Monitoring is a major component of asthma management in children. Regular monitoring allows for diagnosis confirmation, treatment optimization and natural history review. Numerous factors that may affect disease activity and patient wellbeing need to be monitored: response and adherence to treatment, disease control, disease progression, comorbidities, quality of life, medication side-effects, allergen and irritant exposures, diet and more. However, the prioritization of such factors and the selection of relevant assessment tools is an unmet need. Furthermore, rapidly developing technologies promise new opportunities for closer, or even ‘real-time’, monitoring between visits. Following an approach that included needs assessment, evidence appraisal and Delphi consensus, the PeARL Think Tank, in collaboration with major international professional and patient organizations, has developed a set of 24 recommendations on pediatric asthma monitoring, to support healthcare professionals in decision-making and care pathway design.

Background – Allergen immunotherapy is a well-established treatment for canine atopic dermatitis (CAD), but non-invasive, safe, effective, and easy-to-use home-administration routes that promote owner’s compliance are needed. Epicutaneous immunotherapy (EPIT) has been suggested as a promising alternative treatment for human allergies. This study primarily evaluated EPIT’s feasibility, effectiveness, and safety for CAD. Methods – Sixteen client-owned dogs with spontaneous, nonseasonal, mite-sensitive CAD were enrolled for a 6-month, once-weekly, 12-hour EPIT. A costume-made 3D-printed device was designed to deliver the allergen-based formulation. Primary efficacy outcomes included the owner’s assessed pruritus (PVAS10) and treatment efficacy (OGATE), and veterinarian-assessed skin lesions (2D-IGA). Secondary efficacy outcomes were the quality-of-life (QoL) and serological allergen-specific IgE’s concentrations. Effectiveness was defined by the success of the primary efficacy outcomes, according to the ICADA’s COSCAD’18 recommendations. EPIT was deemed safe in the absence of severe side-effects. Results – EPIT effectively improved clinical condition, with a success rate of 73.3% for pruritus, 66.7% for skin lesions, and 93.3% for QoL. A good-to-excellent response to EPIT was rated by 93.3% of owners in OGATE. EPIT significantly improved PVAS10 (p=0.000015), 2D-IGA (p=0.006) and QoL (p=0.000014) scores over six months. A significant difference was evident within one month for PVAS10 (p=0.003) and 2D-IGA (p=0.009) scores. Seven dogs partially desensitised to at least one mite and two fully desensitised to all mites after six months. Severe adverse events were not recorded. Conclusions – This pioneer study emphasises EPIT’s potential as a novel and promising, non-invasive, feasible, effective, safe, and well-tolerated CAD treatment, supporting further investigation.

Background: Anaphylaxis is increasing at pediatric age; however, its characterization is hampered by underdiagnosis and underreporting. The aim of this study was to identify the causes of anaphylaxis in children and adolescents in Portugal, thus contributing to a better knowledge of its etiology, clinical manifestations and management. Methods: During a 10-year period a nationwide notification system for anaphylaxis was implemented, with voluntary reporting by allergists. Data on 533 patients under 18 years of age with anaphylaxis were included. Results: Mean age was 8.5±4.9 years, 61% were male; 45% had asthma. Mean age at the first anaphylaxis episode was 5.3±4.7 years (ranging from 1 month to 17 years of age), 63% at preschool age. Most reactions occurred at home (57%). Food-induced anaphylaxis was the leading cause (77%). The main culprit foods were cow’s milk (32%), tree nuts (16%), shellfish (13%), egg (12%), fresh fruits (11%), fish (8%) and peanut (8%). Other causes included drugs (11%), insect-sting (5%), cold-induced anaphylaxis (4%), exercise-induced (2%), latex (1%) and idiopathic anaphylaxis (1%). Most patients (83%) were admitted to the emergency department; only 46% received adrenaline treatment. Recurrence of anaphylaxis occurred in 41% of the patients (3 or more episodes in 21%). An adrenaline autoinjector was used in 9% of the patients. Conclusions: In the Portuguese pediatric population, food is the leading cause of anaphylaxis. Undertreatment with adrenaline and high recurrence of anaphylaxis highlight the need to improve both the diagnosis and the therapeutic management of this life-threatening entity.

Background: The interplay between COVID-19 pandemic and asthma in children is still unclear. We evaluated the impact of COVID-19 on childhood asthma outcomes. Methods: The PeARL multinational cohort included 1,054 children with asthma and 505 non-asthmatic children aged between 4-18 years from 25 pediatric departments, from 15 countries globally. We compared the frequency of acute respiratory and febrile presentations during the first wave of the COVID-19 pandemic between groups and with data available from the previous year. In children with asthma, we also compared current and historical disease control. Results: During the pandemic, children with asthma experienced fewer upper respiratory tract infections, episodes of pyrexia, emergency visits, hospital admissions, asthma attacks and hospitalizations due to asthma, in comparison to the preceding year. Sixty-six percent of asthmatic children had improved asthma control while in 33% the improvement exceeded the minimal clinically important difference. Pre-bronchodilatation FEV1 and peak expiratory flow rate were improved during the pandemic. When compared to non-asthmatic controls, children with asthma were not at increased risk of LRTIs, episodes of pyrexia, emergency visits or hospitalizations during the pandemic. However, an increased risk of URTIs emerged. Conclusion: Childhood asthma outcomes, including control, were improved during the first wave of the COVID-19 pandemic, probably because of reduced exposure to asthma triggers and increased treatment adherence. The decreased frequency of acute episodes does not support the notion that childhood asthma may be a risk factor for COVID-19. Furthermore, the potential for improving childhood asthma outcomes through environmental control becomes apparent.

