Three Characterisctics of Atopy to Diagnose Allergy in Children with Respiratory Symptomps

Kata Kunci: Alergi, atopi, gejala saluran pernapasan skin prick test, Prevalensi penyakit alergi semakin meningkat dalam dekade terakhir sehingga diperlukan suatu metode yang cepat, tepat dan dapat dipercaya dalam prediktor alergi seorang anak. Akan tetapi, dalam praktek sering penegakan diagnosis alergi tidak tepat sasaran karena pemeriksaan tes alergi hanya didasarkan pada riwayat alergi keluarga. risiko Tujuan dari penelitian ini untuk mengevaluasi kronisitas dan keberulangan gejala dengan paparan yang sama dan riwayat alergi keluarga dapat digunakan sebagai prediktor alergi pada anak yang mengalami gejala saluran pernapasan. Penelitian Cross sectional dengan sampel pasien anak alergi yang mengalami gejala saluran pernapasan yang dikonsultasikan ke Poli Alergi Anak RSUD Dr. Soetomo Surabaya periode 1 Januari – 31 Juli 2019. Data diambil dari dokumen medis RSUD r. Soetomo yang sudah distandarisasi. kesesuaian 3 atopi dengan skin prick test (SPT) menggunakan uji Mc Nemar dan Kappa. Dihitung sensitivitas dan spesifisitas 3 atopi terhadap SPT positif. Jumlah sampel 115 anak, 109 anak memenuhi kriteria inklusi. Jenis kelamin laki-laki 60% dan perempuan 40%, distribusi usia <1 tahun 3,6%, usia 1-<3 tahun 25,8%, usia 3-<5 tahun 22,9%, usia 5-<10 tahun 39,4% dan >10 tahun 8,3%. Terdapat 54 pasien (49,5%) yang memenuhi 3 atopi dan 64 pasien (58,7%) dengan hasil SPT positif. Sensitivitas, spesifisitas, nilai prediksi positif dan nilai prediksi negatif berturut-turut adalah sebesar 81,3%, 95,6%, 96,3% dan 78,2%. Tiga karakteristik atopi memenuhi sensitivitas dan spesifisitas yang baik untuk memprediksi alergi seorang anak. risiko suspek D Penelitian ini menganalisis karakteristik karakteristik

The patient's age, sex were also collected from medical records. Skin prick test results were performed with sterile lancets and commercial allergens extract in the volar area the forearm, on columns which had been drawn. Nine allergens were tested including HDM, cat, fruit, seafood, saltwater fish, cow's milk, chocolate, chicken, and egg. Control specimen used was normal saline (negative) and histamine (positive). Reactions were observed after 20 minutes. The whealand-flare reactions were measured with a ruler in millimeters (1mm=0.001m). The vertical and horizontal diameters of the wheal-and-flare were added and divided by 2, resulting in mean diameter, which was recorded. Skin prick test results were considered to be positive if the diameter was >3 mm than the negative control. he diagnose and Immunology .
, and allergy symptoms , T of allergy was established by Pediatric Allergy consultant A and varies based on the population study Previous study regarding the predictors of uncontrolled respiratory symptoms in children, one of which was caused by any atopic comorbidities . Moreover, according to Pacific Partnership 2015, the top two pediatric diagnosis belongs to 25% of respiratory disorders . A study in German included MAS birth cohort declare family history with allergies is not only a strong predictor to develop allergy, but also increases the risk of developing allergy multimorbidity .
llergic diseases prevalence has increased in the last decade (1,2). (1) (3) A fast, precise and reliable diagnostic method to confirm the diagnosis must be performed. However, in daily practice, there are a lot of misdiagnos case occurs, because it is only based on a family history of allerg . This could be prevented if there is a high quality, high sensitivity and specificity, and simple methods that can be used by physicians to confirm skin tests quickly and accurately There are 3 about someone tendency to have allergy, i.e. chronicity of symptoms, recurrence of symptoms with exposure and family history of aller (4)  . There were 109 patients with y throughout the period. The inclusion criteria were patients aged 0-18 years old, had respiratory symptoms, and underwent a Skin Prick Test (SPT) in and Immunology Outpatient Clinic during the period. Data were collected by consecutive sampling. We used three questionnaires, to predict allergy in children with respiratory symptoms (sneezing, runny nose, cough, wheezing and shortness of breath). Those three questionnaires were used to measure the chronicity of respiratory symptoms occurring more than 2 weeks, recurrence of respiratory symptoms with similar exposure (host dust mite, pet dander or food allergen)) and family history (father, mother and/or siblings) of allergy. These questionnaires have been validated and used by Dr. Soetomo General Hospital in Surabaya, Indonesia (Supplemental files) Pediatric Allergy (5).

Data Analysis
The distribution pattern was shown in a descriptive

RESULTS
A total of 109 children were enrolled in this study. The characteristics of respondents are presented in Table 1. They were consisted of 65 (60%) males and 44 (40%) females. The majority of respondents were aged 5 to 10 years (43 subjects, 39.4%). However, parents tend to incorrectly deduce the probable causing allergy manifestation with food allergy. There are several components to make a specific allergy diagnosis. First, a subject must be had a corresponding symptom to an allergic disease. Second, physician must be had enough knowledge about allergic disorders and specific allergy tests. Third, a quality allergy testing instruments, and finally, a physician must be capable for interpreting the test results in patient with minimal symptoms (8).
*a p value < 0.05 was statistically significant

