Allergy Shmallergy

Simplifying life for families with food allergies.

What is an Oral Food Challenge and How to Prepare February 5, 2018

Let’s start right from the beginning:

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What is a food challenge?

 

Sometimes a skin prick test and/or a blood test does not give a doctor enough information to know if a patient is truly allergic to a particular food.  A food challenge, sometimes known as an Oral Food Challenge (OFC) or just oral challenge, is the best way for an allergist to evaluate a patient’s allergic response.

 

Food challenges are sometimes used to diagnose a food allergy.  While skin prick tests and blood tests are great indicators of a food allergy, they cannot help a doctor or patient understand their individual risk of a reaction.  Only the Oral Food Challenge can demonstrate a person’s true sensitivity to a given food.

 

Oral challenges are also helpful in determining whether a patient has outgrown a food allergy.  Doctors will suggest an oral food challenge when they believe an individual may successfully tolerate a food they previously tested allergic to.

 

How does it work?

For a variety of reasons, doctors may want to test a patient against his/her food allergy.  In a doctor’s office or hospital setting, food is given to that patient every 15 to 30 minutes – beginning with a very small amount and increasing with each “dose”.  The patient is observed and medically evaluated at each interval to check for symptoms of a reaction.  Feeding typically continues until a full portion of that food is consumed safely.

 

If the doctor sees symptoms of a reaction, he/she will stop the test.   If, on the other hand, there are NO symptoms, your doctor may rule out a food allergy and discuss ways to manage that food going forward.

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Where do you go for a food challenge?  Can I do it myself at home?

OFCs are ONLY conducted in a doctor’s office or hospital setting and should only be done under a doctor’s supervision.  It is critical that the patient be checked by a doctor or nurse at each stage in the process for a reaction.  And, should such a reaction occur, the medical staff are on-site ready to respond immediately.

 

You SHOULD NEVER conduct an oral food challenge at home.

 

How safe are OFCs?

 

Food challenges have an excellent safety record because allergists and trained professionals follow medical standards and procedures for the test and they are prepared to handle any emergency that arises.  Thousands of OFCs have been performed worldwide safely.

 

Be aware, there is a risk for an allergic reaction with this test which is why it MUST be performed by a doctor in a medical setting.  The most common reactions in an oral challenge are mild skin and stomach reactions which are typically treated with antihistamines.  Allergists are prepared to use epinephrine and other medications in the unlikely event that a more severe reaction occurs.

 

That said, most doctors recommend an oral challenge when they believe the patient will pass this test.  They try to set their patients up for success.

 

How do I prepare for a food challenge?

 

1.  Remind yourself and/or your child that there is no “passing” or “failing” an oral challenge – there are only results.  In this way, you can keep anticipation and disappointment in check.  [But feel free to go crazy celebrating if you’re able to add another food to your diet later!]

 

2. Have a conversation with your allergist’s office about what to bring and how to prepare it.  Allergists typically recommend how to prepare the food you are testing for.  For example, when my son tested for soy, we brought soy milk; for wheat, we brought toast; for milk and egg, we were instructed to make muffins and French Toast using a particular recipe.  Depending on your child’s age and particular tastes, the allergist may be able to alter the recommended food to make it more palatable.

 

3. You will need to stop taking antihistamines as well as some other medications for at least one week prior to your appointment.  Discuss this with your doctor’s office for further instructions.  ALWAYS take emergency medication (such as a rescue inhaler or epinephrine) should you need it leading up to the oral challenge. Oral challenges can be postponed if need be.

 

4. Prepare for the day.  Oral Food Challenges often take several hours.  Think about what will amuse you and your child for that period of time.  Consider coloring books, small lego sets, matchbox cars, books, a portable DVD player or iPad.  And, yes, that means you might arrive with a giant “tote bag of fun,” looking like you’re ready to move into the doctor’s office like I did.

 

5. Write down questions about the possible results of the test as you go along,  You should have a chance to discuss the results after the challenge has finished.  Some questions you may wish to ask if you can add a new food:

  • What do the results tell us about my allergy?
  • Are there any limits to the quantity/variations of this new food we can add?
  • Can we add this food in its baked AND unbaked forms?
  • What symptoms should I look for over the next few hours and days?
  • Does this alter my Emergency Action Plan?  Can you fill out a new plan so that I can copy this information for the school nurse, after care, babysitter, etc?

 

 

For those of you who have experienced an oral challenge: what advice would you add?

 

Prep Your Meds for School: Refill Options July 28, 2017

Time to get your emergency medications ready for school.  Don’t worry:  there’s still lots of summer fun to be had!  But to maximize summer fun over back-to-school frenzy, there are a few things you can do.

