If blood work shows low levels, when do you feel comfortable doing an oral challenge?

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My false positive, cap-rast, rast and skin test thread got me thinking.

At what point would you consider doing an oral challenge? Please tell me what you think you would do. (This is only to try to help me understand all of the what ifs).

On Jul 29, 2003

e-mom, I think I can simply state - NEVER. I have quite a long story and will attempt to make it brief.

My son had an anaphylactic reaction to peanuts and cashews prior to the age of 3. When he was skin tested, it showed positive to peanuts, cashews, and pistachios. His wheals were bigger than the size of oranges. We learned all of the info re: PA and sent home with prescription for Epi.

A year later he skin tested positive to peanuts and pistachios, negative to cashews. He has his worst reaction with cashews. He did, however, reacted to the skin test. Itchy throat, cough (does have asthma), and diarrhea. They gave him Zyrtec and monitered him for an hour.

Last year he underwent the CAP-RAST. Results came back negative to peanuts, positive to pistachios and CASHEWS. They recommended a food challenge, but my son was too afraid. Every mention of it brought tears to his eyes. I simply explained about 4 months later that if he passed it, he didn't HAVE to eat pb. I reassured him that we could then eat candies/cookies and at restaurants that we could not before. He finally agreed.

We made the appt., arrived, and they began the food challenge. My son was very apprehensive, and they attempted to calm his nerves. They explained that he could NOT react...he tested negative (wrong thing to say to MY child).

They started by placing a small pin size drop of pb on his tongue. He immediately said it burnt/itched. I held him tightly and gave him plenty of water. I already knew that he would think he was reacting, even if he wasn't. He finally relaxed until they wanted to give him a slightly larger amount. He spit it out immediately and wiped it off his lips. Within a minute he had hives all around his mouth, above his eyes, on his arms. They did NOT want to STOP the food challenge. They wanted to continue. Research shows that you can still test positive on a skin test prior to outgrowing it, and she tried to say that when he wiped his face it may have caused irritation to his skin which caused the hives (like a skin prick test). But within seconds after this his skin turned completely beet red, and she agreed to stop it, administered medicine, and monitered him closely for 2-3 hours.

He did have another very scary, possibly anaphylactic reaction after this also. We have not taken him back for further testing since that time.

So to state again, I will probably never allow him to be food challenged, unless he tests negative CAP-RAST for 2 or 3 consecutive years.

On Jul 29, 2003

This is an interesting question considering that we just got really low CAP RAST results a week ago. Matthew's (currently age 25 months) result to peanuts was 17.6 last year...last week it was 1.09.

My allergist wants us to avoid peanuts and test again next summer. If it's even lower then she'll do an oral challenge.

After the initial elation at the low result last week I began investigating how/when/should you do an oral challenge.

I actually emailed Dr. Robert Wood, head of peds at Johns Hopkins. He's very well versed in peanut allergies and was actually part of a recent study on this very topic.

He was kind enough to email me the resutls of the study (which I'll try to attach), but all in all his recommendation was that we wait until age 4 (so two more years instead of just one) as 4 seems to be the "magic" number when the immune system is less likely to "over" react to the pb if he is truly losing his peanut allergy.

For the record, I also emailed Dr. Hugh Sampson...I know that he read it, but I've gotten no response from him. I was quite disappointed. I just wanted his input so that we can make the most informed decision regarding Matthew and the oral challenge.

Anyway...that's the most recent info I have. Dr. Wood was very encouraging in our emails that Matthew's result (falling so low so quickly) was really really great. It's so nice to receive info from experts when you need it!

Not sure I can cut and paste such a large document..but here goes....