characteristics of atopy
According to a multicenter study in China, the prevalence of childhood allergic disease was common in male than female, with ratio 1.1-1.5:1 The result of our study was accordance with the theory above that the largest group of age founded between 5 to 10 years old and male and male was more common than female (1.48:1). Similar to previous report recorded by in , boys also tend to have asthma or another atopic disease more than girls, with ratio 1.8:1. The 13 re were subjects with chronicity of respiratory symptoms with negative SPT results. Negative SPT results might be happen due to chronicity of respiratory symptoms not only due to allergies but also other causes such as tuberculosis infection, rhinosinusitis infection, laryngotrakeobroncomalasia, pertussis, atypical pneumonia and GERD (9) the chronicity . In our study, symptoms obtained high sensitivity and low specificity. So if there is no chronicity of , it means that the SPT is likely to get negative results. However, if there is a chronicity , the SPT will not necessarily get a positive result. Statistically, symptoms symptoms the McNemar test showed different results between chronicity symptoms and SPT results, but the Kappa coefficient revealed a strong degree of agreement and statistical significance. This means that chronicity alone is not strong enough to diagnose allergy that needs to be strengthened by other facts that support an allergy and must be continued with symptoms with exposure ecurrence of symptoms with exposure strong degree of agreement (0.743) and statistically significance (p=0.001). , and y can be used as strong of allergy in children to improve the quality of early detection of allergy. Further studies with prospective methods and a larger number of subjects are needed to analyzed the chronicity and recurrence of symptoms with exposure and family history of allergy as a predictor of allergy in children with respiratory symptoms.
similar Researches in several countries shows house-dust mites (HDM) are the most common cause of sensitization and bronchial asthma . Atopy is the major predisposing factor for asthma identified up to now, and allergen exposure, particularly indoor allergens, is considered as a causal factor for asthma. Food allergy is frequently underestimated in association with asthma however food allergy has been shown to trigger or exacerbate bronchoobstruction in 2 to 8.5% of children with asthma. There is also evidence that double-blind placebo-controlled oral challenge is able to increase unspecific bronchial hyper responsiveness. Sensitization to food can occur early in life involving T cell response, mainly of the Th2 phenotype, but also IgE-mediated hypersensitivity (10-13) (14,15).

ACKNOWLEDGEMENT
We would like to thank the staffs of the Department of Pediatrics in Dr. Soetomo General Hospital/ Faculty of Medicine, Universitas Airlangga, Surabaya for their assistance in data collection. We also appreciate the help of Kinanti Ayu Ratnasari for editing this manuscript.
The authors declare no conflict of interest.
There were only 2 children who showed three atopy characteristics with a negative SPT result. This result might be caused by a non-IgE mediated reaction, so it doesn't trigger wheal on the SPT. A Study of Zuidmeer showed certain fruits such as strawberries, oranges, and tomatoes that thought to directly stimulate mast cells to release histamine. Clinical symptoms of allergies with non-IgE mediated usually appear on mucocutaneous and gastrointestinal The study also noted that there were 12 children whose SPT results were positive but did not meet 3 characteristics of atopy. Sensitization of the skin to allergens such as seafood allergens can be caused by crossreactivity. However, skin sensitization to food allergens is not always the same as cross-reactivity. One allergen in seafood, tropomyosin, is also found in house dust (HDM) which is responsible for high sensitization . (19). (20)

CONFLICT OF INTEREST
The 15 ecurrence of symptoms with re were subjects with r similar e exposur but negative SPT results. Negative SPT results may be caused by complaints of recurrent respiratory symptoms with similar exposure not only because of allergies but also other causes such as recurrent In our study, the r similar e respiratory infections (16). ecurrence of symptoms with exposur obtained high sensitivity and low specificity. So if there are no r similar e ecurrence of symptoms with exposur , it means that the SPT is most likely to get a negative result. However, if there are ecurrence of symptoms with exposur , the SPT will not necessarily get positive results. Another study that assessed the recurrence of clinical symptoms of allergic rhinitis in predicting positive SPT allergic showed quite high sensitivity (86%) but low specificity (20%) (17) . In this study, the y y y by the McNemar test revealed different family history of allergy and SPT results, but Kappa coefficient revealed a very low degree of agreement and no statistical significance. This means that a family history of allerg alone needs to be strengthened by other facts that support an allergy and must be continued with the SPT as a gold standard for allergy diagnostics.
y In this study, the 3 facts about detecting the characteristic of atopy when examined separately do not provide maximum results as illustrated in table 2-4 so that simple quality methods (sensitive and specific) are needed so that practicing physicians can confirm skin tests quickly and accurately. In this study, three characteristics of atopy showed high sensitivity and high specificity. Therefore, if there are no three characteristics of atopy, the SPT is most likely to get a negative result and vice versa. Statistically, this study showed a different result between the three characteristics of atopy with SPT results, but on the other hand, Kappa coefficient revealed strong degree of agreement and statistical significance. This means that the 3 characteristics of atopy are a simple quality detection method (sensitive and specific) and must be followed by the SPT as a gold standard for allergy diagnostics.
SPT as a gold standard for allergy diagnostics.
This study has a high positive and negative predictive value of 96.3% and 78.18%. Similarly, a previous study found combination of several variables including clinical symptoms, triggering season, family history of allergy and treatment history in predicting positive skin test results showing a high PPV and NPV (84% and 74%) . The clinical benefit of using 3 characteristics of atopy which were reducing referral error for SPT, early identification, and management may provide opportunities to prevent the development of clinical symptom. Hence, a better allergy prevention programs will be reach since the natural course of allergic diseases can be suppressed. Finding of this study need to be carefully interpreted due to (4,21) some limitation in this study as a result of retrospective in design and was recall bias because data of 3 characteristics of atopy were obtained from the history taking.
in this study