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?


The Dangers of a Dairy Allergy November 17, 2017

cereal and milk pixabay StockSnap


Three year old, Elijah Silvera, was attending a regular day of preschool in New York City recently, when preschool workers fed him a grilled cheese sandwich despite school papers which formally documented his severe dairy allergy.  Elijah had a severe allergic reaction and went into anaphylaxis.  Standard procedure for anaphylaxis is to administer epinephrine and call 911 immediately.  Instead, the school called Elijah’s mother, who picked up her child and drove him to the hospital herself.  Doctors in the emergency room tried but were unable to save him.


Dairy allergy is the most common food allergy among young children.  And, although the peanut can produce some of the most severe allergic reactions (as well as some of the most tragic headlines), an allergy to milk products can be life-threatening.  The myth that a dairy allergy is not serious and doesn’t require as much vigilance causes great frustration to many who are allergic to milk, as does the idea that a food is “allergy free” if it does not contain nuts. To those who live with it, a dairy allergy requires an enormous amount of preparation and education since milk is an ingredient in so many products.


Dairy is cow’s milk and found in all cow’s milk products, such as cream, butter, cheese, and yogurt.  Doctors sometimes advise patients with a dairy allergy to avoid other animals’ milk (such as goat) because the protein it contains may be similar to cow and could cause a reaction.  Reactions to dairy vary from hives and itching to swelling and vomiting, to more severe symptoms such as wheezing, difficulty breathing, and anaphylaxis.  Strictly avoiding products containing milk is the best way to prevent a reaction.  The only way to help stop a severe food allergy reaction is with epinephrine; patients should always carry two epinephrine auto-injectors with them at all times.


Just like other allergens, cross contamination is a concern for those with a dairy allergy. Even a small amount of milk protein could be enough to cause a reaction. For example, butter and powdered cheese (like the kind you might find on potato chips) are easily spreadable in a pan, within a classroom or on a playground.  And, as with other allergens, hand sanitizer does NOT remove the proteins that cause allergic reactions.  Doctors recommend hand washing with good old soap and water – but wipes work in a pinch.


Those allergic to dairy must not only avoid food; they often have to look out for health and beauty products too.  Dairy can be found in vitamins, shampoo, and lotions.  It is critical to read the ingredient labels of every product you buy each time you buy it as ingredients and manufacturing procedures may change.


In the United States, any food product containing milk or a milk derivative must be listed as DAIRY or MILK under the current labeling laws (see The Ins and Outs of Reading Food Labels, Aug. 2016).  If you are living or traveling elsewhere, this list of some alternative names for dairy may be useful:


milk (in all forms: goat, whole, skim, 1%, 2%, evaporated, dry, condensed, etc)
butter (including artificial butter and margarine)
sour cream
half and half
ice cream
whey (all forms)
caseinates (all forms)
casein hydrolysate
lactalbumin (all forms)
rennet casein


Let’s spread the facts about dairy allergy so that our schools and teachers better understand how to accommodate and care for students with food allergies.   Any allergen can produce severe, life-threatening allergic reactions and all food allergies should be taken seriously and managed with attention.  I sincerely  hope that by informing others we can prevent another tragedy like the one the Silvera family was forced to experience.


Important Story: FDA Warning to Mylan, Maker of the EpiPen, on Device Defects and Review November 6, 2017


Earlier this fall, the FDA issued a warning to Mylan, the makers of EpiPens.  In a scathing letter, the FDA highlighted manufacturing defects as well as Mylan’s failure to conduct adequate internal reviews after receiving many complaints about the life-saving device, EpiPen’s malfunctions.  To date, there have been 7 deaths, 35 hospitalizations and 228 complaints about EpiPen and EpiPen Jr. devices this year.  [See F.D.A Accuses EpiPen Maker of Failing to Investigate Malfunctions, New York Times, Sept. 7, 2017]


Following an FDA inspection of the manufacturing plant, FDA’s letter to Mylan describes EpiPens that were leaking epinephrine and others that malfunctioned.  In March of this year, Mylan issued a recall of a small batch of EpiPen and EpiPen Jr devices.


While it is difficult to connect these defects to the deaths reported, as anaphylaxis itself can be deadly even with properly receiving epinephrine, these reports are not encouraging.


