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August 4, 2017
Members of the allergy community’s hearts go out to 3 year-old Alastair Watson’s family and friends. Alastair died during a routine oral food challenge this week. His death is a tragedy, and we cannot even imagine the horror of this loss.
Oral food challenges have been conducted for decades to test whether someone is allergic to a certain food. This is the first reported fatality associated with an oral food allergy challenge. While even one death is too many, oral food challenges are considered the ‘gold standard’ test to determine if someone is allergic to a food. Allergists use this test when a person’s medical history and/or allergy test results are inconclusive. They are also given to determine if someone with previously diagnosed food allergy has developed tolerance, and may no longer be allergic.
Food allergies currently affect approximately 8 percent of children. Reactions, when they occur, are unpredictable in terms of their severity. Though extremely uncommon, fatalities have occurred related to food allergy. This is why basic management of food allergy includes strict avoidance, carrying an epinephrine auto-injector so it is immediately available at all times, and having a plan for how and when to use such a device.
Diagnosing food allergy is not always simple, but the need to make a proper diagnosis is very important. People need to know exactly what foods to avoid. They also need to know if they are not allergic to certain foods to prevent unnecessary dietary elimination or avoidance. Skin prick and specific IgE blood tests are routinely used to help diagnose food allergy, but unfortunately are not perfect, and require proper evaluation. Board-certified allergists receive specialized training and experience in conducting oral food challenges and are well-equipped to perform this essential procedure.
Oral food challenges should only be conducted when the following steps have been taken, which help to ensure patient safety to the greatest extent possible:
- They are conducted by a provider who is well-trained and experienced with food allergy and anaphylaxis management, has experience in performing an oral food challenge, and there is an established procedure for conducting the challenge.
- There is a proper office or hospital-based set-up, which includes a procedure for preparing and administering the food item by well-trained and experienced staff; layered supervision for the patient, including dedicated nursing and a supervising medical provider close by; a plan for treatment of any resulting reaction; and a post-feeding patient observation period. Resuscitation equipment must be available in case it is needed.
- Documentation of informed consent prior to the challenge should detail that the risks and benefits of the procedure were explained to the patient or caregiver, and that these risks were understood.
- A plan for advising the patient after the procedure based on the outcome.
There are multiple aspects of a person’s history that must be considered to help determine if they are a candidate for an oral food challenge. Challenges are very often cancelled if the patient is having poor asthma control, has had a recent asthma flare, or has had a recent or concurrent illness. These, as well as multiple other factors, can increase the risk of a reaction occurring and potentially influence how severe a reaction is.
The oral food challenge is a safe and very reliable procedure in the hands of well-trained, experienced, and prepared providers. We hope if you have any questions regarding the safety of oral food challenges that you will speak to an allergist in your area to provide you with needed information.
Statement by the American College of Allergy, Asthma & Immunology; American Academy of Allergy, Asthma & Immunology; and the Canadian Society of Allergy and Clinical Immunology.