Predicting outcomes of hazelnut oral food challenge: Pediatric cohort analysis

Hazelnut is a common trigger of IgE-mediated food allergy in children, but clinical tolerance remains difficult to predict. While molecular diagnostics and guideline-based cutoffs offer valuable insights, their real-world applicability across heterogeneous populations is uncertain.

Predictors of outcomes in pediatric hazelnut oral food challenges (OFCs) were evaluated to assess the diagnostic utility of clinical risk assessment and molecular markers.

We conducted a single-center cohort study of 190 OFCs performed between 2022 and 2025. Clinical indication, prechallenge risk classification, laboratory markers, and predefined cofactors were prospectively documented. Outcomes were stratified by tolerance and intolerance. Predictive values for Cor a 14, hazelnut-specific IgE, skin prick test, and physician risk assessment were analyzed. Common thresholds and European Academy of Allergy and Clinical Immunology cutoffs were used.

Overall, 56% of OFCs were tolerated and 44% resulted in confirmed allergy. Cor a 14 ≥ 0.64 kU_A/L was the most accurate serologic predictor of intolerance (positive predictive value 88%, sensitivity 92%, specificity 90%), particularly in high-risk subgroups. Clinical high-risk classification predicted intolerance with a positive predictive value of 85%. Conversely, Cor a 14 < 0.64 kU_A/L and low-risk classification were associated with tolerance (positive predictive value, 93% and 89%, respectively). Age under 5 years, no prior reactions, and no adrenaline prescription further supported tolerance. OFCs enabled therapy optimization and avoided unnecessary oral immunotherapy in 13% of high-risk patients.

Cor a 14 and physician risk assessment reliably predict hazelnut OFC outcomes and guide personalized care. OFCs remain essential for diagnostic clarification and shared decision-making in pediatric allergy practice.