Diagnosis and Management of Food Protein‐Induced Allergic Proctocolitis in the pediatric age: A position paper from the Italian Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the Italian Society for Pediatric Allergy and Immunology

To the Editor: We greatly thank Hoffmann et al for their interest in our article (1) and would like to provide some clarifications regarding their questions. Food protein-induced proctocolitis, also known as allergic proctocolitis (AP), is characterized by the presence of mucoid, frothy, and bloody stools in an otherwise healthy infant (2). As rightly pointed out by Haufmann et al and emphasized in our article, rectal bleeding may have other causes and benign bleedings (idiopathic neonatal transient colitis [INTC]) that are not a result of food allergies and may spontaneously recover in infants, therefore an accurate differential diagnosis becomes essential (1,3). AP diagnosis was made on the basis of the following methodology in our study: mothers of infants whose symptoms resolved typically in 72 to 96 hours (with significant blood in stool, resolution took 1 week) after the elimination were recommended to retake causative foods as part of their normal daily diet after 3 weeks. If infants who had rectal bleeding, diarrhea, and mucus or blood in stool after reexposure to the offending food (via breast milk), they were diagnosed as having AP. Those patients (n:18) having had no symptoms after oral food challenge were excluded from our study (otherwise probable INTC cases). Under these considerations, OFC was applied to all (60/60) of our patients and AP was confirmed in all our patients. In addition, recurrence of symptoms was observed in the patients incidentally exposed to allergenic food during the follow-up period. Because all the patients were referred to our clinic with an AP prediagnosis and our study was essentially designed to provide clinicians more information on the natural course, prognosis, and offending foods of AP, our INTC or AP cases should not be taken as suggestion of a general ratio. The exact prevalence of AP is unknown; the estimated prevalence ranges from 0.16% to 64% of infants with isolated rectal bleeding (3–6). INTC and AP rectosigmoidoscopy both show nodular lymphoid hyperplasia with a pale mucosal surface and diffuse eosinophil infiltration in the lamina propria (7,8). Mori et al (7,9) indicated that microarray analysis enhanced expression of CCL11 (eotaxin-1) was more dominant in neonatal transient eosinophilic colitis, whereas the expression of CXCL13 was more dominant in food protein–induced proctocolitis. CXCL13 and its receptor CXCR5 control the organization of B cells within follicles of lymphoid tissues (10). The pathophysilogy of non–immunoglobulin-E gastrointestinal food allergies remains unknown. There is an urgent need for further studies to characterize mucosal inflammation. In agreement with Haufmann et al, rather than resorting to clinical suspicion and pathological diagnosis, which may lead to confusion, OFC should be conducted as was the case with our study.

Dietary prevention of allergy, atopy, and allergic diseases

Editorial introductions

What do allergists in practice need to know about non–IgE-mediated food allergies

Cow's milk protein allergy is the most common food allergy in infants and young children. It is estimated that up to 50% of pediatric cow's milk allergy is non-IgE-mediated. Allergic proctocolitis is a benign disorder manifesting with blood-streaked stools in otherwise healthy-appearing infants who are breast- or formula-fed. Symptoms resolve within 48-72 h following elimination of dietary cow's milk protein. Most infants tolerate cow's milk by their first birthday. Food protein-induced enterocolitis syndrome presents in young formula-fed infants with chronic emesis, diarrhea, and failure to thrive. Reintroduction of cow's milk protein following a period of avoidance results in profuse, repetitive emesis within 2-3 h following ingestion; 20% of acute exposures may be associated with hypovolemic shock. Treatment of acute reactions is with vigorous hydration. Most children become tolerant with age; attempts of re-introduction of milk must be done under physician supervision and with secure i.v. access. Allergic eosinophilic gastroenteritis affects infants as well as older children and adolescents. Abdominal pain, emesis, diarrhea, failure to thrive, or weight loss are the most common symptoms. A subset of patients may develop protein-losing enteropathy. Fifty percent of affected children are atopic and have evidence of food-specific IgE antibody but skin prick tests and serum food-IgE levels correlate with response to elimination diet poorly. Elemental diet based on the amino-acid formula leads to resolutions of gastrointestinal eosinophilic inflammation typically within 6 wk.

