Practical protocol of the food allergy committee of the seicap on open oral food challenges to nuts

Main Article Content

Cristina Blasco Valero
Ángela Claver Monzón
Natalia Molini Menchón
Antonio Martorell
Carlos García Magán
Sara Pereiro Fernández
Celia Pinto Fernández
Mónica Piquer Gibert
Ana Prieto del Prado
Laura Valdesoiro Navarrete
Marta Vázquez Ortiz
Luis Echeverría Zudaire


nuts, seeds, food allergy, oral food challenge


Food allergy is rising rapidly among children, and allergy to nuts is one of the most prevalent allergies among them. The category “nuts and seeds” include several plant foods from different botanical families, very different from each other. It is not uncommon to detect co-sensitization to different nuts. However, true co-allergy is less frequent. Up to 80% of patients with positive skin prick tests or specific IgE without true history of reaction who avoid certain nuts, might tolerate them in an Oral Food Challenge (OFC). Although molecular diagnostic techniques help to improve nut allergy diagnosis, OFC still remains the gold standard. For this reason, after reviewing the current bibliography and the recommendations of different allergy societies on standardization of open OFC, the Food Allergy Committee of the Spanish Society of Pediatric Allergy, Asthma and Clinical Immunology (SEICAP) food allergy working group proposed a unified protocol to undertake these OFC, which include preliminary recommendations, unification of total dose, number of doses and interval between doses. Additionally, this group offers an interactive table to facilitate calculation of doses specific to each nut under study.

Abstract 810 | PDF Downloads 689 HTML Downloads 187 XML Downloads 14


1. Peters RL, Koplin JJ, Gurrin LC, Dharmage SC, Wake M, Ponsonby AL, et al. The prevalence of food allergy and other allergic diseases in early childhood in a population-based study: HealthNuts age 4-year follow-up. J Allergy Clin Immunol. 2017 Jul;140(1):145–153. 10.1016/j.jaci.2017.02.019

2. Midun E, Radulovic S, Brough H, Caubet JC. Recent advances in the management of nut allergy. World Allergy Organ J. 2021 Jan 13;14(1):100491. 10.1016/j.waojou.2020.100491

3. Eigenmann PA, Lack G, Mazon A, Nieto A, Haddad D, Brough HA, et al. Managing nut allergy: a remaining clinical challenge. J Allergy Clin Immunol Pract. 2017 Mar–Apr;5(2):296–300. 10.1016/j.jaip.2016.08.014

4. Gur CP, Buyuktiryaki B, Soyer O, Murat SU, Sack-esen C, Sekerel BE. Phenotypical characterization of tree nutsand peanut allergies in east mediterranean children. Allergol Immunopathol (Madr). 2020 Jul-Aug;48(4):316–322. 10.1016/j.aller.2019.07.005

5. Datema MR, Zuidmeer-Jongejan L, Asero R, Barreales L, Belohlavkova S, de Blay F, et al. Hazelnut allergy across europedissected molecularly: A EuroPrevall outpatient clinic survey. JAllergy Clin Immunol. 2015;136:382–391. 10.1016/j.jaci.2014.12.1949

6. King RM, Knibb RC, Hourihane JO. Impact of peanut allergy on quality of life, stress and anxiety in the family. Allergy. 2009 Mar;64(3):461–468. 10.1111/j.1398-9995.2008.01843.x

7. Elizur A, Appel MY, Nachshon L, Levy MB, Epstein-Rigbi N, Golobov K, Goldberg MR. NUT Co Reactivity-acquiring knowledge for elimination recommendations (NUT CRACKER) study. Allergy. 2018 Mar;73(3):593–601. 10.1111/all.13353

8. Ram G, Cianferoni A, Spergel JM. Food allergy to uncommonly challenged foods is rare based on oral food challenge. J Allergy Clin Immunol Pract. 2016 Jan–Feb;4(1):156–157. 10.1016/j.jaip.2015.07.017

9. Beyer K, Grabenhenrich L, Härtl M, Beder A, Kalb B, Ziegert M, et al. Predictive values of component-specific IgE for the outcome of peanut and hazelnut food challenges in children. Allergy. 2015 Jan;70(1):90–98. 10.1111/all.12530

