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ALLERGY

Question . 1. Which of the following are characteristic of allergens?


Proteins of molecular weight <10 kd
Proteins of molecular weight 10-70 kd
Explanation: Most allergens are proteins that have
molecular weights of 10-70 kd. Molecules smaller than 10
kd would not bridge adjacent IgE antibody molecules on the
surface of mast cells or basophils. Most molecules larger
than 70 kd would not pass through mucosal surfaces
needed to reach antigen-presenting cells for stimulation of
the immune system. Allergens frequently function in their
natural state as proteolytic enzymes, which may contribute
to increased mucosal permeability and sensitization. (See
Chapter 130 in Nelson Textbook of Pediatrics, 17th ed.)
Proteins of molecular weight >70 kd
Lipopolysaccharides
Carbohydrates
Question . 2. Which of the following factors is characteristic of an atopic
response?
Th1 release of cytokines promoting phagocytosis
Th1 release of cytokines promoting synthesis of opsonizing
antibodies
Th1 and Th2 release of cytokines promoting synthesis of
complement-fixing antibodies
Th2 release of cytokines promoting phagocytosis
Th2 release of cytokines promoting synthesis of IgE
antibodies
Explanation: Nonatopic subjects respond with the
proliferation of T helper type 1 (Th1) cells, which secrete
Th1 type cytokines (e.g., IFN- ) involved in the elicitation of
allergen-specific IgG antibodies. Th1 cells are generally
involved in the eradication of intracellular organisms such
as mycobacteria, because of the ability of Th1 cytokines to
activate phagocytes and promote the production of
opsonizing and complement-fixing antibodies. However,
genetically predisposed atopic individuals respond with a
brisk expansion of T helper type 2 (Th2) cells that secrete
cytokines favoring IgE synthesis. (See Chapter 130 in
Nelson Textbook of Pediatrics, 17th ed.)

Question . 3. Which of the following types of cells are distributed throughout


connective tissues, often adjacent to blood vessels and below epithelial
surfaces that are exposed to the external environment, and release a diverse
array of mediators of allergic inflammation?
Eosinophils
Basophils
Mast cells
Explanation: Mast cells contain or produce a diverse array
of mediators of allergic inflammation. (See Chapter 130 in
Nelson Textbook of Pediatrics, 17th ed.)
Th2 cells
Dendritic cells
Question . 4. Which of the following antigen-presenting cells are actively
phagocytic and reside in peripheral sites such as the skin, intestinal lamina
propria, and lungs?
Eosinophils
Basophils
Mast cells
Th2 cells
Dendritic cells
Explanation: Antigen-presenting cells (APCs) are a
heterogeneous group of cells that present antigens in the
context of the major histocompatibility complex (MHC).
Dendritic cells are actively phagocytic cells that reside in
peripheral sites such as the skin, intestinal lamina propria,
and lungs. (See Chapter 130 in Nelson Textbook of
Pediatrics, 17th ed.)

Question . 5. Which of the following statements best describes the


relationship between allergic disorders and a possible genetic basis?
Allergic disorders are a response to only environmental
factors
Allergic disorders are a response to only environmental
factors and infectious agents
Asthma and allergic rhinitis are the only allergic disorders
with a familial predisposition
Any familial predisposition is related to polymorphisms
of a single gene located on chromosome 10
Explanation: Both environmental and genetic factors are
important in allergic diseases. The clinical expression of
these diseases is a complex interaction of many genetic
loci and polymorphisms in each of these genes. (See
Chapter 130 in Nelson Textbook of Pediatrics, 17th ed.)
Any familial predisposition is related to many genetic loci
and also many polymorphisms
Question . 6. Which of the following factors may contribute to the worldwide
rise in prevalence of allergic diseases, particularly in Westernized metropolitan
areas?
Increasing genetic polymorphisms of CD14
Increased numbers of children in group daycare
Excessive use of antibiotics in first 2 yr of life
Explanation: Widespread antibiotic use, particularly in
young children, alters the microbial flora in the
gastrointestinal tract and may produce an environment that
is less effective in driving a Th1 response. (See Chapter
130 in Nelson Textbook of Pediatrics, 17th ed.)
Reduced exposure to pollutants in Westernized
metropolitan areas since 1980
Reduced exposure to indoor allergens

Question . 7. All of the following may be signs of moderate to severe airway


obstruction resulting from allergic response except:
Dennie lines (Dennie-Morgan folds)
Explanation: Dennie lines (Dennie-Morgan folds) are
prominent symmetric skinfolds that extend in an arc from
the inner canthus beneath and parallel to the lower lid
margin. Like allergic shiners and the allergic salute, they
are signs of persistent rhinorrhea associated with allergic
rhinitis. A "silent chest' in a patient with asthma (answer E)
is a severe sign suggesting inspiratory and expiratory
obstruction. Cyanosis is always present in such severe
cases. (See Chapter 131 in Nelson Textbook of Pediatrics,
17th ed.)
Supraclavicular and intercostal retractions
Cyanosis
Pulsus paradoxus
Respiratory distress with minimal wheezing and a few
crackles
Question . 8. A 7-yr-old boy with asthma has roughness over the extensor
surfaces of the upper arms and thighs, which is caused by keratin plugs
lodged in the openings of hair follicles. This physical finding is termed:
Keratosis pilaris
Explanation: Xerosis, or dry skin, is the most common skin
abnormality of allergic children. Keratosis pilaris, often
found on the extensor surfaces of the upper arms and
thighs, is characterized by roughness of the skin caused by
discrete follicular papules. These are the result of
hyperkeratosis with keratin plugs lodged in the openings of
hair follicles, and re-form after removal. (See Chapter 131
in Nelson Textbook of Pediatrics, 17th ed.)
Fibroepitheliosis
Hidradenitis
Xerosis
Acrochordon

Question . 9. The radioallergosorbent test (RAST) determines:


Bronchial reactivity to subcutaneous serotonin
Bronchial reactivity after inhalation bronchial provocation
test
The proportion of total allergic immunoglobulin
Antigen-specific serum IgE concentrations
Explanation: The RAST (radioallergosorbent test)
determines the serum IgE concentrations against specific
antigens. The RAST correlates well with medical history
and allergy skin testing but is somewhat less sensitive than
skin testing. (See Chapter 131 in Nelson Textbook of
Pediatrics, 17th ed.)
The overall allergic risk profile based on absolute
eosinophil count, total IgE, and skin test results
Question . 10. All of the following statements regarding skin testing for allergic
reactivity are true except:
Antihistamines given prior to testing may inhibit the reaction
Intradermal tests are more sensitive than puncture tests
Positive skin test results by intradermal testing
correlate better than results by puncture tests with
clinical symptoms
Explanation: Positive skin test results obtained by the
puncture technique correlate better than the more sensitive,
less specific intradermal tests with measurements of
specific IgE antibody and with the appearance of clinical
symptoms on exposure to the allergen. (See Chapter 131
in Nelson Textbook of Pediatrics, 17th ed.)
The reaction peaks within approximately 20 min and
usually resolves over 20-30 min
Larger reactions have greater clinical relevance