The data of the ISAAC project in Spain show a prevalence of childhood asthma ranging from 7.1% to 15.3%, with regional differences; a higher prevalence, 22.6% to 35.8%, is described for rhinitis, and atopic dermatitis is found in 4.1% to 7.6% of children. The prevalence of food allergy is 3%. All children in Spain have the right to be visited in the National Health System. The medical care at the primary level is provided by pediatricians, who have obtained their titles through a 4-yr medical residency training program. The education on pediatric allergy during that period is not compulsory and thus very variable. There are currently 112 certified European pediatric allergists in Spain, who have obtained the accreditation of the European Union of Medical Specialist for proven skills and experience in pediatric allergy. Future specialists in pediatric allergy should obtain their titles through a specific education program to be developed in one of the four accredited training units on pediatric allergy, after obtaining the title on pediatrics. The Spanish Society of Pediatric Allergy and Clinical Immunology (SEICAP) gathers over 350 pediatric allergists and pediatricians working in this field. SEICAP has a growing activity including yearly congresses, continued education courses, elaboration of technical clinical documents and protocols, education of patients, and collaboration with other scientific societies and associations of patients. The official journal of SEICAP is Allergologia et Immunophatologia, published every 2 months since 1972. The web site of SEICAP, http://www.seicap.es, open since 2004, offers information for professionals and extensive information on pediatric allergic and immunologic disorders for the lay public; the web site is receiving 750 daily visits during 2011. The pediatric allergy units are very active in clinical work, procedures as immunotherapy or induction of oral tolerance in food allergy, contribution to scientific literature, and collaboration in international projects.

Pediatric Allergy and ImmunologyVolume 4, Issue 3 p. 101-111 Hydrolysed cow's milk formulae* Allergenicity and use in treatment and prevention. An ESPACI position paper L. Businco, L. Businco Department of Paediatrics, University “La Sapienza”, Rome, ItalySearch for more papers by this authorS. Dreborg, Corresponding Author S. Dreborg Department of Paediatrics, University of Linköping, SwedenSten Dreborg, Department of Paediatrics, University Hospital, S-581 85 Linköping, SwedenSearch for more papers by this authorR. Einarsson, R. Einarsson Department of Paediatrics, University of Linköping, SwedenSearch for more papers by this authorP. G. Giampietro, P. G. Giampietro Department of Paediatrics, University “La Sapienza”, Rome, ItalySearch for more papers by this authorA. Hest, A. Hest Department of Paediatrics, Odense University Hospital, DenmarkSearch for more papers by this authorK. M. Keller, K. M. Keller Department of Paediatrics, Johannes Gutenberg-University, Mainz, GermanySearch for more papers by this authorS. Strobel, S. Strobel Department of Clinical Immunology, Hospital for Sick Children, London, EnglandSearch for more papers by this authorU. Wahn, U. Wahn Department of Paediatric Pneumology and Immunology, Universitätsklinikum Rudolf Virchow, Free University, Berlin, GermanySearch for more papers by this author L. Businco, L. Businco Department of Paediatrics, University “La Sapienza”, Rome, ItalySearch for more papers by this authorS. Dreborg, Corresponding Author S. Dreborg Department of Paediatrics, University of Linköping, SwedenSten Dreborg, Department of Paediatrics, University Hospital, S-581 85 Linköping, SwedenSearch for more papers by this authorR. Einarsson, R. Einarsson Department of Paediatrics, University of Linköping, SwedenSearch for more papers by this authorP. G. Giampietro, P. G. Giampietro Department of Paediatrics, University “La Sapienza”, Rome, ItalySearch for more papers by this authorA. Hest, A. Hest Department of Paediatrics, Odense University Hospital, DenmarkSearch for more papers by this authorK. M. Keller, K. M. Keller Department of Paediatrics, Johannes Gutenberg-University, Mainz, GermanySearch for more papers by this authorS. Strobel, S. Strobel Department of Clinical Immunology, Hospital for Sick Children, London, EnglandSearch for more papers by this authorU. Wahn, U. Wahn Department of Paediatric Pneumology and Immunology, Universitätsklinikum Rudolf Virchow, Free University, Berlin, GermanySearch for more papers by this author First published: August 1993 https://doi.org/10.1111/j.1399-3038.1993.tb00077.xCitations: 149 * Before publication, this position paper has been circulated to the members of the Committee on Hypoallergenic Formu lae within The European Society of Pediatric Allergy and Clinical Immunology (ESPACI), and then approved by the Executive Committee of ESPACI, May 26, 1993. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume4, Issue3August 1993Pages 101-111 RelatedInformation

