Allergists respond to death of 3 year-old boy during oral food challenge

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.

While critical details surrounding this tragedy are not available, nor should they be out of respect for the family and all involved, this is an important time to address oral food challenges in general. Understandably, the very active and involved food allergy community, as well as providers, may have significant concerns and likely many questions. That is why the American College of Allergy, Asthma & Immunology, American Academy of Allergy, Asthma & Immunology and the Canadian Society of Allergy and Clinical Immunology have prepared this statement.

This event should serve as a valuable reminder for everyone involved in oral food challenges to review internal procedures and ensure the proper set-up, staffing, supervision, and protocols are in place to continue offering one of the safest procedures in allergy/immunology.

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. As allergists, we use this test when a person's medical history and/or allergy test results are inconclusive. We also use this test 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 can be 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.

It is not practical to only challenge "sure bets", where you are confirming suspected tolerance, as opposed to using the procedure for establishing a diagnosis through provoking a reaction when the history or circumstances of the allergy are unclear. Thus, this is a procedure with well-known, and well-stated risks such as the possibility of a severe reaction. But these risks are not excessive nor do they exceed the risks involved with providing allergen immunotherapy (e.g. subcutaneous immunotherapy injections), a procedure where patients are at risk of severe (even fatal) reactions, or with many procedures offered in other areas of medicine. It is essential to know the risks as a provider, and that such risks for potential reaction must be discussed with every patient considering an oral food challenge, along with the potential benefits.