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Child Health Guideline Identifier

Allergy - food challenges at Starship

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Referral information

  1. Check with criteria below as to whether a food challenge is appropriate for your patient. The triage criteria will provide a guide as to likely time frame.
  2. Provide family with the Advice for families information sheet
  3. Complete Referral form
  • Check with family as to short notice availability - there are often cancellations due to intercurrent illness or need for antihistamine, so it is useful to know which families may be able to come at short notice
  1. Send referral to the Allergy Nurse Specialist, c/- Robyn Buchanan, Level 5 Starship
  • Feel free to bring the referral to the Immunology team meeting on Mondays at 2:10pm, in the conference room, level 6 Starship, and we'd be happy to discuss in person

Criteria and triage

The number of food challenge referrals is high. We balance number of accepted referrals against available resources.

When undertaking food challenges we consider:

  • Nutritional importance of a food
  • Difficulty of avoidance of a food
  • A family or child's need to know
  • Ability to affect natural history (eg early peanut, milk in baking, egg in baking)

We give priority to "major" foods, defined here as:

  • Milk, egg, wheat, soy
  • Other foods may be considered relevant depending on cultural issues or comorbidities eg lentil in vegetarian, almond if also Coeliac.

General principles

In general we want patients and families to avoid foods as completely as necessary for as long as required, but also liberalise the diet as soon as safely possible.

  • We use published data to inform probability of tolerance at challenge.
  • We take into account family preference particularly related to the likelihood of tolerance - a 10% chance may be sufficient for some but not others.

The probability of tolerance will be influenced by:

  • Time from previous reaction - in general we do not consider challenge if there has been a reaction on accidental exposure within:
    • 12 months for milk, milk in baking, egg, egg in baking, wheat, soy for children under 5 years
    • 24 months for milk, milk in baking, egg, egg in baking, wheat, soy for children over 5 years
    • 24 months for peanut, nuts, fish, shellfish for children under 5 years
    • 5 years for peanut, nuts, fish, shellfish for children over 5 years
  • Test results (with result from test to be within 3 months of challenge referral)
    • Some challenges are to determine allergy where there is sensitisation but no prior reaction. In this instance we may accept a low probability of tolerance in order to avoid labelling as allergic unnecessarily
    • Where there is known allergy a 50% chance of tolerance at challenge may be appropriate.
    • In general thresholds above which we would generally not consider challenge:
  SPT in <2yr SPT in >2 yr ssIgE in <2 yr ssIgE in >2 yr
Milk   5  7  15  30
Milk in baking Consider*    
Egg   4  6  2
Egg in baking Consider*    
Peanut  8bc  34b  15
Ara h2 >1KuA/l    
Wheat  10a Consider*   Consider* Consider* 
 Soy Any    
 Nuts 8mm   15mm  
 Other Consider*    

a Christensen 2014, b Peters 2013, c Johannsen 2011, d NW 2008
Consider* - depending on age, tests, family preference, single versus multiple allergies etc

Cancellations and short notice patients

To make best use of available challenge slots the service keeps a register of patients (separate to the booking sheets) interested in filling short notice cancellation slots. An extra sticker for these patients should be brought to the Monday team meeting and the short notice cancellation list will be updated at Monday meetings. The list must be readily available to both the Immunology Nurse Specialist and to the Day Stay challenge nurses.

Challenge triage

Priority 1 - aim at challenge within 6-8 weeks
Infants with sensitization to major foods where allergy is not certain
Infants with peanut sensitization (SPT <5mm) where early introduction may influence likelihood of long term tolerance
Infants / children with milk or egg allergy for whom introduction of milk in baking or egg in baking may influence natural history and in whom home introduction is not appropriate
Priority 2 - aim at challenge within 3-4 months
Infants / children with a history of allergic reactions to major foods who may now be tolerant
- taking in to account time since most recent reaction and test results
Priority 3 - triage to summer catch up, plus offer cancellations
Infants / children with past history of allergic reactions to minor foods who may now be tolerant
- taking in to account time since most recent reaction and test results
Infants / children with sensitization to minor foods who may or may not be allergic
- taking in to account test results
Infants / children where we would generally advise home introduction of a food but the family would prefer hospital supervised challenge

Information for families

Starship information sheet on food challenges

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Document Control

  • Date last published: 22 March 2018
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Immunology
  • Owner: Jan Sinclair
  • Editor: Greg Williams
  • Review frequency: 2 years

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