Question . 11. Which of the following is an advantage of skin testing over


RAST to determine specific IgE?
Skin testing is not affected by administration of
antihistamines
Skin testing has greater sensitivity than RAST
Explanation: Because skin tests are more sensitive than
RAST, they are more reliable than RAST in confirming risk
of life-threatening anaphylactic conditions. All of the other
responses are incorrect. (See Chapter 131 in Nelson
Textbook of Pediatrics, 17th ed.)
Skin testing is semiquantitative
Skin testing is associated with less risk of allergic reaction
Skin testing is not confounded by dermographism
Question . 12. Which of the following physical findings would be least likely on
examination of a child with moderate to severe asthma?
Tachypnea
Wheezing
Clubbing
Explanation: Digital clubbing (hypertrophic pulmonary
osteoarthropathy) is rarely observed in children with
uncomplicated asthma and should prompt evaluation to
exclude other potential diagnoses. (See Chapter 131 in
Nelson Textbook of Pediatrics, 17th ed.)
Decreased air exchange over the right middle lobe
An increased anterior-posterior diameter of the chest

Question . 13. Recommendations to the parents of a child with dust mite


allergy to help reduce dust mite exposure should include all of the following
except:
Use a humidifier regularly
Explanation: Household humidity should be kept at less
than 50% to inhibit survival of mites. Use of vaporizers
should be avoided. Dehumidifiers may be necessary in
damp basements. The air conditioning should be set at the
lowest level during the warmer months. Clothes and
bedding should be washed in hot water (>130F) to kill dust
mites. Carpeted flooring is not recommended. Carpet and
upholstered furniture, if retained, should be vacuumed
weekly using a vacuum with a HEPA filter. (See Chapter
132 in Nelson Textbook of Pediatrics, 17th ed.)
Place the mattress and pillow in allergen-proof
encasements
Wash bed linens in hot water weekly
Remove the old carpet from the bedroom
Question . 14. All of the following statements regarding decreasing exposure
to cat allergens are true except:
Removing the cat from the home is the most effective
means of reducing exposure to cat allergen
Keeping the cat out of the child's bedroom and other rooms
where the sensitized child spends large amounts of time
reduces cat allergen exposure
Washing the cat regularly reduces cat allergen exposure
Using HEPA-filtered air cleaners does not reduce cat
allergen exposure
Explanation: Advice to remove a pet cat from the home or
keep it outdoors is often ignored. In contrast to dust mite
allergens, cat allergen is light and remains suspended in
the air for long periods of time. Regular vacuuming with a
HEPA-filtered and double-thickness-bag vacuum cleaner is
encouraged. (See Chapter 132 in Nelson Textbook of
Pediatrics, 17th ed.)
Removing carpet decreases cat allergen exposure

Question . 15. A 12-yr-old girl with moderate to severe asthma is sensitive to


cat dander. Her family elects to remove the pet cat from the house, but to
retain the present carpeting and upholstered furniture. What is the length of
time required before the levels of cat allergen drop to levels found in homes
without a cat?
Immediately
2 days
2 wk
2 mo
6 mo
Explanation: Cat owners who remove the cat from the
home without also removing carpeting and upholstered
furniture, and thoroughly wiping down all walls and hard
surfaces, should be informed not to expect immediate
results. It may take 6 months to 1 year for the levels of cat
allergen to drop to a level found in homes without a cat.
(See Chapter 132 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 16. Which of the following statements regarding antihistamines is
true?
Classification of antihistamines from type I to type VI is
based on increasing antihistamine activity
Second-generation antihistamines are distinguished by
greater effectiveness than first-generation antihistamines
Antihistamines should not be administered in combination
with decongestants
Antihistamines are more effective in treating than
preventing the action of histamine
The choice of antihistamines should be based on
associated adverse effects and cost
Explanation: There is little reason to choose one
antihistamine over another except for avoidance of adverse
effects, such as sedation, impairment of function, and cost.
The chemical classification of antihistamines (type I to type
VI) does not have functional significance. Secondgeneration antihistamines have fewer sedative adverse
effects. (See Chapter 132 in Nelson Textbook of Pediatrics,
17th ed.)

Question . 17. Which of the following is an advantage of second-generation


antihistamines over first-generation antihistamines?
Second-generation antihistamines are often less expensive
Second-generation antihistamines are more frequently
available in oral preparations
Second-generation antihistamines have less of a
sedative effect and produce less cognitive impairment
Explanation: One of the primary advantages of secondgeneration antihistamines is that they are nonsedating or
much less so than first-generation antihistamines. (See
Chapter 132 in Nelson Textbook of Pediatrics, 17th ed.)
Many more second-generation antihistamines are available
as over-the-counter medications
Second-generation antihistamines are generally more
effective than first-generation antihistamines
Question . 18. Which of the following statements regarding the use of
cromolyn in the management of asthma is true?
Cromolyn prevents antibody-mediated mast cell
degranulation and mediator release
Cromolyn prevents non-antibody-mediated mast cell
degranulation
Cromolyn has no bronchodilator properties
The incidence of adverse effects is low
All of the above
Explanation: Cromolyn prevents bronchoconstriction
caused by immunologic as well as nonimmunologic stimuli
(e.g., frigid air, exercise). It has no bronchodilator
properties and is useful only if given prophylactically. (See
Chapter 132 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 19. The type of adrenergic activity of drugs most desirable in


treatment of asthma is:
1

Explanation: Agents with greater 2-selective activity


provide effective bronchodilation with less cardiac
stimulation (e.g., increase in heart rate) than may occur
with agents with both 1 and 2 activities. (See Chapter 132
in Nelson Textbook of Pediatrics, 17th ed.)
3

Question . 20. A 4-yr-old boy experiences perennial clear rhinorrhea, nasal


congestion, conjunctival injection, allergic shiners, nasal and ocular pruritus,
and occasional fits of sneezing. An environmental history is significant for two
cats in the home and flooding of the basement when it rains. He keeps twenty
stuffed animals on his bed and sleeps with a feather pillow on an old mattress.
He lives in a warm climate. Seasonal worsening of his symptoms has not been
observed. He has perennial allergic rhinitis. Which of the following groups of
allergens would be the most likely to contribute to his symptoms?
Dust mites, tree pollens, and weed pollens
Dust mites, animal danders, and molds
Explanation: Perennial allergic rhinitis is most often
associated with indoor allergens: house dust mites, animal
danders, and molds. (See Chapter 133 in Nelson Textbook
of Pediatrics, 17th ed.)
Tree, weed, and grass pollens
Tree pollen, grass pollen, and milk protein

