Frequency of positive oral food challenges and their outcomes in the allergy unit of a tertiary-care pediatric hospital

Main Article Content

Guilia Ballini
Chiara Gavagni
Caterina Guidotti
Giulia Ciolini
Giulia Liccioli
Mattia Giovannini
Lucrezia Sarti
Daniele Ciofi
Elio Novembre
Francesca Mori
Simona Barni


children; food allergy; food protein-induced enterocolitis syndrome; IgE mediated; oral food challenge; trigger food


Introduction and objective: The oral food challenge (OFC) is the gold standard to diagnose food allergy (FA); however, it is not a procedure free from the risk of having significant allergic reactions, even life-threatening.
The aims of our study were to evaluate the frequency of positive OFCs performed in chil-dren with a suspected diagnosis of IgE- and non-IgE–mediated (food protein–induced enterocolitis syndrome (FPIES)) FA and how the failed challenges were managed.
Materials and methods: A retrospective chart review was done on all children who have had OFCs in a tertiary-care pediatric allergy unit from 2017 to 2019.
Results: 682 patients were enrolled and 2206 challenges were performed: 2058 (93%) for IgE-mediated FA and 148 (7%) for FPIES. There were 262 (11.8%) challenge failures. The transfer to the emergency department was required 3 times (1.1%). None of the failed challenges resulted in death or hospitalization and 13.3% challenges did not require any treatment.
Conclusions: Our findings confirm that food challenges can be performed safely in a specialized setting by well-trained personnel; all food challenge reactions, even the most serious, were reversible, thanks to a prompt recognition and treatment that generally did not worsen over time.

