Food Challenge Test

A food challenge test is the best way to both confirm a food allergy and see if your child has outgrown a food allergy. Your child will be given small but increasing amounts of the food and monitored very closely for any reaction.

Only one food can be tested at a time. During the challenge test, your child will be in a hospital setting. By the end of the day, your child will need to ingest a serving size of the food in question.

If your child has an allergic reaction during the food challenge test:

  • He will be treated by a team of physicians and nurses experienced in the management of allergic reactions.
  • Medications such as epinephrine, antihistamines, steroids and albuterol will be given as needed. Occasionally, a child may need an IV line placed for administration of fluids and/or IV medications.
  • If your child requires further observation, he may need admission to the hospital or emergency room. This is rare.

Why your child may have a food challenge test

  • To see if your child is allergic to a food to which she had a positive allergy test but has never before ingested
  • To see if your child is allergic to a food when the allergy testing and history don’t correlate
  • To see if your child has outgrown a food allergy

Your child ideally should have at least a 50 percent chance of passing the challenge. This is the case for almost all children who have only had a positive skin test but no clinical history of having reacted to the food in the past. For other children, the risk is estimated based on allergy testing, previous severity of reaction, and the passage of time. You may want to discuss your child’s specific risk with your allergist prior to the food challenge appointment.

Your child does not have to do a food challenge test. Remember, this is a decision made between your allergy team, yourself (or your family) and your child. Some families may prefer to wait until there is a greater chance of passing the challenge or the child is older.

It's also important that you feel confident your child will eat the food. If your child is a very picky eater, has oral feeding issues, is anxious or is not ready for a challenge, it's OK to postpone the challenge to a later time.

Be sure that you understand why a food challenge is being recommended. If you are unsure, don’t hesitate to ask questions before the challenge date. 

Before the food challenge

Please call and cancel or reschedule the challenge. Allergic reactions can be more serious in a child who is already sick. We cannot perform a food challenge on a child if he is sick, recovering from a recent asthma flare (asthma symptoms within 1-2 weeks), or has a severe eczema flare/rash.

If your child arrives and is sick, a challenge will not be performed. You should not bring your sick child to food challenges for examination; instead, we may be able to help schedule an office visit if necessary.

Your child should stop taking all antihistamines prior to the challenge. Stop these medicines three days before the challenge:

  • Allegra (fexofenadine)
  • Zyrtec (cetirizine)
  • Xyzal (levocetirizine)
  • Benadryl (diphenhydramine)
  • Atarax (hydroxyzine)
  • Periactin (cyproheptadine)

Stop taking Claritin (loratadine) seven days before the food challenge.

Keep in mind that many over-the-counter cough and cold medicines also contain antihistamines. Please read the labels on any medication your child may take prior to the food challenge and do not take anything with antihistamines for at least three days before the challenge.

Your child should continue to take maintenance asthma medications (like Flovent, Advair and Singulair). Do not give Albuterol, Xopenex or other rescue inhalers on the morning of the challenge. If your child needs them, please call to cancel the appointment.

If your child is on other medications for other conditions, please let us know.

Your child may not have anything to eat after midnight the night before the test. (That means no breakfast the morning of your appointment.) During this time, you may give your child clear liquids only. Clear liquids include:

  • Water
  • Apple juice
  • Fruit juices with no pulp
  • Iced tea
  • Gatorade
  • Jell-O
  • Popsicles
  • Water ice without fruit chunks

If your child is still breastfeeding, she may continue prior to the food challenge.

The day of your child's food challenge

Report to the 2nd floor of The Children's Hospital of Philadelphia's Seashore House (Musculoskeletal Center) to register by 7:30 a.m. An allergy nurse will meet you in the waiting room to bring you and your child to the Day Medicine Unit, where the food challenge is performed. You may park in the Wood Building which will cost approximately $3; please bring your ticket to the office to be stamped.

Due to limited space, we request that only 1-2 adults accompany your child. Please do not bring other children. You should also expect that your visit will last until at least lunch time.

You should bring:

  • Challenge food: A nurse will contact you before the challenge to discuss exactly what type of food to bring for the challenge and how it should be prepared. We kindly ask that you also bring in the packaging in which the food came. It is very important to not bring foods that contain your child’s other allergens, as these will not be allowed. If given instructions on how to prepare food for the challenge (such as with baked egg/milk challenges), it is very important to follow instructions exactly. If there are any questions, please call our office during business hours before to your scheduled challenge.
  • Toys and distractions: You and your child will be here for several hours. Favorite toys, DVDs, books, electronics, etc., will help to stay occupied.
  • About 32 oz. of clear liquids for your child to drink during the challenge: Juice boxes, Jell-O and other clear liquids as listed above are some good choices.
  • Lunch for you and your child: She may be permitted to eat lunch/snacks approximately one hour after the last dose of challenge food is given.
  • Change of clothing: For you and your child in case of vomiting.

During the food challenge

Your visit will last until after lunch (at times, a bit longer).

For IgE-mediated food challenge, the steps include:

  • Check-in and physician exam
  • Increasing doses of the food with five to eight doses in total. There will be 20 minutes in between each dose
  • Monitoring for two and a half hours after the last dose or time of last reaction

For FPIES food challenge, the steps include:

  • Check-in and physician exam
  • Placement of IV line
  • Dosing in two steps with 20 minutes between the doses
  • Monitoring for 4 hours after the last dose

Your participation in the food challenge procedure is of utmost importance. We are now asking your child to eat a food he or she has always been told to avoid. Your child needs to know that the challenge site is a safe place to eat the food. As caregiver, you can help by encouraging and comforting your child.

Insurance coverage

Prior to the date of your visit, our staff can provide you with the necessary procedure codes to share with your insurance company. Please contact your insurance company to discuss insurance coverage and the possibility of out-of-pocket expenses. If your insurance plan requires referrals from your primary doctor, please be sure to get one before your visit.

For more information about your financial responsibilities and a list of resources available to you for insurance- and billing-related questions, please see Billing and Insurance

Possible outcomes of the food challenge

There are three possible outcomes following a food challenge:

  1. Your child will have an allergic reaction. He will need to continue to avoid the food.
  2. Your child will tolerate the food. He will hold off on ingesting more of that food on the day of the challenge, but will then be instructed to keep the food in his diet. (For FPIES, you will be given a protocol outlining how to continue adding the food into your child's diet over the next several weeks.)
  3. Your child refuses to eat a sufficient amount of the food, making the challenge results inconclusive.

What to expect after the challenge

Once at home, there is a rare chance that your child will have a delayed allergic reaction to the food challenge. Contact your allergist or the allergist on call (215-590-1000 and ask for allergy physician on call) immediately if this happens.

Rarely, a food allergy may recur after a child has passed a food challenge. We therefore recommend that your child keep the specific food in his diet about three times per week. Recurrence of allergy has infrequently been reported, and these episodes were associated with infrequent ingestion or avoidance of peanut.

Reviewed by: Allergy Clinical Team
Date: January 2014