Oral food challenges for diagnosis and management of food allergies

INTRODUCTION

The diagnosis of a food allergy requires consideration of the details of an individual's history, knowledge about the epidemiology of different food allergies, and specific test results. When these elements do not clearly confirm or refute an allergy, the clinician, typically an allergy specialist or sometimes a gastroenterologist, may perform a clinician-supervised oral food challenge (OFC) [1-6]. OFCs may also be used to determine if a food allergy has resolved. In addition, they can be undertaken to define other adverse reactions to foods, such as intolerance.

OFCs generally consist of a gradual feeding of the test food under close observation. The test usually results in a definitive conclusion about whether the food was tolerated.

An OFC is preceded by a period of dietary elimination, performed either therapeutically (because the food was already suspected or known to have caused a reaction) or for diagnostic reasons (to determine if elimination of the suspect food resulted in amelioration of symptoms).

This topic review will present the role of diagnostic elimination diets, the selection of patients for OFCs, different types of OFCs, and a general approach to performing an OFC. Other related food allergy topics are covered separately. (See "Diagnostic evaluation of food allergy" and "Management of food allergy: Avoidance" and "History and physical examination in the patient with possible food allergy" and "The natural history of childhood food allergy".)

ELIMINATION DIETS

Elimination diets are performed prior to an oral food challenge. Elimination diets are used diagnostically to determine if symptoms, usually chronic in nature, resolve after the suspected food(s) is removed from the diet. Elimination diets are discussed in greater detail in another review, and avoidance of a food allergen once the allergy is diagnosed is presented separately. (See "Diagnostic evaluation of food allergy" and "Management of food allergy: Avoidance".)

                          

