UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Oral food challenges for diagnosis and management of food allergies

Author
Scott H Sicherer, MD, FAAAAI
Section Editor
Robert A Wood, MD
Deputy Editor
Elizabeth TePas, MD, MS

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) [1-7]. 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 "Food allergy in children: Prevalence, natural history, and monitoring for resolution".)

ELIMINATION DIETS

Elimination diets are performed prior to an OFC. 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 topic 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 log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2017. | This topic last updated: Aug 16, 2017.
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 ©2017 UpToDate, Inc.
References
Top
  1. Nowak-Wegrzyn A, Assa'ad AH, Bahna SL, et al. Work Group report: oral food challenge testing. J Allergy Clin Immunol 2009; 123:S365.
  2. 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.
  3. 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.
  4. 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.
  5. Sampson HA, Aceves S, Bock SA, et al. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol 2014; 134:1016.
  6. Muraro A, Werfel T, Hoffmann-Sommergruber K, et al. EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy 2014; 69:1008.
  7. Bird JA, Groetch M, Allen KJ, et al. Conducting an Oral Food Challenge to Peanut in an Infant. J Allergy Clin Immunol Pract 2017; 5:301.
  8. Fleischer DM, Bock SA, Spears GC, et al. Oral food challenges in children with a diagnosis of food allergy. J Pediatr 2011; 158:578.
  9. 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.
  10. Busse PJ, Nowak-Wegrzyn AH, Noone SA, et al. Recurrent peanut allergy. N Engl J Med 2002; 347:1535.
  11. Fleischer DM, Conover-Walker MK, Christie L, et al. Peanut allergy: recurrence and its management. J Allergy Clin Immunol 2004; 114:1195.
  12. Sicherer SH, Wood RA, Vickery BP, et al. Impact of Allergic Reactions on Food-Specific IgE Concentrations and Skin Test Results. J Allergy Clin Immunol Pract 2016; 4:239.
  13. 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.
  14. Neuman-Sunshine DL, Eckman JA, Keet CA, et al. The natural history of persistent peanut allergy. Ann Allergy Asthma Immunol 2012; 108:326.
  15. Benhamou AH, Zamora SA, Eigenmann PA. Correlation between specific immunoglobulin E levels and the severity of reactions in egg allergic patients. Pediatr Allergy Immunol 2008; 19:173.
  16. Blumchen K, Beder A, Beschorner J, et al. Modified oral food challenge used with sensitization biomarkers provides more real-life clinical thresholds for peanut allergy. J Allergy Clin Immunol 2014; 134:390.
  17. Rolinck-Werninghaus C, Niggemann B, Grabenhenrich L, et al. Outcome of oral food challenges in children in relation to symptom-eliciting allergen dose and allergen-specific IgE. Allergy 2012; 67:951.
  18. van der Zee T, Dubois A, Kerkhof M, et al. The eliciting dose of peanut in double-blind, placebo-controlled food challenges decreases with increasing age and specific IgE level in children and young adults. J Allergy Clin Immunol 2011; 128:1031.
  19. Summers CW, Pumphrey RS, Woods CN, et al. Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center. J Allergy Clin Immunol 2008; 121:632.
  20. Ta V, Weldon B, Yu G, et al. Use of Specific IgE and Skin Prick Test to Determine Clinical Reaction Severity. Br J Med Med Res 2011; 1:410.
  21. Clark AT, Ewan PW. Interpretation of tests for nut allergy in one thousand patients, in relation to allergy or tolerance. Clin Exp Allergy 2003; 33:1041.
  22. Chan JC, Peters RL, Koplin JJ, et al. Food Challenge and Community-Reported Reaction Profiles in Food-Allergic Children Aged 1 and 4 Years: A Population-Based Study. J Allergy Clin Immunol Pract 2017; 5:398.
  23. 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.
  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. Chang A, Robison R, Cai M, Singh AM. Natural History of Food-Triggered Atopic Dermatitis and Development of Immediate Reactions in Children. J Allergy Clin Immunol Pract 2016; 4:229.
  27. Soller L, Mill C, Avinashi V, et al. Development of anaphylactic cow's milk allergy following cow's milk elimination for eosinophilic esophagitis in a teenager. J Allergy Clin Immunol Pract 2017; 5:1413.
  28. Perry TT, Matsui EC, Conover-Walker MK, Wood RA. Risk of oral food challenges. J Allergy Clin Immunol 2004; 114:1164.
  29. 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.
  30. 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.
  31. Skolnick HS, Conover-Walker MK, Koerner CB, et al. The natural history of peanut allergy. J Allergy Clin Immunol 2001; 107:367.
