# Transepidermal Water Loss in Oral Food Challenges in Children With Peanut Allergy: A Randomized Clinical Trial

## TL;DR

This study shows that using transepidermal water loss (TEWL) as a stopping criterion during peanut oral food challenges in children can reduce anaphylaxis rates, making the process safer.

## Contribution

The study introduces TEWL as a novel stopping criterion to enhance safety during oral food challenges in children with peanut allergy.

## Key findings

- Using TEWL reduced anaphylaxis rates from 100% to 63% in the intervention group compared to the control group.
- The median CoFAR score was lower in the TEWL group, indicating less severe reactions.
- Fewer participants in the TEWL group required epinephrine compared to the control group.

## Abstract

This randomized clinical trial investigates whether transepidermal water loss as a measure of skin barrier function can be used as a stopping criterion to reduce anaphylaxis rates during oral food challenges in children with peanut allergy.

Can transepidermal water loss (TEWL) as a measure of skin barrier function be used to reduce anaphylaxis rates and severity during oral food challenges in children with peanut allergy?

In this randomized clinical trial that included 40 children aged 6 months to 5 years with peanut allergy, the anaphylaxis rate among participants with an allergic reaction during a peanut oral food challenge was lower in the group for which TEWL was used as a stopping criterion (63%) than in the control group (100%).

The findings suggest TEWL can augment anaphylaxis prediction during oral food challenges.

Food allergy is a prevalent chronic medical condition in children, with limited diagnostic options. Transepidermal water loss (TEWL) is a measure of skin barrier function with emerging utility in atopy and food allergy.

To determine whether use of TEWL as a stopping criterion can prevent anaphylaxis during a peanut oral food challenge (OFC).

This was a single-center randomized clinical trial of children aged 6 months to 5 years with a history of a clinical peanut allergic reaction and positive peanut skin prick and/or serum immunoglobulin E testing. All participants underwent peanut OFC at an allergy referral clinic. The study began May 1, 2023, and ended August 31, 2024.

The intervention was stopping OFC based on a 1 g/m2/h rise in TEWL plus 1 objective allergic symptom observed by the physician during OFC. Standard OFC stopping criteria or the intervention criteria, whichever came first, were used in the intervention group. OFC stopping criteria from standard research were used in the control group. This was a single-intervention study.

Rate of anaphylaxis, defined as a Consortium for Food Allergy Research (CoFAR) score of 2 or higher, compared between the intervention and control groups using 4 anaphylaxis criteria approaches: CoFAR, Brighton Collaboration, Food Allergy and Anaphylaxis Network (FAAN), and World Allergy Organization (WAO).

A total of 40 participants were included in the final analysis. The mean (SD) age of participants was 31.8 (16.18) months, with a median of 32.5 (range, 9-62) months; 23 (58%) were male. Using CoFAR criteria, among reactors, the anaphylaxis rate was 10 of 16 (63%; 95% CI, 39%-86%) in the intervention group compared with 14 of 14 (100%; 95% CI, 100%-100%) in the control group (P = .02). Using WAO criteria, 2 of 16 participants were reactors in the intervention group (anaphylaxis rate, 13%; 95% CI, 0%-29%) compared with 8 of 14 (57%; 95% CI, 31%-83%) in the control group (P = .02). There was no significant difference when comparing anaphylaxis rates using Brighton or FAAN criteria (eg, rate of 56% [95% CI, 32%-81%] vs 71% [95% CI, 48%-95%] in intervention vs control participants using Brighton criteria [P = .47]). The median CoFAR score in reactors in the intervention vs control groups was 1.8 (IQR, 1.0-2.0) vs 2.6 (IQR, 2.0-3.0) (P = .006). Eight of 16 participants (50%) in the intervention vs 12 of 14 (86%) in the control group required epinephrine (P = .06).

In this randomized clinical trial, prospective use of TEWL as a stopping criterion reduced anaphylaxis rates during OFC in children with peanut allergy, suggesting use of TEWL could make OFC safer and more accessible. Replicating this study in a larger, multicenter population is a reasonable next step.

ClinicalTrials.gov Identifier: NCT05696236