July 9, 2024 • 26 mins
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What is the gold standard in diagnosing an anaphylactic food allergy? It's not a skin test. It's not a blood test. It's an ingestion challenge.
In this episode,Dr. Alice Hoyt discusses the critical role of ingestion challenges when it comes to accurately diagnosing IgE-mediated food allergies. By consuming the suspected allergen under the careful supervision of a board-certified allergist, patients can achieve a precise diagnosis, which is pivotal before embarking on treatment plans like oral immunotherapy or long-term avoidance strategies. She shares valuable insights and tips on how to prepare for an ingestion challenge, ensuring a smooth and reassuring process for both patients and families.
Dr. Hoyt also explores the life-changing impact ingestion challenges can have, especially for young children and their parents. Drawing from the groundbreaking LEAP study, she stresses the importance of confidently introducing potentially allergenic foods to children, highlighting how, in some cases, ingestion challenges provide firsthand safety assurance. Additionally, she touches on the complexities of food allergy skin and blood testing and how these tests should not be considered confirmatory for food allergies.
Tune in to learn how ingestion challenges empower food allergy families and, in some cases, confirms that a child is no longer allergic to a food.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Alice Hoyt (00:04):
Hello and welcome to Food Allergy and your
Kiddo.
I am your host, dr Alice Hoyt,happy to be here today talking
to you about ingestionchallenges.
I did a great episode oningestion challenges with one of
my friends and colleagues, drSamantha Knox, a few years back
(00:25):
reviewing data from ClevelandClinic on the safety of
ingestion challenges.
So I'll definitely put a linkto that episode in the show
notes.
But today what I wanted to talkabout was the importance of an
ingestion challenge and reallybreak down what is an ingestion
challenge, when do you do it,why should you do it?
Should you do it and with whomshould you do it?
(00:49):
So let's get into that.
So what really is an ingestionchallenge?
An ingestion challenge is aformal procedure performed by a
board-certified allergist inwhich a patient who is
potentially allergic to a foodcomes into the office and
essentially eats the food.
Now we don't just give thekiddo a whole tablespoon of
(01:11):
peanut butter and say, here yougo, it's definitely performs in
a more incremental andsequential fashion.
I'll get into some of thespecifics on how we do that, but
first, really, who should havean ingestion challenge?
I think that's a reallyimportant question.
An ingestion challenge shouldbe performed in anyone in whom
(01:33):
the diagnosis of an IgE-mediatedfood allergy or an anaphylactic
food allergy is suspected butnot confirmed.
It should also be performed inchildren with food
protein-induced enterocolitissyndrome when we think that that
syndrome has started to resolve.
(01:54):
Ingestion challenges for foodallergies, like eosinophilic
esophagitis, really have notproven to be beneficial, because
you can have inflammation inyour esophagus from EOE that is
or is not being bothered by aspecific food.
(02:14):
So eating a specific food isnot going to be helpful in
diagnosing the EOE first of all,or whether or not you can
really tolerate that food.
Eoe is really more of a sort ofeczema of the esophagus and so
you can imagine that really kindof.
If you have that inflammationin your throat then when you
swallow kind of any food thenyou can have some symptoms.
(02:35):
So that's not a food allergy inwhich we do an ingestion
challenge, but the ones wereally do ingestion challenges
for are the IgE-mediated foodallergies, meaning your
anaphylactic food allergies andFPIES.
So why are ingestion challengesimportant?
Well, before I can really give afamily a good treatment plan
(02:57):
for a food allergy, I need to bevery sure about their diagnosis
of food allergy.
A few ways I can do that.
One, of course, eliciting areally strong history, a good,
detailed history from a family.
And look, if a kiddo had peanutbutter a few weeks ago and mom
is showing me a picture of thehives and saying she vomited and
all of these things and thehistory and the labs and or skin
(03:22):
testing really support that,okay, this was indeed a peanut
allergy reaction, then I don'tneed to subject that child to an
ingestion challenge just sothat I can see with my own eyes
that, yes, they are allergic.
I get enough information fromthe history, convincing
(03:42):
information from the history.
But let's say a patient hasbeen a five-year-old patient,
reacted to peanut when he wasone and has been avoiding peanut
strictly since then.
And they come to see me aboutoral immunotherapy and the first
thing I really need to dobefore I talk much about oral
immunotherapy is really confirmtheir diagnosis, because this
(04:06):
could absolutely be a case wherethis child had a peanut allergy
but is one of the 20 to 30percent of kids in whom it
self-resolves.
And so in that kiddo I might doskin testing and or blood
testing to inform how are wegoing to try to introduce this
food to this child?
Is it going to be with aningestion challenge Because if
(04:28):
those numbers look veryreassuring that he's not
allergic anymore, then that'sgoing to be my recommendation.
Instead of saying, okay, you'restill allergic here, let's do
this long, drawn out process toteach your body to tolerate the
food immunotherapy, because youmight not need it.
What I learned very early on inmedicine is that before you can
(04:51):
treat something, you need todiagnose it.
You need to be pretty confidentabout your diagnosis.
Does that mean that you aregoing to that you are going to
not give someone an EpiPenbecause you're not sure whether
(05:12):
or not they're allergic, but youthink they're not and so you're
not?
No, no, you can still give themthe treatment, the emergency
treatment, heaven forbid.
They have an accidentalingestion and they react before
you can confirm or rule outtheir, their allergic condition.