In February of this year, we had a frightening experience. [Please read the full story,  The Fire Drill- 5 Key Lessons from an Intensely Scary Night.]  Not long after eating at a restaurant, my 12 year old, food allergic son was rushed home, wheezing severely and coughing.  He was so weak and nauseous that he could barely stumble to the bathroom.  As I asked him questions, trying to evaluate the situation, it was becoming increasingly impossible for him to speak at all.  I wheeled around to grab my EpiPens just steps from where my son sat.  When I turned back around, he was blue.


This is every parent’s worst nightmare.  It was certainly mine.  Amidst the chaos of an increasingly critical and deteriorating situation, my only saving grace was that I held in my hand an EpiPen that would contain the correct amount of the life-saving drug, epinephrine and deliver it safely.


I can’t imagine being in that same moment now, knowing that the EpiPen in my hand may or may not save my son’s life.  That it may or may not have the right dose of medicine.  That the needle may or may not misfire.  Would the knowledge of EpiPen defects cause you to hesitate?  Would you instead call an ambulance that would take even more time to arrive?  When minutes matter, these short hesitations in action, improper delivery of medication, and any other complications that arise during anaphylaxis could be costly…. even deadly.


Bear in mind, Mylan has also increased the cost of EpiPen from $50 in 2008 to over $600 currently.  And, while the high cost of EpiPens are prohibitive, parents are still buying them, and they’re paying for one thing:  reassurance.  They pay for the firm knowledge that this product administers the correct amount of medicine properly every time.  If that can’t be demonstrated, there are plenty of other auto-injectors on the market with a proven track record of reliability to consider.


Despite these less-than-comforting reports, please continue to carry and use your EpiPens and other auto-injectors.  According to the FDA in a recent Bloomberg article, “We are not aware of defective EpiPens currently on the market and recommend that consumers use their prescribed epinephrine auto injector. We have seen circumstances in which adverse events reports increase once a safety issue is publicized, like a recall. We continue to monitor and investigate the adverse event reports we receive.”


I plan to keep you all informed as we continue to follow this story.


To read more on this story, please see EpiPen Failures Cited in Seven Deaths This Year, FDA Files Show posted on Bloomberg, Nov. 2, 2017.


IMPORTANT: EpiPen Recall April 1, 2017

IMG_3211Expanding on its recall in other countries, Mylan is now recalling EpiPens in the United States.


The recall began when reports of two devices outside of the U.S. failed to activate due to a potential defect in a supplier component.


According to Mylan, “The potential defect could make the device difficult to activate in an emergency (failure to activate or increased force needed to activate) and have significant health consequences for a patient experiencing a life-threatening allergic reaction (anaphylaxis). ”


As a precaution, Mylan is recalling EpiPens made my their manufacturer, Meridian Medical Technologies, between December 2015 and July 2016.  This recall applies to both their EpiPen Jr. dose (0.15mg) and their regular dose (0.3mg).   The recall does NOT affect generic EpiPens introduced in December 2016.


Please see below for lot numbers and expiration dates.  Remember to check any EpiPen sets you may have including those outside of your home (for example, at school, daycare or a relative’s house).  Mylan said that recalled EpiPens will be replaced at no cost to the consumer.


For more information as well as product replacement information, please visit Mylan’s site directly.


Mylan EpiPen recall April 2017*Please share widely with friends and family as well as school administrators and nurses.*



If your EpiPens are affected by the recall:

  1.  Contact Stericycle to obtain a voucher code for a free, new replacement EpiPen.  Stericycle: 877-650-3494.  Stericycle will send you a pre-paid return package to ship back your recalled EpiPens.
  2. Bring your voucher information to your local pharmacy to receive your free replacement EpiPens.
  3. Send your recalled EpiPens back to Stericycle using their packaging.  Remember: DO NOT send back your recalled EpiPens until you have replacements in hand.


Mylan continues to update its recall page with their latest information at


Help Fund a Cure for Food Allergies January 10, 2017


“Why can’t I just be like everyone else?”

If you have a child with food allergies, you’ve likely heard this heartbreaking sentiment from your kid.  We’ve all had to console this same child who just wants to put aside his/her food allergies and anxieties even if only for a single day.

Parents would go to any length for the sake of their kids.  Food allergy parents often do by preparing safe food, educating others, strategizing for school, holidays, play dates, and celebrations.


But how many of us have done 3,000 burpees for them?


