Reply to Dr. Stefano Miceli Sopo, et al.To the Editor:We would like to express our sincere appreciation to Dr. Miceli Sopo and colleagues for their thoughtful question regarding our article, “AAAAI-EAACI PRACTALL: Standardizing Oral Food Challenges-2024 Update.”(1, 2) We understand the perspective from which this question would arise.The PRACTALL guideline does not advise a standard dose across all oral food challenges as an absolute requirement for validating whether an individual is allergic. As mentioned on page 9 of the manuscript, “The top dose required to avoid false non-reactive double blind placebo controlled food challenges is variable according to the protein content of the food being tested, but seems to be at least 2–3 g of food protein for most allergens.”(1) The remainder of this paragraph cites evidence supporting a range of dosing strategies from prior studies, which collectively aim to ensure false negative rates under 5%.Table 4 provides recommended age-appropriate portions of common food allergens. In the context of the source of the table, “Conducting an Oral Food Challenge: An Update to the 2009 Adverse Reactions to Foods Committee Work Group Report,”(3), it was the suggestion of the AAAAI work group authors to provide age-appropriate serving size options of each food, acknowledging that a child’s ability to consume a given volume of a food may vary. The listed portions aim to achieve at least 2-3 grams of allergenic protein, and ultimately, it is up to the discretion of the physician to determine the volume of food to be given and total protein quantity to be ingested. On page 9 of the PRACTALL report we also stated, “the top dose also needs to be adapted depending on the age of the patient, to account for age-related differences in serving size,”(1) referring to the notion that a child’s ability to ingest a protein quantity varies by age and developmental ability.In the context of a research study, it would likely be necessary to standardize the challenge across all participants and ultimately use a fixed quantity of protein irrespective of the age-appropriate serving size. However, in the clinical example you have provided, offering either 16 whole peanuts or 2 tablespoons of peanut butter would be appropriate. You would achieve a top dose of 2-3 grams of protein with both options, minimizing the likelihood of a false negative result, and you would approximate an age-appropriate serving for the patient, mimicking the likely amount he would eat in a real-world scenario.Since your clinical scenario is not to be reproduced for research purposes, we believe it would be appropriate to discuss options with the patient and their family to determine which food would be used for the oral food challenge. The selected food for the challenge should ideally reflect what the patient is most likely to eat post-challenge in everyday life.We appreciate the opportunity to respond to Dr. Miceli Sopo and colleagues and hope it reinforces the intended guidance of our report.J. Andrew BirdDepartment of Pediatrics, Division of Allergy and ImmunologyUniversity of Texas Southwestern Medical CenterDallas, TexasMarion GroetchJaffe Food Allergy Institute,Icahn School of Medicine at Mount SinaiNew York, New YorkHugh A. SampsonDepartment of PediatricsIcahn School of Medicine at Mount SinaiNew York, New YorkJ.A.B. has served as a consultant in the past 36 months for Allakos, DBV Technologies, Food Allergy Research & Education (FARE), Genentech, Hanimmune Therapeutics, Infinant Health, Novartis, and Parexel. He has received research support from Abbott, Aimmune, ALK, DBV Technologies, FARE, Genentech, the National Institutes of Health/National Institute of Allergy and Infectious Diseases (NIH/NIAID), Novartis, Regeneron, and Siolta Therapeutics. He serves in non-compensated roles as Chair of the Executive Committee of the Section on Allergy and Immunology of the American Academy of Pediatrics, as a medical advisory board member for the International FPIES Association, as an independent study monitor for Vedanta, and as past Chair of the Stock Epinephrine Advisory Committee for the Texas Department of State Health Services.M.G. receives royalties from UpToDate and the Academy of Nutrition and Dietetics, and consulting fees from Food Allergy Research & Education (FARE). She serves on the medical advisory board of the International FPIES Association, as a Senior Advisor to FARE, as a Health Sciences Advisor for the American Partnership for Eosinophilic Disorders (APFED), and on the editorial board of the Journal of Food Allergy. She has no commercial interests to disclose.H.A.S. reports research support from the Immune Tolerance Network, NIAID/NIH, and Food Allergy Research & Education (FARE), and personal fees from N-Fold LLC, DBV Technologies, Alpina Biotech AG, RAPT Therapeutics, and Siolta Therapeutics.REFERENCESCorresponding author:J. Andrew Bird, MDEmail: drew.bird@utsouthwestern.eduMailing address:UT Southwetsern Medical CenterDepartment of Pediatrics5323 Harry Hines Blvd,Dallas, Texas, USA 75390-90631. Sampson HA, Arasi S, Bahnson HT, Ballmer-Weber B, Beyer K, Bindslev-Jensen C, et al. AAAAI-EAACI PRACTALL: Standardizing oral food challenges-2024 Update. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. 2024;35(11):e14276.2. Miceli Sopo S, Aurelio A, Masellone F, Bersani G, Fontana T. Comment on Hugh Sampson et al. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology. 2025.3. Bird JA, Leonard S, Groetch M, Assa’ad A, Cianferoni A, Clark A, et al. Conducting an Oral Food Challenge: An Update to the 2009 Adverse Reactions to Foods Committee Work Group Report. The journal of allergy and clinical immunology In practice. 2020;8(1):75-90 e17.