Current Opinion in Allergy and Clinical Immunology was launched in 2001. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of allergy and clinical immunology are divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Henry MilgromHenry MilgromDr Milgrom has been on the staff National Jewish Health in Denver for 32 years. He is Professor Emeritus of Pediatrics at the University of Colorado School of Medicine, USA. Dr Milgrom believes that the challenge for healthcare in the 21st century is to provide proficient and cost-effective health management, especially as it pertains to chronic illness. Dr Milgrom believes that outcomes research, or comparative effectiveness research (CER), advances the understanding of the effectiveness, benefits, and harms of diverse treatment strategies. He feels such understanding is particularly important in conditions where cure may not be achievable, and the quality of life is the most important end point. Electronic health records provide a vast quantity of data for analytics, enabling providers to establish evidence-based best practices. A significant proportion of healthcare expenditures is used for interventions with uncertain efficacy. Patterns of care vary widely, and evidence-based insight is often lacking. Providers too often rely on their individual knowledge and judgment rather than to draw on a wider range of evidence and experience. Dr Milgrom believes that the goals of all healthcare providers should include better clinical results and improved patient health. The challenge is to threaten precedent and make it our business to base patient care on actionable insights. All of us have a stake in this endeavour and all of us should participate. René Maximiliano GómezRené Maximiliano GómezDr René Maximiliano Gómez gained his medical degree in 1991 at the Catholic University of Córdoba, Argentina, and he presented his PhD thesis there in May 2016. He is a board-certified specialist in Allergy and Immunology both at Argentinean Association of Allergy & Clinical Immunology and at the National University of Córdoba, Argentina, and a consultant in Allergy, Asthma & Immunology Unit at Alas Medical Institute in Salta, Argentina. He has worked as Medical Director at this last institution, and in the academic field as an invited professor in Immunology (Veterinary Sciences at the Catholic University of Salta) and Dermatology (Faculty of Medicine at the National University of Salta, Argentina). From April 2020 is the Director of School of Health Sciences at Catholic University of Salta, Argentina. Dr Gómez is President of the Ayre Foundation, leading the education and research on allergy and respiratory diseases in Salta, Argentina, and member of the State Ethics’ Committee in Human Research. He served as Scientific Secretary at the Latin American Society of Allergy, Asthma and Immunology (SLaai) in 2013 and held the post until 2017. He was General Secretary of SLaai 2017–18 and Scientific Director of Argentinean Association of Allergy & Clinical Immunology (AAAeIC) 2018–2019, being the President Elect of AAAeIC since 2019. He is also a committee member on allergy diagnosis and molecular allergology at the World Allergy Organization, and associate editor of WAO Journal. Dr Gómez has authored and co-authored about 50 peer reviewed publications. His research focuses on allergens and indoor pollution in asthma/allergic rhinitis, parasites and atopy, chronic urticaria, allergen immunotherapy and registries