The Oral Food Challenge

My Preparation

The day before my daughter’s peanut oral food challenge I found myself, kid-free, in the grocery store scrutinizing the labels of jars of peanut butter. I wanted to ensure whatever I purchased contained only peanuts and had not been cross contaminated with any tree nuts. I felt like a deviant, as if I should apologize to the cashier for buying such an atrocity as peanut butter.

Try not to project your anxiety about the food challenge onto your child
Try not to project your anxiety about the food challenge onto your child

I will admit that I was very nervous the days leading up to her appointment. Just as you, I’ve read all the food allergy horror stories. We got through our son’s anaphylactic reaction unscathed (despite receiving inappropriate advice from our pediatrician’s office), but we were naïve and uneducated then. Now I know what can happen and how quickly things can go south, and knowing that she’d be in a safe place during the food challenge did little to diminish my worry.

I also teetered on the thin line between adequately preparing my daughter so she’d recognize an allergic reaction and would speak up promptly versus instilling fear in her and having her cry wolf because I’d panicked her into psychosomatic symptoms.

The day before the appointment my son asked her whether she was scared and she responded with an emphatic no. He said, “Well, eating peanut butter sounds scary to me!” I tried my best to match her laid back attitude and quiet my son’s commentary.

Morning of Food Challenge

Our allergist was giddy, kind of annoyingly so. But I knew he was curious and nearly as eager as I was to find out whether she was sensitized to peanut. Though he didn’t exactly say so, it was obvious to me that his best guess was that she was not peanut allergic.

He explained that my daughter was completely safe, that they would monitor her extremely closely and would halt the challenge if at any time she exhibited symptoms. He explained the procedure and then left so the assistant could proceed.

The Preparation

The assistant checked my daughter’s skin thoroughly and, with a pen, circled bruises and other marks so we could easily determine whether she had any new rashes on her skin during the challenge. She took her vitals, including her lung function using a volumetric spirometer.

The Procedure

She was given 1/8 teaspoon of peanut butter that she ingested right off the measuring spoon. The assistant set a timer and kept an eye on her. After five minutes she checked my daughter’s vitals and looked over her skin and asked her how she felt (she was fine). After another 10 minutes, my daughter ate twice as much and was checked again after 15 minutes. This continued, with the assistant leaving the room between doses and checks, until she’d eaten a full two tablespoons of peanut butter, much of which having been peanut butter bread with bite missingsmeared on some bread I’d brought. At one point about halfway through the challenge the assistant thought she’d heard some irregular lung sounds, but the allergist listened and said she sounded fine.

Three hours after walking in the door of the allergist’s office, we were packing up all our toys and getting ready to leave. The allergist said everything went great, and although extremely rare, it was still possible for her to have a reaction so we should continue to monitor her for the next 4-6 hours.

Afterward

On the drive home my mind raced thinking about the freedoms my daughter would enjoy not having to worry about avoiding peanuts, as well as the jealousy and other challenges we’d face with having one child with severe food allergies and one without. Those thoughts and concerns would soon be quashed.

Around six o’clock that evening I sent out an email to our extended family explaining that she, for all intents and purposes, had passed the peanut challenge and to be sensitive to what that means for my PA son. Then I sat down beside my daughter and noticed some redness on one of her legs. She allowed me to take a closer look and there was a slight rash on the backs of both thighs with one prominent hive. The next morning, the rash was still there, not raised but definitely there. I honestly don’t think I’d have noticed the rash the previous night or the next day if I hadn’t been looking for it. It wasn’t bothering her at all so I sent her to school and called the allergist’s office when they opened. They advised giving her a daily dose of antihistamine until the rash subsided (it was gone the next morning). He also recommended another food challenge to confirm a peanut allergy. (What!?) My response was that we were done for now, we would continue to avoid peanut, and we’d see him in a year! (Bottom line, my daughter is peanut allergic.)

Advice

If your child is scheduled for a food challenge, here are some tips:

  • Ask whether you need to bring the allergen being tested or whether it will be provided. And ask whether your child is allowed to eat other snacks and drink during the food challenge. For example, for a peanut challenge, your child will need safe crackers or bread as the challenge progresses.
  • Expect to be in the allergist’s office for a long time. Bring age appropriate entertainment (puzzles, crayons, toys, iPad, etc.).
  • Accurately prepare your child by explaining the procedure and allow him to discuss his feelings about it and reassure him as needed. Don’t project your fears or anxiety onto your child. You can discuss your own scary thoughts with a trusted adult.
  • Remember: the food challenge doesn’t end when you leave the allergist’s office. Continue to monitor your child for the next six hours.
  • Allow your child to talk about and work through his emotions, especially if the child had a severe reaction or an allergy was otherwise confirmed.
  • Avoid talking about whether the child failed (or passed) the challenge because those terms make it sound like the child had influence over the outcome. Use more neutral language, such as an allergy “was confirmed” or “ruled out,” when talking to others and to your child.