Food and drug reactions and anaphylaxis 183 The natural progression of peanut allergy: Resolution and the possibility of recurrence David M. Fleischer, MD,a Mary Kay Conover-Walker, MSN, RN, CRNP,a Lynn Christie, MS, RD, LD,b A.Wesley Burks, MD,b and Robert A.Wood, MDa Baltimore, Md, and Little Rock, Ark Background: It was once thought that peanut allergy is a lifelong problem. We previously reported that about 20% of children outgrow their peanut allergy and that more than 60% of patients with a peanut-IgE level of 5 or less passed an oral challenge. Objective: The goal of this study was to further describe the natural progression of peanut allergy by reviewing patients who have undergone oral peanut challenges since the previous study. Methods: Patients with peanut-IgE levels of 5 or less were offered a peanut challenge. Those who passed were further evaluated by questionnaire to assess reintroduction of peanut into their diet and whether any recurrence has occurred. Results: Eighty-four patients were evaluated, and 80 underwent complete analysis. Fifty-five percent with peanut-IgE levels of 5 or less and 63% with peanut-IgE levels of 2 or less passed challenges, compared to 61% and 67%, respectively, in our previous study. The 4 additional patients passed peanut challenges in this study after previously failing. Three patients with initial anaphylactic reactions and 2 patients with initial peanut-IgE levels greater than 70 passed their challenge. Follow- up of those who passed in both studies showed that the majority of patients reintroduced peanut into their diet, but that continued label reading, infrequent/limited ingestion, and aversion to peanut were all common in this population. Two patients had suspected subsequent reactions to peanut after passing their challenge. Conclusions: Patients with a history of peanut allergy and peanut-IgE levels of 5 or less have at least a 50% chance of outgrowing their allergy. Recurrence of peanut allergy may occur but appears to be uncommon. (J Allergy Clin Immunol 2003;112:183-9.) Key words: Peanut allergy, food challenge, recurrence, RAST, food hypersensitivity Peanut allergy is common, with studies from the United States, the United Kingdom, and France estimating a prevalence of 0.4% in children and an overall prevalence of 0.5% to 1% in the general population.1-3 There is evidence that the prevalence is rising, on the basis of a recent report from the Isle of Wight that showed a 2-fold increase in reported allergy, a 3-fold increase in peanut sensitization, and an overall estimate of peanut allergy of 1.5%.4 Consumption of peanut in Western countries may also be rising because of its use as a source of protein in health foods, the popularity of vegetarianism, and increased use of prepared foods. If we couple the rising prevalence and increased consumption with the facts that about 75% of children experience a reaction on their first known exposure,5,6 allergic reactions have the potential to be severe or even fatal,7 and accidental exposures are common,8 these numbers become even more significant. We now know that peanut allergy is not always a lifelong problem on the basis of results from a recent study from our institutions9 as well as reports from other institutions. 10-12 In our study we found that about 20% of children outgrew their peanut allergy. Although this is reassuring for certain patients and families, a new concern has arisen for this limited group of patients with resolved peanut allergy: the possibility of a recurrence of their allergy after reintroduction of peanut into the diet. There have now been 3 reported cases of children who passed a peanut challenge but subsequently had an allergic reaction to peanut.13 In this study we sought to further describe the natural progression of peanut allergy by reviewing patients who have undergone oral peanut challenge since our previous study.9 We characterized their initial reactions and history of other food allergies and atopic diseases to determine any factors that might predict the tendency to outgrow peanut allergy. In addition, we contacted those families whose children passed their peanut challenge either in this study or in our previous study9 to determine whether peanut was reintroduced into the diet, how frequently it was consumed, and whether there was any evidence of a recurrence of their peanut allergy. From the aDepartment of Pediatrics, Johns Hopkins University School of Medicine and the bDepartment of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children

On Jul 29, 2003

If our CAP-RAST results were negative for PA(or whatever the food), I would be willing to challenge, at age 5 or older. I think the immune system is matured then.

I look a it this way. If I am told my dd is no longer allergic according to the tests, there are may contains, restaurant foods and such, ice creams I would want to let her have. So, I would much rather have a food challenge in a setting where they are ready for an emergency, as opposed to having a serious reaction on my own(not that I would challenge on my own, but with regards to a may contain or such).

I would never really trust a challenge entirely, since it took a couple of months of eating PB for my dd to manifest obvious allergy, and never anaphylaxis. So, I would still carry epipens and watch her for a long time after being declared "cured." I just do not trust it would not come back.

I also cannot imagine introduving obvious peanut or nutty foods into her diet. I would just loosen up the other stuff a bit. becca

On Jul 29, 2003

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Originally posted by NaomiR: [b]I think I can simply state - NEVER. I have quite a long story and will attempt to make it brief.

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I was actually going to go back into my original question to add a statement about NEVER doing any oral challenge. You beat me to it [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

[b]

Quote:

So to state again, I will probably never allow him to be food challenged, unless he tests negative CAP-RAST for 2 or 3 consecutive years.[/b]

This sentence is exactly what I'm looking for. Opinions from people on what they might do if...

Thank you NaomiR!! Just wanted to say welcome back. I haven't seen you post in a long time. Glad to have you back.

I'm sorry that your son had to go through that. It must have seem very scary for him (and you I might add). Thank you for sharing your story.

