Scientific Study

Rationale: Supervised oral food challenges (OFCs) are the gold standard for determining allergen tolerance. However, OFCs burden clinicians from the perspective of time, delays to initiation of oral immunotherapy, and barriers for food introduction. Data from in-office OFCs demonstrated high pass rates for almond, macadamia nut, pine nut and Brazil nut: 95%, 86%, 95% and 92%, respectively. Given the high pass rates of these four foods during supervised challenges, and potential benefits of safe diet expansion, there was a need to characterize the safety and outcomes of at-home introduction to these four foods. Methods: 20 patients were selected based on history of sensitization without history of allergic reaction, along with negative or low skin prick testing. Almond, macadamia nut, pine nut and Brazil nut were selected based on the high in-office pass rates and low rates of true allergy in the population. Patients performed at-home OFCs following standardized written instructions provided by the clinical team. Patients were instructed to administer intramuscular epinephrine and activate emergency medical services if anaphylaxis occurred, and to notify the clinical team if any symptoms occurred at any point. Results: Based on reports from parents of these children during follow up visits, all 20 patients were able to safely introduce these foods at home using instructions and felt confident in doing so. There were no adverse reactions or anaphylactic events. Conclusions: OFCs for almond, macadamia nut, pine nut and Brazil nut can be considered for at home challenge with written guidance for sensitized individuals with negative or low testing.

https://doi.org/10.1016/j.jaci.2025.12.398