Age Differences in Food Reaction Severity During Oral Food Challenges in a Large Pediatric Population

Food allergy (FA) reactions can range in severity from mild to life threatening. Concern for severe reactions in young children may lead to over-screening thereby potentially delaying oral introduction. Retrospective review of all oral food challenges (OFC) from 9/9/16 to 2/28/19 at Children’s Hospital of Philadelphia and Vanderbilt University Medical Center. Severe reactions were defined by epinephrine requirement and involvement of lower respiratory (LV) or cardiovascular (CV) sub-scores on the PRACTALL Bock DBPCFC scale. Chi-squared analysis was performed for age comparisons: 0-1 years (infants), 1-2 years (toddlers), 3-5 years (young children), 6-12 years (older children), 13-18 years (teens). Age-based mortality data from The National Food Allergy Death Registry were also analyzed. A total of 746 OFC reactions were reviewed. Of these, 143 (19%) involved CV or LR symptoms and 440 (59%) required epinephrine. Infants and toddlers had significantly fewer reactions involving either CV or LR symptoms (3% and 12%, respectively) vs older age groups (23% in young children, p=0.008 and p=0.02; 22% in older children, p=0.02 and p=0.02; 19% in teens, p=0.04 and p=non-significant vs toddlers). Similarly, epinephrine requirement was lower in composite infants and toddlers (47%) compared to young children (61%, p=0.007), older children (62%, p=0.002) and teens (67%, p=0.003). FA deaths were highest in teens (63%) and older children (34%). Notably, no deaths were reported in infants under age 1. Severe FA reactions and mortality increase with age and are particularly low in infants, supporting early allergen oral introduction.