Background: Allergy is witnessing major advances, in particular with the advent of biological therapies for treating allergic diseases. Given the novelty of these therapeutics, we aimed to explore by a worldwide survey, the prescription and the management of hypersensitivity reactions (HR) of biological agents (BA) in Allergy. Method: We built up an anonymous online questionnaire, sent out by mail and social media and circulated for 40 days. Results: 348 responses were from 59 countries, with a majority from Europe (62.6%). 97% of responders practiced allergy and 48.5%, exclusively so. Allergy was mentioned as a full specialty in 69.5 % of cases. 71% of responders confirmed the right of prescription of BA for allergists in their country and 78.4 % prescribed BA in their clinical practice. Europe included almost all the allergists who did not have the right of prescribing BA (95.5%), specifically France (91%). The most prescribed BA were Anti IgE (78.1%) and anti IL5 (43.9%). The most declared HR to BA were local reactions (74.1%) followed by anaphylaxis like symptoms (6.8%) and delayed exanthemas (5.1%). Desensitization was considered in 18.9% of cases. These HR were reported in 48.8% of cases. Conclusion: Although BA are now a pillar in the treatment of allergic diseases and allergists are familiar with management of HR associated with BA, their prescription is not authorized for allergists in all countries. BA showed to be generally safe but HR, which may be severe, could occur with a lack of consensus on the management.

To the Editor,We read carefully the research letter “Is asthma protective of COVID-19?” by Carli et al recently published.1Important topic for asthma patients in the coronavirus disease 2019 (COVID-19) pandemic were considered, including that until recently weak evidence that patients with chronic respiratory disorders are at a lower risk of being infected or becoming severely ill with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).Reflecting only about previous reports from China and Italy where asthma was underrepresented in COVID-19 patients, the authors accept the heterogeneous condition that it is asthma, speculating that T2-immunity, interferon-mediated immune responses and increased number of eosinophils in the airways could have a protective effect against COVID-19 severity.1The epidemiology of COVID-19 is changing rapidly with new data. More recent reports from the United States of America and from several European countries, in particular the United Kingdom (UK), states a higher asthma prevalence in patients with COVID-19, suggesting that asthma is more common in COVID-19 patients than it was previously reported in Asia and in the first European surveys.2Data from the UK Biobank, a large prospective case-control study, found an asthma prevalence of 17,9% in 605 COVID-19 hospitalized patients, mostly of them adults, surpassing the prevalence of asthma in the general population.3Besides that, in the OpenSAFELY Collaborative Study (UK), it was found a significant increased risk of severe CoViD-19 in patients with asthma, including death, in particular related with the recent use of oral corticosteroid (OCS).4 These findings can indicate an increased asthma severity and/or poor control and, in accordance with data from previous coronavirus outbreaks, that systemic corticosteroids were associated with a higher viral load.5We agree with Carli et al1 that further studies focused on asthma and its different phenotypes are needed to provide a better understanding of the impact of SARS-CoV-2 infection in patients with asthma.6 Nevertheless, for the moment, it seems crucial that patients with asthma do not stop their controller medication, that may lead to a higher risk of asthma exacerbations, increased OCS use and higher probability to emergency room access and hospitalization that represent themselves significant risk factors for coronavirus exposure and spread.In conclusion, according with the available data, patients with asthma must still be included in the high-risk groups for COVID-19 and more data are needed to understand the relationship between asthma and COVID-19.

Even though respiratory viruses are one of the most common triggers for asthma exacerbations, not all of these viruses affect patients equally. There is no strong evidence supporting that patients with asthma have a higher risk of becoming seriously ill from coronavirus disease 2019 (COVID-19), although recent reports from the United States of America and the United Kingdom suggest that asthma is much more common in children and adults with mild to severe COVID-19 than it was previously reported in Asia and in Europe. As in previous severe acute respiratory syndrome (SARS) outbreaks, patients with asthma, especially children, appear to be less susceptible to the coronavirus with a low rate of asthma exacerbations. Different expression of viral receptors and T2 inflammation can be responsible for different outcomes. Future studies focused on asthma and on other allergic disorders are needed to provide greater understanding of the impact of underlying asthma and allergic inflammation on COVID-19 susceptibility and disease severity. But, for the moment, it’s crucial that asthmatic patients maintain their controller medication, from inhaled corticosteroids to biologics, without self-making any dose adjustments or stopping medication. New data are emerging daily, rapidly updating our understanding of this novel coronavirus.