10. Brough HA, Caubet JC, Mazon A, Haddad D, Bergmann MM, Wassenberg J, et al. Defining challenge-proven coexistent nut and sesame seed allergy: A prospective multicenter European study. J Allergy Clin Immunol. 2020 Apr;145(4):1231–1239. 10.1016/j.jaci.2019.09.036

11. Bird JA, Leonard S, Groetch M, Assa’ad A, Cianferoni A, Clark A, et al. Conducting an oral food challenge: an update to the 2009 adverse reactions to foods committee work group report. J Allergy Clin Immunol Pract. 2020 Jan;8(1):75–90. 10.1016/j.jaip.2019.09.029

12. Sampson HA, Gerth van Wijk R, Bindslev-Jensen C, Sicherer S, Teuber SS, Burks AW, et al. Standardizing double-blind, placebo-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;130:1260–1274. 10.1016/j.jaci.2012.10.017

13. Bindslev-Jensen C, Ballmer-Weber BK, Bengtsson U, Blanco C, Ebner C, Hourihane J, et al. European academy of allergology and clinical immunology. standardization of food challenges in patients with immediate reactions to foods—position paper from the european academy of allergology and clinical immunology. Allergy. 2004 Jul 59(7):690–697. 10.1111/j.1398-9995.2004.00466.x

14. Verhoeckx KCM, Vissers YM, Baumert JL, Faludi R, Feys M, Flanagan S, et al. Food processing and allergenicity. Food Chem Toxicol. 2015 Jun;80:223–240. 10.1016/j.fct.2015.03.005

15. T Rahaman, T Vasiljevic, L Ramchandran. Effect of processing on conformational changes of food proteins related to allergenicity. Trends in Food Science & Technology. 2016:49:24e34. 10.1016/j.tifs.2016.01.001

16. Masthoff LJ, Hoff R, Verhoeckx KC, van Os-Medendorp H, Michelsen-Huisman A, Baumert JL, et al. A systematic review of the effect of thermal processing on the allergenicity of tree nuts. Allergy. 2013 Aug;68(8):983–993. 10.1111/all.12185

17. Beyer K, Morrow E, Li XM, Bardina L, Bannon GA, Burks AW, et al. Effects of cooking methods on peanut allergenicity. J Allergy Clin Immunol 2001;107:1077–1081. 10.1067/mai.2001.115480

18. Bases de datos Española de Composición de Alimentos [Consorcio BEDCA y Agencia Española de Seguridad Alimentaria y Nutrición].

19. Bird JA, Groetch M, Allen KJ, Bock SA, Leonard S, Nowak-Wegrzyn AH, et al. Conducting an oral food challenge to peanut in an infant. J Allergy Clin Immunol Pract. 2017 Mar-Apr;5(2):301–311. 10.1016/j.jaip.2016.07.019

20. Zhu J, Pouillot R, Kwegyir-Afful EK, Luccioli S, Gendel SM. A retrospective analysis of allergic reaction severities and minimal eliciting doses for peanut, milk, egg, and soy oral food challenges. Food Chem Toxicol. 2015 Jun;80:92–100. 10.1016/j.fct.2015.02.023

21. Houben GF, Baumert JL, Blom WM, Kruizinga AG, Meima MY, Remington BC, et al. Full range of population Eliciting Dose values for 14 priority allergenic foods and recommendations for use in risk characterization. Food Chem Toxicol. 2020 Dec;146:111831. 10.1016/j.fct.2020.111831

22. Westerhout J, Baumert JL, Blom WM, Allen KJ, Ballmer-Weber B, Crevel RWR, et al. Deriving individual threshold doses from clinical food challenge data for population risk assessment of food allergens. J Allergy Clin Immunol. 2019 Nov;144(5):1290–1309. 10.1016/j.jaci.2019.07.046

23. Van Erp FC, Knulst AC, Kok IL, van Velzen MF, van der Ent CK, Meijer Y. Usefulness of open mixed nut challenges to exclude tree nut allergy in children. Clin Transl Allergy. 2015 May 16;5:19. 10.1186/s13601-015-0062-y

24. Nachshon L, Zipper O, Levy MB, Goldberg MR, Epstein-Rigby N, Elizur A. Subjective oral symptoms are insufficient predictors of a positive oral food challenge. Pediatr Allergy Immunol. 2021 Feb;32(2):342–348. 10.1111/pai.13392