Question . 21. A 7-yr-old girl presents with allergic nasal symptoms that are
prominent from the middle of August through the first frost. Which of the
following allergens is the most likely cause of her symptoms?
Milk protein
Tree pollen
Grass pollen
Weed pollen
Explanation: In temperate climates, airborne pollen
responsible for SAR appears in distinct phases: trees
pollinate in the spring, grasses in the early summer, and
weeds in the late summer. (See Chapter 133 in Nelson
Textbook of Pediatrics, 17th ed.)
Question . 22. A teenage boy presents in April with symptoms consistent with
seasonal allergic rhinitis. On examination of his nose, which of the following
findings suggest the need for further evaluation to exclude another diagnosis?
Nasal polyps
Explanation: Nasal polyps and nasal septal deviation are
structural disorders that can mimic allergic rhinitis. (See
Chapter 133 in Nelson Textbook of Pediatrics, 17th ed.)
Pale-to-purple nasal mucosa
Thin, clear nasal secretions
A transverse nasal crease
Continuous open-mouth breathing
Question . 23. A 12-yr-old presents with sneezing, clear rhinorrhea, and nasal
itching. Physical examination reveals boggy, pale nasal edema with a clear
discharge. The most likely diagnosis is:
Foreign body
Vasomotor rhinitis
Neutrophilic rhinitis
Nasal mastocytosis
Allergic rhinitis
Explanation: Allergic rhinitis is often seasonal and
associated with allergic conjunctivitis. Eosinophils

predominate in the nasal secretions.Chapter 133


Question . 24. Two weeks later, the patient described in Question 23
complains of headache, poor nasal airflow requiring mouth breathing, fever,
and a change in the nature of the nasal discharge to mucopurulent discharge.
The most likely diagnosis is:
Sinusitis
Explanation: Sinusitis is a possible complication of allergic
rhinitis. A change in the nature of the nasal discharge,
facial pain, and fever may all herald the onset of sinusitis.
(See Chapter 133 in Nelson Textbook of Pediatrics, 17th
ed.)
Foreign body
Rhinitis medicamentosa
Choanal stenosis
Ciliary dyskinesia
Question . 25. A 12-yr-old child presents with watery rhinorrhea, paroxysmal
sneezing, and nasal obstruction. The serum IgE level is normal, and skin test
results are negative. The physical examination is remarkable only for swollen
turbinates and clear nasal secretions. A trial of antihistamine-decongestant
therapy for 3 wk has not relieved symptoms. Which of the following is the
recommended management?
Institute strict measures to avoid outdoor allergen
exposure.
Begin seasonal use of oral sympathomimetic drugs.
Begin seasonal use of topical intranasal
corticosteroids.
Explanation: Topical intranasal corticosteroids (e.g.,
fluticasone, budesonide) should be used in children with
allergic rhinitis that is resistant to antihistaminedecongestant therapy. A consultation with an allergist is
recommended for patients with allergic rhinitis that does not
respond to intranasal corticosteroids. (See Chapter 133 in
Nelson Textbook of Pediatrics, 17th ed.)
Give a 10-day course of amoxicillin
Give a 10- to 14-day course of cefpodoxime

Question . 26. Which of the following is most useful in establishing the


diagnosis of seasonal allergic rhinitis?
History of good clinical response to an intranasal
corticosteroid preparation
History of exacerbation of symptoms in the spring
Explanation: Seasonal allergic rhinitis follows a welldefined course of cyclical exacerbation, whereas perennial
allergic rhinitis causes year-round symptoms.Chapter 133
Elevated serum IgE level
Positive result on skin testing for the house dust mite
allergen
Nasal eosinophils
Question . 27. Common triggers of asthma in children include all of the
following except:
Secondary tobacco smoke
Ozone
Cold air
Exercise
Gelatin
Explanation: Asthma symptoms may be provoked by
numerous events or exposures.Chapter 134
Question . 28. The parents of a 3-yr-old girl with a history of several previous
coughing and wheezing exacerbations are wondering if their toddler is likely to
develop persistent asthma. Which of the following is a strong risk factor for
persistent asthma in toddlers with recurrent wheezing?
Eczema
Explanation: Only a minority of young children who
experience recurrent wheezing will go on to have persistent
asthma in later childhood. Several risk factors have been
identified. Chapter 134
Colic
Living on a farm
Female gender

Otitis media with effusion


Question . 29. A 4-yr-old boy with asthma has had mild wheezing only four
times since you began treating him 6 mo ago with theophylline (Slo-bid
Gyrocaps) twice each day. He previously experienced coughing and wheezing
at least three times each week. (A peak serum theophylline concentration 5
mo ago was 16 g/mL). For the past 4 days, he has again experienced mild
coughing and wheezing responsive to inhaled albuterol. Two days ago, an
emergency department physician began treatment with erythromycinsulfisoxazole (Pediazole) for otitis media. This morning the youngster began
vomiting. The likely cause of the vomiting is:
Provocation by coughing (post-tussive emesis)
Sequelae of otitis media
Theophylline toxicity
Explanation: The erythromycin (a macrolide antibiotic)
component of Pediazole inhibits hepatic theophylline
metabolism, thus potentially producing theophylline toxicity.
(See Chapter 134 in Nelson Textbook of Pediatrics, 17th
ed.)
Albuterol toxicity
Pediazole intolerance
Question . 30. A 10-yr-old child has intermittent symptoms of mild asthma.
The most appropriate treatment option is:
Environmental control and patient education only?no
medication is indicated
Oral theophylline
Cromolyn
Inhaled 2-agonist as needed for symptoms
Explanation: For mild intermittent symptoms of asthma,
recommended treatment is with a short-acting inhaled 2agonist as needed for symptoms. The intensity of treatment
depends on the severity of exacerbations. The need for
short-acting inhaled 2-agonist use more than two times a
week may indicate the need to initiate long-term-control
therapy. (See Chapter 134 in Nelson Textbook of
Pediatrics, 17th ed.)
Daily inhaled corticosteroid

Question . 31. The child described in Question 30 experiences worsening of


symptoms, which are now persistent and of moderate severity. The most
appropriate treatment option is:
Oral theophylline
Inhaled