But really, you really want toconfirm the diagnosis.
And that brings me back toingestion challenges.
(05:33):
An ingestion challenge is theway to confirm whether or not a
person is allergic.
So how do you do an ingestionchallenge?
In my practice, we providefamilies with a checklist of
items they need to bring in.
This is after we've had a goodappointment usually two
appointments and have discussedwhy.
(05:53):
I think we need to do aningestion challenge because we
want to confirm that their childis indeed allergic before we
move forward with a treatmentplan, and that treatment plan
could also be avoidant.
So again, before I commit achild to a diagnosis which is
the terminology that I usebecause it's my job to give the
accurate diagnosis that is myjob as a doctor is to diagnose
(06:14):
and treat.
That is my job as a doctor isto diagnose and treat.
Before I can do that, I reallyneed to be confident about my
diagnosis.
We'll talk them through what tobring in, which, if it's a
five-year-old with a possiblepeanut allergy, we're gonna have
them bring in peanut butter,have them bring in some snacks
that they really like.
Also bring in their favoritebowl spoon, measuring spoons,
(06:36):
because ultimately we're gonnawant to see that kiddo ingest
two tablespoons of peanut butter, which is a serving size.
So in an ingestion challenge,then you really want a kiddo to
ingest the serving size fortheir age of the food and you
want them to ingest it withinabout an hour.
And this is where allergistskind of vary in their style of
doing ingestion challenges.
(06:57):
But really for the most part wewant them to eat the food in
about an hour and we start witha very small amount, like maybe
half a pea-sized little taste ofpeanut butter, make sure the
kiddo has no reaction to it andthen, every 15 minutes, increase
the amount until, within aboutfive doses, they have ingested
(07:19):
all of those two tablespoons.
Now, if they start havingsymptoms, we stop.
We stop the challenge and wellbefore we've even started the
challenge, we do what's calledan informed consent process
where we talk through thepotential risks, the potential
benefits and the alternativeswhen it comes to doing an
ingestion challenge.
The risks are, of course,having an IgE-mediated or an
(07:41):
anaphylactic reaction which cancause high swelling, trouble
breathing, vomiting.
Ultimately could result indeath.
That is very unlikely,especially when done in the
environment of being with aboard-certified allergist very
unlikely, but there is alwaysthat risk and again, I'm going
to encourage you to go back andlisten to that episode that I
(08:03):
recorded with Dr Knox where wetalked through that.
The benefits to doing thechallenge is that you're going
to know whether your kid'sallergic and even if the
challenge is positive and thishappens, that a challenge is
positive if an allergist is nothaving positive challenges, then
they're not doing enoughchallenges and they're not doing
enough challenges when achallenge is positive meaning
(08:25):
that the child has a reactionthen you're stopping the
challenge and if medication isneeded, you're administering it.
In my practice I'll actuallymake sure, before we start the
challenge, that the family hasthe child's epinephrine
autoinjector and then, if weneed to use epi, I talk the
parent through how to use it, sothat this is fortunately
(08:45):
unfortunately an excellent timefor them to get hands on
training in using their child'sepinephrine auto injector, so
they're actually the onesadministering the medication
that's going to stop theallergic reaction.
And so then, if the challengeis positive, then we stop.
We observe for another fewhours.
(09:05):
In most cases with challenges,if epi is needed, one dose is
needed.
On occasion two doses would beneeded and in those times you're
definitely having that kiddo goto the emergency room just for
further monitoring.
(09:26):
Kiddo eats two tablespoons ofpeanut butter over the course of
an hour.
After two hours, no issues.
A child's not allergic andyou've ruled out peanut allergy.
That child does not need oralimmunotherapy.
In that case you'll probablyrecommend, or I would probably
recommend, keeping it in thediet at least three times per
week.
And that's really extrapolatinginformation from the LEAP study
, learning early about peanutand LEAP-1.
So that is really why and howto do an ingestion challenge for
(09:53):
an IgE-mediated food allergy.
If you're doing it for FPIES,it's a horse of a different
color because FPIES reactionsremember FPIES, food
protein-induced enterocolitissyndrome that's going to have
delayed symptoms.
So maybe a two-year-old who hadsignificant repeated vomiting
and diarrhea three hours aftereating scrambled eggs last year,
(10:17):
then if you think that thischild, if the allergist thinks
that this child and the parentthinks that this child is now
going to tolerate scrambled eggs, like maybe you've worked with
your allergist and gotten bakedegg into the diet.
There's definitely nuance tomanaging kiddos with F-Pies and
I had great, great conversationwith Dr Anna Novak-Wegren about
(10:39):
this.
I'll link to that episode too.
But when you do the F-Pieschallenges then they are going
to be longer, they are going tobe sometimes in a hospital
setting because a lot of timesyou'll want to have an IV
available in case that childneeds fluid resuscitation.
Because with FPIES, fpies isnot treated.
An FPIES reaction is nottreated with epinephrine, it's
(11:01):
treated with fluid resuscitationand Zofran or Ondansetron,
which is an anti-emetic.
And are there any alternativesto doing an ingestion challenge?
Right, we talked about therisks, I'll talk about the
benefits.
But what about alternatives?
An alternative to doing aningestion challenge would be
(11:23):
awesome, because we wouldn'thave to subject somebody to an
allergic reaction to confirm orrule out their allergy.
Unfortunately, right now, therereally are not any good
alternatives to doing aningestion challenge.
