No Testing Required: Reframing Early Allergy Introduction

For families navigating a suspected food allergy in infancy, one of the most persistent misconceptions is that allergy testing must come first. Marcus Shaker, MD, of Dartmouth Geisel School of Medicine at Dartmouth Health Children’s, pushed back on that assumption in his Eastern Allergy Conference (EAC) 2026 presentation, emphasizing that no testing is required before early introduction of allergenic foods in most cases.¹

Using a case-based approach, Shaker walked through the case of a child with a suspected egg allergy as a clinical illustration. While further evaluation with a board-certified allergist-immunologist would be appropriate before additional egg exposure, he noted that peanut introduction could proceed without testing. Families could try a small amount, approximately a sixteenth of a teaspoon of peanut flour mixed into a soft food, advancing as tolerated. If any reaction occurs, the guidance is clear: pause and seek evaluation.

“There's very good data that this is a safe and effective approach with a low rate of severe reactions, even safer in infants,” Shaker told HCPLive. “We have health economic data that [shows immunotherapy] can save potentially millions or even billions of dollars over time.”

Rescue Refeeding: A Viable Path When Allergy Develops

For children who develop food allergies, Shaker emphasized that a diagnosis is no longer a one-way door to indefinite avoidance. In 2026, he noted, early food immunotherapy represents a viable "rescue refeeding" approach, with strong supporting evidence for both safety and efficacy.

Oral immunotherapy in early childhood is effective and safe in preschoolers, with particular safety advantages in young infants.² Shaker described the rate of severe reactions as low and characterized the evidence base as solid.

For families of a child with a confirmed egg allergy, Shaker outlined a collaborative path: working with a board-certified allergist-immunologist to review and implement a rescue refeeding protocol as a long-term partnership, rather than a discrete intervention.

The Dartmouth Spoon Sheet Approach: Home Multi-Food OIT

Shaker referenced Dartmouth's own published experience as an example of how immunotherapy can be made more accessible. The Dartmouth Spoon Sheet Home OIT Program evaluated children with food allergies receiving oral immunotherapy, with a meaningful proportion receiving multi-food OIT that included peanut, tree nut, or milk.³

The program is designed to address equity and access barriers, particularly relevant in rural settings where repeated clinic visits for dose escalation can be prohibitive. Repeated clinic visits for food oral immunotherapy can limit equity and access in rural locations, and home protocols are cost-effective.

Shared Decision-Making

Shaker said that the role of the clinician is not simply to convey data but to meet families where they are emotionally. He cited Sir William Osler—"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head"—as a framing device for the conversation about food allergy management.

Read part 1 of our interview with Shaker here: Early Allergen Introduction in Infants: Reducing Food Allergy Risk Without Routine Testing

Shaker has no reported disclosures.

References

1. Shaker M. Food Allergy Prevention and Rescue Refeeding in 2026. Session presented at the Eastern Allergy Conference (EAC) 2026 in Palm Beach, Florida, on May 28.

2. Chua GT, Mack DP, Shaker MS, Chan ES. Oral food immunotherapy in patients with atopic dermatitis. Ann Allergy Asthma Immunol. 2024;133(3):278-283. doi:10.1016/j.anai.2024.05.022

3. Shaker M, Hughes S. Real-World Multi-Food Home Oral Immunotherapy Using Daily Micro-Dose Schedules Has Low Rates of Adverse Reactions. Journal of Allergy and Clinical Immunology. 2024;153(2):AB119-AB119.doi:https://doi.org/10.1016/j.jaci.2023.11.394