Why patients don’t come to the table for oral food challenges and how to sweeten the menu

Published Online: June 3, 2015

Particularly for children, the proper diagnosis of food allergy is crucial to avoid nutritional and social consequences. Although a diagnosis may be determined by evaluating a combination of the medical history, skin tests, and/or serum tests, in many cases these are insufficient and a medically supervised oral food challenge (OFC) is required. The OFC is time-consuming and carries risks, but it is a standard, recommended test typically conducted in the office setting. Families may decline the OFC and maintain avoidance. There have not been studies evaluating the motivational factors that could result in a family deferring this important procedure.

In a recent issue of The Journal of Allergy and Clinical Immunology: In Practice, Davis et al. report the results of a study in which the team administered a structured questionnaire to parents of children who had not undertaken OFCs that had been offered at a prior visit. The questionnaire was completed by the parents of 102 children attending the Jaffe Food Allergy Institute, a food allergy referral center in New York City. Overall, these children had been offered 183 OFCs. Of the OFCs offered, 36% were not undertaken because of scheduling problems. Parents could choose more than one reason for deferral. Excluding scheduling, the most common reason for deferral, selected by 57%, were related to the child’s pickiness/disinterest or perceived lack of practicality of the food. Other categories resulting in deferral  included fear and emotional impact of the test (40%), doubt about passing (29%), and a variety of other reasons (21%)  such as having failed prior tests, worry the allergy could worsen, and cost. Importantly, 17% had tried the food at home, which could be dangerous.

Although studies are needed to address interventions to reduce unnecessary deferrals, the authors emphasize that many of the reasons identified in the study should be rectifiable with simple anticipatory guidance. The authors suggest discussing how the food may be obtained free of cross-contact with other allergens, nutritional value, and managing issues such as sibling allergies. Detailed discussions about risks and benefits and the physician’s estimation of the chance of tolerating the food, the safety precautions used during the procedure, and noting that the OFC may improve quality of life and allay fears and doubts. Additionally, it should be emphasized that the food should not be tried at home!

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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