisation (FS) varies considerably across Europe, and is reported to be on the rise. Such changes in prevalence due to geographical loca- tion and over time, suggest environmental influences. Method The objective of this study was to investigate which environmental determinants are predictors of FS in childhood and adulthood, focusing on early-life exposure, including infant diet. All 2196 school-age children and 2185 adults who comple- ted an extensive questionnaire and blood sampling in the pan-European EuroPre- vall project, were included. Data on childhood and adulthood environmental de- terminants (including, but not limited to, sibship size, day care attendance, pet ownership, farm environment, and smoking), and infant diet (including breastfeeding, and timing of introduction to infant formula and solids), were extracted. Demographic determinants were also included. Associations between the determinants, and sensitisation to foods (sIgE20.35 kU/L), were evaluated through multivariable logistic regression. Secondary outcomes included inhalant sensitisation (IS) and primary (non-cross-reactive) FS, in order to assess whether there are differences between predictors for FS and IS. Results Regarding childhood environmental determinants, having a pet dog in early child- hood was associated with lower prevalence of childhood FS (OR 0.65 [95%-Cl 0.48-0.90]). No other environmental determinants and no infant dietary determi- nants were found to be independently associated with FS in childhood or adulthood. Significantly contributing demographic predictors were higher gesta- tional age at delivery (OR 0.93 [95%-Cl 0.87-0.99] per week increase in age) for childhood FS, and lower age and male sex for adult FS (OR 0.97 [95%-Cl 0.96- 0.98] per year increase in age, and 1.39 [95%-Cl 1.12-1.71] for male sex). Regar- ding the secondary outcomes, the most notable finding was that early-life farm exposure was associated with lower prevalence of IS in adulthood.Background Food intake in early life plays an important role in providing nutrients and setting the child up for lifelong eating habits. One aspect of early-life foods that has been ignored is the role of the pH, on the development of oesophageal inflammation. The acidic environment within the oesophageal lumen has been linked to oeso- phageal inflammation and barrier injury, relating to oesophageal diseases such as EoE and GORD. We noticed an increase in the incidence of both EoE and GORD alongside an increase in the sales of infant/toddler foods, commonly containing fruit or citric acids to create a preservative free option. Method We measured the pH of commercially available ifant/toddler/toddler foods; pouches, infant/toddler jars and infant formula and compared to home-made foods. We considered a pH of <4 as likely to cause oesophageal/epithelial damage. Results 29 of 60 tested commercially available infant and toddler feeds and bottles in Australian supermarkets were found to have a pH less than 4. This was infrequent with home-prepared foods where the pH was less than 4 in 2 of the 8 foods. In particular, products containing apple puree and citric acid were acidification factors. Conclusion Many commercially available infant/toddler foods have the capacity to induce epi- thelial injury due to its low pH. This has implications that require further investiga- tion for the pathogenesis and also for the prevention and treatment of oesopha- geal diseases. Epithelial barrier integrity and inflammation has become a recent focus in the aetiology of allergic diseases; which are also dramatically increasing in the last few decades.Background Most children with cow's milk protein allergy (CMPA) outgrow their allergy, however, a significant proportion seen in specialist services have a more persis- ting phenotype. In the absence of a change in skin prick test (SPT) wheal, clini- cians may not undertake formal re-evaluation via challenge Aim: To evaluate diagnostic utility of SPT and serum IgE in a cohort of older chil- dren with persistent CMPA, in predicting tolerance to 1000mg (~30mls CM) at food challenge (FC). Method Participants aged 6-17years underwent DBPCFC to CM as part of the SOCMA study (Clinicaltrials.gov NCT02216175). DBPCFC were performed according to the PRACTALL Consensus. Anaphylaxis was defined as objective respiratory or