And what about an alternativeto an ingestion challenge?
So we talked about the risks ofan ingestion challenge, the
(11:45):
benefits of an ingestionchallenge, but is there a good
alternative to doing aningestion challenge?
Well, let's think about whywe're doing the challenge, and
it's really to either confirm orrule out whether the patient is
allergic.
So in most cases, when you'reabout to perform an ingestion
challenge, or when you'rediscussing it, planning it, it's
(12:06):
because a patient has beenavoiding food.
When you perform the ingestionchallenge, if the challenge is
negative, then they'll no longerhave to avoid food.
If it's positive, then you'veconfirmed the diagnosis.
But is there a way to confirmthe diagnosis or rule out the
diagnosis without actuallydirectly exposing the kiddo to
(12:27):
the food?
And unfortunately, right nowthere's not a good alternative.
There are some tests that aregetting better at telling us
whether or not it's likely lesslikely, more likely that a kiddo
will react when they ingest thefood, but we're really just not
(12:48):
there yet.
Ultimately, at the end of theday, if we're doing a test and
telling a family they're notallergic, I think it's very
important that that family feelsvery confident introducing that
food.
This, I think, is especiallyimportant in young kiddos under
(13:08):
the age of five, in which theLEAP study has told us how
important the immune system isand how malleable the immune
system is during that time.
What I mean by that is if afamily is concerned about an egg
allergy or a peanut allergy,whatever the allergy may be, and
(13:29):
we talk through the history, wetalk through the testing and
the test results and I'm prettyconfident that the child is not
allergic, well, it doesn'treally matter how confident I am
.
It really needs to be theparent who's confident that the
child is going to safely ingestthe food.
And studies have absolutelyshown that if I as an allergist
(13:50):
just say but I'm not allergic,go home and feed it to the kid,
in most cases that doesn'thappen right and also in most
cases that doesn't generate agood relationship with the
allergist because we're clearlynot recognizing the importance
of the family being able to seethat child safely eating the
food and feeling confident thatthey as a parent you as a parent
(14:11):
can give your kid that food andthat the food won't hurt your
child, right?
So the ingestion challenge isso important there's not really
a good alternative right now,not in its intention of
confirming or ruling out thediagnosis, but also at the end
of the day, it's reallyimportant for families to feel
(14:35):
empowered to give their child afood that use the allergist feel
is very safe.
And when you do that ingestionchallenge it allows the family
to see firsthand yes, this foodis safe.
Now I'm not going to go superinto detail about FPI's
challenges and you shoulddefinitely listen back to that
FPI's episode that I did.
But FPI's challenges youdefinitely want to do a
(14:59):
challenge when you think thatFPI's has resolved, because
FPI's is a disease process wheresometimes a kiddo might react,
sometimes not.
That is very different thanIgE-mediated food allergies or
anaphylactic food allergieswhere if you're giving a child a
very reasonable amount of theallergen, like a full serving
(15:19):
size, if they don't react inthat challenge, it is highly
unlikely that that child isallergic, even with a
fluctuating what's calledthreshold, meaning there's a
threshold at which a patient isgoing to have a reaction and
people can have pretty highthresholds, meaning like they
could eat one or two peanuts andnot react.
(15:40):
But if they eat three, thenlike they're having a reaction.
But that's why when you do achallenge, but if they ate three
, then like they're having areaction.
But that's why when you do achallenge, the allergen is just
really wanting to see you eat avery generous amount of the
allergen.
We talked about the risks, wetalked about the benefits and I
just so.
We talked about the risks, wetalked about the benefits and I
just went through.
(16:00):
Is there an alternative?
Not really.
So what do you do?
Continue to avoid the food,right?
So that's why it is importantto have a discussion about
ingestion challenges.
So that's really what aningestion challenge is and why
you do an ingestion challenge.
I really want to underscore theimportance of the ingestion
(16:25):
challenge because so manyfamilies their kiddo presents
with an allergic reaction andmaybe is presenting to the
emergency room and thenfollowing up with a pediatrician
or even an allergist, and theyget testing done, skin testing,
and then multiple things mightbe positive on skin tests.
Testing done, skin testing, andthen multiple things might be
(16:46):
positive on skin tests.
Let's say, somebody does apanel.
Even though the kiddo reactedto cashew, they're doing a panel
of all these things which youcan do a test.
Right, you can have a test done, but the goal of any sort of
food allergy testing should beto help you safely introduce and
incorporate that food into akiddo's diet.
(17:06):
So what do I mean by that?
If a family comes to see mebecause they're 18-month-old,
had peanut butter for the firsttime and had an allergic
reaction, they say she's neverhad tree nuts before and we're
not going to give her any untilwe know she's not allergic.
So then yeah, absolutely, I'mgoing to work with the family,
do either skin testing or bloodtesting.
(17:26):
I do a lot more blood testingthan I do skin testing, just
because I feel that it gives memore information.
And then if we do immunotherapy, then I'm able to track those
numbers.
Yes, you can track skin testingtoo.
I've talked about skin testingand blood testing before and I
won't go into that on thisepisode, but if you want to know
(17:50):
more about that, then send me amessage or leave a note in the
comments.
So when you have had skintesting done, it's not okay.
Skin testing is positive.
Here's your EpiPen.
See you later.
It should be okay.
Skin testing is positive.
Blood testing is positive.
How positive especially doesthis blood testing look?
Because not all blood testing iscreated equal.