Final Thoughts

I honestly didn’t care what the food challenge outcome was; my only hope was that my daughter didn’t suffer a severe reaction and subsequent emotional trauma. (She’s extremely sensitive.) I definitely got my wish because as far as reactions go, she couldn’t have had a milder one.

The one thought that haunts me though is…Did I ruin my daughter’s chance of outgrowing the allergy by doing the food challenge? I’ve read that strict avoidance with no exposures is the best bet for outgrowing a food allergy. My daughter’s reaction was so mild…maybe she was “in the middle” of outgrowing it and now that’s she’s been exposed, her immune system is in overdrive and her chances of outgrowing it have decreased. Only time will tell.  But even so, * I wouldn’t have changed my decision to go forward with the food challenge. At least now we know that we are justified in having her diligently avoid peanut and carrying epinephrine for her.

*I can’t find scientific justification for this fear, which is why I crossed out these thoughts!

17 Comments

  1. Joan says:

    Here’s a good read for you:

    http://foodallergybitch.blogspot.com/2012/02/total-avoidance-best-chance-to-outgrow.html

    I have not yet found the source of this myth. I would stand down from worrying about this.

    1. Thanks again for your comment and link to that particular blog entry. It’s interesting…it’s been in only the last year that we got more diligent in managing my son’s peanut allergy by eliminating foods that have a “made in facility with peanuts” or on the same line. Our allergist said if we trusted the brand, that we didn’t have be that strict. Never mind that those labels are voluntary anyway and half the stuff he continues to eat is probably made in a plant that also handles peanuts but they just don’t disclose that info. And soon after we made that change I read an article that said complete avoidance can lower the child’s threshold level. We didn’t ease up on our criteria though because what a way to confuse a 5 year old who’s trying to learn how to manage his allergy.

      I appreciate your perspective on things.

      Stephanie

  2. Thanks for that. I can tell you *my* source: our former allergist. During our first visit, right after my son’s ana reaction, he told me that avoidance was the best chance of outgrowing. But he also told me that Mars uses crushed peanuts in their plain M&M candy coating, which is also inaccurate…one of the many reasons why we fired him.

  3. Di says:

    Just had a very similiar peanut challenge outcome to yours yesterday. My son reacted to peanut butter, just a small taste, when he was 1… hives covering face and body, swollen, itchy eyes. Fast forward to age 4.5. Blood test showing negative, but skin test positive. Allergist suggested UKnow Allergy test. It showed an extremely low level, but to one of the 4 peanut protein that cause severe reactions. Allergists convinces me he is confident that he will pass peanut challenge. Peanut challenge my son had itchy ears at one point, then blotchy marks around mouth and on last large dose of peanuts he started rubbing eyes like mad and was really upset. They kept us an extra half hour to make sure symptoms subsided, which they did. Doc called it a passed test and said we have to give him peanuts min 2x a week. Not totally convinced when we left the office but relieved his reactions were so mild. Around 6pm noticed that his belly, waist, and upper thighs are scratched raw and bumps and a few welts. I gave him benedryl and called doctor office today. They told me he is fine, still considered not allergic and to continue on plan to give him peanuts 2x a week. I’m sorry but my gut tells me thsi is just the wrong thing to do. I also am questioning whether this is going to set him back and if he was nearly grown out of allergy and now we’ve set him back. I think I need a new allergist!!!

    1. I’m in shock! I would most certainly find a new allergist for a second opinion. Would love to hear how it goes if you do. Please tell me you carry epi for him?!

  4. Di says:

    yes, i still am carrying epi-pen. allergiest said he won’t renew it once it expires?!! looking for a good allergist in philadelphia area now so we have a plan moving forward. I almost feel foolish for doing the challenge considering both the skin test and UKnow test were postitive.

    1. Try not to feel foolish…you were following a supposed expert’s advice. But I would certainly go with your gut on this one until you can get a second opinion since that’s the most conservative approach. Please keep me posted, and good luck.