cardiovascular signs. Results 47 young people (median age 11 years, 58% male) participated; 30 reported pre- vious anaphylaxis to CM. 35 (74%) had positive challenges to <1000mg CM protein. ROC Curve analysis demonstrated the highest diagnostic performance for serum IgE to CM (AUC 0.89) and casein (AUC 0.84). In contrast, SPT had poo- rer diagnostic utility, with AUC 0.53 for CM extract/fresh milk and 0.72 for casein extract. End-point titration using fresh CM performed better, with AUC of 0.69. Conclusion Standard SPT was of limited utility in determining clinical reactivity in this age group. Although these data require replication, we recommend not relying on SPT alone in assessing for possible resolution in persistent CMPA.Background Peanut and tree nuts are phylogenetically distant with established cross reactivity Thus, many patients with peanut allergy are told to avoid all tree nuts. The extent of co-sensitization is not completely understood and may significantly vary based on geographical regions. Herein, we characterize the patterns of tree nut co-sensi tization in a sub-group of peanut allergic children from Toronto and Vienna. Method Pediatric patients from Toronto, Canada and Vienna, Austria with peanut allergy ir the Markers of Nut Allergy Study (MONAS) were included. Co-sensitization to tree nut extracts (hazelnut, walnut, pistachio, cashew, almond, pecan and brazil nut) as well as tree nut-derived allergens (Cor a 1.030, Cor a 1.040, Cor a 8, Cora 9, Cora 11, Cor a 14; Jug r 1, Jug r 2; Ana o 3; Ber e 1) were assessed by the Allergy Explo- rer (ALEX; Macro Array Diagnostics, Vienna, Austria). Co-sensitization patterns were also analyzed in three age groups (<6, 7-12, 213 years old). A serum IgE le- vel = 0.30 kUa/L was considered positive. Results The study included a total of 109 patients with peanut allergy (mean age of 944.7 years) sensitized to at least one of the main seed storage proteins (Ara h 1, 2, 3, 6). The majority had IgE to all 4 of them (85-94%). Co-sensitization to tree nut ex- tracts was observed to hazelnut (72%), pistachio (69%), pecan (68%), cashew (58%), walnut (56%), almond (43%) and Brazil nut (23%). Among those allergenic sources, sensitization to the marker seed storage proteins (Cor a 9, 11, 14; Jugr 1, 2; Ana o 3) showed an increased frequency by 10-20% across age groups. In concordance with increased sensitization to environmental allergens, IgE binding to PR10 family allergens (Ara h 8 and Cor a 1) doubled from age group 1 to 3. Sensitization to marker allergens such as Ana 0 3 or Cor a 14 did not match the rates of extract sensitization (42% vs. 58% and 23% vs. 72%, respectively).Results The study included a total of 109 patients with peanut allergy (mean age of 944.7 years) sensitized to at least one of the main seed storage proteins (Ara h 1, 2, 3, 6). The majority had IgE to all 4 of them (85-94%). Co-sensitization to tree nut ex- tracts was observed to hazelnut (72%), pistachio (69%), pecan (68%), cashew (58%), walnut (56%), almond (43%) and Brazil nut (23%). Among those allergenic sources, sensitization to the marker seed storage proteins (Cor a 9, 11, 14; Jugr 1, 2; Ana 0 3) showed an increased frequency by 10-20% across age groups. In concordance with increased sensitization to environmental allergens, IgE binding to PR10 family allergens (Ara h 8 and Cor a 1) doubled from age group 1 to 3. Sensitization to marker allergens such as Ana 0 3 or Cor a 14 did not match the rates of extract sensitization (42% vs. 58% and 23% vs. 72%, respectively). Conclusion Patients with peanut allergy are frequently sensitized to one or more tree nut(s), except for almond and Brazil nut. The fact that co-sensitization to marker proteins such as Ana 0 3 and Cor a 14 did not match extract data suggests a significant lower clinical cross reactivity. Thus, careful clinical assessment is required to dis- tinguish between sensitization and true allergy when providing counseling to pe- diatric patients with peanut allergy.Background Cashew allergy may be associated to anaphylactic reactions. Main cashew aller- gens show a strong cross-reactivity with pistachio due to a high homology bet- ween their seed proteins. In case of a negative allergy work-up to cashew, it is so- metimes suggested not to reintroduce pistachio at home, without a previous su- pervised