The predictive value of a positive prick skin test to peanut in atopic, peanut-naïve children

Abstract

Although allergy testing before food ingestion is generally not recommended, many peanut-naive children undergo prick skin tests (PSTs) to peanut because of atopy. Children with positive PSTs are generally advised to avoid peanuts either indefinitely or until a definitive diagnosis is made through challenge. To describe peanut challenges in atopic, peanut-naive children with PST to peanuts > or = 3 mm and the PST properties in this population. Between 1994 and 2001, 47 patients were identified who had a positive peanut PST, no previous peanut ingestion, and had undergone a peanut challenge. Forty-nine percent of the challenges were positive. The mean of the largest wheal diameter (95% confidence interval [CI]) of the PST in children having a negative and positive challenge was 6.3 mm (CI, 5.3 to 7.3) and 10.3 mm (CI, 8.9 to 11.8), respectively. At a PST cutoff of > or = 5 mm, the sensitivity and negative predictive value (95% CI) was 100% (85.2 to 100) and 100% (29.2 to 100), whereas the specificity and positive predictive value (95% CI) was 12.5% (2.7 to 32.4) and 52.3% (36.7 to 67.5), respectively. We show that 49% of atopic, peanut-naïve children sensitized to peanut developed allergic symptoms during oral provocation with peanut. Although the sensitivity of the PST at > or = 5 mm for the detection of peanut allergy in this study was 100%, our small sample size limits the applicability of this value. Further investigation is needed to determine whether children with wheal diameters of 3 or 4 mm, perhaps coupled with low peanut-specific IgE, could undergo less resource-intensive, accelerated challenges.