2-agonist

as needed for symptoms

Daily inhaled corticosteroid and oral theophylline


Daily inhaled corticosteroid and a long-acting inhaled
2-agonist
Explanation: For moderate persistent symptoms of
asthma, recommended treatment is with a daily-inhaled
corticosteroid and a long-acting inhaled 2-agonist.
Alternatives to the inhaled 2-agonist are sustained-release
theophylline and a leukotriene receptor antagonist. In
addition, for moderate persistent symptoms of asthma, a
short-acting 2-agonist is also used as needed for quick
relief of symptoms.Chapter 134
Daily inhaled corticosteroid, a long-acting inhaled
agonist, and oral theophylline

2-

Question . 32. A 12-yr-old asthmatic boy has developed an asthma


exacerbation in the past few days. Asthma symptoms have continued to
progress despite frequent albuterol use at home. He comes to the emergency
department with chest tightness, dyspnea, and wheezing, and in moderate
respiratory distress. In this setting, management should include all of the
following except:
Close monitoring
Supplemental oxygen
Inhaled albuterol
Theophylline
Explanation: Initial emergency department management of
an asthma exacerbation includes close monitoring of
clinical status, treatment with supplemental oxygen, inhaled
-agonist every 20 min for 1 hr, and if necessary, systemic
glucocorticoids (2 mg/kg/day) given either orally or
intravenously. Inhaled ipratropium may be added to the agonist treatment if no significant response is seen with the
first inhaled -agonist treatment. If a child responds poorly
to intensive therapy with nebulized albuterol, ipratropium,
and parenteral glucocorticoids, then adding intravenous
theophylline could be considered.Chapter 134

Systemic glucocorticoids
Question . 33. A 7-yr-old girl has had intermittent asthma symptoms over the
past 5 yr. Her asthma symptoms have been treated with inhaled albuterol as
needed. She mostly has exercise-induced asthma symptoms, which happens
on most school days except when she uses her albuterol inhaler before going
to recess and physical education classes. In the past year, she has had two
asthma exacerbations with viral upper respiratory tract infections, and she has
used a total of 5 albuterol metered-dose inhalers. The most appropriate
management for this asthmatic girl is:
Continue albuterol as needed and before physical exercise
activities
Begin daily controller medication with an inhaled
glucocorticoid, initially used more frequently to gain
control, then a reduced amount in a few months to
maintain control
Explanation: Low-dose inhaled glucocorticoids,
leukotriene pathway modifiers, and cromolyn/nedocromil
are the recommended controllers for mild persistent
asthmatics; sustained-release theophylline is an alternative.
Chapter 134
Begin daily inhaled glucocorticoid in a low dose, increasing
the dose monthly until good control is obtained
Administer daily oral glucocorticoid treatment for one week,
with concurrent daily inhaled glucocorticoid
Begin use of a long-acting inhaled -agonist each morning
Question . 34. Components of the U.S. National Asthma Education &
Prevention Program (NAEPP) guidelines include all of the following except:
Regular assessment and monitoring
Control of factors contributing to asthma severity
Asthma pharmacotherapy, especially the use of antiinflammatory controller medications
Genetic profiling
Explanation: The NAEPP guidelines were recently
adapted for childhood asthma in a joint-effort publication of
the American Academy of Allergy, Asthma & Immunology
with the U.S. National Institutes of Health's National Heart,
Lung and Blood Institute and the American Academy of
Pediatrics entitled Pediatric Asthma: Promoting Best
Practice.Chapter 134

Patient education
Question . 35. Features characteristically associated with atopic dermatitis
include all of the following except:
Allergic rhinitis or asthma
Elevated serum IgE level
Peripheral blood eosinophilia
Lymphopenia
Explanation: Most patients with atopic dermatitis have
peripheral blood eosinophilia and elevated serum IgE level.
Nearly 80% of patients with atopic dermatitis develop
allergic rhinitis and/or asthma.
Question . 36. Major features of atopic dermatitis in children include all of the
following except:
Pruritus
Facial and extensor eczema
Angioedema
Explanation: Angioedema is similar to urticaria but has
deeper tissue involvement. Urticaria and angioedema are
not characteristic features of atopic dermatitis
Chronic or relapsing course
Personal or family history of atopic disease
Question . 37. A 2-yr-old is diagnosed with atopic dermatitis. Which of the
following environmental modifications is recommended?
A bland diet, especially minimizing meats
Installation of wool carpeting instead of synthetic carpeting
Use of a liquid rather than powder laundry detergent,
and adding a second rinse cycle
Explanation: Using a liquid rather than a powder laundry
detergent and adding a second rinse cycle will facilitate
removal of the detergent. Soaps should have minimal
defatting activity and a neutral pHChapter 135
Use of soaps that are especially effective in removing fatty
substances

Bathing less often than daily


Question . 38. The most appropriate prognosis to convey to the parents of the
2-yr-old with atopic dermatitis described in Question 37 is:
The child will be asymptomatic with environmental
modifications
Symptoms will gradually worsen during childhood and
persist stably through adulthood
Symptoms will exhibit a remittent but progressively
worsening course through adulthood
Symptoms will gradually decrease over the next
several years with an approximately 50% chance of
spontaneous improvement
Explanation: Atopic dermatitis generally tends to be more
severe and persistent in young children. With control of
trigger factors and appropriate local treatment, reasonable
but not complete resolution of symptoms is usually
possible. Periods of remission appear more frequently as
the child grows older. Spontaneous resolution of atopic
dermatitis has been reported to occur after age 5 yr in 4060% of patients affected during infancy, particularly if their
disease is mild. Recent studies have reported that atopic
dermatitis disappears in approximately 20% of children
followed from infancy until adolescence, but it had become
less severe in 65%. (See Chapter 135 in Nelson Textbook
of Pediatrics, 17th ed.)
Symptoms will resolve completely at puberty
Question . 39. Which of the following is the major feature of atopic dermatitis?
Onset shortly before or during puberty
Pruritus
Explanation: All patients with atopic dermatitis have
pruritus. However, not all patients with atopic dermatitis
have other allergic symptoms, elevated IgE levels, or S.
aureus skin infections. (See Chapter 135 in Nelson
Textbook of Pediatrics, 17th ed.)
C. Staphylococcus aureus cutaneous infections
Elevated serum IgE
Immediate skin test reactivity to allergens