Some of the peanut testing,specifically peanut component
(18:13):
testing, can be very helpful inme sort of restratifying the
likelihood of a kiddo having theallergy as opposed to other
blood tests are just not reallyas helpful, for whatever reason.
Or like some foods like a verylow cashew IgE number can be
(18:34):
very relevant, as opposed to avery low soy number might not be
, might not indicate as stronglythat this child is very likely
to be allergic.
So not all tests are createdequal.
Not all results should beinterpreted equal to each other.
But once you're doing a testyou have to have a game plan for
(18:56):
how you're going to help thatfamily.
Or I, as an allergist, have tohave a game plan for how I'm
going to help that family getthe food into the diet, because
what I don't want to do istesting and say, okay, well, all
this testing is positive,you're allergic, see you later.
If the testing's positive, thenwe say we really dive into the
history really and say have theyever had any of this food?
Let's do some ingestionchallenges here, unless the
(19:23):
numbers are crazy high, and eventhen we're having discussions
right, because before I'mcommitting someone to a
diagnosis, we're having adiscussion.
So, doing the ingestionchallenge to say, okay, pecans
are safe for you, and walnutsand pecans, they cross-re react.
Walnuts are safe for you,cashew, pistachio they cross
react.
Doing a challenge to cashew,it's positive.
Ok, cashew is not safe for you,pistachio is not safe for you.
(19:46):
So you can see that I'm notjust doing a test and saying, ok
, you're allergic.
The testing does not say whetheror not someone is allergic.
I'll repeat that Testing doesnot confirm that someone is
allergic.
Testing positive tests help usrisk stratify whether or not we
(20:09):
think someone is allergic.
They help us inform whether ornot we think someone is allergic
.
But it's really that next stepof the ingestion challenge
that's going to tell us whetheror not this person is indeed
allergic.
And there are plenty of kids who, for multiple reasons one of
the biggest reasons they haveeczema.
(20:31):
They have positive tests tolots of things.
That doesn't mean they'reallergic to all those things.
So you can see, it's veryimportant when you, as a parent,
are told that X, y and Zallergy tests are positive, it
doesn't mean that they'repositive for the allergy.
(20:52):
It doesn't mean your kiddo ispositive for the allergy, it
means that there's an increasedlikelihood that your kiddo is
positive for the allergy.
It means that there's anincreased likelihood that your
kiddo has an allergy becauseyour kiddo is sensitized.
They have positive tests, theyare sensitized, but they should
not be deemed clinicallyallergic until there is clinical
suspicion, meaning they haveingested the food and have had
(21:14):
symptoms that suggest that theyare clinically allergic.
And again I will say look, ifyou have an ERA H2, which is a
peanut component test that isgreater than 100, then chances
are, yes, you are allergic topeanuts, but not all testing is
that slam dunk and I'll tell you, I guarantee you, there's
(21:34):
someone out there who has thatnumber and they're tolerant of
peanuts, for whatever reason.
So all of this to come back tothe importance of the ingestion
challenge being a part of thediscussion when you and your
allergist are talking about whatis it that your kiddo is
allergic to?
(21:54):
And really the thought of, okay, going back and seeing your
allergist every year to repeattesting.
Like yeah, that's totally fine,good, like, stay engaged with
your allergist.
I like to see my patients atleast twice per year, especially
now.
School forums, new treatmentsfor food allergies, new tests,
just there's so much more in theworld of food allergy now
(22:17):
compared to even like five yearsago, right?
So I like to see my patientsevery six months and I also like
to stay engaged in what's goingon with them have they had
accidental ingestions?
Just all the things so that Ican provide them with the most
advanced care.
But when you're doing that sortof annual skin testing and or
blood testing, you want it to bewith a reason, and the reason
(22:38):
is how is it going to change ourplan?
Meaning okay, if the testing islooking like things are,
numbers are going down and maybeyou've had an accidental
ingestion and there's been noreaction, then absolutely, maybe
we should be doing an ingestionchallenge and those numbers are
helping to inform thelikelihood of okay.
(22:59):
Do we think that it's going tobe a positive challenge?
There are numbers that givesort of a positive predictive
value of when a challenge isgoing to be positive, but I'll
tell you, nothing is 100%.
So I don't, I absolutely don'tthink allergists should be doing
ingestion challenges justwilly-nilly and being cavalier
(23:19):
about anything.
But I know that sometimeschildren are committed to
diagnoses that they don't have,all because an ingestion
challenge has not been performed.
Wrapping up here ingestionchallenges are super important.
They should be done byboard-certified allergists who
(23:40):
are well-versed in performingthese procedures because, again,
there is risk to theseprocedures.
But they're definitelyimportant in helping families
navigate life with foodallergies because, first and
foremost, they're confirming orruling out whether or not they
even need to avoid a food.
Also, even with positivechallenges, when kiddos have
reactions, there's stillevidence that support that it
(24:02):
improves the family's quality oflife.
I've had families tell me okay,well, now you know, I've seen
this now and I've treated it nowand that will help them moving
forward.
It empowers them to be moreconfident that should their
child have an axon ingestion,they know how to manage it
because they did manage it.
(24:25):
So if your kiddo has a foodallergy and or has been
diagnosed with a food allergybut has never had an ingestion
challenge, then I woulddefinitely encourage you to talk
with your allergist about whenshould you guys do an ingestion
challenge and also, of course,talk about the latest therapies
available for food allergies.