  5. Di says:

    Will do! Thanks so much for letting me bounce this off of you… not too many ppl that would understand. I appreciate it 🙂

  6. Thyra says:

    Perhaps someone can shed some light on my 13 yr. old test results. She had a skin test and only a very slight reaction occurred. Then the blood test showed less than 0.35 reading, however the ARA H2 showed a higher rate of 0.47, the Dr. said it was up to me whether to have a challenge done. I don’t know what to do, I know higher levels in ARA H2 mean a great risk of having a severe reaction. He basically told me that she has a 20% chance of having a reaction, but didn’t state if he thought it would be severe or mild. I suppose he doesn’t know. She hasn’t been exposed to peanuts since she was 1.5 yrs old, the first reaction was small hives around the mouth, the second she coughed and cried a bit, no medicine was given, it went away.

    Any help would be appreciated. Thanks
    T

    1. Tough call. When I’m not sure, and assuming I highly trust the doctor, I’ve asked, “If this were your child, what would you do?” Also, what does your daughter think? Give her all the facts, tell her the possible outcomes, and let her decide. She’ll of course want your opinion and you can tell her your thoughts and concerns. Best of luck to you and your daughter, and post an update if you want; I’d love to know what you decide/the outcome.

      Sent from my iPhone

      1. Thyra says:

        Well we did the challenge. My daughter just turned 14, and it took some convincing to have the test done. She passed, very small amount of redness on the lips, nothing that bothered her. No hives or itchiness or anything really. We are very happy, and we went to Dairy Queen. She is to have peanuts once a week or two weeks. We were very happy we did the test. I hope others are as successful as we were!

      2. Yay! Hope all continues to go well go her!

        Sent from my iPhone

  7. runningmama says:

    We are scheduled for a oral challenge test mid September… My son is 4.5. First symptoms at 14 months when I fed him Reese Peanut Butter cup cereal- dry (I consumed peanut butter throughout my pregnancy and nursed and am addicted myself so thought he definitely would not be allergic) and within a few minutes his lips swelled and had hives on his chin (while he held his bowl out to ask for more..). He also had a severe milk allergy & severe eczema with respiratory symptoms which he has since outgrown (phew!). He has “passed” the skin test and blood test- but they never told me the levels/numbers on the blood test- just that he passed and we were not to give any peanut until the oral challenge test. Should I ask for the numbers?? We have been avoiding peanut since 10 months of age- I do have many fears (I have epi pens everywhere- my purse, his back pack, my home, daycare etc.) and he is starting to independently manage his allergy (at Halloween asking each home if there are peanuts in the candy, since he can’t have peanuts..lol). At one point around 2.5 he ate boxed brownies that my mom had made and in the fine print it read “processed in a factory that also processes peanuts” which she failed to see (it wasn’t even listed anywhere near the ingredients!). He developed hives on his chin (2+ hours later) which we treated with benedryl, and there were no other symptoms. I’m hopeful he will pass, and the testing is in a hospital setting (and I will bring my own epi pens). Thanks for your site. We did the oral challenge for milk and I remembered to bring my ipad then, so hopefully that will keep him occupied for this next one!

    1. Good job avoiding peanut for so long! Honestly, the numbers won’t mean anything at this point (unless maybe they were high, which they’re not or your allergist wouldn’t recommend a challenge). The food challenge is the only definitive test. It sounds like you’re in good hands and your son will be in the safest place possible if he were to have a reaction. Fingers crossed that he gets cleared to eat peanut products. Best wishes to you, and I’d love to know the results if you feel like sharing afterward!

      Sent from my iPhone

  8. Barbara says:

    Had a food challenge for peanuts for my four year old daughter. Skin test negative and blood test negative for the first time. Test went fine. Nothing happened no reaction. This past week she ate peanut butter twice and both times complained about an itchy mouth. I am confussed. Calling the Dr. In the morning. Anyone else have this experience?

    1. Hi, Barbara – That is certainly confusing. I hope the doctor can provide some insight. Since she was being tested, it sounds like food allergies are an issue or suspected, and since new food allergies can arise at any time, it’s possible she’s developed an allergy to peanut. If that’s the case or suspected, please do ensure the doctor prescribes and epinephrine auto-injector for her if she doesn’t already have one. I’ve posted your question to our Facebook community…maybe someone who’s had a similar experience to yours will respond. https://www.facebook.com/PeanutFreeParenting Would love to know the outcome if you want to post an update. Best wishes.

    2. Thyra says:

      My daughter did the peanut challenge, had a tingly mouth and a bit of a red lip. Our doctor considered that a success (as did I). She now eats some type if peanut product once/wk-2wks. She does have a tingly mouth but nothing that is alarming. Out doctor said if something develops such as hives then give her benedryl. So far she has been fine and fairly comfortable eating peanuts. (We lives peanut free for 12 yrs.). Good luck to you, I hope this helps.

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