“To eat, or not to eat”, after a negative oral food challenge
Published online January 17, 2025
Oral food challenges (OFC) are a mainstay of clinical practice for both the diagnosis of food allergy and to assess for resolution of allergy. If the patient doesn’t react (develop symptoms) during the feeding test, it is considered negative, and the patient is instructed to reintroduce the food into their diet on a regular basis. This reintroduction is recommended to prevent allergy recurrence and improve the patient’s nutrition. However, the proportion of children achieving dietary introduction following a negative OFC, and barriers and enablers of this, are poorly understood. By better understanding these factors, clinicians may be able to identify and support children at risk of reintroduction failure.
Gibson et al. conducted a scoping review, published in The Journal of Allergy and Clinical Immunology: In Practice, to examine the proportion of patients who achieve reintroduction after a negative OFC, the ways in which successful reintroduction is described, and the barriers and enablers of change. Four health databases (PubMed, Embase, CINAHL, Web of Science) were searched for literature published between January 2000 and November 2023. The search included primary studies published in English in which those under the age of 18 had undergone an OFC for IgE mediated food allergy and described the number of children that were successful at reintroduction and the barriers and enablers of this. Studies were excluded if children had a non-IgE mediated food allergy, had undergone immunotherapy or were sent home on a modified reintroduction protocol (e.g. egg or milk ladder). Non-primary studies and abstracts were also excluded.
In total, 22 studies conducted across 10 countries were included. Ten (45%) of the studies had been published in the preceding 5 years, and 19 (86%) in the last 10 years. A total of 2,268 negative oral food challenges were included, with sample sizes of individual studies ranging between 12 and 694, with patients potentially undergoing more than one OFC to different foods. What was considered successful reintroduction varied between the studies, with some providing clear guidance – e.g., two teaspoons, three times a week, up to monthly. Using the criteria provided by the study, successful reintroduction ranged from less than 20% up to almost 90%. Barriers to reintroduction included fear and anxiety about allergic reactions for the child and their caregivers, symptoms when consuming the food, and food aversion or refusal. The food being reintroduced was also important, with nuts and peanuts observed to be reintroduced less frequently than egg and milk.
Understanding the factors that may reduce the likelihood of a family being able to offer and regularly consume the food can help clinicians identify the children who are at risk and provide additional support as needed.
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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