(24:45):
Whether it's oral immunotherapyor sublingual immunotherapy.
You always want to do anevidence-based type of treatment
for food allergy and rememberavoidance is still absolutely a
management strategy for foodallergies.
So don't ever feel like you'renot being proactive for your
child if you're not doingimmunotherapy.
That is not an accuratestatement.
(25:07):
So that's the show on ingestion.
Challenges, questions, comments, reach out, comments, reach out
.
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
(25:28):
episode and visit us atfoodallergyandyourkiddocom where
you can submit your family'squestions.
God bless you and God blessyour family.
Hello and welcome to Food Allergy and your
Kiddo.
I am your host, dr Alice Hoyt,happy to be here today talking
to you about ingestionchallenges.
I did a great episode oningestion challenges with one of
my friends and colleagues, drSamantha Knox, a few years back
(00:25):
reviewing data from ClevelandClinic on the safety of
ingestion challenges.
So I'll definitely put a linkto that episode in the show
notes.
But today what I wanted to talkabout was the importance of an
ingestion challenge and reallybreak down what is an ingestion
challenge, when do you do it,why should you do it?
Should you do it and with whomshould you do it?
(00:49):
So let's get into that.
So what really is an ingestionchallenge?
An ingestion challenge is aformal procedure performed by a
board-certified allergist inwhich a patient who is
potentially allergic to a foodcomes into the office and
essentially eats the food.
Now we don't just give thekiddo a whole tablespoon of
(01:11):
peanut butter and say, here yougo, it's definitely performs in
a more incremental andsequential fashion.
I'll get into some of thespecifics on how we do that, but
first, really, who should havean ingestion challenge?
I think that's a reallyimportant question.
An ingestion challenge shouldbe performed in anyone in whom
(01:33):
the diagnosis of an IgE-mediatedfood allergy or an anaphylactic
food allergy is suspected butnot confirmed.
It should also be performed inchildren with food
protein-induced enterocolitissyndrome when we think that that
syndrome has started to resolve.
(01:54):
Ingestion challenges for foodallergies, like eosinophilic
esophagitis, really have notproven to be beneficial, because
you can have inflammation inyour esophagus from EOE that is
or is not being bothered by aspecific food.
(02:14):
So eating a specific food isnot going to be helpful in
diagnosing the EOE first of all,or whether or not you can
really tolerate that food.
Eoe is really more of a sort ofeczema of the esophagus and so
you can imagine that really kindof.
If you have that inflammationin your throat then when you
swallow kind of any food thenyou can have some symptoms.
(02:35):
So that's not a food allergy inwhich we do an ingestion
challenge, but the ones wereally do ingestion challenges
for are the IgE-mediated foodallergies, meaning your
anaphylactic food allergies andFPIES.
So why are ingestion challengesimportant?
Well, before I can really give afamily a good treatment plan
(02:57):
for a food allergy, I need to bevery sure about their diagnosis
of food allergy.
A few ways I can do that.
One, of course, eliciting areally strong history, a good,
detailed history from a family.
And look, if a kiddo had peanutbutter a few weeks ago and mom
is showing me a picture of thehives and saying she vomited and
all of these things and thehistory and the labs and or skin
(03:22):
testing really support that,okay, this was indeed a peanut
allergy reaction, then I don'tneed to subject that child to an
ingestion challenge just sothat I can see with my own eyes
that, yes, they are allergic.
I get enough information fromthe history, convincing
(03:42):
information from the history.
But let's say a patient hasbeen a five-year-old patient,
reacted to peanut when he wasone and has been avoiding peanut
strictly since then.
And they come to see me aboutoral immunotherapy and the first
thing I really need to dobefore I talk much about oral
immunotherapy is really confirmtheir diagnosis, because this
(04:06):
could absolutely be a case wherethis child had a peanut allergy
but is one of the 20 to 30percent of kids in whom it
self-resolves.
And so in that kiddo I might doskin testing and or blood
testing to inform how are wegoing to try to introduce this
food to this child?
Is it going to be with aningestion challenge Because if
(04:28):
those numbers look veryreassuring that he's not
allergic anymore, then that'sgoing to be my recommendation.
Instead of saying, okay, you'restill allergic here, let's do
this long, drawn out process toteach your body to tolerate the
food immunotherapy, because youmight not need it.
What I learned very early on inmedicine is that before you can
(04:51):
treat something, you need todiagnose it.
You need to be pretty confidentabout your diagnosis.
Does that mean that you aregoing to that you are going to
not give someone an EpiPenbecause you're not sure whether
(05:12):
or not they're allergic, but youthink they're not and so you're
not?
No, no, you can still give themthe treatment, the emergency
treatment, heaven forbid.
They have an accidentalingestion and they react before
you can confirm or rule outtheir, their allergic condition.
But really, you really want toconfirm the diagnosis.
And that brings me back toingestion challenges.
(05:33):
An ingestion challenge is theway to confirm whether or not a
person is allergic.
So how do you do an ingestionchallenge?
In my practice, we providefamilies with a checklist of
items they need to bring in.
This is after we've had a goodappointment usually two
appointments and have discussedwhy.
(05:53):
I think we need to do aningestion challenge because we
want to confirm that their childis indeed allergic before we
move forward with a treatmentplan, and that treatment plan
could also be avoidant.
