Oral Peanut Challenge for Peanut Allergy

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Are you preparing for an oral food challenge? In this post, I share my son’s health status after completing his first-ever open oral peanut allergy challenge. Learn more about our experience with his food allergies, how we prepared for his challenge and eventually got to revise his anaphylaxis protocol.

Coloured peanut M&Ms in a small white plate with allergy bracelets and EpiPens in the background.

Always consult your family doctor, medical professional or allergy specialist for medical advice.

  1. Diagnosing Food Allergies
  2. What is an Open Challenge?
  3. Challenge Preparation
  4. Negative (Passed) Oral Food Challenge
  5. Positive Oral Food Challenge
  6. My Son’s Allergy Story
  7. Parenting an Allergy Kid
  8. School Anaphylaxis Protocol
  9. Allergy Family Life
  10. Additional Notes
  11. Health Insurance for Allergy Testing
  12. Food Allergy Resources

Diagnosing Food Allergies

It’s always best to consult your family doctor or medical professional with your questions. Each patient’s medical history is different, and you need to get a proper evaluation and possibly a physical examination (e.i. skin reactions, breathing issues, change in blood pressure, etc.) before getting a referral to an allergy specialist.

Some people have non-conclusive allergy skin tests (also called skin prick, puncture or scratch test) or don’t show elevated IgE antibodies on a blood test which is why oral food challenges can be helpful.

Once your allergist reviews your (or your child’s) medical records and decides that it’s time to consider an oral food challenge, the doctor, nurse or clinic staff will provide you with specific instructions to help you with the Challenge Preparation. You might also have to sign a consent form.

As a mother, I appreciate how stressful it is to consider such a test for your child. However, food challenges can help evaluate possible outgrown allergies. Knowing is important as it means being able to reduce your child’s list of allergies or even eliminate it if they only react to one food. Which hopefully could make your family life a little less stressful.

Doing an oral food challenge in a clinical setting with medical supervision is best to monitor potential adverse reactions.

Allergy skin prick test on arms of young boy.
Allergy Skin Prick Test – 3 Months Prior to Oral Peanut Challenge

What is an Open Challenge?

Open oral food challenge means that the person understands that they are about to eat the known allergen (peanuts in my son’s case).

With younger children, if they refuse to eat the food, the appointment would most likely end. I wouldn’t want to forcibly make an allergy child eat something they couldn’t consume before. Communication is necessary to decide if an oral challenge is best for your child.

During an oral peanut challenge, the person starts with eating a small portion of the allergy food (e.i. a crumb size piece of a peanut). The amount slowly increases (with waiting time in between) under careful observation.

For an oral peanut challenge, a person might have to eat about 25 peanuts over 3 to 4 hours. I went through my son’s allergy notes and jotted down that he ate a total of 18 peanuts during his challenge. See the main post picture for an example of that portion.

You may also have to get a skin prick test that same day. My son did, which surprised us because we were not expecting it.

During an oral peanut allergy challenge, a person is given a very small portion (dose) to start.

Challenge Preparation

On test day, my son had to be in good health and couldn’t eat for two hours before the challenge. In my notes, asthma and other medications could be continued, but no cold medication for two days prior. Ask your allergist if unsure.

We had to bring my son’s EpiPen(s) (Epinephrine Auto-Injector), and it’s possible that your allergist might want you to bring allergy medication(s).

Smarties and peanut M&M’s were on our list of candies to bring. I remember laughing when we witnessed the allergist placing the candy we brought in his cabinet (in a different room). Interestingly, the ones we brought were not the peanut M&Ms my son ate during the challenge.

The total time for a challenge is around 5 hours, but it’s always possible that it could take longer if a reaction occurs. Most of the challenge is waiting time. To keep you entertained, bring the following items: electronic devices, a toy, and books/magazines.

A change of clothes is nice to have if your child gets sick.

I packed a lunch for myself and my son in case we got hungry. After a few hours, once given the okay to eat lunch, we walked to a nearby park to get some fresh air. We still had to go for one last final examination to check for delayed symptoms of an allergic reaction before we could leave to go home.