Question . 40. A 5-yr-old boy with severe atopic dermatitis develops illness
with dozens of vesicles primarily covering areas of skin previously affected by
atopic dermatitis. The distribution crosses many dermatomes. Findings include
fever and lymphadenopathy. The most likely diagnosis is:
Chickenpox
Zoster
Kaposi varicelliform eruption
Explanation: Kaposi varicelliform eruption, or eczema
herpeticum, results from herpes simplex virus infection of
skin with altered immunity, usually from atopic dermatitis.
Kaposi varicelliform eruption is clinically distinguished from
zoster by its random distribution, which may involve many
dermatomes. Additionally, lesions of eczema herpeticum
are often isolated and are not grouped, as are the vesicles
of zoster. Similar eruptions have been described in
association with vaccinia virus (smallpox vaccination) and
coxsackievirus infections. (See Chapter 135 in Nelson
Textbook of Pediatrics, 17th ed.)
Eczema vaccinatum
Coxsackievirus infection
Question . 41. A 14-yr-old presents with acute-onset urticaria that has
gradually worsened over the past 10 days. Detailed history reveals no clues to
the possible etiology. Findings on physical examination are normal except for
urticaria. Which of the following diagnostic options is recommended?
Systematic elimination diets to determine a possible
ingestant cause
Allergy skin testing
Explanation: No laboratory test confirms or excludes the
diagnosis of urticaria. Allergy skin testing can be helpful in
sorting out causes of acute urticaria, especially when
supported by historical evidence. Drugs and foods are the
most common causes of acute urticaria. A skin biopsy is
indicated only if urticarial vasculitis is suspected. (See
Chapter 136 in Nelson Textbook of Pediatrics, 17th ed.)
Serum IgE and RAST
Skin biopsy
None of the above

Question . 42. Which of the following treatment options is recommended for


the patient described in Question 42?
A bland diet
Wearing cotton garments
Oral antihistamine
Explanation: Antihistamines are usually effective for
treatment of urticaria. Diphenhydramine and hydroxyzine
are effective but also cause sedation. A nonsedating
antihistamine (e.g., Loratadine) is often the preferred
therapy for urticaria for school-aged children to minimize
the effect on learning and school performance. (See
Chapter 136 in Nelson Textbook of Pediatrics, 17th ed.)
Oral prednisone
Topical corticosteroid
Question . 43. Which of the following laboratory tests is most likely to give
abnormal results in a patient with chronic urticaria?
Serum IgE level determination
Skin prick testing for egg sensitivity
C4 level assay
Assay for antibodies to thyroglobulin
Explanation: There is an increased association of chronic
urticaria with Hashimoto thyroiditis. Such patients generally
have antibodies to thyroglobulin, or a microsomal-derived
antigen (peroxidate) even if they are euthyroid. The
incidence of abnormal thyroid function (either increased or
decreased T4 and/or increased or decreased TSH) is
approximately 20%. Patients with chronic urticaria usually
have normal IgE levels. (See Chapter 136 in Nelson
Textbook of Pediatrics, 17th ed.)
Heterophile antibody testing

Question . 44. A 12-yr-old girl with repeated episodes of streptococcal


pharyngitis experiences another episode of sore throat. The rapid strep test
result is positive, and oral amoxicillin is started, with the first dose given in the
office. One hour later, she experiences a "funny feeling" and a tingling
sensation around her mouth. Next she becomes apprehensive, has difficulty
swallowing, and develops a hoarse voice. On arrival at the emergency
department, she has giant urticaria and the following vital signs: pulse 130,
respiratory rate 32/min, blood pressure 70/30 mm Hg, and temperature
37.2C. The most appropriate therapy is administration of:
Epinephrine
Explanation: Intramuscular epinephrine is the treatment of
choice. If the blood pressure does not respond, lactated
Ringer's solution should be administered. Benadryl,
cimetidine, and prednisone are second-line therapeutic
agents to be administered after epinephrine and fluids.
(See Chapter 137 in Nelson Textbook of Pediatrics, 17th
ed.)
Prednisone
Diphenhydramine
Albuterol
Lactated Ringer's solution
Question . 45. The most likely diagnosis for the patient described in Question
45 is:
Streptococcal toxic shock
Scarlet fever
Stevens-Johnson syndrome
Reye syndrome
Anaphylaxis
Explanation: Anaphylaxis to penicillin usually occurs within
30-90 min of administration of this drug. Anaphylactic shock
is often missed as a diagnosis unless a complete history is
obtained and there is a high index of suspicion. (See
Chapter 137 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 46. The mother of an 8-yr-old boy with acute streptococcal


tonsillitis calls to report that now, within 15 min after the first dose of oral
penicillin V that you prescribed, he is complaining of itching and has developed
hives. Which of the following should you recommend?
A dose of oral Benadryl, with instructions to call again if he
has not improved within 30 min
Immediate return to your office or the nearest
emergency department
Explanation: The urticarial reaction described in the
question may develop into anaphylaxis; the latter requires
emergency treatment. In addition, the penicillin V should be
stopped and a substitute nonpenicillin antibiotic chosen.
(See Chapter 137 in Nelson Textbook of Pediatrics, 17th
ed.)
Careful monitoring at home, with instructions to return to
your office or the nearest emergency department if he
becomes short of breath or loses consciousness
Schedule a visit for a laboratory test to determine serum
trypticase level
Substitution of erythromycin for penicillin
Question . 47. All of the following statements regarding anaphylaxis are true
except:
Virtually any foreign substance can elicit an anaphylactic
reaction
Most anaphylactic reactions are due to drugs, latex, foods,
and Hymenoptera venom
Oral drugs carry a higher risk of anaphylaxis than that
associated with injected drugs
Explanation: Reactions to medications can be reduced
and minimized by using oral medications in preference to
injected forms. (See Chapter 137 in Nelson Textbook of
Pediatrics, 17th ed.)
Anaphylactic reactions to foods usually begin within
minutes to 2 hr of exposure
Exercise alone can elicit an anaphylactoid reaction

Question . 48. Administration of which of the following drugs is the treatment


of choice for anaphylaxis?
Diphenhydramine orally
Diphenhydramine by intravenous infusion
Aqueous epinephrine (1:1,000) by subcutaneous injection
Aqueous epinephrine (1:1,000) by intramuscular
injection
Explanation: The principal treatment of choice for
anaphylaxis is aqueous epinephrine, 1:1,000, 0.01 mL/kg
(maximum 0.3 mL for a child or 0.5 mL for an adult) by
intramuscular injection, which can achieve more rapid
effective concentrations than obtainable with subcutaneous
injection. Intravenous epinephrine may be added as a
continuous drip for persistent shock. Intramuscular or
intravenous H1 and H2 antagonist antihistamines, oxygen,
intravenous fluids, inhaled -agonists, and corticosteroids
may also be required.
Aqueous epinephrine (1:1,000) by intravenous infusion
Question . 49. A 16-yr-old with history of anaphylaxis to Hymenoptera suffers
a sting on an extremity. The first-aid kit that is available includes aqueous
epinephrine 1:1,000 and other necessary medical supplies. All of the following
measures for management of this sting are appropriate except:
Infiltration of one half of the epinephrine dose
subcutaneously around the site of the sting
Repeat doses of aqueous epinephrine at 15-min intervals if
necessary
Placement of a tourniquet above the site of the sting
Incision of and suction of venom from the site of the
sting
Explanation: With anaphylaxis due to injection of allergen
extract or to a Hymenoptera sting on an extremity, one half
of the dose of epinephrine may be diluted in 2 mL of normal
saline and infiltrated subcutaneously at the site of the sting
to slow absorption. Doses can be repeated at 15-min
intervals if necessary. A tourniquet above the site can also
slow systemic distribution. The tourniquet can be loosened
after improvement or briefly at intervals of 3 min. Immediate
transport to an appropriate medical facility should be
arranged