So again, before I commit achild to a diagnosis which is
the terminology that I usebecause it's my job to give the
accurate diagnosis that is myjob as a doctor is to diagnose
(06:14):
and treat.
That is my job as a doctor isto diagnose and treat.
Before I can do that, I reallyneed to be confident about my
diagnosis.
We'll talk them through what tobring in, which, if it's a
five-year-old with a possiblepeanut allergy, we're gonna have
them bring in peanut butter,have them bring in some snacks
that they really like.
Also bring in their favoritebowl spoon, measuring spoons,
(06:36):
because ultimately we're gonnawant to see that kiddo ingest
two tablespoons of peanut butter, which is a serving size.
So in an ingestion challenge,then you really want a kiddo to
ingest the serving size fortheir age of the food and you
want them to ingest it withinabout an hour.
And this is where allergistskind of vary in their style of
doing ingestion challenges.
(06:57):
But really for the most part wewant them to eat the food in
about an hour and we start witha very small amount, like maybe
half a pea-sized little taste ofpeanut butter, make sure the
kiddo has no reaction to it andthen, every 15 minutes, increase
the amount until, within aboutfive doses, they have ingested
(07:19):
all of those two tablespoons.
Now, if they start havingsymptoms, we stop.
We stop the challenge and wellbefore we've even started the
challenge, we do what's calledan informed consent process
where we talk through thepotential risks, the potential
benefits and the alternativeswhen it comes to doing an
ingestion challenge.
The risks are, of course,having an IgE-mediated or an
(07:41):
anaphylactic reaction which cancause high swelling, trouble
breathing, vomiting.
Ultimately could result indeath.
That is very unlikely,especially when done in the
environment of being with aboard-certified allergist very
unlikely, but there is alwaysthat risk and again, I'm going
to encourage you to go back andlisten to that episode that I
(08:03):
recorded with Dr Knox where wetalked through that.
The benefits to doing thechallenge is that you're going
to know whether your kid'sallergic and even if the
challenge is positive and thishappens, that a challenge is
positive if an allergist is nothaving positive challenges, then
they're not doing enoughchallenges and they're not doing
enough challenges when achallenge is positive meaning
(08:25):
that the child has a reactionthen you're stopping the
challenge and if medication isneeded, you're administering it.
In my practice I'll actuallymake sure, before we start the
challenge, that the family hasthe child's epinephrine
autoinjector and then, if weneed to use epi, I talk the
parent through how to use it, sothat this is fortunately
(08:45):
unfortunately an excellent timefor them to get hands on
training in using their child'sepinephrine auto injector, so
they're actually the onesadministering the medication
that's going to stop theallergic reaction.
And so then, if the challengeis positive, then we stop.
We observe for another fewhours.
(09:05):
In most cases with challenges,if epi is needed, one dose is
needed.
On occasion two doses would beneeded and in those times you're
definitely having that kiddo goto the emergency room just for
further monitoring.
(09:26):
Kiddo eats two tablespoons ofpeanut butter over the course of
an hour.
After two hours, no issues.
A child's not allergic andyou've ruled out peanut allergy.
That child does not need oralimmunotherapy.
In that case you'll probablyrecommend, or I would probably
recommend, keeping it in thediet at least three times per
week.
And that's really extrapolatinginformation from the LEAP study
, learning early about peanutand LEAP-1.
So that is really why and howto do an ingestion challenge for
(09:53):
an IgE-mediated food allergy.
If you're doing it for FPIES,it's a horse of a different
color because FPIES reactionsremember FPIES, food
protein-induced enterocolitissyndrome that's going to have
delayed symptoms.
So maybe a two-year-old who hadsignificant repeated vomiting
and diarrhea three hours aftereating scrambled eggs last year,
(10:17):
then if you think that thischild, if the allergist thinks
that this child and the parentthinks that this child is now
going to tolerate scrambled eggs, like maybe you've worked with
your allergist and gotten bakedegg into the diet.
There's definitely nuance tomanaging kiddos with F-Pies and
I had great, great conversationwith Dr Anna Novak-Wegren about
(10:39):
this.
I'll link to that episode too.
But when you do the F-Pieschallenges then they are going
to be longer, they are going tobe sometimes in a hospital
setting because a lot of timesyou'll want to have an IV
available in case that childneeds fluid resuscitation.
Because with FPIES, fpies isnot treated.
An FPIES reaction is nottreated with epinephrine, it's
(11:01):
treated with fluid resuscitationand Zofran or Ondansetron,
which is an anti-emetic.
And are there any alternativesto doing an ingestion challenge?
Right, we talked about therisks, I'll talk about the
benefits.
But what about alternatives?
An alternative to doing aningestion challenge would be
(11:23):
awesome, because we wouldn'thave to subject somebody to an
allergic reaction to confirm orrule out their allergy.
Unfortunately, right now, therereally are not any good
alternatives to doing aningestion challenge.
And what about an alternativeto an ingestion challenge?
So we talked about the risks ofan ingestion challenge, the
(11:45):
benefits of an ingestionchallenge, but is there a good
alternative to doing aningestion challenge?
Well, let's think about whywe're doing the challenge, and
it's really to either confirm orrule out whether the patient is
allergic.
So in most cases, when you'reabout to perform an ingestion
challenge, or when you'rediscussing it, planning it, it's
(12:06):
because a patient has beenavoiding food.
When you perform the ingestionchallenge, if the challenge is
negative, then they'll no longerhave to avoid food.
