ORAL FOOD CHALLENGE CONSENT Date Time I give my cnsent and authrize Dr. t perfrm an ral fd challenge t the fllwing fd:. What is an Oral Fd Challenge? If allergy test results and medical histry d nt shw fr certain whether r nt yur child has a fd allergy t a specific fd, we recmmend that yur child have an ral fd challenge test. The ral fd challenge invlves eating a serving f the allergic fd in a slw, graded fashin under medical supervisin. The fd challenge prcedure is the mst accurate test t determine whether a fd needs t be avided r will n lnger need t be avided. The fd challenge is undertaken when yur child is in generally gd health and can discntinue antihistamines fr a brief perid (usually 3-10 days) befre the test. What will happen during the Oral Fd Challenge? During the fd challenge, yur child will be given very small amunts f the specific fd being tested. If tlerated, increasing amunts f the challenge fd will be given with clse bservatin at each stage. Yur child will be bserved fr symptms such as itching, rash, abdminal pain, r difficulty breathing. If any symptms develp, yur child will be treated immediately. In mst cases, this will invlve the use f Benadryl r epinephrine t prevent any allergic reactins frm getting wrse. In studies f fd challenges, many children develp mild symptms during a fd challenge that require these treatments. Very rarely, ther treatments are needed fr mre serius reactins. What are the risks r discmfrts f an Oral Fd Challenge? The discmfrts assciated with the fd challenge are generally n mre than thse encuntered when eating the fd. Symptms usually are shrt-lived (less than 2 hurs). Symptms may include an itchy skin rash, nausea, abdminal discmfrt, vmiting, diarrhea, stuffy runny nse, sneezing, r wheezing. The majr risks invlved include severe breathing difficulties and rarely a drp in bld pressure. While a severe utcme such as death is theretically pssible, this has nt ccurred frm medically supervised ral fd challenges. The risk f a reactin is reduced by starting the challenge with very small amunts f fd, administering the fd ver a prlnged time perid and stpping the challenge at the first sign f a reactin, and by nt giving any fd suspected t cause a majr reactin.
Medicatins, persnnel and equipment will be immediately available t treat allergic reactins shuld they ccur. What are the alternatives t an Oral Fd Challenge? If yu chse nt t have the ral fd challenge, the safest thing t d is t cmpletely restrict the fd in questin frm yur child s diet. The nature and purpse f the Oral Fd Challenge, the risks invlved and the alternatives have been explained t me and all f my questins, if any, have been answered t my satisfactin. I acknwledge that the practice f medicine is nt an exact science and I acknwledge that n guarantee has been made as t the results that may be btained. Patient s Signature Witness Signature Signature f Physician Obtaining Cnsent Physician ID number If patient is a minr: Signature f Parent r Guardian
Fd Challenge Data Cllectin Sheet Review f systems Cnstitutinal: Fatigue, fever, sleeping prblems HEENT: chrnic cngestin, muth breathing, runny nse, frequent sneezing, pst-nasal drip, shrtness f breath, eye swelling / itch / redness, itchy ear(s), ear pain, difficulty swallwing, harseness Respiratry/ Thrax: cugh, shrtness f breath, wheezing. Cardivascular: chest pain, irregular heartbeat, blacking ut Gastrintestinal: abdminal pain, diarrhea, cnstipatin, heartburn, nausea, vmiting, Current medicatins Histry f present illness Cmplaints: Recent expsure / reactin histry: Fd-specific IgE results: Skin test results: Targeted physical exam Weight: Pre-challenge exam: Pst-challenge exam:
Fd challenge data Fd name: Target dse: Medicatins dses fr treating reactins: Benadryl: Epinephrine: Prednislne: Pst challenge assessment and plan: Dse percentage Time Given Symptms Treatment 1% 4% (smetimes I cmbine 1% and 4% t start with 5% f ttal) 10% 15% 20% 25% 25%
Oral fd challenge preparatin In preparatin f the ral fd challenge, yur child shuld nt have anything t eat r drink fr tw hurs prir t the challenge. Antihistamines shuld be stpped prir t the ral fd challenge. Hydrxyzine (Atarax) r Claritin shuld be stpped at least 7 days prir t the fd challenge. Zyrtec r Allegra need t be stpped at least 5 days prir t challenge and Benadryl (diphenhydramine) needs t be stpped at least 2 days prir t the challenge. Nasal antihistamine sprays (e.g., Astelin, Patanase) have t be stpped 24 hurs prir t the challenge. Please be aware that many cld and cugh medicines cntain antihistamines (ingredients such as diphenhydramine, chlrpheniramine, brmpheniramine). Check with yur allergist if yu want t use these medicatins within 1 week f the scheduled ral fd challenge. Yur child shuld nt discntinue any inhaled sterid asthma medicatins (such as Flvent, Budesnide, Pulmicrt. Qvar, Asmanex r Alvesc) prir t the ral fd challenge. Hwever, yu need t stp: - Singulair 24 hurs befre the challenge; - Lng-acting brnchdilatrs (e.g., Serevent, Advair, Fradil, Dulera, Symbicrt) at least 12 hurs befre the challenge; - Shrt acting brnchdilatrs-rescue inhalers (e.g. allbuterl, Xpenex, Maxair) have t be stpped at least 4 hurs befre the challenge. If yur child is sick r has a significant rash n the day f the ral fd challenge, the challenge may need t be rescheduled. Please call us at least ne day prir t the challenge if there are any symptms that may require the challenge t be rescheduled. The ral fd challenge is administered ver at least an hur with a minimum f 2 hurs f bservatin after the challenge has been administered. Please plan n spending abut 4 hurs in the ffice fr the ral fd challenge visit.
