David Stukus, MD, on What Clinicians Should Know About the Oral Food Challenge

Approximately 4% to 6% of US children are estimated to have at least one food allergy, according to the Centers for Disease Control and Prevention. Milk, eggs, wheat, crustacean shellfish, and peanuts are all among the most common food allergens.¹

Currently, the oral food challenge is the gold standard for diagnosing food allergies, even among infants and toddlers, said David Stukus, MD, director of the Complex Asthma Clinic and associate professor of pediatrics in the section of Allergy/Immunology at Nationwide Children’s Hospital in Columbus, Ohio.

However, some clinicians may be hesitant to use this diagnostic test in younger children, he said.

Consultant360 discussed the oral food challenge further with Dr Stukus, who recently spoke during the session, “Demystifying Oral Food Challenges in Infants and Toddlers.” at the 2018 American College of Allergy, Asthma, and Immunology Annual Scientific Meeting.

He shared his insight on who should perform oral food challenges, when they should be considered, common misconceptions, and how to reassure parents of young children.

Consultant360: What are the biggest misconceptions about oral food challenges, especially when it comes to administering them to infants and toddlers?

Dr Stukus: Many parents and even health care professionals think that younger children are at risk for more severe reactions. This line of thinking makes sense, since infants and toddlers have small airways and are unable to communicate if they do not feel well. However, multiple studies, as well as clinical experience, both show that infants and toddlers actually tend to have less severe reactions compared with older children and teenagers.

We always want to use the clinical history and testing to help identify the best candidates for oral food challenges and proceed cautiously, but this does not need to differ from our approach to older children or adults.

C360: What makes the oral food challenge the gold standard for food allergy diagnosis? Are there other diagnosis options or alternatives?

Dr Stukus: Both skin prick and serum immunoglobulin E (IgE) tests are useful tests when applied and interpreted in the proper clinical context. However, they both have high rates of falsely elevated results and cannot always accurately predict which child has a true food allergy. These tests also cannot predict severity of future reactions.

Oral food challenges are considered the gold standard for food allergy diagnosis, as ingestion is the best 'test' to determine if someone has a food allergy. Food allergies cause reproducible reactions with every ingestion, and if someone can tolerate 1 to 2 servings of a food without any symptoms, they are not likely allergic to that food.

C360: Is an oral food challenge safe for a primary care physician to perform?

Dr Stukus: Allergists receive additional training and clinical experience that enable them to be best suited to identify the proper candidates for oral food challenges, perform the challenge in the outpatient office setting, and, most importantly, be prepared to recognize and treat signs and symptoms of an allergic reaction, should one occur. Primary care physicians generally do not have this level of training, experience, or capability to perform oral food challenges in their office setting.

C360: When should a clinician order an oral food challenge for a young child? What factors should they consider?

Dr Stukus: There are many factors to consider, and oral food challenges can be used to both establish an initial diagnosis of food allergy or determine whether someone with known food allergy has developed tolerance over time. The clinical history is the most important factor to consider, including type of suspected food, character and severity of symptoms, treatment given during the reaction, time since last reaction, ability to tolerate similar foods, or other medical conditions, such as asthma.

Results of skin prick and/or serum IgE testing are also important factors that need to be considered prior to an oral food challenge. Willingness of the family to incorporate the food into their child's diet and willingness of the child to eat the food also need to be considered.

C360: How can clinicians best reassure a nervous parent when an oral food challenge is needed for their child?

Dr Stukus: I tell families that this is the best part of my job. When successful, their child no longer needs to avoid the food they were concerned about or follow any of the rigorous management strategies to avoid accidental ingestion. Even when symptoms occur during an oral food challenge, they are often mild, as we always proceed slowly and stop as soon as symptoms develop. Even when symptoms occur, families still benefit by gaining a better sense of how much food needs to be ingested prior to symptom onset, what a reaction looks like, and how quickly children improve with proper treatment.

Oral food challenges are safe and invaluable learning opportunities for everyone involved. In fact, in my own experience, I have even done very careful food challenges when I know that the child will have symptoms for a few select families that have an extreme misunderstanding of risk involved with casual exposures. It was life-changing for them to learn that their child could eat a few small bites without having an immediate-onset, life-threatening reaction.

—Christina Vogt

References:

1. Food allergies in schools. Centers for Disease Control and Prevention. Page last updated February 14, 2018. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Accessed on November 13, 2018.

2. Kanuga JG, Stukus DR, Greiwe JC, Prince B. Demystifying oral food challenges in infants and toddlers. Symposium presented at: 2018 American College of Allergy, Asthma, and Immunology Annual Scientific Meeting; November 15-19, 2018; Seattle, WA.