challenge. The objective of the study was to verify if an allergy evalua- tion is concordant for the two allergenic sources. Method We run a retrospective study, including all patients who underwent an allergy work-up to cashew and pistachio at the University Hospital of Montpellier bet- ween 2005 and 2020. We evaluated the results of skin prick tests (SPT) with the prick by prick method, specific IgE (pistachio, cashew and seed protein rAna 0 3), and results of the oral food challenge (OFC), besides collecting information on possible comorbidities and co-sensitizations. Results We included 96 patients, 43 males (44.8%), with a median age of 10 years old (8 months - 26 years). OFC to cashew was positive in 23 patients (24.0%). OFC to pistachio was positive in 16 (16.7%). SPT for cashew were negative in 16 patients, 14 (87.5%) of which had a positive SPT for pistachio. SPT for pistachio were ne- gative in 16 patients, 9 (56.3%) of which had a positive SPT for cashew. Moreover, we found that 58 patients had a negative OFC for cashew with 2 (3.4%) of them having a positive OFC to pistachio; while 66 patients had a negative OFC to pistachio with 9 (13.6%) of them having a positive OFC to cashew. The post-hoc analysis showed that the specificity of the SPT for cashew is 73.1%, while for pistachio is 77.2%. Finally, the OFC to cashew positive predictive value for an allergy to pistachio is 77.2%. Conclusion The results of this preliminary study showed that there is a difference between sensitization and allergy to cashew and pistachio and that in patients with posi- tive SPT and IgE to pistachio, it is not recommended to authorize a reintroduction at home, even if they are not allergic to cashew. In case of cashew or nistachio sensitization. it is required to nerform an OFC for MM On <Background Coconut is the fruit of the coconut tree belonging to the palm family (Arecaceae). Although coconut fruit is a drupe, it is commonly considered to be a nut and pa- tients with peanut and tree nut allergies often avoid it. Despite an increase in the prevalence of food allergy worldwide, coconut allergy has remained low and publi- shed papers are limited to case reports and small case series. Papers published on association between coconut and tree nuts allergies were based on result of the tests rather than challenge proven allergy. We studied the outcomes of coco- nut oral food challenges (OFC) and supervised feeds (SF) performed within our Paediatric Allergy Department. Method We performed a retrospective review of our food challenge database from No- vember 2013- December 2019. Statistical analysis of age, skin prick tests (SPT) and specific IgE (SIgE) data was performed using SPSS statistics package. Results We performed 35 OFC and 12 SF. Median overall age (N=45) was 6 years (IQR (3.00, 11.00)). Outcome of 43 OFC and SFs were available for analysis. 4 (9%) had positive outcomes; 2/4 children (50%) presented as anaphylaxis- 1 child required 2x adrenaline IM, the other 2 x IM adrenaline and IV fluid bolus. The Mean (SD) SPT results for the positive OFCs were 0.75 (0.95) mm and 1.38 (1.39) mm for negative OFCs. The Mean (SD) SIgE result for the positive OFCs was 8.95kua/L; Median SIgE for negative OFCs was 2.05kua/L (IQR (0.58, 4.12)) Binary logistic model showed a 95.8% accuracy rate of predicting a negative out- come of an OFC/SF based on SPT and SIgE but only 25% accuracy in predicting a positive outcome. Mean time to allergic reaction was 123.75 minutes following the initial dose of coconut. 3/4 children completed challenge before experiencing the reaction. History of suspected allergy was reported in eight patients; others were challen- ged because of other food allergies, particularly nuts.Background Seventy-five percent of hen's egg allergic children who avoid hen’s egg could be tolerant to baked egg. Until now, several studies have examined the relevance of egg specific IgE (sIgE) levels to predict baked egg tolerance. The goal of this re- trospective study is to analyze the outcome of the baked egg oral food challenge (OFC) in function of egg sIgE levels, while evaluating immunological parameters associated with clinical reactions. Method Between 2015 and 2019, forty-two children (1y-13y) with a history of hen’s egg al- lergy underwent a baked egg challenge at the pediatric