If it's positive, then you'veconfirmed the diagnosis.
But is there a way to confirmthe diagnosis or rule out the
diagnosis without actuallydirectly exposing the kiddo to
(12:27):
the food?
And unfortunately, right nowthere's not a good alternative.
There are some tests that aregetting better at telling us
whether or not it's likely lesslikely, more likely that a kiddo
will react when they ingest thefood, but we're really just not
(12:48):
there yet.
Ultimately, at the end of theday, if we're doing a test and
telling a family they're notallergic, I think it's very
important that that family feelsvery confident introducing that
food.
This, I think, is especiallyimportant in young kiddos under
(13:08):
the age of five, in which theLEAP study has told us how
important the immune system isand how malleable the immune
system is during that time.
What I mean by that is if afamily is concerned about an egg
allergy or a peanut allergy,whatever the allergy may be, and
(13:29):
we talk through the history, wetalk through the testing and
the test results and I'm prettyconfident that the child is not
allergic, well, it doesn'treally matter how confident I am
.
It really needs to be theparent who's confident that the
child is going to safely ingestthe food.
And studies have absolutelyshown that if I as an allergist
(13:50):
just say but I'm not allergic,go home and feed it to the kid,
in most cases that doesn'thappen right and also in most
cases that doesn't generate agood relationship with the
allergist because we're clearlynot recognizing the importance
of the family being able to seethat child safely eating the
food and feeling confident thatthey as a parent you as a parent
(14:11):
can give your kid that food andthat the food won't hurt your
child, right?
So the ingestion challenge isso important there's not really
a good alternative right now,not in its intention of
confirming or ruling out thediagnosis, but also at the end
of the day, it's reallyimportant for families to feel
(14:35):
empowered to give their child afood that use the allergist feel
is very safe.
And when you do that ingestionchallenge it allows the family
to see firsthand yes, this foodis safe.
Now I'm not going to go superinto detail about FPI's
challenges and you shoulddefinitely listen back to that
FPI's episode that I did.
But FPI's challenges youdefinitely want to do a
(14:59):
challenge when you think thatFPI's has resolved, because
FPI's is a disease process wheresometimes a kiddo might react,
sometimes not.
That is very different thanIgE-mediated food allergies or
anaphylactic food allergieswhere if you're giving a child a
very reasonable amount of theallergen, like a full serving
(15:19):
size, if they don't react inthat challenge, it is highly
unlikely that that child isallergic, even with a
fluctuating what's calledthreshold, meaning there's a
threshold at which a patient isgoing to have a reaction and
people can have pretty highthresholds, meaning like they
could eat one or two peanuts andnot react.
(15:40):
But if they eat three, thenlike they're having a reaction.
But that's why when you do achallenge, but if they ate three
, then like they're having areaction.
But that's why when you do achallenge, the allergen is just
really wanting to see you eat avery generous amount of the
allergen.
We talked about the risks, wetalked about the benefits and I
just so.
We talked about the risks, wetalked about the benefits and I
just went through.
(16:00):
Is there an alternative?
Not really.
So what do you do?
Continue to avoid the food,right?
So that's why it is importantto have a discussion about
ingestion challenges.
So that's really what aningestion challenge is and why
you do an ingestion challenge.
I really want to underscore theimportance of the ingestion
(16:25):
challenge because so manyfamilies their kiddo presents
with an allergic reaction andmaybe is presenting to the
emergency room and thenfollowing up with a pediatrician
or even an allergist, and theyget testing done, skin testing,
and then multiple things mightbe positive on skin tests.
Testing done, skin testing, andthen multiple things might be
(16:46):
positive on skin tests.
Let's say, somebody does apanel.
Even though the kiddo reactedto cashew, they're doing a panel
of all these things which youcan do a test.
Right, you can have a test done, but the goal of any sort of
food allergy testing should beto help you safely introduce and
incorporate that food into akiddo's diet.
(17:06):
So what do I mean by that?
If a family comes to see mebecause they're 18-month-old,
had peanut butter for the firsttime and had an allergic
reaction, they say she's neverhad tree nuts before and we're
not going to give her any untilwe know she's not allergic.
So then yeah, absolutely, I'mgoing to work with the family,
do either skin testing or bloodtesting.
(17:26):
I do a lot more blood testingthan I do skin testing, just
because I feel that it gives memore information.
And then if we do immunotherapy, then I'm able to track those
numbers.
Yes, you can track skin testingtoo.
I've talked about skin testingand blood testing before and I
won't go into that on thisepisode, but if you want to know
(17:50):
more about that, then send me amessage or leave a note in the
comments.
So when you have had skintesting done, it's not okay.
Skin testing is positive.
Here's your EpiPen.
See you later.
It should be okay.
Skin testing is positive.
Blood testing is positive.
How positive especially doesthis blood testing look?
Because not all blood testing iscreated equal.
Some of the peanut testing,specifically peanut component
(18:13):
testing, can be very helpful inme sort of restratifying the
likelihood of a kiddo having theallergy as opposed to other
blood tests are just not reallyas helpful, for whatever reason.
Or like some foods like a verylow cashew IgE number can be
(18:34):
very relevant, as opposed to avery low soy number might not be
, might not indicate as stronglythat this child is very likely
to be allergic.
So not all tests are createdequal.
Not all results should beinterpreted equal to each other.
But once you're doing a testyou have to have a game plan for
(18:56):
how you're going to help thatfamily.