On Jul 29, 2003

Quote:

Originally posted by MattsMommy: [b]My allergist wants us to avoid peanuts and test again next summer. If it's even lower then she'll do an oral challenge.

[/b]

There seems to be a recurrent theme with Allergists advice on retesting. Blood tests at least 2-3 times consecutively getting lower results then possibly doing an oral challenge.

Quote:

[b]I actually emailed Dr. Robert Wood, head of peds at Johns Hopkins. He's very well versed in peanut allergies and was actually part of a recent study on this very topic.

He was kind enough to email me the resutls of the study (which I'll try to attach), but all in all his recommendation was that we wait until age 4 (so two more years instead of just one) as 4 seems to be the "magic" number when the immune system is less likely to "over" react to the pb if he is truly losing his peanut allergy.

[/b]

That's great that Dr. Wood sent you the study.

BTW, I think you will have the record for the longest post [img]http://uumor.pair.com/nutalle2/peanutallergy/wink.gif[/img]

I'll have to read it tomorrow as it's way past my bedtime.

Thank you for sharing your story and the study!!!

[This message has been edited by e-mom (edited July 30, 2003).]

On Jul 29, 2003

Quote:

Originally posted by becca: [b]I look a it this way. If I am told my dd is no longer allergic according to the tests, there are may contains, restaurant foods and such, ice creams I would want to let her have. So, I would much rather have a food challenge in a setting where they are ready for an emergency, as opposed to having a serious reaction on my own(not that I would challenge on my own, but with regards to a may contain or such).

[/b]

Yes, I absolutely agree.

Quote:

[b]I would never really trust a challenge entirely, since it took a couple of months of eating PB for my dd to manifest obvious allergy, and never anaphylaxis. So, I would still carry epipens and watch her for a long time after being declared "cured." I just do not trust it would not come back.

[/b]

This is the part that scares the hell out of me. I think I might define "long time" as until they are 50. [img]http://uumor.pair.com/nutalle2/peanutallergy/wink.gif[/img]

Quote:

[b]I also cannot imagine introduving obvious peanut or nutty foods into her diet. I would just loosen up the other stuff a bit. becca [/b]

This is exactly what I've been telling a few of my friends who ask questions about pa in general. I just have a hard time drilling into his (and everyone else's for that matter) head for years about how bad peanuts are for him and to suddenly say "hey, guess what, you now can have peanuts". It just doesn't sit well with me at all.

Thanks becca!!

On Jul 29, 2003

Lol e-mom...sorry it's so freaking long! Since I didn't get it from the internet and couldn't provide a link, I didn't know how else to do it..lol.

Yes if you can, take the time to read it. For me it was comforting to hear from someone with his expertise that it's "okay" to be happy and to really believe that this might be gone sometime in the near future.

And I'm so happy I emailed him as it has changed what we'll do...at the very least we'll wait until age 4. I might even contact him again then and see what he says. By then (two years from now) I assume there will be even newer data on this.

It's just so motivational to know it really DOES happen...and that it would behoove us to wait longer.

Again, it's a long read, but has lots of interesting info.

Maddy Matthew 2 yrs

On Jul 30, 2003

Just wanted to add our son was six years old when he tested negative on CAP-RAST and did not pass the food challenge.

e-mom, Thanks for your welcoming me 'back'. I never was really gone, just reading mainly in lurkdom. Most of my attention has been on my infant (see post Celiac disease under OT). We also homeschool and so my life is pretty busy non-stop.

MattsMommy - Wonderful article also! I did take the time to read it last night (ok, most of it). I did contact Dr. Hugh Sampsom via e-mail last year after all of this happened. He responded twice, but did not provide any wonderful information as did Dr. Wood. He kindly said that since he never treated my son he could not offer any advice.

On Jul 30, 2003

Everything happens for a reason, right?

Well, I say this because we have 2 failed attempts to the allergist in 1 year! The first one back in May was cancelled due to Austin having a cold so the Hospital is not letting anyone sick inside due to SARS. The second appointment last week I took Austin and Megan and they wouldn't let his sister in the hospital due to SARS. No siblings allowed unless they have appointments. Now the allergist's office are kind enough to send out a letter before our appointment to remind us to stop all antihistamines 7 days ? prior to the appointment but don't let me know not to bring my other children if they don't have an appointment???? I could have got a babysister.

I was so pissed off. I haven't scheduled another appointment but told our family doctor that he can handle Austin's EA's just fine so what the heck do I need to see an allergist for anyway...Oh, CapRast's every year, that's right. Ok, I will call them back to at least book that because I do want to see if there is a difference with the one and only he had over a year ago.