allergy clinic of UZ Leuven. This OFC consisted of 6 incremental doses of cake (1, 2, 4, 8, 16 and 32 g), provi- ded with a 15-minute dose interval. Children who consumed the 63 g cumulative dose of cake (8 g egg protein) without symptoms, were considered to have pas- sed the challenge. Immunological parameters were measured at baseline and 1 hour after the baked egg challenge. Results Of the 42 children (median age 4y, 70 % boys), 33 had multiple food allergies and 9 were mono-sensitized to egg. Sixty-nine percent had a history of Grade | ana- phylaxis while four children experienced Grade II, three Grade III and six Grade IV adverse events upon exposure to egg. During the baked egg OFC, 39 children suc- cessfully consumed 63 g of cake whereas 2 children experienced minor symp- toms (itch, erythema or diffuse rash). For these 2 children, blood results showed baseline egg sIgE levels < 1 kU/L and no increase in tryptase level after the OFC. At baseline, the median IgE levels were 0.66 kU/L for egg white, 0.17 kU/L for OVM, 0.38 KU/L for ovalbumin (OVA) and 140.5 KU/L for total IgE. Of these 42 children, 35 had OVM sIgE levels < 1.2 kU/L, whereas 7 exceeded this cut-off. A strong positive correlation was established between age and both OVM sIgE (P<0.0001, r=0.62) and total IgE (P<0.0001, r=0.72), while a weaker correlation was found with OVA sIgE (P=0.04, r=0.32) and egg white sIgE (P=0.007, r=0.41).Results Of the 42 children (median age 4y, 70 % boys), 33 had multiple food allergies and 9 were mono-sensitized to egg. Sixty-nine percent had a history of Grade | ana- phylaxis while four children experienced Grade Il, three Grade III and six Grade IV adverse events upon exposure to egg. During the baked egg OFC, 39 children suc- cessfully consumed 63 g of cake whereas 2 children experienced minor symp- toms (itch, erythema or diffuse rash). For these 2 children, blood results showed baseline egg sIgE levels < 1 kU/L and no increase in tryptase level after the OFC. At baseline, the median IgE levels were 0.66 kU/L for egg white, 0.17 kU/L for OVM, 0.38 KU/L for ovalbumin (OVA) and 140.5 KU/L for total IgE. Of these 42 children, 35 had OVM sigE levels < 1.2 kU/L, whereas 7 exceeded this cut-off. A strong positive correlation was established between age and both OVM sIgE (P<0.0001, r=0.62) and total IgE (P<0.0001, r=0.72), while a weaker correlation was found with OVA sIgE (P=0.04, r=0.32) and egg white slgE (P=0.007, r=0.41). Conclusion This study shows that either children with low or high egg sIgE values can pass the baked egg OFC. Hereby, the age of the child and the severity of their allergic reaction could play an important role. Furthermore, we saw that both egg sIgE and total IgE levels increased with age in our cohort. Ultimately, this study shows that predictive cut-off values for baked egg tolerance are influenced by the cha- racteristics of the study population and that an OFC remains essential before in- troducing baked egg at home.Background Hen's egg is a common cause of childhood food allergy, affecting 0.5-2.5% of young children. Oral food challenge (OFC) is the “gold standard” to confirm the diagnosis of egg allergy. The aim of our study was to evaluate the usefulness of sIgE antibodies to egg white (EW) and its dominant allergen, ovomucoid (OV), in predicting cooked egg challenge outcome. Method 109 children (mean age 5yrs, range 1-16yrs) with clinical history of egg adverse reaction and/or egg sensitization (positive EW or OVM sIgE), who underwent OFC with boiled egg under medical supervision, were enrolled in this retrospective study. Only patients who had available egg-slgE analysis within 2 years before OFC were evaluated. According to slgE, we divided patients into 4 groups for EW- sIgE (E1 <5kU,/L, E2 5-19.9kUa/L, E3 20-29.9kU,/L, E4 230kU,/L) and 4 groups for OVMsIgE (01 <0.5kU,/L, 02 0.5-4.9kUa/L, 03 5-9.9kUa/L, 04 210kUa/L). Results 51% of patients had familiy history of atopic disorders and the majority of them was affected by other atopic conditions (53% atopic dermatitis, 13% asthma, 13% thinoconjunctivitis, 56% other food allergies). The onset of egg allergy (mean age 1yr) was characterized by cutaneous symptoms in 68% patients (40% urticaria/angioedema, 28% atopic dermatitis), gastrointestinal (Gl) ones in 22%, respiratory (RE) ones in 6% and anaphylaxis in 11%. 