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Jan 11, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual. J Allergy Clin Immunol 1988; 82:986.
  2. American College of Allergy, Asthma, & Immunology. Food allergy: a practice parameter. Ann Allergy Asthma Immunol 2006; 96:S1.
  3. Nowak-Wegrzyn A, Assa'ad AH, Bahna SL, et al. Work Group report: oral food challenge testing. J Allergy Clin Immunol 2009; 123:S365.
  4. NIAID-Sponsored Expert Panel, Boyce JA, Assa'ad A, et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126:S1.
  5. Fiocchi A, Schünemann HJ, Brozek J, et al. Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report. J Allergy Clin Immunol 2010; 126:1119.
  6. Rancé F, Deschildre A, Villard-Truc F, et al. Oral food challenge in children: an expert review. Eur Ann Allergy Clin Immunol 2009; 41:35.
  7. Eigenmann PA, Sicherer SH, Borkowski TA, et al. Prevalence of IgE-mediated food allergy among children with atopic dermatitis. Pediatrics 1998; 101:E8.
  8. Sicherer SH, Sampson HA. Food hypersensitivity and atopic dermatitis: pathophysiology, epidemiology, diagnosis, and management. J Allergy Clin Immunol 1999; 104:S114.
  9. Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol 2005; 3:1198.
  10. Fleischer DM, Bock SA, Spears GC, et al. Oral food challenges in children with a diagnosis of food allergy. J Pediatr 2011; 158:578.
  11. Wainstein BK, Studdert J, Ziegler M, Ziegler JB. Prediction of anaphylaxis during peanut food challenge: usefulness of the peanut skin prick test (SPT) and specific IgE level. Pediatr Allergy Immunol 2010; 21:603.
  12. Perry TT, Matsui EC, Kay Conover-Walker M, Wood RA. The relationship of allergen-specific IgE levels and oral food challenge outcome. J Allergy Clin Immunol 2004; 114:144.
  13. Sicherer SH, Morrow EH, Sampson HA. Dose-response in double-blind, placebo-controlled oral food challenges in children with atopic dermatitis. J Allergy Clin Immunol 2000; 105:582.
  14. Shreffler WG, Beyer K, Chu TH, et al. Microarray immunoassay: association of clinical history, in vitro IgE function, and heterogeneity of allergenic peanut epitopes. J Allergy Clin Immunol 2004; 113:776.
  15. Knight AK, Shreffler WG, Sampson HA, et al. Skin prick test to egg white provides additional diagnostic utility to serum egg white-specific IgE antibody concentration in children. J Allergy Clin Immunol 2006; 117:842.
  16. Perry TT, Matsui EC, Conover-Walker MK, Wood RA. Risk of oral food challenges. J Allergy Clin Immunol 2004; 114:1164.
  17. Celik-Bilgili S, Mehl A, Verstege A, et al. The predictive value of specific immunoglobulin E levels in serum for the outcome of oral food challenges. Clin Exp Allergy 2005; 35:268.
  18. Skolnick HS, Conover-Walker MK, Koerner CB, et al. The natural history of peanut allergy. J Allergy Clin Immunol 2001; 107:367.
  19. Aldámiz-Echevarría L, Bilbao A, Andrade F, et al. Fatty acid deficiency profile in children with food allergy managed with elimination diets. Acta Paediatr 2008; 97:1572.
  20. Zijlstra WT, Flinterman AE, Soeters L, et al. Parental anxiety before and after food challenges in children with suspected peanut and hazelnut allergy. Pediatr Allergy Immunol 2010; 21:e439.
  21. Busse PJ, Nowak-Wegrzyn AH, Noone SA, et al. Recurrent peanut allergy. N Engl J Med 2002; 347:1535.
  22. Fleischer DM, Conover-Walker MK, Christie L, et al. Peanut allergy: recurrence and its management. J Allergy Clin Immunol 2004; 114:1195.
  23. Hourihane JO, Grimshaw KE, Lewis SA, et al. Does severity of low-dose, double-blind, placebo-controlled food challenges reflect severity of allergic reactions to peanut in the community? Clin Exp Allergy 2005; 35:1227.
  24. David TJ. Anaphylactic shock during elimination diets for severe atopic eczema. Arch Dis Child 1984; 59:983.
  25. Flinterman AE, Knulst AC, Meijer Y, et al. Acute allergic reactions in children with AEDS after prolonged cow's milk elimination diets. Allergy 2006; 61:370.
  26. Sicherer SH. Food allergy: when and how to perform oral food challenges. Pediatr Allergy Immunol 1999; 10:226.
  27. Niggemann B, Rolinck-Werninghaus C, Mehl A, et al. Controlled oral food challenges in children--when indicated, when superfluous? Allergy 2005; 60:865.
  28. Bindslev-Jensen C. Standardization of double-blind, placebo-controlled food challenges. Allergy 2001; 56 Suppl 67:75.
  29. Sampson HA, Gerth van Wijk R, Bindslev-Jensen C, et al. Standardizing double-blind, placebo-controlled oral food challenges: American Academy of Allergy, Asthma & Immunology-European Academy of Allergy and Clinical Immunology PRACTALL consensus report. J Allergy Clin Immunol 2012; 130:1260.