Transport to an emergency department


Question . 50. The most common single cause of anaphylaxis outside of the
hospital is:
Insect sting allergy
Drug allergy
Food allergy
Explanation: Food allergy is the most common cause of
anaphylaxis occurring outside of the hospital, accounting
for about one half of the anaphylactic reactions reported in
pediatric surveys. (See Chapter 137 in Nelson Textbook of
Pediatrics, 17th ed.)
Latex allergy
Food-associated exercise-induced anaphylaxis
Question . 51. A 12-yr-old child with a history of allergy to yellow jackets is
stung and immediately begins experiencing tightness in the chest and
wheezing. The drug of first choice for management of this child is:
Inhaled albuterol
Subcutaneous epinephrine
Intramuscular diphenhydramine
Intramuscular epinephrine
Explanation: The principal treatment of choice of
anaphylaxis is aqueous epinephrine, 1:1,000, 0.01 mL/kg
(maximum 0.3 mL for a child or 0.5 mL for an adult) by
intramuscular injection, which can achieve more rapid
effective concentrations than obtainable with subcutaneous
injection. (See Chapter 137 in Nelson Textbook of
Pediatrics, 17th ed.)
Oral corticosteroids

Question . 52. Which of the following would be the optimal long-term


management of the child described in Question 51?
Daily oral non-sedating antihistamine
Daily low-dose oral corticosteroid
Daily inhaled corticosteroid
Inhaled corticosteroid immediately upon insect sting
Immunotherapy
Explanation: Children experiencing systemic anaphylactic
reactions to an insect sting should be evaluated and treated
with immunotherapy, which is >90% protective. (See
Chapter 137 in Nelson Textbook of Pediatrics, 17th ed.)
Question . 53. A 2-yr-old child who has completed 8 days of a 10-day course
of cefaclor presents with low-grade fever, malaise, irritability,
lymphadenopathy, and a generalized erythematous rash that is mildly pruritic.
The most likely diagnosis is:
Partially treated meningitis
Infectious mononucleosis
Kawasaki disease
Type I hypersensitivity reaction
Type III hypersensitivity reaction
Explanation: Serum sickness is a classic example of a
type III hypersensitivity reaction, or immune complex
disease. The symptoms develop as antibodies appear
against the antigen at a time when the antigen is still
present. Immune complexes may stimulate complement
and deposit in joints, the skin, and the renal glomeruli. (See
Chapter 138 in Nelson Textbook of Pediatrics, 17th ed.)

Question . 54. A 14-yr-old child received equine-derived antivenom for a


snake bite 5 yr ago and now requires it again. Results of skin testing to the
product are negative. Which of the following statements is true?
Premedication with corticosteroids is warranted to prevent
serum sickness
Negative skin tests indicate that it is highly unlikely that he
will develop serum sickness
He should not receive this product more than once
Serum sickness may begin within a few days of
administration of the antivenom
Explanation: Because he received the preparation
previously, he may experience an accelerated form of
serum sickness starting before the usual time course of 712 days following injection. Premedication with
corticosteroids does not prevent serum sickness. Skin
testing helps to identify the potential for immediate-type
hypersensitivity (IgE antibody-mediated) to the serum
components but does not predict serum sickness (a type III,
immune complex-mediated hypersensitivity reaction). If
there is no alternative treatment, then there is no
contraindication to receive the product more than once.
(See Chapter 138 in Nelson Textbook of Pediatrics, 17th
ed.)
Question . 55. Risk factors for adverse drug reactions include:
Topical administration (compared with parenteral
administration)
Low dose (compared with high dose)
Frequent, intermittent dosing frequency (compared
with prolonged, continuous dosing)
Explanation: Risk factors for adverse drug reactions
include previous exposure, previous reaction, age (20-49
yr), route of administration (parenteral), dose (high), and
dosing schedule (intermittent), as well as genetic
predisposition (e.g., in slow acetylators). Frequent,
intermittent administration is more likely to elicit
sensitization than prolonged, continual administration. (See
Chapter 139 in Nelson Textbook of Pediatrics, 17th ed.)
No previous exposure (compared with previous
administration)
All of the above

Question . 56. Which of the following statements concerning adverse drug


reactions is true?
Adverse drug reactions are primarily IgE mediated
Drug-induced thrombocytopenia results from circulating
immune complexes
Both parental and topical exposures to a drug increase
the risk for an adverse reaction
Explanation: Parenteral administration poses greater risk
than topical administration, but both contribute to risk for an
adverse reaction. Adverse drug reactions are immune
complex reactions (Gell and Coombs type III)
Approximately 80% of patients with a history of penicillin
allergy will have evidence of penicillin-specific IgE
antibodies on testing
Epidermal detachment of >30% suggests Stevens-Johnson
syndrome
Question . 57. A 7-yr-old boy presents with fever and otalgia. On examination,
he has a bulging right tympanic membrane. As you hand his mother a
prescription for amoxicillin, she informs you that when the child was 4 yr old,
he broke out in an itchy rash during treatment with amoxicillin. The most
appropriate approach to management of this patient would be:
Reassure the mother that since more than 2 yr have
passed, it is highly unlikely that the child is still allergic and
he can now take the amoxicillin safely
Explain to the mother that most adverse drug reactions to
amoxicillin are not IgE mediated and that amoxicillin can be
safely given.
Prescribe a cephalosporin and explain to the mother that
there is no cross-reaction between penicillins and
cephalosporins
Prescribe a macrolide antibiotic and explain to the
mother that there is no cross-reaction between
penicillins and macrolides
Explanation: Risk factors for adverse drug reactions
include previous exposure and previous reaction. A
macrolide is recommended for otitis media in penicillinallergic patients
Give the child a prescription for amoxicillin, and instruct the
mother to pre-treat him with diphenhydramine (which is

available without a prescription)