24/109 patients (22%) experienced positive OFC: 10 (42%) developed anaphylaxis, 18 (75%) cutaneous symptoms, 14 (58%) GI symptoms, 5 (21%) oral itch, 5 (21%) RE symptoms. Considering EWslgE in patients with positive OFC outcome, 13/24 (54%) belonged to E1 group, 4/24 (17%) to E2, 3/24 (12%) to E3 and 4/24 (17%) to E4. Regarding OVMsIgE, 10/24 (42%) belonged to 01, 9/24 (37%) to 02, 1/24 (4%) to 03, 4/24 (17%) to 04. Children who experienced ana- phylaxis during OFC had EWslgE as following: 5/10 (50%) < 5kU,/L, 2/10 (20%) 5-Results 51% of patients had familiy history of atopic disorders and the majority of them was affected by other atopic conditions (53% atopic dermatitis, 13% asthma, 13% rhinoconjunctivitis, 56% other food allergies). The onset of egg allergy (mean age yr) was characterized by cutaneous symptoms in 68% patients (40% urticaria/angioedema, 28% atopic dermatitis), gastrointestinal (GI) ones in 22%, respiratory (RE) ones in 6% and anaphylaxis in 11%. 24/109 patients (22%) experienced positive OFC: 10 (42%) developed anaphylaxis, 18 (75%) cutaneous symptoms, 14 (58%) GI symptoms, 5 (21%) oral itch, 5 (21%) RE symptoms. Considering EWslgE in patients with positive OFC outcome, 13/24 (54%) belonged to E1 group, 4/24 (17%) to E2, 3/24 (12%) to E3 and 4/24 (17%) to E4. Regarding OVMsIgE, 10/24 (42%) belonged to 01, 9/24 (37%) to 02, 1/24 (4%) to 03, 4/24 (17%) to 04. Children who experienced ana- phylaxis during OFC had EWslgE as following: 5/10 (50%) < SkUa/L, 2/10 (20%) 5- 19.9 kUa/L and 3/10 (30%) =20kU,/L. Conclusion In our population most children with clinical history of egg allergy and/or egg sen- sitization passed boiled egg challenge. Althought only few reacted (22%), a signi- ficant percentage (42%) developed anaphylaxis. It is noteworthy that the majority of children with OFC positive outcome belonged to lower sIgE groups; in particular, 71% patients had EWsIgE <20kU,/L and 83% had OVMsIgE <10kU,/L. Therefore, sigE value wasn't predictive of OFC outcome or OFC reaction severity, confirming the importance of performing OFC, regardless of sIgE value.Background Cow's milk protein allergy (CMA) is the most common food allergy in infants. Amino acid (AA) formulas are commonly used in the management of CMA. The American Academy of Pediatrics defines clinical documentation of infant growth and hypoallergenicitiy required for commercialization of AA formulas in the Uni- ted States (US). To evaluate safety and use in routine clinical practice settings, a post-market surveillance study (PMSS) with a commercialized hypoallergenic AA formula (HAA) was conducted. To our knowledge, this was the first such study with an AA infant formula. Method This prospective, PMSS was conducted February 2017-May 2018 at 30 US sites. Subjects diagnosed with CMA were included in this analysis. Enrollment was open for 14 months. Caregiver consent was obtained for infants meeting the in- clusion criteria: <12 months of age, >37 weeks corrected gestation age at en- rollment and planned use of HAA. There were no mandated clinic visits; subjects were followed by their healthcare providers (HCP) as per usual care. Data were collected for 4 months after enrollment or until discontinuation of formula. Com- plementary food intake (CFI) and HAA caregiver satisfaction were assessed at medical visits. Results 144 infants were enrolled, 100 (69%) with CMA diagnosis. 84% of subjects with CMA had severe CMA based on protocol criteria: history of anaphylaxis, or failure of extensively hydrolyzed formula to resolve symptoms or physician judgement. Demographics are listed in Table 1. Six serious adverse events reported in 6 sub- jects (3 with severe CMA); all were unrelated (5 of 6) or unlikely (1 of 6) related to HAA. Total of 125 adverse events (AE) were reported in 43 subjects (26 with se- vere CMA). Most AE were reported as unrelated (78%) or unlikely (10%) related to HAA; the 9% AE reported as probable related to HAA, frequently listed emesis orResults 144 infants were enrolled, 100 (69%) with CMA diagnosis. 