for allergic diseases. Alessandro FiocchiAlessandro FiocchiAlessandro Fiocchi MD is the Director of Allergy at the Pediatric Hospital Bambino Gesù (OPBG), Rome, Vatican City. Formerly director of Pediatrics at the Melloni University Hospital in Milan, Italy, he is an expert in the field of food allergy. After post-graduate degrees and professional qualification in pediatrics, allergy medicine, pulmonology, and neonatology, he dedicated his research and clinical work to the care of children with asthma and allergic disease. Currently, he leads a research group focusing on food allergy, asthma, and specific immunotherapy. This group is based in the OPBG, a health care and research institution specialized in pediatric and developing ages. As the largest Pediatric Hospital in Italy, OPBG guarantees total coverage for all health care needs, including allergy. Since 2001, he has organized international meetings in Milan, Italy, and other countries. He has founded and presides over the Italian Research Foundation for Allergy and Asthma in Childhood – Allegria ONLUS, a charity dedicated to clinical and research studies. As chair of the Adverse Reactions to Foods Committee of the American College of Allergy, Asthma, and Immunology, he co-chaired several International Food Allergy Symposiums, the last in Anaheim, November 2012, with Sami Bahna and Amal Assa’ad. As chair of the Special Committee on Food Allergy of the World Allergy Organization (WAO), he worked with Hugh Sampson to co-chair both the WAO Food Allergy Symposium in Bangkok, 2007, and in Buenos Aires, 2009. Under his chairmanship, WAO published the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines in 2010 and the Clinical Use of Probiotics in Pediatric Allergy (CUPPA) position paper on the use of probiotics in pediatric allergy. Since January 2014, Dr Fiocchi has been Editor-in-Chief of the World Allergy Organization Journal. His publications cover the fields of food allergy diagnosis, follow-up, epidemiology, specific immunotherapy and childhood asthma. Motohiro EbisawaMotohiro EbisawaMotohiro Ebisawa is the Director of Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Japan, and the visiting Professor of the Jikei University School of Medicine, Japan. He graduated from The Jikei University School of Medicine in Tokyo, Japan, in 1985 and took short visiting resident course in the department of Pediatrics at St. Thomas Hospital in London, UK. He completed his postgraduate studies at the Jikei University School of Medicine, where he earned his PhD. He did postdoctoral fellowship on the analysis of “mechanisms of eosinophil specific recruitment” in Dr Robert P. Schleimer's laboratory at Johns Hopkins University, USA, from 1991–1993. He also had a chance to visit Dr Hugh Sampson's food allergy unit regularly during his fellowship. After coming back to Japan, he started food allergy practice and research at Sagamihara National Hospital in 1995. He has published more than 200 papers on international journals in addition to numerous numbers in domestic ones. He is a leading expert in food allergies in Japan and currently serves as the President of World Allergy Organization (WAO), where he has served in different leadership roles since 2010 (member at large 2010–2013, Treasurer 2014–2015, Secretary General 2016–2017), and President-elect (2018–2019). He also serves as associate editor of Pediatric Allergy and Immunology and Current Opinion of Allergy and Clinical Immunology.

