Crossing the threshold: can outcome data from food challenges be used to predict risk of anaphylaxis in the community?

There is increasing interest in using data from oral food challenges (OFC) performed under medical supervision to assist in allergy risk management, both in industry (allergen risk management) (1) and in the clinical management of the allergic individual (2). Data relating to the minimum eliciting dose (MED) needed to trigger symptoms can inform the need for precautionary allergen labelling (PAL) on food (1). However, given that “zero risk” for food-allergic individuals is not considered to be a realistic proposition (3), it is also important to consider the severity of symptoms which might be experienced: for example, a pragmatic approach, using a level of exposure that causes only minimal, transient oral symptoms in under 1% of the food-allergic population, may be acceptable to guide the use of PAL (4). However, there is often an assumption that individuals with a lower MED (i.e. who react to a lower doses of allergen) are at a greater risk of anaphylaxis (5).