Oral Fd Challenge Parent Guide Yur child is scheduled t have a fd challenge. A serving f the fd will be given t yur child ver the curse f an hur (apprximately). We will be bserving yur child fr any changes related t eating the fd bth during the challenge and fr abut 2-3 hurs after the challenge. Please bring a full serving f the fd with yu n the day f the challenge appintment. Yu may want t cnsider bring multiple ptins f the fd in case yur child refuses t eat smething. We d nt have the capacity t d any cking in clinic, but we d have a safe micrwave available t reheat fds that are brught in frm hme. Als bring safe snacks / drinks fr yur child t eat after the challenge, during the bservatin perid. Examples f fds fr challenges: Milk challenge-cnsider cheese r ygurt in additin t liquid milk. Be sure t check the labels fr any ther fds yu may be aviding. Bring bttles r sippy cups s yur child can drink frm smething familiar. Als cnsider pwdered milk which can be added t many fds. Egg challenge- cnsider making French tast with an entire egg. If yu sak the egg in the bread vernight, it s easier and saks mre evenly. Ck the French tast at hme and bring it in with yu n the mrning f the challenge. We can warm it in the micrwave. Yu may bring in syrup, jelly r any ther safe cndiment. Sme kids will eat a scrambled egg. Sy challenge- cnsider sy ygurt in additin t sy milk. Yu may cnsider trying t get creative with tfu. Wheat challenge-cnsider 2 slices f bread (check fr milk and r / egg ingredients if yu are aviding thse), a serving f whle wheat cereal such a Wheat Chex, Frsted Mini Wheat (again, check the label fr ther ingredients that yu may be aviding), r Cream f Wheat cereal Peanut challenge-reese s peanut butter cups r Reese s Pieces wrk well fr kids wh can tlerate milk. Yu can als use peanut butter. The dse is 2 tablespns f peanut butter. Mst f the majr label peanut butter (examples: Jiff, Skippy) d nt carry a may cntain tree nuts label. The peanut butter can be spread n safe bread, crackers, celery r any ther safe vehicle. Tree Nut challenges- Yu need a nut that is nt cntaminated with peanut r ther nuts if yur child is aviding peanut r ther tree nuts. The best way t assure there is n cntaminatin is t purchase the nuts in the shell and crack them at hme. Please be aware that yu cannt buy cashews in the shell. The serving size will vary with the nuts. Please cntact us fr guidance. Yu can grind the nuts and put them int a safe hmemade ckie, muffin r brwnie. Nuts can be sprinkled n tp f pudding r ygurt if either f thse fds is safe fr yur child. Nte: manufacturer-guaranteed pure almnd butter Barney Butter (www.barneybutter.cm); als www.justalmnds.cm Meat r fish Challenges- a serving f meat r fish is usually abut the size f a deck f cards. Make sure the meat/fish is nt prcessed r packaged with fds such as sy r milk if these fds are being avided. Deli s can cntaminate fds if they share equipment between cheese and meats. Fish can be crss-cntaminated if it is packaged r stred with ther seafd. Dn t frget t bring cndiments such as ketchup, mustard r BBQ sauce if thse are fds that are safe fr yur child.
In additin, cnsider a fruit-based smthie as the vehicle. The icy texture can hide the crunchiness f tree nuts r sesame seeds and the cldness decreases the taste assciated with sy r cw s milk. T make hme-made smthies, use abut a cup f fresh r frzen berries, peaches, banana r any ther fruit that is safe. Add crushed ice and blend in a fd prcessr r blender until smth. Freeze the smthie in a plastic cntainer with a tight fitting lid. Bring the smthie and the challenge substance t the visit. If yur child tlerates milk r sy, yu can add milk-based r sy-based ygurt t the smthie t give it a better base. If yu are using the smthie fr a milk r egg challenge, cnsider using dried milk pwder r dried egg pwder t keep the vlume as small as pssible. If yu mix the challenge substance in the smthie when yu are making it, be careful f the ttal amunt f smthie that yu make. We will need yur child t eat the entire smthie if yu mix the challenge substance in as yu g.
Pre-Fd challenge Checklist Mailed ral fd challenge parent guide Called 1 week prir t OFC. Appintment cnfirmed. Discntinue antihistamines (7 days fr hydrxyzine / Claritin, 5 days fr Zyrtec / Allegra, 2 days fr Benadryl). Discntinue Singulair 24 hurs prir. Discntinue SABAs, LABAs, nasal antihistamine sprays and H2 blckers the day prir. Histry f: Asthma y n If yes, current symptms? Eczema y n If yes, current symptms? Allergic rhinitis y n If yes, current symptms? Current URI, fever, gastrintestinal illness, r ther health prblems? Infrmed patient/parent t cntact us if any new health cncerns / symptms develp prir t the appintment. Nthing t eat/drink fr 4 hurs prir t challenge. Small meal 2 hurs prir k fr infants and yung children. Infrmed patient t bring prepared fd. Trial f fd / meal in allergen-free frm at hme. Infrmed patient f minimum duratin f prcess (usu. 3 hurs). They need t remain in ffice under bservatin fr 2 hurs after cmpletely eating the fd.