So, e-mom good question. For those that do not know of my son's situation I'll let you know.

I have boy and girl twins. My great female doctor at the time they were 6 months told me due to my dh's environmental allergies and studies she had been reading on allergies/food allergies, to avoid shellfish and nuts/peanuts until they were 3-4 years old. Wierd that when she told me this I felt very compelled to listen to her and take this seriously. They both never ate anything with peanuts or nuts but did have (a cookie called Nilla, little round vanilla cookies)that on the box had a may contain warning on them.

My FIL passed away 4 months shy of their 3rd birthday and my sister made these chocolate chip cookies. My Mom and Dad were over to babysit for 2 hours and on the way out they were giving a half a cookie to our kids before their nap. My Mom said that Austin started sneezing immediately. Megan was laughing because he couldn't stop sneezing. Then he started coughing and itching his eyes. My Mom thought he was catching a cold perhaps and it was time for a nap so she put them down. Austin started crying and my Mom brought him downstairs to watch T.V. while Megan slept. She told me he said he didn't feel well and my Mom thought he was coming down with something. We came home 2 hours later and here comes Austin with Grandma and he was all red in the face(from what I thought was from crying)and sniffling a lot still. I gave him some dimetapp(it has antihistamine in it for colds)and 15 minutes later he was a new little boy. He never had hives. That night, dh had his first chocolate chip cookie and said to me "Is there peanut butter in these?" I was on the phone to my sister so fast and she told me she had put a 1/4 cup perhaps in the batch she made. So, to the Doctor's we went a few days later and left with epipen's and a allergist appointment. The scratch for peanut was positive at the allergists and a further appointment a year later for peanut again was done in which again was positive(plus to 10 tree-nuts) in which he tested negative to. He isn't allergic to tree-nuts for sure because after I gave him Honey-nut cheerios(with almonds)and he ate those with no problems. I stopped giving him anything with tree-nuts since coming over to this site and reading about cross-contamination issues.

Since the above appointments to the allergist he has reacted to smelling peanut products. He starts sneezing, itching his eyes, and telling me he doesn't feel well. The first time was walking by a bowl of PeanutButter Cups in packages for Halloween at my Sister's. The Second time was at a Bakery with Mixed Nuts in packaged containers.

The third appointment with the allergist was the CapRast test. He scored 9.43. The allergist gives anyone 15 and under a Challenge. I declined after asking what everyone here thought. I trust a lot of your allergists more than mine because some of you have top notch allergists and I believe them more than a small city allergist(324,000?)

I also have dealt with full body hives in Austin twice now this summer. Once was probably viral but the other was environmental. He was playing soccer the second time and came to me asking for a scratch on the back. I lifted his shirt and viola. Atarax is amazing.

The family doctor thinks because Austin is so sensitive environmentally, that he isn't surprised of his peanut allergy. His doc does recommend CapRasting though to see if the numbers come down. I was going to ask for a smell challenge(the last appointment)but now I'll just wait until his Dad is around to come with us since that will be scary for me to do alone.

I know this is long and usually I don't write long posts but there are a lot of new member's now(Hi and Welcome to all of you [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img] )

I have read so much on Challenges and scores and other people's experiences and have concluded this. Use the CapRast's scores every year or other and get at least 3. Then you have a better idea of where their peanut allergy sits. I mean if they are consistently scoring high then perhaps give it a break for a while because obviously your not going to do a challenge in the near future.

If the score is low(like Austin's)then do at least 3 CapRasts(at different times of the year). I say that because if your child has environmental allergies than at least you know that hasn't affected the test in anyway. If Austin's score goes higher then no Challenge. If his score goes down to Negative then I will set the guidelines up for a Challenge because I have read about so many bad Challenges that at least now I can tell the allergist what I'm comfortable with him doing in a Challenge.

Hope this helps and Thanks to all who let us know about their experiences with Challenges. It really gives us parents some backbone dealing with this scary subject.

On Jul 30, 2003

Quote:

Originally posted by MattsMommy: [b]Yes if you can, take the time to read it. For me it was comforting to hear from someone with his expertise that it's "okay" to be happy and to really believe that this might be gone sometime in the near future.

[/b]

Well, I finally was able to read ALL of it. Thanks again for posting it. I think I'll print it out to bring to our new allergist and she what her opinion/experience is.

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[b]By then (two years from now) I assume there will be even newer data on this.

[/b]

One can only hope. [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

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[b]Again, it's a long read, but has lots of interesting info.

