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Food Challenge Testing: Diagnosing Allergies with Precision
When it comes to accurately diagnosing food allergies, skin prick tests and blood tests provide valuable information, but they have limitations. Both can sometimes indicate sensitivity to foods that a person can actually eat without problems. This is why allergists consider the oral food challenge the "gold standard" for food allergy diagnosis.
At LACK Clinic, we regularly conduct food challenges to provide definitive answers about food allergies, helping families avoid unnecessary dietary restrictions while ensuring safety for those with true allergies.
What is a food challenge test?
A food challenge is a carefully controlled test in which a person consumes gradually increasing amounts of a specific food under close medical supervision to determine whether they are truly allergic to it.
This procedure serves several important purposes:
- Assessing the threshold amount needed to trigger a reaction
- Confirming whether a suspected food allergy truly exists
- Testing tolerance to similar foods within the same food group
- Evaluating tolerance to baked or processed versions of allergenic foods
When might a food challenge be recommended?
When test results and history don't align
Sometimes skin or blood tests show sensitisation, but your child has never reacted to the food, or the history of reaction is unclear. A food challenge can clarify whether true allergy exists.
Monitoring potential resolution of allergies
Many children, particularly those with egg or milk allergies, outgrow their allergies over time. Declining levels of allergen-specific IgE antibodies in blood tests or reduced skin test reactions may indicate this is happening, but a food challenge provides definitive confirmation.
Assessing tolerance to cross-reactive foods
If your child is allergic to one food, they might also react to related foods. For example, a child allergic to cashews might also react to pistachios. Supervised challenges can safely determine which specific foods within a group need to be avoided.
Evaluating tolerance to processed forms
Some children who react to raw egg can tolerate baked egg in cakes or biscuits. Similarly, some milk-allergic children can tolerate milk when it's extensively heated. Food challenges can safely identify these distinctions, potentially allowing for a less restrictive diet.
How the food challenge procedure works
Food challenges follow a careful protocol designed to maximise safety while providing clear diagnostic information.
Before the challenge
Preparation is crucial for a successful and safe food challenge:
- Stop antihistamines several days before the challenge (as advised by your allergist)
- Ensure your child is in good health — no active asthma, eczema flares, or infections
- Complete a thorough medical review with your healthcare provider before the challenge
During the challenge
The challenge proceeds through these stages:
- Starting with tiny amounts: Often just a small smear or crumb is given first
- Gradual increases: If no reaction occurs, larger amounts are given every ~20 minutes
- Careful observation: Your child is monitored closely after each dose
- Full serving: If all previous steps are tolerated, a full age-appropriate portion is given
- Observation period: You’ll remain for 1–2 hours post-final dose to monitor for delayed reactions
During this process, our medical team:
- Monitors vital signs at each stage
- Watches for subtle signs of allergic reactions
- Is prepared to treat symptoms immediately if needed
Possible outcomes
- Positive challenge: A reaction confirms the allergy, and treatment is given
- Negative challenge: No symptoms indicate the food is safe to eat
- Inconclusive challenge: Ambiguous symptoms may require re-testing in the future
Safety measures during food challenges
Safety is the cornerstone of food challenge testing at LACK Clinic.
Medical environment
All food challenges are conducted in a fully equipped clinical space with:
- Emergency medications and monitoring equipment on hand
- Trained medical staff experienced in recognising and treating allergic reactions
- Immediate access to advanced care if needed
Controlled dosing
The step-by-step dosing protocol ensures that:
- Reactions are detected at the earliest stage
- The challenge can be stopped immediately if needed
- Only minimal exposure occurs before intervention if a reaction happens
Expert supervision
Your child will be cared for by:
- Allergy specialists with extensive paediatric experience
- Clinicians trained in conducting safe food challenges
- Professionals who can distinguish between anxiety symptoms and allergic reactions
What to expect during a food challenge
Knowing what to expect can help both you and your child feel more prepared for the day.