  32. Davis N, Egan M, Sicherer SH. Factors resulting in deferral of diagnostic oral food challenges. J Allergy Clin Immunol Pract 2015; 3:811.
  33. Venter C, Mazzocchi A, Maslin K, Agostoni C. Impact of elimination diets on nutrition and growth in children with multiple food allergies. Curr Opin Allergy Clin Immunol 2017; 17:220.
  34. 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.
  35. Knibb RC, Ibrahim NF, Stiefel G, et al. The psychological impact of diagnostic food challenges to confirm the resolution of peanut or tree nut allergy. Clin Exp Allergy 2012; 42:451.
  36. Franxman TJ, Howe L, Teich E, Greenhawt MJ. Oral food challenge and food allergy quality of life in caregivers of children with food allergy. J Allergy Clin Immunol Pract 2015; 3:50.
  37. 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.
  38. Caffarelli C, Petroccione T. False-negative food challenges in children with suspected food allergy. Lancet 2001; 358:1871.
  39. Sampson HA. Use of food-challenge tests in children. Lancet 2001; 358:1832.
  40. Ahrens B, Niggemann B, Wahn U, Beyer K. Positive reactions to placebo in children undergoing double-blind, placebo-controlled food challenge. Clin Exp Allergy 2014; 44:572.
  41. Niggemann B, Lange L, Finger A, et al. Accurate oral food challenge requires a cumulative dose on a subsequent day. J Allergy Clin Immunol 2012; 130:261.
  42. Miceli Sopo S, Monaco S, Greco M, Onesimo R. Prevalence of adverse reactions following a passed oral food challenge and factors affecting successful re-introduction of foods. A retrospective study of a cohort of 199 children. Allergol Immunopathol (Madr) 2016; 44:54.
  43. 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.
  44. 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.
  45. Bindslev-Jensen C. Standardization of double-blind, placebo-controlled food challenges. Allergy 2001; 56 Suppl 67:75.
  46. Niggemann B, Yürek S, Beyer K. Severe anaphylaxis requiring intensive care during oral food challenge-It is not always peanuts. Pediatr Allergy Immunol 2017; 28:201.
  47. 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.
  48. Yanagida N, Sato S, Asaumi T, et al. Risk Factors for Severe Reactions during Double-Blind Placebo-Controlled Food Challenges. Int Arch Allergy Immunol 2017; 172:173.
  49. Nowak-Węgrzyn A, Chehade M, Groetch ME, et al. International consensus guidelines for the diagnosis and management of food protein-induced enterocolitis syndrome: Executive summary-Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2017; 139:1111.
  50. http://acaai.org/allergists-respond-death-3-year-old-boy-during-oral-food-challenge.
  51. 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.
  52. Noone S, Ross J, Sampson HA, Wang J. Epinephrine use in positive oral food challenges performed as a screening test for food allergy therapy trials. J Allergy Clin Immunol Pract 2015; 3:424.
  53. Mankad VS, Williams LW, Lee LA, et al. Safety of open food challenges in the office setting. Ann Allergy Asthma Immunol 2008; 100:469.
  54. 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.
  55. 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.
  56. 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.
  57. 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.
  58. 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.
  59. 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.
  60. 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.
  61. 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.
  62. 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.
  63. Rance F, Dutau G. Labial food challenge in children with food allergy. Pediatr Allergy Immunol 1997; 8:41.
  64. Grabenhenrich LB, Reich A, Bellach J, et al. A new framework for the documentation and interpretation of oral food challenges in population-based and clinical research. Allergy 2017; 72:453.
  65. 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.
  66. 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.
  67. Lee J, Garrett JP, Brown-Whitehorn T, Spergel JM. Biphasic reactions in children undergoing oral food challenges. Allergy Asthma Proc 2013; 34:220.
  68. Tripathi A, Commins SP, Heymann PW, Platts-Mills TA. Diagnostic and experimental food challenges in patients with nonimmediate reactions to food. J Allergy Clin Immunol 2015; 135:985.
  69. 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.
  70. Gau J, Wang J. Rate of food introduction after a negative oral food challenge in the pediatric population. J Allergy Clin Immunol Pract 2017; 5:475.
  71. Eigenmann PA, Caubet JC, Zamora SA. Continuing food-avoidance diets after negative food challenges. Pediatr Allergy Immunol 2006; 17:601.
  72. 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.