Editorial introductions.

Current Opinion in Allergy and Clinical Immunology was launched in 2001. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of allergy and clinical immunology are divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Henry MilgromDr Milgrom has been on the staff National Jewish Health in Denver for 32 years. He is Professor Emeritus of Pediatrics at the University of Colorado School of Medicine, USA. Dr Milgrom believes that the challenge for healthcare in the 21st century is to provide proficient and cost-effective health management, especially as it pertains to chronic illness. Dr Milgrom believes that outcomes research, or comparative effectiveness research (CER), advances the understanding of the effectiveness, benefits, and harms of diverse treatment strategies. He feels such understanding is particularly important in conditions where cure may not be achievable, and the quality of life is the most important end point. Electronic health records provide a vast quantity of data for analytics, enabling providers to establish evidence-based best practices. A significant proportion of healthcare expenditures is used for interventions with uncertain efficacy. Patterns of care vary widely, and evidence-based insight is often lacking. Providers too often rely on their individual knowledge and judgment rather than to draw on a wider range of evidence and experience. Dr Milgrom believes that the goals of all healthcare providers should include better clinical results and improved patient health. The challenge is to threaten precedent and make it our business to base patient care on actionable insights. All of us have a stake in this endeavour and all of us should participate. René Maximiliano GómezDr René Maximiliano Gómez gained his medical degree in 1991 at the Catholic University of Córdoba, Argentina, and he presented his PhD thesis there in May 2016. He is a board-certified specialist in Allergy and Immunology both at Argentinean Association of Allergy & Clinical Immunology and at the National University of Córdoba, Argentina, and a consultant in Allergy, Asthma & Immunology Unit at Alas Medical Institute in Salta, Argentina. He has worked as Medical Director at this last institution, and in the academic field as an invited professor in Immunology (Veterinary Sciences at the Catholic University of Salta) and Dermatology (Faculty of Medicine at the National University of Salta, Argentina). Dr Gómez is President of the Ayre Foundation, leading the education and research on allergy and respiratory diseases in Salta, Argentina, and member of the State Ethics’ Committee in Human Research. He served as Scientific Secretary at the Latin American Society of Allergy, Asthma and Immunology (SLaai) in 2013 and held the post until 2017. He was General Secretary of SLaai 2017–18 and Scientific Director of Argentinean Association of Allergy & Clinical Immunology (AAAeIC) 2018–2019, being the President Elect of AAAeIC since 2019. He is also a committee member on allergy diagnosis and molecular allergology at the World Allergy Organization, and associate editor of WAO Journal. Dr Gómez has authored and co-authored more than 40 peer reviewed publications. His research focuses on allergens and indoor pollution in asthma/allergic rhinitis, parasites and atopy, chronic urticaria, allergen immunotherapy and registries for allergic diseases. Alessandro FiocchiAlessandro Fiocchi MD is the Director of Allergy at the Pediatric Hospital Bambino Gesù (OPBG), Rome, Vatican City. Formerly director of Pediatrics at the Melloni University Hospital in Milan, Italy, he is an expert in the field of food allergy. After post-graduate degrees and professional qualification in pediatrics, allergy medicine, pulmonology, and neonatology, he dedicated his research and clinical work to the care of children with asthma and allergic disease. Currently, he leads a research group focusing on food allergy, asthma, and specific immunotherapy. This group is based in the OPBG, a health care and research institution specialized in pediatric and developing ages. As the largest Pediatric Hospital in Italy, OPBG guarantees total coverage for all health care needs, including allergy. Since 2001, he has organized international meetings in Milan, Italy, and other countries. He has founded and presides over the Italian Research Foundation for Allergy and Asthma in Childhood – Allegria ONLUS, a charity dedicated to clinical and research studies. As chair of the Adverse Reactions to Foods Committee of the American College of Allergy, Asthma, and Immunology, he co-chaired several International Food Allergy Symposiums, the last in Anaheim, November 2012, with Sami Bahna and Amal Assa’ad. As chair of the Special Committee on Food Allergy of the World Allergy Organization (WAO), he worked with Hugh Sampson to co-chair both the WAO Food Allergy Symposium in Bangkok, 2007, and in Buenos Aires, 2009. Under his chairmanship, WAO published the Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines in 2010 and the Clinical Use of Probiotics in Pediatric Allergy (CUPPA) position paper on the use of probiotics in pediatric allergy. Since January 2014, Dr Fiocchi has been Editor-in-Chief of the World Allergy Organization Journal. His publications cover the fields of food allergy diagnosis, follow-up, epidemiology, specific immunotherapy and childhood asthma. Motohiro EbisawaMotohiro Ebisawa is the Director of Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Japan, and the visiting Professor of the Jikei University School of Medicine, Japan. He graduated from The Jikei University School of Medicine in Tokyo, Japan, in 1985 and took short visiting resident course in the department of Pediatrics at St. Thomas Hospital in London, UK. He completed his postgraduate studies at the Jikei University School of Medicine, where he earned his PhD. He did postdoctoral fellowship on the analysis of “mechanisms of eosinophil specific recruitment” in Dr Robert P. Schleimer's laboratory at Johns Hopkins University, USA, from 1991–1993. He also had a chance to visit Dr Hugh Sampson's food allergy unit regularly during his fellowship. After coming back to Japan, he started food allergy practice and research at Sagamihara National Hospital in 1995. He has published more than 200 papers on international journals in addition to numerous numbers in domestic ones. He is a leading expert in food allergies in Japan and currently serves as the President of World Allergy Organization (WAO), where he has served in different leadership roles since 2010 (member at large 2010–2013, Treasurer 2014–2015, Secretary General 2016–2017), and President-elect (2018–2019). He also serves as associate editor of Pediatric Allergy and Immunology and Current Opinion of Allergy and Clinical Immunology.