Length of appointment
A complete food challenge typically takes 3–6 hours, depending on:
- How many doses are planned
- Whether any reactions occur
- The observation period required
The food itself
For food challenges, we may:
- Ask you to bring the specific food from home
- Provide the food in a standardised form
- Mask the food in another food (such as pudding or applesauce) for young children who might refuse it otherwise
Activities during the challenge
The waiting periods between doses can seem long, especially for children. We recommend:
- Bringing quiet activities, books, or devices for entertainment
- Planning for both you and your child to be present for the entire day
- Bringing lunch or snacks for yourself (your child may be limited to the challenge food until the test is complete)
Managing anxiety
It's natural for both children and parents to feel anxious during food challenges. Our team:
- Explains each step clearly and answers questions
- Distinguishes between anxiety symptoms and allergic reactions
- Provides support throughout the process
Preparation for a food challenge
Proper preparation helps ensure the food challenge provides accurate results.
Medication adjustments
Several medications can interfere with challenge results:
- Antihistamines must be stopped 3–7 days before (depending on the specific medication)
- Continue asthma controller medications as prescribed
- Your allergist will provide specific guidance about which medications to continue or stop
Food restrictions
Prior to the challenge:
- Your child should avoid the test food completely
- A light meal is recommended before arrival (unless instructed otherwise)
- Follow any specific dietary instructions provided by your allergist
What to bring
On the day of the challenge, bring:
- The specific food in its original packaging (if requested)
- Activities to keep your child occupied
- Lunch for yourself and possibly your child (for after the challenge)
- A list of any questions or concerns to discuss
After a food challenge: Next steps
The information gained from a food challenge guides your child's ongoing management plan.
If the challenge is negative
If your child successfully tolerates the food:
- Regular consumption is typically recommended to maintain tolerance
- Your allergist will suggest how frequently to include the food in your child's diet
- A clear plan for incorporating the food at home will be provided
If the challenge is positive
If your child has a reaction confirming the allergy:
- Clear avoidance instructions will be reinforced
- Emergency medication prescriptions will be provided or updated
- An action plan will be created or revised for managing accidental exposures
Follow-up care
After any food challenge, your allergist will:
- Schedule appropriate follow-up appointments
- Answer any questions about the results
- Provide written documentation of the outcome for schools or caregivers
- Discuss the timing of any future challenges for other foods
The value of definitive diagnosis
While food challenges require time and can cause anxiety, they provide invaluable benefits:
Preventing unnecessary restrictions
Research shows that up to 80% of children avoiding foods based solely on positive skin or blood tests can actually tolerate those foods when challenged. Identifying these cases through food challenges helps:
- Expand dietary options
- Reduce anxiety around food
- Simplify social situations involving food
- Improve nutritional variety
Confirming necessary avoidance
For children who do react during challenges, the test provides:
- Certainty about the diagnosis
- Validation of the need for strict avoidance
- Clear evidence for schools and caregivers
- Educational opportunity about recognising reactions
Improved quality of life
Whether positive or negative, having definitive answers about food allergies typically:
- Reduces anxiety around uncertain diagnoses
- Provides clarity for making dietary decisions
- Simplifies management plans
- Establishes a clear baseline for monitoring changes over time
Food challenges for specific allergies
Different food allergens may require slightly different challenge protocols.
Milk and egg challenges
For milk and egg allergies, we may test:
- Tolerance to baked forms (in cakes or biscuits)
- Raw versus cooked forms
- Whole foods versus smaller protein components
Peanut and tree nut challenges
With nut allergies, challenges might assess:
- Specific threshold levels
- Cross-reactivity between different nuts
- Responses to specific preparation methods
Multiple food challenges
For children avoiding numerous foods, we strategically plan challenges:
- Starting with the foods most likely to be tolerated
- Spacing challenges to minimise disruption
- Prioritising nutritionally important foods
The expertise behind food challenges
At LACK Clinic, our approach to food challenges is informed by Professor Lack's pioneering research on food allergy development and management. This research has:
- Refined protocols for safe challenge administration
- Identified predictors of challenge outcomes
- Established best practices for incorporating previously restricted foods back into the diet
Our team's extensive experience conducting food challenges in children of all ages ensures both safety and accurate results.
Taking the next step
If you think your child might benefit from a food challenge, discuss this with your allergist. They can:
- Assess whether a challenge is appropriate
- Explain the specific protocol for your child's situation
- Address any concerns you might have about the procedure
- Schedule the challenge at a suitable time
While food challenges require a significant time commitment and careful preparation, they provide definitive information that can transform your approach to managing your child's diet and allergies.
By potentially expanding safe food options or confirming the need for avoidance, food challenges represent a valuable tool in achieving the clearest possible understanding of your child's allergic status.
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