Can we make oral food challenges safer?

August 28, 2017

As I suspect most of you have heard, there was a recent fatality during a supervised oral food challenge in a three-year-old boy in Alabama. As a grandfather, I can only imagine the grief his family and friends are enduring. I also feel for the traumatic effect this may have had on the team of health care professionals involved with his care. As reported in a joint communication between the American College of Allergy, Asthma, and Immunology, the American Academy of Allergy, Asthma, and Immunology, and the Canadian Society of Allergy and Clinical Immunology, we do not know the critical details of this event. We do know this was the first known fatality during this kind of oral challenge, and that other food allergy fatalities – such as those occurring due to accidental ingestion of a food allergen – are also exceedingly rare. Nevertheless, one death is too many, and in my opinion, as practicing allergists we should not minimize the tragic fatality that occurred in Alabama.

So, how does this recent tragedy fit into the grand scheme of how allergists approach food allergy? Are we doing too many oral challenges? Should we limit oral challenges to hospital-based referral centers? Should every food allergen ingestion be treated with intramuscular epinephrine?

Now is a time of reflection on our practice standards and systems for providing safe and effective care. At the same time, without reliable biomarkers for confirming food allergy, and with increasing evidence that appropriate exposure to certain food allergen(s) in question appears to be beneficial as a strategy for primary prevention, secondary prevention, and possibly facilitating the transition from a “desensitized” to “tolerant” state, removing oral food challenges from our tool kit is not a reasonable solution.

When I think about what separates practicing allergists from other physicians, one of the first things that comes to mind is our proficiency and experience treating anaphylaxis. Most of this expertise comes from our remarkable track record keeping our patients safe during subcutaneous immunotherapy treatment for allergic rhinitis, allergic asthma, and venom allergy. Over the course of an allergist’s career, he or she typically oversees tens of thousands of immunotherapy injections, and perhaps hundreds of systemic reactions to these reactions. In contrast, while most of us have seen a dramatic increase in the number of food allergy patients in our practices, we do not have the same volume of collective experience managing acute food allergic reactions during supervised challenges. No doubt our experience managing systemic reactions to SCIT helps us when managing food challenge reactions, though there are important differences between SCIT reactions and food reactions. For example, food challenge patients tend to be younger, food challenges are intended to provoke symptoms rather than administer allergen below the reaction threshold, and the usual patterns of systemic reaction symptoms during food challenges and SCIT reactions differ.

I strongly support the joint statement of the College and its colleagues at the Academy and the Canadian Society. The focus of this document was to remind the practicing allergist of the importance of adhering to accepted standards of safety when performing food challenges. In addition, I propose that the College and other allergy specialty societies consider an anaphylaxis educational initiative that specifically focuses on the differences between SCIT and food challenge reactions. By using SCIT as a comparator while educating allergists on food allergy anaphylaxis management, I believe we can more effectively highlight the potential pitfalls managing food challenge reactions that might otherwise take decades to achieve.

Stephen A. Tilles, MD, FACAAI
ACAAI President