Question . 58. The parents of a 6-yr-old girl relate a history of urticarial
reaction and vomiting following administration of amoxicillin in the past. Skin
testing to major and minor determinants of penicillin is positive. Which of the
following statements regarding administration of a cephalosporin constitutes
appropriate advice for the parents?
The child can receive a cephalosporin with no greater risk
of anaphylaxis than in the general population
There is a 2% risk of anaphylaxis to a cephalosporin
Explanation: Although the risk of allergic reactions to
cephalosporins in patients with positive skin tests to
penicillin appears to be low (less than 2%), anaphylactic
reactions after administration of a cephalosporin have
occurred in patients with a positive history of penicillin
anaphylaxis. If a patient has a history of penicillin allergy
and requires a cephalosporin, skin testing to major and
minor determinants of penicillin should preferably be done
to determine if the patient has penicillin-specific IgE
antibodies. If results of skin tests are negative, the patient
can receive a cephalosporin with no greater risk than in the
general population. If skin tests are positive to penicillin,
recommendations may include administration of an
alternative antibiotic, cautious graded challenge with
appropriate monitoring, in view of the 2% risk of an
anaphylactic reaction, and desensitization to the required
cephalosporin. (See Chapter 139 in Nelson Textbook of
Pediatrics, 17th ed.)
There is a 9% risk of anaphylaxis to a first-generation
cephalosporin but an almost 0% risk of anaphylaxis to a
fourth generation cephalosporin
There is a 9% risk of anaphylaxis to a cephalosporin
There is a 50% risk of anaphylaxis to a cephalosporin

Question . 59. A 14-yr-old girl, who has a long-standing seizure disorder for
which she takes phenytoin, develops fever and a urinary tract infection and is
prescribed trimethoprim-sulfamethoxazole. After 9 days of antibiotic treatment
she has recurrence of fever and develops confluent purpuric macules on her
face and trunk with erosive mucosal lesions of her mouth and conjunctivae. A
skin biopsy reveals 8% epidermal detachment. Which of the following best
describes this disorder?
Toxic shock syndrome
Anticonvulsant hypersensitivity syndrome
Allergy to sulfamethoxazole
Stevens-Johnson syndrome
Explanation: Stevens-Johnson syndrome is a blistering
mucocutaneous disorder induced by drugs, classically
sulfonamides. Epidermal detachment of less than 10%
suggests Stevens-Johnson syndrome. (See Chapter 139 in
Nelson Textbook of Pediatrics, 17th ed.)
Toxic epidermal necrolysis
Question . 60. All of the following may be manifestations of insect allergy
except:
Rhinitis and conjunctivitis
Asthma
Wheal and flare
Anaphylaxis
Uveitis
Explanation: Clinical findings in allergy caused by insects
are similar to those occurring with usual inhalant allergens
(e.g., rhinitis, conjunctivitis, asthma). Biting insects may
cause local reactions that do not involve IgE. Venom from
stinging insects causes IgE-mediated sensitivity that may
lead to urticaria and anaphylaxis. (See Chapter 140 in
Nelson Textbook of Pediatrics, 17th ed.)

Question . 61. All of the following statements concerning allergic reactions to


stinging insects are true except:
The majority are due to Hymenoptera
There is substantial cross-reactivity among vespid venoms
Systemic reactions can occur after the first sting
Most reactions are IgE mediated
Negative results on skin testing and RAST reliably
exclude the likelihood of anaphylaxis
Explanation: There are patients with convincing histories
of sting anaphylaxis with negative skin test results and
RAST results. (See Chapter 140 in Nelson Textbook of
Pediatrics, 17th ed.)
Question . 62. Immunotherapy provides symptomatic improvement in all of the
following except:
Ragweed allergy
Local reaction to bee sting
Explanation: Local reactions to Hymenoptera venom in
children are not managed by immunotherapy. (See Chapter
140 in Nelson Textbook of Pediatrics, 17th ed.)
Tree pollen allergy
House dust mite allergy
Anaphylaxis to a wasp sting

Question . 63. An 8-yr-old boy experienced immediate urticaria surrounding a


large local reaction to a honeybee sting 2 mo ago. He had no other symptoms.
Skin testing with honeybee venom has been strongly positive at a weak
concentration. Appropriate recommendations include all of the following
except:
Hymenoptera venom immunotherapy
Explanation: Immunotherapy is indicated only for systemic
reactions. Individuals with local reactions are not at
increased risk for severe systemic reactions on a
subsequent sting and are not candidates for Hymenoptera
venom immunotherapy. (See Chapter 140 in Nelson
Textbook of Pediatrics, 17th ed.)
An epinephrine auto-injector (EpiPen) for administration
after a subsequent sting
Wearing shoes when outdoors
A Medic-Alert bracelet
Wearing long pants
Question . 64. A 10-yr-old girl was stung on her left cheek by a yellow jacket.
She is experiencing pain. By 4 hr following the sting the left side of her face is
so swollen that her left eye is virtually closed. There are no other complaints.
The best course of action would be:
Apply cold compresses, and consider antihistamines
and pain medication
Explanation: The child has experienced a large local
reaction to the sting. Supportive care directed at the
reaction is appropriate. Individuals who have experienced
only large local reactions, or children younger than 17 yr
who have experienced systemic reactions confined to the
skin (generalized urticaria), are not at significantly
increased risk for a severe systemic reaction upon
subsequent stings, so testing for allergy and providing
emergency medications are not warranted. (See Chapter
140 in Nelson Textbook of Pediatrics, 17th ed.)
Perform or refer her for skin testing to Hymenoptera venom
Prescribe self-injectable epinephrine and provide
instructions to school/camp
All of the above

Question . 65. A 7-yr-old boy was stung by an unidentified insect and within
minutes developed generalized urticaria, a repetitive cough, difficulty
breathing, and extreme dizziness. He was treated in the emergency
department with antihistamines, epinephrine, and corticosteroids. Which of the
following statements is accurate?
If skin tests to Hymenoptera venom are performed 1 wk
later and results are negative, he is not a candidate for
venom immunotherapy
Testing and venom immunotherapy cannot be undertaken
until the insect is identified
Venom immunotherapy could reduce the risk for a
severe anaphylaxis on a subsequent sting from more
than 50% to less than 3%
Explanation: Venom immunotherapy is highly effective in
reducing the risk of anaphylaxis. While venom
immunotherapy carries some risks for local and systemic
adverse effects, the benefits outweigh the risks for those at
high risk for anaphylaxis from a subsequent sting. Those at
high risk include any individual with positive results on skin
tests/RAST who experienced a systemic reaction to a sting
with symptoms beyond generalized skin rashes (e.g.,
respiratory, cardiovascular reactions) or those 17 yr of age
and older with systemic reactions confined to the skin
(generalized urticaria). Test results may be negative during
a refractory period in the weeks following the reaction, so
they should be repeated, along with RAST, after 4-6 wk if
they are negative initially. It is not necessary to know
exactly which insect caused the sting before proceeding
with testing and treatment. Although venom immunotherapy
may not be indicated for patients without identifiable IgE to
the venom, in cases of anaphylaxis proximate to a sting,
patients should be equipped with self-administered
epinephrine because the risk for a subsequent anaphylactic
reaction is increased. (See Chapter 140 in Nelson
Textbook of Pediatrics, 17th ed.)
If results of venom skin tests are negative, he does not
need to have self-administered epinephrine readily
available