84% of subjects with CMA had severe CMA based on protocol criteria: history of anaphylaxis, or failure of extensively hydrolyzed formula to resolve symptoms or physician judgement. Demographics are listed in Table 1. Six serious adverse events reported in 6 sub- jects (3 with severe CMA); all were unrelated (5 of 6) or unlikely (1 of 6) related to HAA. Total of 125 adverse events (AE) were reported in 43 subjects (26 with se- vere CMA). Most AE were reported as unrelated (78%) or unlikely (10%) related to HAA; the 9% AE reported as probable related to HAA, frequently listed emesis or constipation as the event. No anaphylaxis reported during the study. Overall, 71% had CFI including cereal [99%, first intake mean age 6.0 mo]; dairy [20%, 8.9 mo]; single fruit/vegetable [75%, 7.5 mo]; animal protein [30%, 9.6 mo]. Twelve subject: (12%) had a documented reaction to complementary foods. Eighty-two percent o1 caregivers indicated satisfaction with HAA. Conclusion A prospective surveillance program outside of a controlled clinical trial indicated HAA use in infants with CMA was safe and associated with high caregiver satisfaction. Complementary food reactions were reported in 12% of infant with CMA. N (%) Gender Male 51 (51) Female 49 (49) Mean [Std] Gestational birth age, weeks 37.6 [2.6]Background The purpose was to analyze the clinical and immunological features of the cow's milk allergy in infants, depending on the phenotype of the disease. Method It was studied 216 children with cow's milk allergies, aged from 1.5 to 12 months (group |). The comparison group (group II) consisted of 30 healthy children who did not have a history of food allergy symptoms. We studied the state of humoral immune status (immunoglobulins A, M, G, total IgE and cytokines (IL-2, IL-4, IL-6, IL-8, TNFa) in serum, saliva, and coprofiltrate. It was used the sandwich ELISA enzyme-linked immunosorbent assay. Statistical processing of the material was carried out using specialized software packages for research ("Excel-2010" and "Statstica 10.0" for Windows). Results Clinical and laboratory analysis allowed us to identify the cutaneous, gastrointes- tinal and mixed phenotype of CMA in children with the formation of Ig E positive and Ig E negative endotype. We recorded a change in the fecal level of immuno- globulins and cytokines in all children with CMA, regardless of the clinical phenotype. SF and MF were characterized by an increase in fecal production of Ig M and G, against a background of a slight increase in Ig E and a moderate de- crease in secretory Ig A. In these patients, a moderate increase in the content of anti-inflammatory cytokines (IL 4 and IL13) was noted against a background of a decrease in the production of pro-inflammatory cytokines (IFN-y, IL8) and increa- sed TNF-a. We detected the most pronounced changes in the fecal level of cyto- kines and immunoglobulins in children with the gastrointestinal phenotype CMA. Conclusion The dynamics of the cytokine in coprofiltrate, saliva and blood serum reflects the current state of the immune system and local protection and, in combination with other indicators, has diagnostic value in determining the localization and degree of activity of allergic inflammation, forming a clinical phenotype of the disease. The significant decrease of secretory Ig A and INF-y and the increase of fecal le- ui an 7Conclusion The dynamics of the cytokine in coprofiltrate, saliva and blood serum reflects the current state of the immune system and local protection and, in combination with other indicators, has diagnostic value in determining the localization and degree of activity of allergic inflammation, forming a clinical phenotype of the disease. The significant decrease of secretory Ig A and INF-y and the increase of fecal le- vels of Ig E, IL-4, IL-8, IL-13, TNF-a were found. This confirms the role of local aller- gic inflammation in the pathogenesis of food allergy, and necessitates studying the fecal level of biomarkers to optimize diagnostic and therapeutic approaches.Background Component specific-IgE to Ara h2 had been shown to be superior to peanut-speci- fic IgE in the diagnosis of peanut allergy in children. However, the predictive value of Ara h2 in the diagnosis of peanut allergy in Southeast Asian children has not been evaluated. We aim to evaluate the utility of Ara h2 in predicting the outcome of open food challenge (OFC) in Singaporean children with peanut sensitization. Method This is a prospective cohort study conducted in a tertiary hospital in Singapore from January 2017 to February 2019. Children with egg allergy who are less than 2 