[/b]

I have to say that I was quite surprised to read that they are basically saying they recommend a more frequent exposure to peanut in order to keep the allergy from resensitizing itself.

So, with this study only, the low levels they have shown, I could be possibly be doing more harm to my son by keeping all peanuts and nuts away from him? What? [img]http://uumor.pair.com/nutalle2/peanutallergy/confused.gif[/img]

I'm definitely getting him a CAP-rast done now. I'm very interested in what his levels are going to read.

Good yet still confusing.

[This message has been edited by e-mom (edited July 30, 2003).]

On Jul 30, 2003

To All:

In case some of you missed it, I posted a critique of this study on the research board. When thinking of doing a food challenge, please consider some of these points. This was not the perfect study. These are just my opinions has a scientist/cell biologist working in the biopharmaceutical industry:

1) The results were based on only 80 children (mean age of 5 years old). Not statistically significant when 1.5 MILLION may have PA! 2) Of those, 20 children never ingested peanuts and were diagnosed by RAST or skin test. Therefore, there is no clinical proof any of these children would have actually reacted to peanut ingestion. These tests only indicate a possibility of a reaction. Our own allergist has said he has patients with high RAST scores who eat peanuts without any problems. 3)I have searched and searched the journal article and I can not find the actual amount (in grams or milligrams) of peanut each child was challenged with (very suspect). Perhaps it was a very small amount that would not illicit a reaction in most of these children anyway. 4)Of those PA children that passed the food challenge, 81% showed only a localized skin reaction to their first ingestion of peanuts (only 9% of this group had what the authors define as an anaphylactic reaction) 5) Greater than 45% of all PA children failed the challenge. 50/50 are not great odds when dealing with life and death! 6) They followed-up with the group who passed with surveys and questions about further reactions. Only 67% of the group that passed answered the researcher's survey leaving out a large chunk of this group from further study. 7)On average, the follow-up time was 1.6 years following the peanut challenge. Not nearly long enough in my opinion. The authors even admit that the allergy can return any time even after years without any problems. 8) Of those that passed the peanut challenge, 67% still limit their peanut consumption to no more than once a month at most. This would, of course, increase the likelihood there would be NO reactions in the 1.5-2 years following the peanut challenge. 9) My own opinion - I don't like science that leaves conclusions up to patient surveys that are often subjective. If the surveys are not written properly, the results can be skewed. 10) The 50% outgrowth value ocurred in children with very low peanut IgE levels of less than 5 kUa/L. Therefore, this patient population would most likely not be considered severely allergic. But remember, 45% of those in this group still failed the challenge which gives you an idea of the accuracy of these values.

Those are my major conerns with this study.

Troy

On Jul 30, 2003

Quote:

Originally posted by smack: [b]Everything happens for a reason, right?

Well, I say this because we have 2 failed attempts to the allergist in 1 year!

[/b]

It does make you wonder, doesn't it?

Good to hear from you Smack!!

Quote:

[b]Now the allergist's office are kind enough to send out a letter before our appointment to remind us to stop all antihistamines 7 days ? prior to the appointment but don't let me know not to bring my other children if they don't have an appointment???? I could have got a babysister.

I was so pissed off.

[/b]

I would have been steaming, too!!!!!

Quote:

[b]They both never ate anything with peanuts or nuts but did have (a cookie called Nilla, little round vanilla cookies)that on the box had a may contain warning on them.

[/b]

My kids eat these cookies ALL of the time. However, our do not have any type of warning on them. Hmmmmm?

Quote:

[b]I know this is long and usually I don't write long posts but there are a lot of new member's now(Hi and Welcome to all of you [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img] )

[/b]

I want to thank you for sharing your story. I can envision myself pretty much handling the oral challenge in a very similar way that you have mentioned. Ds has never had any blood work done so basically that's were I'm going to start.

On Jul 30, 2003

Quote:

Originally posted by choguy: [b]In case some of you missed it, I posted a critique of this study on the research board. When thinking of doing a food challenge, please consider some of these points. This was not the perfect study. These are just my opinions has a scientist/cell biologist working in the biopharmaceutical industry:

[/b]

Thanks Troy!!! These are valid points and definitely worth mentioning as I did not see your earlier posts regarding this. Several of your points had crossed my mind while reading it but I'm trying to keep an open mind so I kept reading. They are definitely a major concern for me as well. I'll check out the research thread. Again, thank you.

It is so much easier to see when you break down their study as my head kept spinning reading all of the stats.

Does anyone else feel like they are playing a game of tug 'o war?

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