Reviewer ’s report  
 
Title: Food IgG4 antibodies are elevated not only in children with wheat allergy but also in  
children with gastrointestinal diseases  
 
Version: 1 Date: 22 Dec 2015  
 
Reviewer: Carlo caffarelli  
 
Reviewer's report:  
 
The authors have addressed many points raised from the first review. In some cases they have 
been able to do this adequately. Some issues remain as discussed below. Authors should take 
into account that refere nces have been suggested for the author's consideration and they were not 
mandatory. They have been provided only with the aim of helping the discussion on some topics.  
 
- It is of interest for the readers to know that 50 children with wheat allergy are t he same 
presented in a previous published paper (ref # 8). Please clearly state this (line 73).  
 
- I believe that a more detailed description of food challenge is necessary, even if the paper 
does not examine food challenge procedure. There is a need of in formation on food 
challenge procedure to enhance robustness of the study.  Authors should take into 
account that International guideline (PRACTALL consensus report J ALLERGY CLIN 
IMMUNOL 2012, 130, 1260 -74) underlines that blood pressure must be measured a nd its 
drop is important for scoring the food challenge outcome. The suggested paper (Ann 
Allergy Asthma Immunol 2012; 108: 285 -6) describes blood pressure during food 
challenge tests. In ref # 8, nothing is said about monitoring blood pressure during food  
challenge. The same guideline reports criteria for considering challenge results as 
positive. Did Authors follow the same criteria or different ones? These points should be 
clarified to be sure that study results are reliable. Another question arises abou t symptoms 
developed during diagnostic wheat challenge. In Ref # 8 it has been reported that children 
with positive challenge to wheat had onset of eczema and loose stools within 2 hours. It 
is known that these are delayed reactions (PRACTALL consensus rep ort J ALLERGY 
CLIN IMMUNOL 2012, 130, 1260 -74). I would ask Authors to clarify this issue.  
 
- It seems that Authors have misunderstood a previous question. Please provide in the 
results, data on sensitivity, specifity of IgG4 and IgG antibodies.  
- In Tabl e 1, no healthy child had positive IgG4 to wheat or to rice. An explanation for 
such findings should be provided.  
 
- Figures 1 -4 remain difficult to follow. Median values have not been shown. I believe that 
Authors should consider to report data in Tables and to delete Figures.  
 
- Speculation on intestinal permeability. Authors should take into account that the recent 
publication (ref # 20) on enhanced intestinal permeability caused by food allergens is not 
an original study but a review of studies performed in vitro or in animals. The paper by 
Majamaa (ref # 21) on increased intestinal permeability in children with atop ic dermatitis 
is an in vitro study too. I therefore, believe that it would be essential to consider also 
clinical studies as the suggested paper (Clin. Exp. Allergy 1993;23(1):28 -31) or other 
similar studies in children with eczema.  
 
- Speculation on patch  test results. Obviously, I agree that patch test is not recommended 
for diagnosing of IgE -mediated allergic reactions as confirmed by the suggested paper 
(Pediatr Allergy Immunol 2015,26;416 -422).  Of course, there is also evidence at this 
time that IgG d etection is not recommended. Therefore, it has been proposed to the 
Authors to consider that their findings on IgG are in agreement with studies on patch test 
in showing that a non IgE -mediated mechanism does not contribute to onset of immediate 
food hyper sensitivity reactions in humans.  
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required  in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional  statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of la nguage in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this  manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied f or patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  
If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the a uthors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer  review policy of the journal  
 
 
Reviewer ’s report  
 
Title: Food IgG4 antibodies are elevated not only in children with wheat allergy but also in  
children with gastrointestinal diseases  
 
Version: 1 Date: 22 Dec 2015  
 
Reviewer: Carlo caffarelli  
 
Reviewer's report:  
 
The authors have addressed many points raised from the first review. In some cases they have 
been able to do this adequately. Some issues remain as discussed below. Authors should take 
into account that refere nces have been suggested for the author's consideration and they were not 
mandatory. They have been provided only with the aim of helping the discussion on some topics.  
 
- It is of interest for the readers to know that 50 children with wheat allergy are t he same 
presented in a previous published paper (ref # 8). Please clearly state this (line 73).  
 
- I believe that a more detailed description of food challenge is necessary, even if the paper 
does not examine food challenge procedure. There is a need of in formation on food 
challenge procedure to enhance robustness of the study.  Authors should take into 
account that International guideline (PRACTALL consensus report J ALLERGY CLIN 
IMMUNOL 2012, 130, 1260 -74) underlines that blood pressure must be measured a nd its 
drop is important for scoring the food challenge outcome. The suggested paper (Ann 
Allergy Asthma Immunol 2012; 108: 285 -6) describes blood pressure during food 
challenge tests. In ref # 8, nothing is said about monitoring blood pressure during food  
challenge. The same guideline reports criteria for considering challenge results as 
positive. Did Authors follow the same criteria or different ones? These points should be 
clarified to be sure that study results are reliable. Another question arises abou t symptoms 
developed during diagnostic wheat challenge. In Ref # 8 it has been reported that children 
with positive challenge to wheat had onset of eczema and loose stools within 2 hours. It 
is known that these are delayed reactions (PRACTALL consensus rep ort J ALLERGY 
CLIN IMMUNOL 2012, 130, 1260 -74). I would ask Authors to clarify this issue.  
 