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  1. Check the Date:  Check the expiration dates on your epinephrine auto-injectors.  If they are due to expire between now and December, it may be a good time to consider refilling your prescription.
  2. Know Your Options:
    • There are several choices of epinephrine auto-injectors these days and they all efficiently deliver the same life-saving drug (epinephrine) in different ways.  I’ll outline those different auto-injectors below.
    • Talk to your doctor and consider your lifestyle when choosing your auto-injector.
    • Be sure you, your school nurse, caretaker, and child are all familiar with how to operate the auto-injector(s) you choose to stock at home, school and elsewhere.
  3. Update Your Emergency Action Plan:  Your doctor may have provided you with one or you can take Allergy Shmallergy’s Emergency Action Plan to your doctor on your next appointment.  Make a copy for home, your car, on-the-go, and school.
  4. Ask Directly:  You may need to ask your doctor specifically for the auto-injector you wish to use.  Some doctors prescribe only one without discussion, but are certainly willing to write a prescription for the auto-injector that works best for you.

 

What ARE the options for epinephrine auto-injector:

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Auvi-Q:

Yes, it’s back on the market and better than ever.  Auvi-Q delivers epinephrine via a compact package that speaks to you.  You heard that right: it talks you through an injection, even counting down the length of time you are supposed to hold the device in place.  Plus, the needle automatically retracts, reducing the possibility of post-injection injury.  Each Auvi-Q is about the size of a deck of playing cards, easy to carry for everyone (especially teens, young adults and fathers – who can fit them in their pockets).

 

*Auvi-Q automatically ships and delivers their auto-injectors directly to you.  Initiate this process with your doctor.  To read more about their direct delivery service as well as their cost-coverage programs, refer to the Affordability program page.

 

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Adrenaclick:

Adrenaclick has a slimmer profile than the well-know EpiPen, but is about the same length. Adrenaclick is a no frills epinephrine auto-injector, often used as a generic for EpiPen.  In fact, responding to the rising costs of brand name epinephrine auto-injectors, CVS pharmacies (among others) replaced its stock of auto-injectors with Adrenaclick. In their words, “Patients can now purchase the authorized generic for Adrenaclick®… This authorized generic is a Food and Drug Administration (FDA)-approved device with the same active ingredient as other epinephrine auto-injector devices.”

 

*IMPORTANT, Adrenaclick operates differently than EpiPens and they DO NOT come with a trainer.  If you choose to use this useful auto-injector, be sure to also place an order for an Andrenaclick trainer.  And, do your research for best pricing locally.

 

EpiPen:

EpiPens are the most widely used and most familiar of the epinephrine auto-injectors.  In fact, its familiarity is what keeps many customers coming back.  School nurses and even non-allergic individuals may be more accustomed to its look and how to use it.  In addition, EpiPens are substantial – making them easy to find in a backpack or purse.  In 2016 Mylan, the manufacturers of EpiPen, released a generic of its own product in response to public pressure over its pricing.  Both products contain the same medication and use the same or similar injector mechanisms.  EpiPen’s price has not been reduced in any way and is the most expensive auto-injector on the market.  The generic version is less expensive, but still a price worth considering for many.

*Mylan does offer coupons which can be found on their website.

 

Understanding the New Peanut Allergy Prevention Guidelines January 31, 2017

**Not a medical professional.  As always, please discuss specific recommendations for your child with your doctor.  The below is to inform you of pediatric guideline changes and their purpose.**

 

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Earlier this month, experts from the National Institute of Allergy and Infectious Disease (NIAID) issued new recommendations to help families prevent peanut allergies.

 

While there are a lot of intricacies involved in the research and its findings, the results are clear:  early introduction of peanuts can help prevent the development of a peanut allergy.  And, that’s big news!

 

Background:

Peanut allergies (and food allergies in general) are a growing problem.  The rate of food allergy has doubled in the last 10 years alone.  And, only 1 of every 4 children allergic to peanuts will outgrow their allergy.

 

Prior to 2000, doctors didn’t give new parents much advice about feeding their infants allergenic foods (such as milk, eggs, peanuts, fish, etc).  Beginning around 2000, the general consensus was that delayed introduction might help developing immune systems handle these proteins more efficiently.  In 2008, doctors didn’t really give parents a strong direction either way.  However, that same year, researchers compared the rate of peanut allergy among Jewish kids in the UK (where they delay introduction), to those in Israel (where they feed a peanut-based snack as some of their babies’ first foods) and were stunned to see the difference.  Children in Israel had a far smaller rate of peanut allergy than their counterparts in the United Kingdom.  It became clear doctors and researchers needed to revisit their guidance.

 

Thus, began the 5 year LEAP study (Learning Early about Peanut Allergy), one of the most successful allergy trials that has been conducted to date.  It took children with severe eczema or egg allergy and broke them into two groups: one group was fed peanuts early and one avoided them.  Published in the New England Journal of Medicine, the study revealed that early introduction of peanut reduced the incidence of developing a peanut allergy by up to 80% and had lasting effects.

