Editorial

Continuing March 27, 2025 our tradition, even this first edition of 2025 presents clinical experiences, focus and insights of crucial topics for training and updating the allergist pediatrician. An example is the article by Leone et al. “Honey-Induced FPIES: A Rare Presentation and Pathogenetic Insights” (p. 35). We know well that food protein-induced enterocolitis (FPIES) is not always easy to suspect, not just because the symptoms arise with considerable delay compared to the ingestion of the responsible food (from 6 to 24 hours), but also because many symptoms, with the exception of repeated vomiting and diarrhea, are unusual for food allergy: lethargy, pallor, hypotension, and hypothermia, in fact, suggest a septic rather than anaphylactic shock for the absence of potentially suggestive skin and respiratory symptoms. The lack of a temporal relationship between the ingestion and onset of symptoms may be initially misleading, but it should lead us to hypothesize a non-IgE mediated immunological reaction, a spy of a delayed inflammatory reaction even if we do not fully know its physiopathological bases. Experience leads us to suspect FPIES mainly in infants given cow’s milk, since the proteins in milk are by far the predominant cause worldwide. Suspecting the disease even when foods other than milk were involved, it emerged that many other foods can be responsible, albeit more rarely, such as cereals, rice, fish and seafood or other unthinkable foods such as honey as reported by Leone et al. In conclusion, the authors recommend that the suspicion of FPIES is formulated in the presence of classic symptoms even when completely unusual foods are at stake. It follows that all the foods ingested in the previous hours, even the apparently harmless ones, should be included in the squad of suspicious substances; together with this, oral provocation tests according to the specific methodology scheduled for FPIES should be performed.

Still on the subject of food allergy, we point out another systematic review of the literature by Riccio et al., titled: “The characteristics and effectiveness of school-based educational interventions in the management of children with food allergies: a systematic review” (p. 11). The conclusions are all too obvious: food education for staff and teaching of first aid practices in the event of anaphylaxis are very important to achieve a reasonable level of safety in schools. Less obvious are the other findings that emerged from the analysis and that have an extremely relevant practical impact. Above all, the authors underline that: 1. there are still no studies comparing the different intervention methods to achieve these objectives; we do not know which intervention technique is the best; 2. there are no suggestions on possible measures to control the effectiveness of the interventions; the follow-up times are relatively short and do not allow definitive conclusions; 3. the allergist figure and the professional nurse are indispensable, and on this point there is unanimous agreement. Therefore, it is hoped for new, more homogeneous studies completed by an adequate follow-up.

Two other articles take into consideration very thorny and often frustrating problems. The first, “Management of reported beta lactam hypersensitivity in the emergency department setting” by Franceschini et al. (p. 3), addresses the problem of suspected allergy to beta-lactams, a diagnostic suspicion often raised by pediatric emergency room operators. Especially during the cold season, they often have to deal with febrile children with skin manifestations, which arise during antibiotic therapy. It is very difficult to establish the real nature of these lesions and to discriminate between an infectious or allergic origin. When in doubt, one tends to warn about the possibility that it is an allergy to antibiotics due to the risk of more serious reactions to subsequent administrations that this review tries to clarify. It focuses on the immediate and delayed skin symptoms associated with beta-lactam allergy, tries to identify clinical parameters to define the high- and low risk of allergy to beta-lactams, and finally proposes a decision-making algorithm. Still in the emergency room field, the second work, “Risk factors for severe systemic reactions to hymenoptera venom in children. A review” (p. 18) - by the SIAIP Commission for the primary and secondary prevention of allergic diseases, carries out a truly up-to-date review of the literature on hymenoptera venom allergy. The subject is relevant because it represents the second most frequent cause of anaphylaxis in children and significantly affects their quality of life ¹. Although anaphylactic reactions in children tend to be mild, to affect mainly or exclusively the skin and to have a more favorable prognosis than in adults, it is still impossible to assess with certainty the risk of having a more severe anaphylactic reaction to a subsequent hymenoptera sting, while the clinical and therapeutic implications are serious. The frequency of pediatric allergy to hymenoptera is relatively high in Italy, as reported in a study in Italian children that observed a sensitization rate to hymenoptera venom of about 3.7% and a frequency of systemic reactions less than 1% ². In a similar Israeli study, much higher frequencies were reported (6.5%). However, most of the otherwise scarce published data are the result of questionnaires rather than observational studies in a pediatric age, which may justify both the discrepancy in the results and the difficulty in finding useful criteria to define the risk of anaphylaxis in children. The conclusions therefore cannot be univocal and the authors underline the need and urgency of controlled clinical studies in a pediatric age in order to plan prophylaxis and therapeutic interventions. A final mention goes to the article by Dinardo et al. of the SIAIP diagnostic commission: “Allergic skin tests: an update on Skin Prick Test and Prick to Prick” (p. 26 ). The authors have examined, evaluated the pros, cons and limits of all the currently available methods for performing immediate-response skin tests: the classic skin prick tests (single or multiple), the prick to prick (or prick by prick) with fresh foods and the new generation automatic skin prick, developed to solve or rather reduce the problems related to the standardization of the method. This is a very interesting and extremely up-to-date review that discusses and compares the different procedures, with new information on the indications and limits of what is still today the gold standard of allergy diagnostics.