Erythritol is a low-molecular-weight sugar alcohol with zero calories and it is widely used as a sweetener in beverages, confectioneries, and health foods. Although there are scattered case reports of erythritol allergy, erythritol allergy is not always easy to diagnose. A 9-year-old boy developed generalized urticaria, restlessness, hypotension, and 2 episodes of vomiting during exercise after consuming a jelly drink. Suspecting an allergy to erythritol in a jelly drink, a prick test and oral food challenge test with the jelly drink were performed, but the results were negative. Six months later, he ingested another jelly drink containing erythritol and again developed generalized urticaria. A prick test for erythritol was negative, but an intradermal test was positive. In an oral food challenge test, the patient developed generalized urticaria after consuming 2 g of erythritol. Because erythritol is a low-molecular-weight compound, not a protein, it is not easily identified as a causative allergen in patients with food allergies, and prick tests are unlikely to be positive in such allergic patients. Healthcare providers should therefore be aware that erythritol can be a food allergen.

Objective: To identify challenges facing raising awareness of the importance of disaster stockpiling by families raising children with food allergies.

Methods: We conducted a questionnaire survey targeting family members of patients hospitalized for oral food challenge (OFC) tests to promote awareness of the importance of stockpiling. In cases where patients underwent two OFC tests during the research period, the second questionnaire was administered.

Results: Seventy-nine valid responses were obtained. Households were more likely to have obtained emergency food in advance of a future disaster if their family included individuals with allergies to multiple allergens (P=0.030). In the first survey, 43% of respondents reported stockpiling less than one serving of allergen-free canned food. This response decreased to 27% in the second survey. The most common response remained "one to three servings." The most useful information for household stockpile planning was "a suggested content list for a one-week stockpile," while "stockpiling drinking water and a portable gas stove" was identified as important for future preparation.

Conclusions: Healthcare providers should encourage families to continuously review and enhance their household stockpiles by providing specific guidance on the types and quantities of food required for a one-week supply, and appropriate cooking methods during disaster situations.

In recent years, there have been some reports of food protein-induced enterocolitis syndrome (FPIES) triggered by rice. However, there are few reports on nutritional management following the elimination of rice in cases of rice-induced FPIES. Herein, we report on our experience a 6-month-old girl who was diagnosed with FPIES due to rice. She began to vomit repeatedly 30 minutes after consuming rice porridge for the first time. Based on the appearance of symptoms after rice intake, negativity for rice-specific IgE antibodies, negative skin test results, and positive food oral challenge test results, she was diagnosed with FPIES due to rice. As treatment, rice consumption was completely eliminated, and her growth and development were observed while providing nutritional guidance. We managed nutrition by using wheat products as the staple food, changing the form of wheat intake and eventually using oatmeal. At 2 years and 4 months of age, an oral rice challenge test produced negative results and, thereafter, she increased her rice intake at home, eventually developing tolerance to rice at 2 years and 8 months of age. Although FPIES triggered by rice is a rare disease, this disease should be considered as one of the differential diagnoses in cases of repeated vomiting of unknown cause.

There have been several reports of traumatic adverse events caused by insufficient restraint during the use of an EpiPen^®. While many of these reports discuss proper restraint posture, few emphasize the importance of maintaining restraint until the EpiPen^® is completely removed from the body. We herein present a case involving a 4-year-old boy who was prescribed an EpiPen^® because of allergies to walnuts and cashews. The boy developed an allergic reaction after inadvertently consuming baked sweets containing walnuts. His mother administered the EpiPen^® by holding his legs and pressing it against his thigh. Believing that the needle retracted automatically, she released her hold before the EpiPen^® was fully removed. As a result, the child moved his legs, causing a laceration on his right thigh. Although the mother was familiar with the importance of firm restraint as outlined in the current educational materials and guidance, the injury could have been prevented if she had been clearly instructed not to release the restraint until the EpiPen^® was completely withdrawn. This case highlights the need to enhance guidance on EpiPen^® usage to emphasize maintaining restraint until the device is fully removed.

Objective: This study evaluated the safety of peanut oral food challenges (OFC) for toddlers aged 1-2 years.

Merhods: From April 2016 to December 2024, the OFCs with loading dose of 0.1 g, 0.2 g and 0.5 g of peanut butter were performed to patients who met at least one of the criteria: Ara h 2-sIgE ≥1.0 U_A/mL, a positive result of peanut skin prick test, and a history of allergic reactions after peanut ingestion. The proportions of grade 2 or higher symptoms based on Anaphylaxis guidelines 2022 were evaluated between two groups; toddlers aged 1-2 years and children aged 3-6 years. For more high-risk patients, preliminary OFCs with a total dose of less than 0.1 g of peanut butter were performed.

Results: Sixty-eight patients were evaluated. The proportions of grade 2 symptoms were 24% (6/25) in the 1-2 years group and 28% (12/43) in the 3-6 years group (OR 0.82, 95%CI 0.21 - 2.85, P=0.78). One patient among the 1-2 years group showed an anaphylactic reaction.