years old with a positive skin prick test (SPT) to peanut and who underwent pea: nut OFC were recruited into the study. Those who did not have Ara h2 test perfor- med were excluded. Positive SPT is defined as mean wheal diameter of > 3mm. Positive serum IgE to peanut is defined as 215 kU/L and a positive Ara h2 test is defined as = 0.35 kU/L. Results Twenty-nine patients with a positive SPT to peanut underwent peanut OFC. Five were excluded as Ara h2 levels were not measured. Twenty-one (87.5%) patients had negative Ara h2 and three (12.5%) had positive Ara h2. Nineteen patients (90.5%) with negative Ara h2 passed OFC and were peanut tolerant. Two patients (9.5%) with negative Ara h2 failed OFC and were diagnosed as peanut allergic. In the Ara h2-positive group, 33.3% (1/3) failed OFC and confirmed to be peanut allergic. Twenty-three patients (95.8%) had negative serum IgE to peanut and only 1 patient (4.2%) had a positive serum IgE. The positive serum IgE patient had ne- gative Ara h2 and passed OFC subsequently. In the serum IgE-negative group, 87.0% (20/23) passed OFC, whilst 13.0% (3/23) failed OFC. Three (13.0%) of the serum IgE-negative group had positive Ara h2 (2.00 - 3.63 kU/L) with 1 of these patients failed OFC. In our study cohort, Ara h2 2 0.35 kU/L has high specificity of 90.5% but low sensitivity (33.3%) in the diagnosis of peanut allergy.Conclusion Component specific-IgE to Ara h2 levels of 2 0.35 KU/L predicts a higher risk of clinical reaction during OFC in peanut-sensitized children. A larger prospective co- hort study is required to determine the predictive values of Ara h2 in the diagnosis of peanut allergy in children. Peanut To- Peanut Variable lerant (PT) Allergy (PA) P value* (ns21) (n=3) Demographics 0.347 13 (61.9) 1 (33.3) Female sex 0.682 10.943.6 10.0+2.6 Age (mths) 8 15 (71.4) 2 (66.7) Race, Chinese 0.865 History of atopy Rhinitis 0(0) 1 (33.3) 0.007 Atopic dermatitis 14 (66.7) 2 (66.7) 1.000 Asthma 0 (0) 1 (33.3) 0.007 Drug allergy 0(0) 0(0) - Urticaria/angioedema 2 (9.5) 0(0) 0.575Background The use of cannabis as a recreational drug, as a nutritional supplement and as a therapeutic agent for pain and neurological disorders is gai- ning increasing popularity. Concordant with its increased use, more un- wanted side effects are being reported. While the psychoactive proper- ties have been well described, the immunomodulatory and allergic po- tential of cannabis is less well known. Sensitisation can occur by the inhaled, ingested or cutaneous route. The main allergen attributed to cannabis allergy is Cans3, a non-specific lipid transfer protein (LTP). We present two cases of cannabis allergy highlighting the diverse clinical range of symptoms and illustrating the diagnostic challenges. Method Both patients were evaluated with a clinical history, skin prick testing and serological profiling as well as basophil activation testing as an in vitro functional assay. Results A 21-year-old patient, who regularly smokes cannabis, presented with recurrent urticaria. On further questioning she also reported rhinocon- junctivitis when handling cannabis plants. Skin prick test with cannabis flowers revealed specific sensitisation. Laboratory findings demonstrated neither evidence of specific IgE to Cannabis sativa, nor any other sensitisations. A 25-year-old atopic patient presented with abdominal cramps, dyspnoea, urticaria and dizziness after consuming an almond milk shake with a powdered cannabis supplement. Skin prick test revealed sensitisation to the cannabis powder as well as concur- rent sensitisation to birch pollen. Consistent with atopy, the patient had a grossly elevated level of total IgE, together with sensitisations to Betv1 and Prup3, but not to Cannabis sativa. Basophil activation testing revealed activation and degranulation upon stimulation with cannabis flowers in the 1st patient and cannabis powder in the 2nd patient.Results A 21-year-old patient, who regularly smokes cannabis, presented with recurrent urticaria. On further questioning she also reported rhinocon- junctivitis when handling cannabis plants. Skin prick test with cannabis flowers revealed specific sensitisation. Laboratory findings demonstrated neither evidence of specific IgE to Cannabis sativa, nor any other sensitisations. A 25-year-old atopic patient presented with abdominal