Abstract 26 | PDF Downloads 20 XML Downloads 0 HTML Downloads 0


1. Calvani M, Bianchi A, Reginelli C, Peresso M, Testa A. Oral food challenge. Medicina (Kaunas). 2019;55(10):651. https://
2. Perry TT, Matsui EC, Conover-Walker MK, Wood RA. Risk of oral food challenges. J Allergy Clin Immunol. 2004;114(5):1164–1168.
3. Connors L, O’Keefe A, Rosenfield L, Kim H. Non-IgE-mediated food hypersensitivity. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):56.
4. Itazawa T, Adachi Y, Takahashi Y, Miura K, Uehara Y, Kameda M, et al. The severity of reaction after food chal-lenges depends on the indication: a prospective multicenter study. Pediatr Allergy Immunol. 2020;31(2):167–174. https://
5. Wang KY, Lee J, Cianferoni A, Ruffner MA, Dean A, Molleston JM, et al. Food protein-induced enterocolitis syndrome food challenges: experience from a large referral cen-ter. J Allergy Clin Immunol Pract. 2019;7(2):444–450.
6. Pena LE, Guffey D, Minard CG, Anvari S, Davis CM. The role of intravenous access during oral food challenges in food protein-induced enterocolitis syndrome. Allergy Asthma Proc. 2017;38(6):467–473.
7. Sampson HA, van Wijk RG, Bindslev-Jensen C, Sicherer S, Teuber SS, Burks AW, et al. Standardizing double-blind, pla-cebo-controlled oral food challenges: American Academy of Allergy, Asthma & Immunology-European Academy of Allergy and Clinical Immunology PRACTALL Consensus Report. J Allergy Clin Immunol. 2012;130(6):1260–1274. https://doi. org/10.1016/j.jaci.2012.10.017
8. Muraro A, Werfel T, Hoffmann-Sommergruber K, Roberts G, Beyer K, Bindlsev-Jensen C, et al. EEACI food allergy and anaphylaxis guidelines: diagnosis and management of food Allergy. Allergy. 2014;69(8):1008–1025. all.12429
9. Nowak-Węgrzyn A, Chehade M, Groetch ME, Spergel JM, Wood RA, Allen K, et al. International consensus guidelines for the diagnosis and management of food protein–induced enterocolitis syndrome: executive summary. Workgroup Report of the Adverse Reactions to Foods Committee, American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol. 2017;139(4):1111–1126.e4. https://doi. org/10.1016/j.jaci.2016.12.966
10. Barni S, Sarti L, Mori F, Liotti L, Pucci N, Novembre E. A mod-ified oral food challenge in children with food protein-induced enterocolitis syndrome. Clin Exp Allergy. 2019;49:1–4. https://
11. Niggemann B, Beyer K. Time for a new grading system for allergic reactions? Allergy. 2016;71(2):135–136.
12. Akuete K, Guffey D, Israelsen RB, Broyles JM, Higgins LJ, Green TD, et al. Multicenter prevalence of anaphylaxis in clinic-based oral food challenges. Ann Allergy Asthma Immunol. 2017;119(4):339–348.
13. Cianferoni A, Khullar K, Saltzman R, Fielder J, Garrett JP, Naimi DR, et al. Oral food challenge to wheat: a near-fatal anaphylaxis and review of 93 food challenges in children. World Allergy Organ J. 2013;6(1):14. https://doi. org/10.1186%2F1939-4551-6-14
14. Weinberger T, Rowland JC, Nowak-Wegrzyn A. Food rein-troduction rates following negative oral food challenges to peanut and hazelnut: a survey study. J Allergy Clin Immunol. 2019;7(2):708–710.
15. Srisuwatchari W, Vichyanond P. Oral food challenges: result of a 1–16 year experience at a major teaching hospital in Thailand. Asia Pac Allergy. 2018;8(2):e21. https://doi. org/10.5415%2Fapallergy.2018.8.e21
16. Abrams EM, Becker AB. Oral food challenge outcomes in a pediatric tertiary care center. Allergy Asthma Clin Immunol. 2017;13:43.
17. Beigelman A, Strunk RC, Garbutt JM, Schechtman KB, Jaenicke MW, Stein JS, et al. Clinical and laboratory factors associated with negative oral food challenges. Allergy Asthma Proc. 2012;33(6):467–473.
18. DunnGalvin A, Daly D, Cullinane C, Stenke E, Keeton D, Erlewyn-Lajeunesse M, et al. Highly accurate prediction of food challenge outcome using routinely available clinical data. J Allergy Clin Immunol. 2011;127:633–639. https://doi. org/10.1016/j.jaci.2010.12.004
19. Jarvinen KM, Amalanayagam S, Shreffler WG, Noone S, Sicher SH, Sampson HA, et al. Epinephrine treatment is infrequent and biphasic reactions are rare in food-induced reactions during oral food challenges in children. J Allergy Clin Immunol. 2009;124:1267–1272. jaci.2009.10.006
20. Hossny E, Ebisawa M, El-Gamal Y, Arasi S, Dahdah L, El-Owaidy R, et al. Challenges of managing food allergy in the developing world. World Allergy Organ J. 2019;12(11):100089.