ContextIgE mediated food allergy affects 6–8% of children and the prevalence is thought to be increasing. Current national guidelines for the diagnosis and management of these children include the use...

Reconciling breast-feeding and early food introduction guidelines in the prevention and management of food allergy

Oral food challenge (OFC) is the gold standard for diagnosis of IgE-mediated and non-IgE mediated food allergy. It is usually conducted to make diagnosis, to monitor for resolution of a food allergy, or to identify the threshold of responsiveness. Clinical history and lab tests have poor diagnostic accuracy and they are not sufficient to make a strict diagnosis of food allergy. Higher concentrations of food-specific IgE or larger allergy prick skin test wheal sizes correlate with an increased likelihood of a reaction upon ingestion. Several cut-off values, to make a diagnosis of some food allergies (e.g., milk, egg, peanut, etc.) without performing an OFC, have been suggested, but their use is still debated. The oral food challenge should be carried out by experienced physicians in a proper environment equipped for emergency, in order to carefully assess symptoms and signs and correctly manage any possible allergic reaction. This review does not intend to analyse comprehensively all the issues related to the diagnosis of food allergies, but to summarize some practical information on the OFC procedure, as reported in a recent issue by The Expert Review of Food Allergy Committee of Italian Society of Pediatric Allergy and Immunology (SIAIP).

Epidemiologic data suggest an increased prevalence of pediatric food allergies and intolerances (FAIs) during the last decades. This changing scenario has led to an increase in the overall healthcare costs, due to a growing demand for diagnostic and treatment services. There is the need to establish Evidence-based practices for diagnostic and therapeutic intervention that could be adopted in the context of public health policies for FAIs are needed.This joint position paper has been prepared by a group of experts in pediatric gastroenterology, allergy and nutrition from the Italian Society for Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and the Italian Society for Pediatric Allergy and Immunology (SIAIP). The paper is focused on the Diagnostic Therapeutic Care Pathway (DTCP) for pediatric FAIs in Italy.

In Italy, according to the International Study on Asthma and Allergies in Childhood study, the prevalence of current asthma, allergic rhinoconjunctivitis, and atopic eczema in 2006 was 7.9%, 6.5%, and 10.1% among children aged 6-7 and 8.4%, 15.5%, and 7.75% among children aged 13-14 yr. University education in this field is provided by the Postgraduate Schools of Pediatrics and those of Allergology and Clinical Immunology, as well as several annual Master courses. The Italian Society of Pediatric Allergology and Immunology (SIAIP) was founded in 1996 and counts about 1000 members. SIAIP promotes evidence-based management of allergic children and disseminates information to patients and their families through a quite innovative website and the National Journal 'Rivista Italiana di Allergologia Pediatrica'. In the last decade, four major regional, inter-regional, and national web-based networks have been created to link pediatric allergy centers and to share their clinical protocols and epidemiologic data. In addition, National Registers of Primary Immune-deficiencies and on Pediatric HIV link all clinical excellence centers. Research projects in the field of pediatric allergy and immunology are founded by the Italian Ministry of Education, University and Research (MIUR) and by the National Research Council (CNR), but the overall investments in this research area are quite low. Only a handful Italian excellence centers participate in European Projects on Pediatric Allergy and Immunology within the 7th Framework Program. The European Academy of Allergy and Clinical Immunology currently hosts two Italians in its Executive Committee (EC) and one in the EC of the Pediatric Section; moreover, major European Academy of Allergy and Clinical Immunology meetings and courses in the area of pediatrics (e.g., PAAM, Venice, 2009) have been held in Italy in the last 3 yr. Italian hallmarks in the management of allergic diseases in childhood are a quite alive and spread interest in Molecular Allergology and a remarkable predominance of sublingual (SLIT) compared to the subcutaneous (SCIT) immunotherapy.