Question . 66. A 15-yr-old with a history of seasonal hay fever now also has
itchy eyes, profuse tearing, and reddened and edematous conjunctivae. A
treatment option effective for the ocular symptoms would be:
Topical antihistamines
Topical decongestants
Topical mast cell stabilizers
Topical nonsteroidal anti-inflammatory drugs
All of the above?each is an effective secondary
treatment regimen for ocular allergies
Explanation: Allergic conjunctivitis in the patient with hay
fever generally responds well to treatment regimens
including topical application of antihistamines, topical
decongestants, topical mast cell stabilizers, and topical
nonsteroidal anti-inflammatory drugs. Children often
complain of stinging or burning with use of topical
ophthalmic preparations and usually prefer oral
antihistamines for allergic conjunctivitis. (See Chapter 141
in Nelson Textbook of Pediatrics, 17th ed.)
Question . 67. The patient described in Question 66 continues to have
symptoms. The most appropriate next step in management would be:
Combination therapy such as with an antihistamine and a
vasoconstrictive agent
Immunotherapy
Topical corticosteroids
Oral corticosteroids
All of the above?each is an effective tertiary treatment
regimen for ocular allergies
Explanation: Tertiary treatment of ocular allergy includes
topical, or rarely oral, corticosteroids. Local administration
of topical corticosteroids may be associated with increased
intraocular pressure, viral infections, and cataract
formation. Allergen immunotherapy can be very effective in
seasonal and perennial allergic conjunctivitis, especially
when associated with rhinitis. It can decrease the need for
oral or topical medications to control allergy symptoms.
(See Chapter 141 in Nelson Textbook of Pediatrics, 17th
ed.)

Question . 68. All of the following statements concerning allergic reactions to


foods are true except:
Skin tests are of little diagnostic value for cell-mediated
gastrointestinal hypersensitivity
Cow's milk sensitivity is the most common cause of proteininduced enteropathy
Gastrointestinal anaphylaxis is mediated by IgA
Explanation: Gastrointestinal anaphylaxis generally
presents as acute abdominal pain and vomiting that
accompanies other IgE-mediated allergic symptoms. (See
Chapter 142 in Nelson Textbook of Pediatrics, 17th ed.)
The majority of children with positive results on prick skin
tests to a food will not react when the food is ingested
Elimination diets are the only means to establish the
diagnosis of food allergies
Question . 69. Which of the following is an uncommon clinical manifestation of
food allergies?
Acute urticaria
Angioedema
Wheezing
Diarrhea
Chronic fatigue
Explanation: Chronic fatigue is not recognized to be
caused by food allergies. Acute urticaria and angioedema
(but not chronic urticaria and angioedema), acute
rhinoconjunctivitis, bronchospasm (wheezing), vomiting,
and protracted diarrhea are all manifestations of food
allergies. (See Box 142-1 and Chapter 142 in Nelson
Textbook of Pediatrics, 17th ed.)

Question . 70. All of the following foods are characteristically associated with
allergy except:
Peanuts
Tree nuts
Legumes
Explanation: Peanuts, tree nuts, eggs, and seafood all are
characteristically associated with food allergies. (See
Chapter 142 in Nelson Textbook of Pediatrics, 17th ed.)
Eggs
Seafood
Question . 71. Because of a strong family history on both sides, the parents of
a newborn baby ask for guidance about preventing their child from developing
an allergy to peanuts. Which of the following approaches is recommended?
Begin and extend breast-feeding until age 2 yr, with
exclusion of peanuts from the mother's diet while breastfeeding
Begin and extend breast-feeding until age 2 yr, with the
mother ingesting gradually increasing amounts of creamy
peanut butter from 18-24 mo of age
Begin and continue breast-feeding as routinely
recommended, with the mother regularly ingesting small
amounts of peanuts but not introducing peanuts in the
child's diet until age 1 yr
Begin and continue breast-feeding as routinely
recommended, excluding peanuts from the mother's
diet while breast-feeding and from the child's diet until
age 3 yr
Explanation: There is no consensus on whether food
allergies can be prevented. However, several authorities
recommend delaying introduction of major food allergens to
infants from atopic families. Recommendations include
promotion of breast-feeding with maternal exclusion of
peanut and nut products from the mother's diet and delay in
introducing major allergenic foods: cow's milk until 1 yr of
age; egg until 18-24 mo of age, and peanuts, tree nuts, and
seafood until 3 yr of age. (See Chapter 142 in Nelson
Textbook of Pediatrics, 17th ed.)
Use only creamy peanut butter and not chunky peanut
butter or whole peanuts in the child's diet (after 1 yr of age)

Question . 72. A 6-mo-old infant develops protracted projectile vomiting, and


lethargy about 2 hr after ingesting a milk formula. The most likely diagnosis is:
Generalized anaphylaxis
Milk-induced enterocolitis syndrome
Explanation: Food protein-induced enterocolitis syndrome
typically manifests in the first several months of life with
irritability, protracted vomiting and diarrhea, not infrequently
resulting in dehydration. Vomiting generally occurs 1-3 hr
following feeding, and continued exposure may result in
bloody diarrhea, anemia, abdominal distention, and failure
to thrive. Symptoms are most commonly provoked by cow's
milk- or soy protein-based formulas but occasionally result
from food proteins passed in maternal breast milk. (See
Chapter 142 in Nelson Textbook of Pediatrics, 17th ed.)
Gastrointestinal anaphylaxis
Allergic eosinophilic esophagitis
Allergic eosinophilic gastroenteritis

Question . 73. Which of the following is the most definitive test for diagnosing
a food protein-induced enterocolitis?
Positive clinical history
Positive food challenge
Explanation: Unfortunately there are no laboratory studies
that help identify foods responsible for cell-mediated
reactions. Consequently, elimination diets followed by food
challenges are the only way to establish the diagnosis.
(See Chapter 142 in Nelson Textbook of Pediatrics, 17th
ed.)
Positive result on skin prick test
Positive RAST result
Quantitative IgE level