cramps, dyspnoea, urticaria and dizziness after consuming an almond milk shake with a powdered cannabis supplement. Skin prick test revealed sensitisation to the cannabis powder as well as concur- rent sensitisation to birch pollen. Consistent with atopy, the patient had a grossly elevated level of total IgE, together with sensitisations to Betv1 and Prup3, but not to Cannabis sativa. Basophil activation testing revealed activation and degranulation upon stimulation with cannabis flowers in the 1st patient and cannabis powder in the 2nd patient. Conclusion Here, we have presented two patients with clinically relevant cannabis sensitisation acquired by different routes. Both patients tested positive on skin testing, but serological testing was inconclusive. However, in vi- tro functional testing by BAT supports the clinical working diagnosis of cannabis allergy. The pathomechanism is either a primary cannabis al- lergy or a crossreactivity, for instance through sensitisation to LTP. More widely available standardised molecular allergy testing for cannabis al- lergen components will ultimately lead to increased diagnostic certainty of cannabis allergy.Background Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare but life-threatening distinct form of wheat allergy. The severity of it varies from pruritus, urticaria to dyspnea, collapse, and shock. Some patients only manifest as pruritus and urticaria but no anaphylaxis after wheat ingestion combined with certain exacerbating factors, such as exercise, alcohol or nonsteroidal anti-inflammatory drugs, which is called wheat- dependent exercise-induced urticaria (WDEIU). We aimed to analyze the clinical characteristics of WDEIU and explore the relationship between WDEIU and WDEIA. Method The clinical features and laboratory examinations of 9 patients with WDEIU attending Department of Allergy, Peking Union Medical College Hospital from May 2008 to August 2019 were retrospectively analyzed. Meanwhile, we randomly selected 18 WDEIA cases as controls. Results Among nine WDEIU patients, 8 were males and 1 was female, the mean age of onset was 23.4+11.8 years. The median time from onset to diag- nosis was 36 months. They presented urticaria (9/9) , laryngeal obstruc- tion (3/9) and lip edema (1/9). 55.6% (5/9) patients had positive specific-IgE to wheat, 77.8% (7/9) patients had positive specific-IgE to gluten and 83.3% (5/6) patients had positive specific-IgE to w-5 gliadin. The mean age of onset of severe allergic reaction in WDEIA was 42.9412.2 years. 72.2% (13/18) of them had a history of urticaria, and the median time from onset of urticaria to that of anaphylaxis was 7 (1.5-47) years. The age of onset was significantly lower in WDEIU group than that in WDEIA group (23.4411.8 vs 42.9+12.2, p=0.001), and the serum gluten specific-IgE level was significantly lower than the control group (0.55 kU,/L vs 1.34 kUa/L, p=0.014). Patients with WDEIU had lower w-5 gliadin specific-IgE levels, but there was no statistically eiqnificant difference (n=) N40)Results Among nine WDEIU patients, 8 were males and 1 was female, the mean age of onset was 23.4+11.8 years. The median time from onset to diag- nosis was 36 months. They presented urticaria (9/9) , laryngeal obstruc- tion (3/9) and lip edema (1/9). 55.6% (5/9) patients had positive specific-IgE to wheat, 77.8% (7/9) patients had positive specific-IgE to gluten and 83.3% (5/6) patients had positive specific-IgE to w-5 gliadin. The mean age of onset of severe allergic reaction in WDEIA was 42.9412.2 years. 72.2% (13/18) of them had a history of urticaria, and the median time from onset of urticaria to that of anaphylaxis was 7 (1.5-47) years. The age of onset was significantly lower in WDEIU group than that in WDEIA group (23.4411.8 vs 42.9+12.2, p=0.001), and the serum gluten specific-IgE level was significantly lower than the control group (0.55 kU,/L vs 1.34 kUa/L, p=0.014). Patients with WDEIU had lower w-5 gliadin specific-IgE levels, but there was no statistically significant difference (p=0.069). Conclusion WDEIU is a rare disease and difficult to recognize, which may be the early stage of WDEIA. Diagnosis was based on medical history, serum specific IgE detection, and/or skin prick test. Early diagnosis and inter- vention of WDEIU may be helpful to prevent severe allergic reactions.