Oral Peanut Challenge Test Day November 2020 – My Son Wasn’t Sure How to Feel That Day (Seemed Reflective)

Negative (Passed) Oral Food Challenge

In November of 2020, my son passed his oral peanut challenge but still reacted enough on the skin prick test given on the same day. What that meant for him was that he still had to carry his EpiPen at school and when out and about with life until further notice.

With his negative test (passed oral peanut challenge), he had to continue eating a certain amount (dose given by the allergist) of peanuts daily for 30 days. Obviously, knowing and being close to your child when they do eat peanuts or peanut-containing foods is crucial in case they do have mild reactions. Follow your allergist’s instructions.

After the first month, the frequency decreased from eating peanuts daily to twice weekly until his next yearly appointment. A challenging task to keep up when you’ve been told all your life to avoid peanuts and to be extra vigilant about reading food labels.

We’ve tried our best to remind him that consuming peanuts regularly will help him build and maintain better immunity. He’s encouraged to try as often as he wants, knowing that doing so could eventually mean not needing an EpiPen.

We still have EpiPens on hand in case we need them.

Positive Oral Food Challenge

Picture this scenario: You’re at the allergist’s office, ready for your (or your child’s) oral challenge. You eat a small amount of the food, and then signs of an allergic reaction appear a few minutes later. Now what? It could be a good learning experience. It might be an opportunity for you (or your child) to feel what a controlled food allergy reaction is like and for you to witness the best way to treat it. It could also diminish the anxiety families often build up around food allergies and reactions.

Having an allergy reaction in a medical clinic is, in some ways, reassuring. Experiencing mild symptoms with a risk of a severe allergic reaction with professionals by your side is a little easier to manage. Plus, the clinic’s protocol for an allergy reaction during a challenge could be different than what you have for yourself or your child.

A positive result is not always a bad thing. If that happens to you (or your child), the allergist will likely tell you to continue avoiding the food in question until the next appointment. And there’s always the possibility of repeating the test later.

Age 5 with Allergy Bracelet, EpiPen in Waist Belt & Age 13 No More EpiPen for School After Passing Oral Challenge.

My Son’s Allergy Story

My eldest son received his allergy diagnosis at the young age of two-and-a-half years old. He’s thirteen now. He did both the skin prick test and then eventually blood work (4.5 years old) to confirm his allergies and also to check the severity. Some of his reactions to tree nuts, fruits, trees, ragweed, and animals are milder. He carries an EpiPen for the peanut allergy and avoids eating raw hazelnuts. We’ve had to give him allergy medication for mild reactions to touching nuts and eating certain fruits. And thankfully, he’s never had a severe life-threatening peanut anaphylaxis reaction.

Allergy Timeline:

  • First reaction to peanut butter: 12 months
  • Second reaction to peanut butter cookie (crumb): 18 months
  • First skin prick test: 2.5 years old
  • First blood work (IgE): 4.5 years old
  • Tested every 2 years (skin prick test) until 10 years of age
  • Tested yearly (skin prick test) from 10 to 12 years of age
  • First Oral Peanut Challenge (with skin test): 11 years old
  • Monitored closely for one year while consuming peanuts: 12 years old
  • He now consumes a handful of peanuts with no reaction: 13 years old

The first time he reacted to peanuts was when I gave him a pea-sized amount of peanut butter when he was around twelve months old. He got hives around his mouth pretty much right away. I decided to try again at eighteen months, but this time with a small piece of a peanut butter cookie. He got hives around his mouth instantly. After that reaction, we waited to see an allergist. Until that appointment, he avoided all nuts and peanut-containing foods.

The allergist diagnosed my son with a peanut allergy with a skin prick test and a positive blood test. He was pricked every two years up until about ten years of age to monitor changes. After that, the doctor tested him yearly again with skin pricks. And it was at the age of eleven, in November of 2020, that he did his first open oral food challenge test for peanuts, which he passed (negative challenge).

When my son was younger, he often felt unwell or vomited when consuming raw fruits. As for his seasonal allergies, other than sneezing a lot and having a runny nose at times, he’s managed those symptoms well without medication. 