21. McWilliam V, Koplin J, Lodge C, Tang M, Dharmage S, Allen K. The prevalence of tree nut allergy: A systematic review. Curr Allergy Asthma Rep. 2015;15(9):54. s11882-015-0555-8
22. Fleischer DM, Bock SA, Spears GC, Wilson CG, Miyazawa NK, Gleason MC, et al. Oral food challenges in children with a diagnosis of food allergy. J Pediatr. 2011;158(4):578–583.e1.
23. Calvani M, Berti I, Fiocchi A, Galli E, Giorgio V, Martelli A, et al. Oral food challenge: safety, adherence to guidelines and predictive value of skin prick testing. Pediatr Allergy Immunol. 2012;23(8):755–761.
24. Noone S, Ross J, Sampson HA, Wang J. Epinephrine use in positive oral food challenges performed as screening test for food allergy therapy trials. J Allergy Clin Immunol Pract. 2015;3(3):424–428.
25. Benhamou AH, Zamora SA, Eigenmann PA. Correlation between specific immunoglobulin E levels and the severity of reactions in egg allergic patients. Pediatr Allergy Immunol. 2008;19:73– 179.
26. Ruffner MA, Ruymann K, Barni S, Cianferoni A, Brown-Whitehorn T, Spergel JM. Food protein-induced enterocolitis syndrome: insights from review of a large referral population. J Allergy Clin Immunol Pract. 2013;1(4):343–349.
27. Vila Sexto L. Latest insights on food protein-induced enterocolitis syndrome: an emerging medical condition. J Investig Allergol Clin Immunol. 2018;28(1):13–23.
28. Katz Y, Goldberg MR, Rajuan N, Cohen A, Leshno M. The prev-alence and natural course of food protein-induced enterocolitis syndrome to cow’s milk: a large-scale, prospective population-based study. J Allergy Clin Immunol. 2011;127:647– 653.
29. Blackman AC, Anyari S, Davis CM, Anagnostou A. Emerging triggers of food protein-induced enterocolitis syndrome: lessons from a pediatric cohort of 74 children in the United States. Ann Allergy Asthma Immunol. 2019;122(4):407–411.
30. Nomura I, Morita H, Hosokawa S, Hoshina H, Fukuie T, Watanabe M, et al. Four distinct subtypes of non–IgE-mediated gastrointestinal food allergies in neonates and infants, distinguished by their initial symptoms. J Allergy Clin Immunol. 2011;127(3):685–688. jaci.2011.01.019
31. Douros K, Tsabouri S, Feketea G, Grammeniatis V, Koliofoti EG, Papadopoulos M, et al. Retrospective study identified fish and milk as the main culprits in cases of food protein-enterocolitis syndrome. Acta Paediatr. 2019;108(10):1901–1904. https://doi. org/10.1111/apa.14779
32. Xepapadaki P, Kitsioulis NA, Manousakis E, Manolaraki I, Douladiris N, Papadopoulos NG. Remission patterns of food protein-induced enterocolitis syndrome in a Greek Pediatric Population. Int Arch Allergy Immunol. 2019;180(2):113–119.
33. Nowak-Wegrzyn A, Sampson HA, Wood AW, Sicherer SH.
Food protein-induced enterocolitis syndrome caused by solid food Proteins. Pediatrics. 2003;111(4):829–835. https://doi. org/10.1542/peds.111.4.829
34. Mehr S, Frith K, Barnes EH, Campbell DE. Food protein-induced enterocolitis syndrome in Australia: a population-based study, 2012–2014. J Allergy Clin Immunol. 2017;140(5):1323–1330.
35. Infante S, Marco-Martin G, Sanchez-Domìniguez M, Rodriguez-Fernandez A, Fuentes-Aparicio V, Alvarez-Perea A, et al. Food protein-induced enterocolitis syndrome by fish: not necessarily a restricted diet. Allergy. 2018;73(3):728–732.
36. Pérez Ajami RI, Carriòn Sari SK, Aliaga Mazas Y, Boné Calvo J, Guallar Abadia MI. Experience in food protein-induced enterocolitis syndrome in a pediatric allergy clinic. An Pediatr (Barc). 2020;92(6):345–350.
37. Diaz JJ, Espìn B, Segarra O, Dominguez-Ortega G, Blasco-Alonso J, Cano B, et al. Food protein-induced enterocolitis syndrome: data from a multicenter retrospective study in Spain. J Pediatr Gastroenterol Nutr. 2019;68(2):232–236.
38. Miceli Sopo S, Monaco S, Badina L, Barni S, Longo G, Novembre E, et al. Food protein-induced enterocolitis syndrome caused by fish and/ora shellfish in Italy. Pediatr Allergy Immunol. 2015;26(8):731–736.
39. Katz Y, Goldberg MR. Natural history of food protein-induced enterocolitis syndrome. Curr Opin Allergy Clin Immunol. 2014;14(3):229– 239.
40. Jarvinen KM, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES): current management strategies and review of the literature. J Allergy Clin Immunol Pract. 2013;1(4):317–322.