Conclusions: The peanut OFC with doses of 0.1 g, 0.2 g and 0.5 g of peanut butter administered to toddlers aged 1-2 years might not be dangerous than those of OFCs to children aged 3-6 years. However, modifications are needed to further enhance safety.

How to plan and conduct research based on my experiences was described. The starting point for clinical research is a clinical question (CQ). The case should be reviewed in detail, and be published as a case report. Once the initial CQ has been solidified through a series of cases, a case-control study will be conducted. It is important to set up a control. As the final step, a randomized controlled trial should be undertaken. The accumulation of such evidence will lead to future guidelines and standardization of treatment. On the other hand, honest research always involves setbacks. How to overcome setbacks was also described. Regardless of setbacks, I sincerely hope that you will continue to walk forward.

Patients should be provided the best care with medicine based on evidence. Clinical studies are the basis for forming this evidence. They are classified into three categories: interventional studies, observational studies, and systematic reviews that integrate the results of these studies. The level of evidence is determined by the study design, and the more reliable results are produced by studies of the higher level. However, even if the level of evidence is high, studies with concerns about the research methods themselves may not produce results that reflect the truth which should be revealed. We need to pay attention not only to the level of evidence but also to its quality. The quality of evidence is evaluated using tools like Risk of Bias 2.0 for randomized controlled trials and ROBINS-E for observational studies. Medical researchers are expected to conduct high-quality studies and publish the results in journals, while medical professionals who use evidence in their practice are expected to interpret research papers carefully, considering both the level and quality of evidence.

Vitamin D is synthesized in the body through exposure to ultraviolet rays and is also obtained from dietary sources. Vitamin D has been shown to be involved in allergic diseases through its immunomodulatory function. It is thought to play a role in suppressing excessive allergic reactions by acting on immune cells such as T cells and dendritic cells, and promoting immune tolerance. Many epidemiological studies have suggested that vitamin D deficiency is a risk factor for food allergies. The CHIBA study confirmed that the blood vitamin D levels of breast-fed infants were low, and the rate of egg white sensitization was high. However, the results of intervention studies using vitamin D conducted in other countries have not yet reached a conclusion regarding its preventive effects. Vitamin D deficiency is a serious problem in Japan, and interventions that take into account the unique lifestyle and nutritional background of the Japanese are necessary. Therefore, we conducted a randomized controlled trial using vitamin D with the aim of preventing food allergies (the Vitamin D mediated Prevention of Allergic march in Chiba (D-PAC) study), and were able to achieve a high preventive effect. In the future, clinical applications that increase the effectiveness of vitamin D supplementation are expected through investigations into the optimal timing and optimal concentration of administration.

Chapter 11 of the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2023 describes the various aspects, focusing on school and preschool life, exercise, vaccination, perioperative management, disaster, and comorbidities. If special consideration is required in school or preschool, the instruction table for school life management and cooperation with parents and school is referred for appropriate action. Exercise-induced bronchoconstriction (EIB) is a phenomenon in which wheezing and dyspnea occur temporarily during or after exercise. The stakeholders should properly understand EIB and cooperate to prevent EIB from school children. Vaccinations can be administered to children with asthma as well as to healthy children, with adequate care and attention. For general anesthesia or surgery, maintain good control and consider stepping up treatment or systemic corticosteroids as needed. Disaster preparedness is important on a daily basis, and there are pamphlets available on emergencies. In severe mental and physical disabilities, it is necessary to differentiate asthma from other diseases and to devise inhalation techniques. In neurodevelopmental disorders, it is desirable to devise treatment adapted to the characteristics of the child. In food allergy, it requires careful attention to asthma control status.

Since the publication of the first edition in 2000, the Japanese Pediatric Guideline for the Treatment and Management of Asthma (JPGL) has provided standard treatment and management guidelines, contributing to improved clinical care. JPGL2023, following methodology adopted from "Minds Clinical Practice Guidelines", conducted systematic reviews of 14 Clinical Questions (CQs) and revised the associated guidelines to align clinical practices with evidence-based medicine (EBM). Chapter 12 presents remaining challenges towards the establishment of better guidelines. Development of high-quality evidence specifically focused on the Japanese pediatric population is of particular importance. Critical priorities include the establishment of prevention strategies, understanding infant wheezing pathophysiology, optimization of its treatment, and development of long-term outcome assessment and therapeutic strategies for adolescent asthma. It is also necessary to clarify the appropriate positioning of new therapeutic options, including allergen immunotherapy, biological agents, maintenance and reliever therapy, and high-flow nasal cannula oxygen therapy. Promoting standardized treatment and equalizing medical care based on the Basic Act on Allergic Disease Measures as well as developing research promotion systems also remain crucial challenges. Systematic efforts are required to address these challenges.