Or I, as an allergist, have tohave a game plan for how I'm
going to help that family getthe food into the diet, because
what I don't want to do istesting and say, okay, well, all
this testing is positive,you're allergic, see you later.
If the testing's positive, thenwe say we really dive into the
history really and say have theyever had any of this food?
Let's do some ingestionchallenges here, unless the
(19:23):
numbers are crazy high, and eventhen we're having discussions
right, because before I'mcommitting someone to a
diagnosis, we're having adiscussion.
So, doing the ingestionchallenge to say, okay, pecans
are safe for you, and walnutsand pecans, they cross-re react.
Walnuts are safe for you,cashew, pistachio they cross
react.
Doing a challenge to cashew,it's positive.
Ok, cashew is not safe for you,pistachio is not safe for you.
(19:46):
So you can see that I'm notjust doing a test and saying, ok
, you're allergic.
The testing does not say whetheror not someone is allergic.
I'll repeat that Testing doesnot confirm that someone is
allergic.
Testing positive tests help usrisk stratify whether or not we
(20:09):
think someone is allergic.
They help us inform whether ornot we think someone is allergic
.
But it's really that next stepof the ingestion challenge
that's going to tell us whetheror not this person is indeed
allergic.
And there are plenty of kids who, for multiple reasons one of
the biggest reasons they haveeczema.
(20:31):
They have positive tests tolots of things.
That doesn't mean they'reallergic to all those things.
So you can see, it's veryimportant when you, as a parent,
are told that X, y and Zallergy tests are positive, it
doesn't mean that they'repositive for the allergy.
(20:52):
It doesn't mean your kiddo ispositive for the allergy, it
means that there's an increasedlikelihood that your kiddo is
positive for the allergy.
It means that there's anincreased likelihood that your
kiddo has an allergy becauseyour kiddo is sensitized.
They have positive tests, theyare sensitized, but they should
not be deemed clinicallyallergic until there is clinical
suspicion, meaning they haveingested the food and have had
(21:14):
symptoms that suggest that theyare clinically allergic.
And again I will say look, ifyou have an ERA H2, which is a
peanut component test that isgreater than 100, then chances
are, yes, you are allergic topeanuts, but not all testing is
that slam dunk and I'll tell you, I guarantee you, there's
(21:34):
someone out there who has thatnumber and they're tolerant of
peanuts, for whatever reason.
So all of this to come back tothe importance of the ingestion
challenge being a part of thediscussion when you and your
allergist are talking about whatis it that your kiddo is
allergic to?
(21:54):
And really the thought of, okay, going back and seeing your
allergist every year to repeattesting.
Like yeah, that's totally fine,good, like, stay engaged with
your allergist.
I like to see my patients atleast twice per year, especially
now.
School forums, new treatmentsfor food allergies, new tests,
just there's so much more in theworld of food allergy now
(22:17):
compared to even like five yearsago, right?
So I like to see my patientsevery six months and I also like
to stay engaged in what's goingon with them have they had
accidental ingestions?
Just all the things so that Ican provide them with the most
advanced care.
But when you're doing that sortof annual skin testing and or
blood testing, you want it to bewith a reason, and the reason
(22:38):
is how is it going to change ourplan?
Meaning okay, if the testing islooking like things are,
numbers are going down and maybeyou've had an accidental
ingestion and there's been noreaction, then absolutely, maybe
we should be doing an ingestionchallenge and those numbers are
helping to inform thelikelihood of okay.
(22:59):
Do we think that it's going tobe a positive challenge?
There are numbers that givesort of a positive predictive
value of when a challenge isgoing to be positive, but I'll
tell you, nothing is 100%.
So I don't, I absolutely don'tthink allergists should be doing
ingestion challenges justwilly-nilly and being cavalier
(23:19):
about anything.
But I know that sometimeschildren are committed to
diagnoses that they don't have,all because an ingestion
challenge has not been performed.
Wrapping up here ingestionchallenges are super important.
They should be done byboard-certified allergists who
(23:40):
are well-versed in performingthese procedures because, again,
there is risk to theseprocedures.
But they're definitelyimportant in helping families
navigate life with foodallergies because, first and
foremost, they're confirming orruling out whether or not they
even need to avoid a food.
Also, even with positivechallenges, when kiddos have
reactions, there's stillevidence that support that it
(24:02):
improves the family's quality oflife.
I've had families tell me okay,well, now you know, I've seen
this now and I've treated it nowand that will help them moving
forward.
It empowers them to be moreconfident that should their
child have an axon ingestion,they know how to manage it
because they did manage it.
(24:25):
So if your kiddo has a foodallergy and or has been
diagnosed with a food allergybut has never had an ingestion
challenge, then I woulddefinitely encourage you to talk
with your allergist about whenshould you guys do an ingestion
challenge and also, of course,talk about the latest therapies
available for food allergies.
(24:45):
Whether it's oral immunotherapyor sublingual immunotherapy.
You always want to do anevidence-based type of treatment
for food allergy and rememberavoidance is still absolutely a
management strategy for foodallergies.
So don't ever feel like you'renot being proactive for your
child if you're not doingimmunotherapy.
That is not an accuratestatement.
(25:07):
So that's the show on ingestion.
Challenges, questions, comments, reach out, comments, reach out
.
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
(25:28):
episode and visit us atfoodallergyandyourkiddocom where
you can submit your family'squestions.
God bless you and God blessyour family.
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