Until his oral peanut challenge, our family did not have peanuts or nuts in the house. He avoided the consumption of peanuts and all nuts.

My Son’s Allergy Symptoms:

  • Hives (with peanuts, some tree nuts)
  • Itchy throat/tongue (with peanuts, some tree nuts)
  • Feeling sick or vomiting (when eating some raw fruits and berries)
  • Sneezing, runny nose, coughing, sore throat (seasonal allergies)

Luckily, he’s never had severe allergic reactions or emergency room visits for any of these foods or allergies. My son has never consumed peanuts or nuts other than when knowingly testing. We’ve always been very careful.

Parenting an Allergy Kid

Not knowing if your kid has allergies is stressful, especially when they do react to certain foods. Getting a proper allergy diagnosis helps in avoiding one or many top allergens or other foods that could potentially make your child very sick.

As parents, we try our best to advocate for our kids, but with allergies, there’s always some degree of worrying. Attending birthday parties was probably the most nerve-racking for me. Travelling was also at the top. My son never really went anywhere without us, and I do admit not wanting to send him to camp at a young age. Once kids can communicate and understand their allergies better, then it becomes a little easier.

As for school, he attended a peanut-free and nut-free elementary school. But there are always parents that send their kids to school with peanut butter sandwiches or snacks with nuts or peanuts. I did receive a few phone calls, especially when he was in kindergarten because someone had peanut-containing food in their lunch. I always appreciated those calls and their protocol for cleaning up, as it made me feel like they cared.

As for intermediate school (grades 7 and 8), let’s just say that the Anaphylaxis Protocol became our child’s responsibility. Our experience is below.

School Anaphylaxis Protocol

Preparing an allergy child for school is nerve-racking. Medical forms (Plan of Care, Allergy Anaphylaxis Protocol, Consent for Administration of Medication, etc.) must be filled out each year for school, the bus and after-school care (if applicable).

In elementary school, for the first few years, my son had an EpiPen on him (in a belt on his waist) at all times. Once he was able to communicate with others more efficiently, he had the EpiPen in his backpack. Keep in mind that in our area, most elementary schools are nut-free and peanut-free, which is helpful. The school office keeps a file for each allergy kid with a second EpiPen in case of an emergency. And at the start of a new year, the school calls to review the anaphylaxis protocol.

Last year was different for us as my son started grade seven (intermediate) in a new school. I soon realized that even with all the necessary medical forms filled out, I never once got a reply email or a phone call from the school to go over my son’s allergy anaphylaxis protocol. That had me nervous, but at the same time, I knew that he was possibly outgrowing the allergy. He carried his EpiPen in his backpack, I packed his lunch each day (there was no cafeteria food anyways), and I prayed that he would be safe.

Before he started grade 8 (13 years old, 2022), I didn’t know what to do. It was time to fill out the necessary medical forms, and I wasn’t sure if the allergist would want to test him again. I called the allergist’s office and spoke directly with the doctor. Together we decided to skip the skin pricks this year because my son can eat a handful of peanuts without reaction.

He no longer has to carry an EpiPen at school. We have a few at home when he does decide to eat peanuts or nuts. We still monitor him closely in case of symptoms.

It was the first time—in ten years—that I did not have to fill out the anaphylaxis protocol form. Instead, I got to fill out one form indicating that my son no longer needed the allergy protocol. I feel relieved and excited writing these words out, but my caution with peanut and nut allergies will remain for a while.

For allergy parents reading this, please call your child’s school each year to review their allergy protocol. It could save a life!

Cooking and baking homemade peanut-free and nut-free meals and treats. Allergen-Friendly Recipes on Fresh is Real.

Allergy Family Life

Living with family members with food allergies, intolerances, and even food sensitivities can be challenging when travelling, eating out, attending events or school, or especially during holidays.

You learn how to educate yourself with books, videos and support groups. You relearn how to cook, bake and clean in a new way.

Controlling what is in your home is much easier to do. It can be as simple as not having the allergen(s) in the house. When visiting someone’s home or doing activities with others, you become much more vigilant and often are on high alert for possible exposures and cross-contamination. Over the years, we got good at cooking many of our meals and usually packing lunches for the family when out and about.

