Overview: Why pediatric oral food challenges matter
Oral food challenges (OFCs) are the gold standard in diagnosing and reassessing food allergies in children. When carefully conducted in a controlled hospital setting, OFCs help clinicians determine whether a child has outgrown an allergy or may tolerate a food with reduced risk. A recent study published in Nutrients reinforces that OFCs are generally safe, but certain preexisting conditions can raise the odds of a reaction. Understanding these risk factors helps families and clinicians prepare for testing and work to minimize adverse outcomes.
The study at a glance
Researchers analyzed 205 OFCs performed in a single pediatric allergy center and found an overall failure rate of 32.2%, where “failure” means a reaction occurred during the test. Most reactions were mild to moderate and managed in the clinical setting. Severe multisystem reactions were uncommon, occurring in about 2% of challenges and all required epinephrine.
The foods most often tested were cow’s milk protein (CMP) and hen’s egg, comprising roughly half and two-fifths of the challenges, respectively. Notably, the study emphasized that reactions during OFCs do not negate the value of the test; instead, they underscore the importance of supervision, careful selection, and readiness to treat reactions promptly.
Key risk factors identified
The analysis pinpointed two major preexisting conditions that increased the likelihood of a failed OFC: asthma and multi-food allergy. Specifically:
- Asthma was associated with a higher chance of reaction during OFCs (p = 0.028).
- Multi-food allergy (having allergies to multiple foods) also raised the risk of a test ending with a reaction (p = 0.021).
Moreover, the combination of asthma or multi-food allergy with a prior history of anaphylaxis further amplified the risk. These findings highlight that certain patients require heightened precaution, slower dose escalation, and more intensive monitoring during OFCs.
How this informs clinical practice
For clinicians, the message is clear: patient selection and individualized planning are essential. Before an OFC, a thorough review of the child’s medical history—especially asthma control status, number of food allergies, and any past anaphylactic events—can guide decisions about whether to proceed and how to structure the test.
Incorporating objective measures can further enhance safety. The study explored using specific Immunoglobulin E (IgE) thresholds from blood tests to support risk assessment. For instance, a baked milk challenge showed a useful cutoff around 58.1 kU/L with acceptable sensitivity and specificity, though the authors cautioned that these thresholds are meant to aid, not replace, clinical judgment or long-term tolerance assessments.
Practical implications for families
Families preparing for OFCs should discuss risk factors openly with their allergy team. If a child has asthma or multiple food allergies, clinicians may implement additional safety steps, such as:
- Ensuring optimal asthma control before testing
- Choosing the safest incremental dosing plan tailored to the child
- Having emergency medications and trained staff readily available
- Using adjunctive testing (e.g., sIgE levels) to finalize the safety plan
Importantly, a higher risk of reaction does not mean an OFC should be avoided altogether. When conducted with appropriate precautions, OFCs remain a critical tool to confirm or rule out allergies and guide dietary management, potentially improving quality of life for children and families.
Conclusion: Safer, smarter OFCs through informed screening
The study reinforces that oral food challenges are safe in controlled settings, with most reactions being mild and manageable. The presence of asthma or multi-food allergy identifies a subset of children who require meticulous planning and heightened vigilance. By combining detailed clinical history, targeted serology (sIgE) thresholds, and careful monitoring, clinicians can optimize OFC safety and accuracy, helping pediatric patients navigate food allergies with confidence.
