Conventional and Molecular Approaches to Pediatric Wheat Allergy: Insights from an East Mediterranean Cohort

Introduction: Wheat allergy (WA) diagnosis in children is complex due to the low specificity of conventional tests. This study evaluates clinical characteristics and the diagnostic utility of skin prick tests (SPT), specific IgE (sIgE), and molecular allergology, including Tri a 19, Tri a 14 and Alpha-Amylase Inhibitors (AAI), in a pediatric cohort from the East Mediterranean. Methods: Sixty-three children (median age 30 months) evaluated for IgE-mediated WA were retrospectively analyzed. Patients were classified as wheat-allergic (n=30) or wheat-sensitized (n=33) based on oral food challenges (OFC) or recent systemic reactions. Sensitization was assessed via SPT, ImmunoCAP, and the ALEX2 multiplex platform. Results: Most participants (93.7%) were multi-allergic, with high sensitization rates to rye (89.6%) and barley (77.1%). Wheat-allergic patients had significantly higher rates of anaphylaxis (83.3% vs 9%, p<0.001). Optimal cutoffs were 6.73 kU/L for wheat sIgE (AUC 0.828, sensitivity 93.3%) and 5 mm for SPT (AUC 0.898, sensitivity 90.0%). In multiplex analysis, Tri a 19 (>0.61 kUA/L) and AAI (>2.92 kUA/L) were significant predictors of reactivity. Tri a 14 sensitization was observed in four intolerant patients, two of whom experienced anaphylaxis. While Tri a 14 showed 100% specificity at a 12.96 kUA/L cutoff, AAI achieved an AUC of 0.801, providing critical utility for Tri a 19-negative patients. All patients challenged with gluten-free oats demonstrated tolerance. Conclusions: Pediatric WA in this region involves a high atopic burden and frequent multi-allergy. Systemic reactivity, including to Tri a 14, occurs despite relatively low sIgE levels. Incorporating molecular components like Tri a 19/14, and AAI into diagnostic algorithms improves risk stratification.