In 2016, I completed, with honours, a Culinary Nutrition course to learn more about healthier cooking without some of the top allergens. Shortly after that, I created the food blog Fresh is Real. I take pride in developing and sharing safe allergen-friendly recipes with the world. The bread recipes are the most popular as the ingredients are free of all top allergens.

Additional Notes

Throughout the years, different specialists have provided us with varied information. Initially, I thought we were ok with foods that did not include nuts or peanuts on the labels. Eventually, we were told by the allergist that the items must say nut-free or peanut-free (prepared in a free-from facility) and that we could not chance cross-contamination. That meant checking labels and ingredients on a new level and cooking meals at home from scratch as much as possible.

As I went through my son’s medical files to write this post, it was clear that much of the information I got over the past decade was a little confusing. Always do your research to learn as much as you can about the latest food allergy research.

When my son was younger, we often questioned if potatoes fried in peanut oil were ok. One day while we were out at a park with an EpiPen on hand, a nurse friend by our side, and the reassurance of a nearby hospital, we decided to give him one fry cooked in peanut oil. After waiting a few minutes, he had no abdominal pain, no hives and felt and appeared fine, so we gave him a small portion of fries to enjoy.

Refined peanut oil is processed, meaning the protein is most likely non-existent and usually safe for peanut allergies. Always consult your doctor or medical specialist with your questions.

Lastly, if you go back to the top of this post, the portion of M&M chocolate-covered peanuts on the white plate is precisely the number (total dose) of peanuts my son ate during the challenge.

Health Insurance for Allergy Testing

Here in Canada, specifically in Ontario, allergy testing and oral challenges are covered.

For food sensitivity or intolerance testing, you can pay out of pocket. You don’t need a doctor’s referral. However, your family doctor might be able to provide you with a requisition for the blood work.

Contact your insurance company or review your medical insurance plan to learn if you have allergy testing coverage.

If you live in the United States or elsewhere, please share if allergy testing or oral food challenges are covered. I’ll collect the information and add it to the post.

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Food Allergy Resources

Allergen-Friendly Recipe Blogs:
The Allergy Mom
Everyday Allergen Free
Allergy Free Alaska
The Allergy Chef
Fresh is Real

Allergy Websites:
American College of Allergy
Asthma and Allergy Foundation of America
Canadian Allergy, Asthma, and Immunology Foundation
Food Allergy Canada
Canadian Society of Allergy and Clinical Immunology

Allergen-Friendly Books:
Food Without Fear
Kid’s Guide to Life with Food Allergies
The Washington Manual Allergy, Asthma, and Immunology Subspecialty Consult (3rd Edition)

Allergen-Friendly Cookbooks:
Allergen-Free Family Cookbook: Gluten-Free, Dairy-Free, Casein-Free, Soy-Free, and Nut-Free Recipes

Allergy-Free and Easy Cooking: 30-Minute Meals without Gluten, Wheat, Dairy, Eggs, Soy, Peanuts, Tree Nuts, Fish, Shellfish, and Sesame

An Allergy Mom’s Lifesaving Instant Pot Cookbook: 60 Fast and Flavorful Recipes Free of the Top 8 Allergens

The Easy Allergy-Free Cookbook: 85 Recipes without Gluten, Dairy, Tree Nuts, Peanuts, Eggs, Fish, Shellfish, Soy, or Wheat

The Corn Free, Gluten Free, and Top 8 Allergy Free Cookbook

The Allergy-Free Pantry: Make Your Own Staples, Snacks, and More Without Wheat, Gluten, Dairy, Eggs, Soy or Nuts

Allergy Magazines:
Allergic Living

Video (YouTube):
Quick Example of an Oral Nut Challenge (1:46)
Allergists Debunk 11 Food Allergy Myths | Debunked (9:20)

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Even certified gluten-free ingredients such as GF oats, corn, seeds, etc., can create health problems for individuals following a GF diet. Always consult a medical professional if unsure about ingredients for your needs.