  30. Caffarelli C, Petroccione T. False-negative food challenges in children with suspected food allergy. Lancet 2001; 358:1871.
  31. Sampson HA. Use of food-challenge tests in children. Lancet 2001; 358:1832.
  32. Briggs D, Aspinall L, Dickens A, Bindslev-Jensen C. Statistical model for assessing the proportion of subjects with subjective sensitisations in adverse reactions to foods. Allergy 2001; 56 Suppl 67:83.
  33. Chinchilli VM, Fisher L, Craig TJ. Statistical issues in clinical trials that involve the double-blind, placebo-controlled food challenge. J Allergy Clin Immunol 2005; 115:592.
  34. Niggemann B, Wahn U, Sampson HA. Proposals for standardization of oral food challenge tests in infants and children. Pediatr Allergy Immunol 1994; 5:11.
  35. Personnel and equipment to treat systemic reactions caused by immunotherapy with allergenic extracts. American Academy of Allergy and Immunology. J Allergy Clin Immunol 1986; 77:271.
  36. Reibel S, Röhr C, Ziegert M, et al. What safety measures need to be taken in oral food challenges in children? Allergy 2000; 55:940.
  37. Sicherer SH. Food protein-induced enterocolitis syndrome: case presentations and management lessons. J Allergy Clin Immunol 2005; 115:149.
  38. Mankad VS, Williams LW, Lee LA, et al. Safety of open food challenges in the office setting. Ann Allergy Asthma Immunol 2008; 100:469.
  39. Sicherer SH, Simons FE. Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community. J Allergy Clin Immunol 2005; 115:575.
  40. Vlieg-Boerstra BJ, Bijleveld CM, van der Heide S, et al. Development and validation of challenge materials for double-blind, placebo-controlled food challenges in children. J Allergy Clin Immunol 2004; 113:341.
  41. van Odijk J, Ahlstedt S, Bengtsson U, et al. Double-blind placebo-controlled challenges for peanut allergy the efficiency of blinding procedures and the allergenic activity of peanut availability in the recipes. Allergy 2005; 60:602.
  42. Grimshaw KE, King RM, Nordlee JA, et al. Presentation of allergen in different food preparations affects the nature of the allergic reaction--a case series. Clin Exp Allergy 2003; 33:1581.
  43. Chatterjee U, Mondal G, Chakraborti P, et al. Changes in the allergenicity during different preparations of Pomfret, Hilsa, Bhetki and mackerel fish as illustrated by enzyme-linked immunosorbent assay and immunoblotting. Int Arch Allergy Immunol 2006; 141:1.
  44. Bernhisel-Broadbent J, Strause D, Sampson HA. Fish hypersensitivity. II: Clinical relevance of altered fish allergenicity caused by various preparation methods. J Allergy Clin Immunol 1992; 90:622.
  45. Kilburn SA, Nordlee JA, Hefle SL, et al. An evaluation of the sensitivity of subjects with peanut allergy to very low doses of peanut protein: a randomized, double-blind, placebo-controlled food challenge study. J Allergy Clin Immunol 1997; 100:596.
  46. Taylor SL, Hefle SL, Bindslev-Jensen C, et al. A consensus protocol for the determination of the threshold doses for allergenic foods: how much is too much? Clin Exp Allergy 2004; 34:689.
  47. Taylor SL, Hefle SL, Bindslev-Jensen C, et al. Factors affecting the determination of threshold doses for allergenic foods: how much is too much? J Allergy Clin Immunol 2002; 109:24.
  48. Bindslev-Jensen C, Ballmer-Weber BK, Bengtsson U, et al. Standardization of food challenges in patients with immediate reactions to foods--position paper from the European Academy of Allergology and Clinical Immunology. Allergy 2004; 59:690.
  49. Rance F, Dutau G. Labial food challenge in children with food allergy. Pediatr Allergy Immunol 1997; 8:41.
  50. Kok EE, Meijer Y, Kentie PA, et al. Oropharyngeal symptoms predict objective symptoms in double-blind, placebo-controlled food challenges to cow's milk. Allergy 2009; 64:1226.
  51. Flinterman AE, Hoekstra MO, Meijer Y, et al. Clinical reactivity to hazelnut in children: association with sensitization to birch pollen or nuts? J Allergy Clin Immunol 2006; 118:1186.
  52. Järvinen KM, Amalanayagam S, Shreffler WG, et al. Epinephrine treatment is infrequent and biphasic reactions are rare in food-induced reactions during oral food challenges in children. J Allergy Clin Immunol 2009; 124:1267.
  53. Flammarion S, Santos C, Romero D, et al. Changes in diet and life of children with food allergies after a negative food challenge. Allergy 2010; 65:797.
  54. Eigenmann PA, Caubet JC, Zamora SA. Continuing food-avoidance diets after negative food challenges. Pediatr Allergy Immunol 2006; 17:601.
  55. Flinterman AE, Pasmans SG, Hoekstra MO, et al. Determination of no-observed-adverse-effect levels and eliciting doses in a representative group of peanut-sensitized children. J Allergy Clin Immunol 2006; 117:448.