That’s what fellow food allergy parent, Mike Monroe, plans to do on January 25th in order to raise money for ongoing research for a cure for food allergies.  Mike’s goal is to raise $50,000 to support cutting-edge research examining novel applications of cellular therapy for the millions of kids with food allergies being explored at Children’s National Medical Center in Washington, D.C.



marines_burpee by U.S. Embassy Tokyo via Flickr


What’s a burpee, you might ask?  It’s a combination of push-up/plank, squat and jump performed in combination.  Try one right now!  Do another.  I think you’ll agree: it’s NOT easy!  Mike plans to complete 3,000 of these in under 12 hours.

What can you do to support Mike?


1.  Watch this video about Mike’s incredible motivation – his son, Miles:



2.  Consider a donation:  Every little bit helps get us all closer to a cure for food allergies.

3K Burpee Challenge for Food Allergies

3.  Share this post!  Please share this with your family and friends, share via Facebook, Twitter, Instagram and other social media channels.  Let’s support Mike and researchers to help our own kids and the millions who face life threatening food allergies every day!





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YouTube Video:


The Future of Food Allergies: Recommendations from the Experts December 8, 2016

Last week, the National Academies of Sciences put out a report outlining the gaps in global food allergy management.  Titled, “Finding a Path to Safety in Food Allergy Assessment of the Global Burden, Causes, Prevention, Management, and Public Policy,” the authors made recommendations that would lead to significant change in the quality of life of patients and families living with food allergies.


This was an important and informative report which helps prioritize ways in which we may see adjustments to food allergy diagnosis, information and policy in the future.  I listened to the live presentation while furiously taking notes, but you can read the report for yourself at:

#foodallergies #peanutallergy medical doctor government law


In case you missed it, here are the highlights and some reflections:


Prevalence of Food Allergies:

The committee noted that although no formal studies have been able to corroborate the information, doctors across the country have confidently noted the increased prevalence of food allergies.  Studies of this sort are difficult to conduct and expensive, Dr. Hugh Sampson of the Icahn School of Medicine at Mount Sinai in New York noted.  However, the true prevalence of food allergies would help lawmakers and other health-related institutions prioritize food allergies as the “major health problem” it is in this country.  It is currently estimated that between 12 and 15 millions American are living with food allergies.

Recommendation: The CDC or other organization conduct a food allergy prevalence test that will help inform us of current food allergy levels and serve as a baseline for future assessments.


Standardized Diagnosis:


This is no one, standard way to diagnose food allergies.  Some doctors use skin tests (otherwise known as “scratch tests”) and some use IgE blood tests.  Still others consider the use of IgG testing to detect food intolerances.  Each test varies in conclusiveness and none can accurately predict the reaction a person will have to an allergen.  Only an oral challenge can determine the type and severity of an allergic reaction.


[More on this testing in a separate post.]


Recommendation: Doctors follow a standardized set of tests and protocols to inform them of a patient’s allergy and future medical action.



While there has been much in the news about best strategies to prevent food allergies from developing, advice on the ground from doctors and within parenting circles is lagging.


Recommendation: Clear, concise and solid advice about the early introduction of food and its benefits would greatly help parents and patients alike.


Education and Training

Misconceptions still abound.  Some dangerous.  Timely, proper management of food allergies saves lives.


Recommendation:  The launch of an educational campaign to align doctors, patients and general public regarding the diagnosis, prevention and management of food allergies.  This is especially important in organizations that provide emergency services as well as in medical schools and other healthcare institutions.


Policies and Practices


The list of major allergens identified in each country has not been updated since they were established in 1999.  And, labeling laws (particularly those known as Precautionary Allergen Labels, PALs – “may contain” and “made on equipment with” are two examples) aren’t currently effective at helping consumers assess risk.


Recommendation:  Reassess the priority list of major allergens to better identify regional allergens. Develop a new, risk-based system for labeling – specifically to address issues related to PALs – and outline guidelines for the labeling of prepackaged food such as those distributed at schools, on airlines, and in other public venues. Additionally, the committee recommended that federal agencies re-imagine and standardize food allergy and anaphylaxis response training for employees who work at public venues (schools, airlines, etc).



I was encouraged to listen to the guidance from the committee in each area.  There is certainly a long way to go in getting federal and state-level attention for the growing epidemic that is food allergies.  But by identifying current gaps and taking action to improve communication of standardized, evidence-based information and advice, I am confident we can help improve the lives of those living with food allergies in the near future.