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What to Expect at an Oral Food Challenge: A Food Allergy Specialty Nurse Shares Insights

By: Anne F. Russell BSN, RN, AE-C

In this article, Anne Russell interviews Elizabeth Scannell Stieb.

Elisabeth Scannell Stieb, RN, BSN, AE-C is a food allergy specialty nurse with a passion for assisting families. An essential member of the Massachusetts General Hospital Food Allergy Center (MGH-FAC) team, she participates in leadership, clinical care, advocacy, research and education. Lisa has nearly 30 years of pediatric experience with 20 years specializing in allergy/pulmonary. Since asthma often co-exists with food allergy, families also benefit from her credentials as board certified asthma educator. She’s been a school nurse and manages food allergies as mother of two children with this diagnosis. She has extensive experience performing oral food challenges.

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There are several types of oral food challenges (OFCs). In an open OFC, the patient and clinic team know the allergen being challenged. One reason to provide an open OFC is to determine if the patient can tolerate the food allergen without a reaction. What factors are considered when deciding if a patient is a candidate for this test?

Criteria include skin prick test results, blood IgE levels and a clinical history of allergic reactions. We consider age, child/parent anxiety level, the child’s readiness and the family’s willingness to routinely include the food in the child’s diet after a successful OFC.

We evaluate other conditions including eczema, asthma and allergic rhinitis. Any flaring asthma or eczema, acute seasonal allergies or other illness means delaying an OFC. In addition to making the challenge difficult to interpret, if a child reacts, it may be more severe. Patient safety is our major concern.

We challenge toddlers especially when it is nutritionally vital to include a certain protein. For example, a successful OFC in a toddler who cannot have milk can relieve a family’s limitation, offer expanded diet options and lift some financial burdens.

You prepare, evaluate and monitor OFC patients in collaboration with allergists. How do you proceed?

Before the appointment, families are informed that OFCs take 4 to 5 hours. I ask parents not to schedule OFCs around special occasions because it then involves emotional high stakes. Children feel burdened that an unsuccessful OFC means avoidance measures and that emergency treatment plans must continue for a trip or party.

We start OFCs with a baseline physical exam of the child. We review medical history and consent. Then we begin dosing the food. Typically there are several doses in increasing amounts adding up to a total goal based on grams of protein or portion size. Medications are available to quickly treat any allergic reaction. Between dosing, we evaluate the child. If the child is reaction free, we advance to the next larger food dose.

Do you prefer that patients bring the OFC food?

At MGH-FAC, we expect families to bring the challenge food. For example, baked milk or baked egg OFCs include a cupcake recipe to bake beforehand. Successful baked milk and baked egg OFCs are intermediate steps which are often followed in 6–12 months with OFCs to unbaked milk or egg.

Parents often worry their child will refuse challenge food. Some children take longer to eat but eventually do so. We have several ways to mask the taste. Green beans with chocolate syrup anyone?

After a successful OFC, we want the challenge food eaten daily for a 4-5 day probationary period to check for delayed reactions (e.g., eczema flare). It’s psychologically beneficial because the food is intentionally given and not just given during the OFC. After this period, the food should be regularly included in the diet and shouldn’t be omitted without speaking with us first.

How do you assist patients/families with anxiety?

Parents should be calm and open when discussing upcoming OFCs with children. They should reinforce that they’re done in the clinic because it’s a safest place with trained nurses and doctors. Children should report symptoms directly to our team and not try to interpret them. We trust their symptom description and won’t doubt them. To prepare for the OFC, we provide written instructions and they can access educational videos produced here at the Food Allergy Center. Upon arrival we review the process again. We monitor patients by conducting assessments every 15 minutes. Frequent monitoring reassures patients.

When parents worry about a child’s anxiety, I describe the OFC steps so they know what to expect. Viewing our videos has reduced anxiety. Additionally, we can consult with our pediatric psychologist, who may meet patients for sessions before an OFC and be available during it to help manage anxiety.

Sometimes we notice fathers attending OFCs who haven’t been at other appointments. Some mothers reveal they don’t attend because they think the father is less anxious and less likely to unintentionally influence OFCs with symptom observations or suggestions. I respect parental insight to know this would be counterproductive.

What if a reaction occurs?

Consistent with others’ experience, about 35 of 100 of our OFC patients have allergic reactions. About 6 of 100 have symptoms requiring epinephrine. Rarely, a second dose of epinephrine may be administered and very rarely we may advise additional observation.

We use the term “pass,” but not the word “fail” to describe results. Years ago I learned how negative the word fail can be from a teen who felt she “did not fail, but earned a C-.” Her symptoms were mild, not severe. This experience changed my use of the word fail. Children link failure to lack of trying and may believe they can control reactions. We explain they can’t control reactions. Their body wasn’t ready to safely consume the food.

Emotional reactions vary. Some are sure they were still allergic with no change to daily life. Others are very disappointed.

Do you enjoy celebrating when patients pass?

We’re thrilled for children who pass OFCs! Some remain cautious about eating the food. It’s an adjustment, like learning to avoid the food. If other food allergies remain, they learn to read ingredient labels differently. Children entirely cleared of food allergies may feel they’ve lost part of their identity, but quickly adapt!

mGH-FAC videos are excellent! How can readers view them?

Videos are available free at www.foodallergycenter.org.

Anne F. Russell, BSN, RN, AE-C is a Nursing faculty member at Spring Arbor University and has specialized in food allergy/ anaphylaxis for 20 years. She gratefully acknowledges Wayne Shreffler, M.D., Ph.D., for article review.

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