- It seems that Authors have misunderstood a previous question. Please provide in the 
results, data on sensitivity, specifity of IgG4 and IgG antibodies.  
- In Tabl e 1, no healthy child had positive IgG4 to wheat or to rice. An explanation for 
such findings should be provided.  
 
- Figures 1 -4 remain difficult to follow. Median values have not been shown. I believe that 
Authors should consider to report data in Tables and to delete Figures.  
 
- Speculation on intestinal permeability. Authors should take into account that the recent 
publication (ref # 20) on enhanced intestinal permeability caused by food allergens is not 
an original study but a review of studies performed in vitro or in animals. The paper by 
Majamaa (ref # 21) on increased intestinal permeability in children with atop ic dermatitis 
is an in vitro study too. I therefore, believe that it would be essential to consider also 
clinical studies as the suggested paper (Clin. Exp. Allergy 1993;23(1):28 -31) or other 
similar studies in children with eczema.  
 
- Speculation on patch  test results. Obviously, I agree that patch test is not recommended 
for diagnosing of IgE -mediated allergic reactions as confirmed by the suggested paper 
(Pediatr Allergy Immunol 2015,26;416 -422).  Of course, there is also evidence at this 
time that IgG d etection is not recommended. Therefore, it has been proposed to the 
Authors to consider that their findings on IgG are in agreement with studies on patch test 
in showing that a non IgE -mediated mechanism does not contribute to onset of immediate 
food hyper sensitivity reactions in humans.  
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required  in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional  statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of la nguage in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this  manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied f or patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  
If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the a uthors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer  review policy of the journal  
 
 
Please review this paper.
user
Reviewer ’s report  
 
Title: Food IgG4 antibodies are elevated not only in children with wheat allergy but also in  
children with gastrointestinal diseases  
 
Version: 1 Date: 22 Dec 2015  
 
Reviewer: Carlo caffarelli  
 
Reviewer's report:  
 
The authors have addressed many points raised from the first review. In some cases they have 
been able to do this adequately. Some issues remain as discussed below. Authors should take 
into account that refere nces have been suggested for the author's consideration and they were not 
mandatory. They have been provided only with the aim of helping the discussion on some topics.  
 
- It is of interest for the readers to know that 50 children with wheat allergy are t he same 
presented in a previous published paper (ref # 8). Please clearly state this (line 73).  
 
- I believe that a more detailed description of food challenge is necessary, even if the paper 
does not examine food challenge procedure. There is a need of in formation on food 
challenge procedure to enhance robustness of the study.  Authors should take into 
account that International guideline (PRACTALL consensus report J ALLERGY CLIN 
IMMUNOL 2012, 130, 1260 -74) underlines that blood pressure must be measured a nd its 
drop is important for scoring the food challenge outcome. The suggested paper (Ann 
Allergy Asthma Immunol 2012; 108: 285 -6) describes blood pressure during food 
challenge tests. In ref # 8, nothing is said about monitoring blood pressure during food  
challenge. The same guideline reports criteria for considering challenge results as 
positive. Did Authors follow the same criteria or different ones? These points should be 
clarified to be sure that study results are reliable. Another question arises abou t symptoms 
developed during diagnostic wheat challenge. In Ref # 8 it has been reported that children 
with positive challenge to wheat had onset of eczema and loose stools within 2 hours. It 
is known that these are delayed reactions (PRACTALL consensus rep ort J ALLERGY 
CLIN IMMUNOL 2012, 130, 1260 -74). I would ask Authors to clarify this issue.  
 
- It seems that Authors have misunderstood a previous question. Please provide in the 
results, data on sensitivity, specifity of IgG4 and IgG antibodies.  
- In Tabl e 1, no healthy child had positive IgG4 to wheat or to rice. An explanation for 
such findings should be provided.  
 
- Figures 1 -4 remain difficult to follow. Median values have not been shown. I believe that 
Authors should consider to report data in Tables and to delete Figures.  
 
- Speculation on intestinal permeability. Authors should take into account that the recent 
publication (ref # 20) on enhanced intestinal permeability caused by food allergens is not 
an original study but a review of studies performed in vitro or in animals. The paper by 
Majamaa (ref # 21) on increased intestinal permeability in children with atop ic dermatitis 
is an in vitro study too. I therefore, believe that it would be essential to consider also 
clinical studies as the suggested paper (Clin. Exp. Allergy 1993;23(1):28 -31) or other 
similar studies in children with eczema.  
 
- Speculation on patch  test results. Obviously, I agree that patch test is not recommended 
for diagnosing of IgE -mediated allergic reactions as confirmed by the suggested paper 
(Pediatr Allergy Immunol 2015,26;416 -422).  Of course, there is also evidence at this 
time that IgG d etection is not recommended. Therefore, it has been proposed to the 
Authors to consider that their findings on IgG are in agreement with studies on patch test 
in showing that a non IgE -mediated mechanism does not contribute to onset of immediate 
food hyper sensitivity reactions in humans.  
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required  in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional  statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of la nguage in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this  manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied f or patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  
If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the a uthors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer  review policy of the journal  
 
 
assistant