 

Current Recommendations:

Based on their findings, the NIAID broke down their recommendations into three categories:

 

Guideline 1:

If the baby has an egg allergy (which is inexplicably related to peanut allergy) or has severe eczema (a persistent, scaly rash associated with allergy), speak with your doctor or a specialist about testing for peanut allergy.  And, speak with her/him about best ways to proceed with introduction.

 

In their own words, the NIAID states:

“Guideline 1 recommends that if your infant has severe eczema, egg allergy, or both (conditions that increase the risk of peanut allergy), he or she should have peanut-containing foods introduced into the diet as early as 4 to 6 months of age. This will reduce the risk of developing peanut allergy.

Check with your infant’s healthcare provider before feeding your infant peanut-containing foods. He or she may choose to perform an allergy blood test or send your infant to a specialist for other tests, such as a skin prick test. The results of these tests will help to determine if peanut should be introduced into your infant’s diet and, if so, the safest way to introduce it. If your infant’s test results indicate that it is safe to introduce peanut-containing foods, the healthcare provider may recommend that you introduce peanut-containing foods to your infant at home. Or, if you prefer, the first feeding may be done in the healthcare provider’s office under supervision. On the other hand, testing may indicate that peanut should be carefully introduced at a specialist’s facility or not introduced at all because your child may already have developed an allergy to peanut.

Follow your healthcare provider’s instructions for introducing peanut-containing foods to your infant.”

 

Guideline 2:

If your child has mild to moderate eczema, peanut-containing products can be introduced beginning at 6 months of age.  Check with your doctor or specialist to confirm that his/her case of eczema is considered mild to moderate and discuss introduction.

From NIAID:

“Guideline 2 suggests that if your infant has mild to moderate eczema, he or she may have peanut-containing foods introduced into the diet around 6 months of age to reduce the risk of developing peanut allergy. However, this should be done with your family’s dietary preferences in mind. If peanut-containing foods are not a regular part of your family’s diet (and your infant does not have severe eczema, egg allergy, or both), do not feel compelled to introduce peanut at such an early stage.

Your child’s healthcare provider can tell you whether your child’s eczema is mild to moderate. You may then choose to introduce peanut-containing foods at home. However, if you or your healthcare provider prefer, the first feeding can be done in the provider’s office under supervision.”

 

Guideline 3:

If your child does not have an egg allergy OR eczema, you may freely introduce peanuts with other solid foods.

 

The flow chart and summary from Science News, spells it out clearly if you need a visual.

 

 

How DO you introduce peanuts to an infant?  Do I need to look out for anything special?

  • First feeds should be offered after you have tried other first foods (such as rice cereal) so that the baby learns to suck and swallow these news textures and to ensure that your baby tolerates these typical foods.
  •  DO NOT feed babies whole peanuts as they pose a choking hazard.  Babies lack both the teeth and the development to properly manage peanuts.
  • Once introduced, watch for 10 minutes and up to 2 hours for signs of a reaction.  In a baby, you might see: hives, cough or gasping, vomiting, you might notice they are more cuddly and needy.  If you suspect a reaction, seek immediate medical attention.
  • Once tolerated, aim for regular ingestion.  The recommended frequency is 2g of peanut protein three times a week.

 

What does 2g of peanut protein look like?

In Israel, parents feed their children a snack called Bamba – a dissolvable, airy snack that contains peanut protein.  Shaped like a Cheese Doodle, 2/3 bag of Bamba equals 2g of peanut protein.  To begin, you can crush the Bamba and mix it with water to feed.

 

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photo by robinmcnicoll via Flickr – unaltered and posted according to Creative Commons Attribution 2.0

If you’d like to use peanut butter, 2g of peanut protein is equal to 2 tsp or 1 household spoon (as in, from your utensil drawer).  Mix SMOOTH peanut butter with hot water and COOL.  You can then mix it with fruit or vegetable puree before serving.

 

Two grams of peanut flour or protein is equal to 2 tsp.  Again, these can be mixed with fruit or vegetable purees.

 

(Peanut containing cereals were not specifically recommended because of the varying levels of peanut protein as well as sugar and sodium content by brand.)

 

A few notes: 

For those of you, like me, whose children are already allergic.  This is not instruction to begin feeding them peanuts.  DO NOT!

 

And for those of you, like me, who read these guidelines and felt guilty about eating peanuts during pregnancy and breastfeeding… or NOT eating peanuts during pregnancy and breastfeeding…  or delaying introduction (as we were instructed at that time):

 

You did not cause your child’s food allergy.  There IS no single cause of food allergies.  As Dr. Matthew Greenhawt of Children’s Hospital Colorado kindly offered, “This was nobody’s fault.  You followed the best data at the time.  Your avoidance didn’t cause [your child’s] peanut allergy.”  I’ll be honest, I welled with tears hearing this from an allergist.

 

This exciting news represents a paradigm shift in the prevention of food allergies.  Here’s hoping that future generations won’t be plagued by the same number and severity of cases!

 

Download NIAID’s full recommendation report here:  Addendum Guidelines for the Prevention of Peanut Allergy in the United States.