Biphasic reactions in children undergoing oral food challenges

Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Allergy and Asthma Proceedings (Impact Factor: 3.35). 05/2013; 34(3):220-6. DOI: 10.2500/aap.2013.34.3669
Source: PubMed

ABSTRACT Literature regarding biphasic reactions in the pediatric population is sparse. We aimed to determine the prevalence of biphasic reactions in children with food allergies undergoing oral food challenges (OFCs) and examine whether any clinical or treatment factors are associated with biphasic reactions. A retrospective chart review of OFCs conducted between July 2007 and March 2011 was performed. Charts were reviewed from time of challenge to 48 hours after challenge to capture data on any biphasic reactions. Uniphasic and biphasic reactions were compared in terms of specific clinical features and treatments. Of 614 positive challenges, 9 resulted in a biphasic reaction (1.5%). Six of the biphasic reactions occurred in challenges where the initial reaction met anaphylaxis criteria. The biphasic reactions were to eggs (4), peanuts (3), and milk (2). The symptom-free interval ranged from 2 to 24 hours. There were no statistically significant differences in clinical features between uniphasic and biphasic reactions, but there appeared to be a higher percentage of initial reactions with multiple organ involvement and meeting anaphylaxis criteria in the biphasic group. Biphasic reactors were significantly more likely to have received steroids for their initial reaction. A higher percentage of biphasic reactors also appeared to have received epinephrine, multiple doses of epinephrine, and antihistamines for their initial reactions. Biphasic reactions are rare in children undergoing OFCs and may be associated with more severe allergic reactions. Children with severe reactions may benefit from a 24-hour period of observation.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Previous studies report epinephrine use for positive oral food challenges (OFCs) to be 9-11% when generally performed to determine outgrowth of food allergies. Epinephrine use for positive OFCs performed as screening criteria for enrollment in therapeutic trials for food allergy has not been reported. The objective of this study was to assess the characteristics and treatment for positive OFCs performed for screening subjects for food therapeutic trials. Retrospective review of positive screening OFCs from 2 treatment trials, food allergy herbal formula-2 (n = 45) and milk oral immunotherapy (n = 29), conducted at the Icahn School of Medicine at Mount Sinai was performed. The most common initial symptom elicited was oral pruritus, reported for 81% (n = 60) of subjects. Overall, subjective gastrointestinal symptoms (oral pruritus, throat pruritus, nausea, abdominal pain) were most common (97.3% subjects), followed by cutaneous symptoms (48.7%). Of the 74 positive double-blind, placebo-controlled food challenge, 29 (39.2%) were treated with epinephrine; 2 of these subjects received 2 doses of epinephrine (6.9% of the reactions treated with epinephrine or 2.7% of all reactions). Biphasic reactions were infrequent, which occurred in 3 subjects (4%). Screening OFCs to confirm food allergies can be performed safely, but there was a higher rate of epinephrine use compared with OFCs used for assessing food allergy outgrowth. Therefore, personnel skilled and experienced in the recognition of early signs and symptoms of anaphylaxis who can promptly initiate treatment are required. Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
    01/2015; 3(3). DOI:10.1016/j.jaip.2014.10.008
  • [Show abstract] [Hide abstract]
    ABSTRACT: A biphasic reaction is the recurrence of anaphylaxis symptoms within 72 hours of the initial anaphylactic event, without re-exposure to the trigger. Biphasic reactions are uncommon and unpredictable, and risk factors for biphasic reactions are poorly understood. To identify predictors of biphasic anaphylactic reactions in patients with anaphylaxis in the emergency department (ED). Patients of all ages who presented to the ED and met diagnostic criteria for anaphylaxis from April 2008 to January 2013 at an academic medical center with 73,000 annual patient visits were consecutively included. We collected data on patient characteristics, suspected triggers, signs and symptoms, ED management, and disposition. Univariate analyses were performed to estimate the association between potential predictor variables and biphasic reactions. We report associations as odds ratios (OR) and corresponding 95% CIs. Among 541 patients with anaphylaxis, median age was 34.6 years (interquartile range, 18-52 years), and 320 (59%) were female patients. Twenty-one patients (4%) had biphasic reactions. Two pediatric patients, ages of 5 years old and 16 years old, developed a biphasic reaction. The median time between the resolution of initial symptoms and onset of the biphasic reaction was 7 hours (range, 1-72 hours). Biphasic reactions were associated with a history of prior anaphylaxis (OR 2.6 [95% CI, 1.1-6.4]; P = .029), unknown precipitant (OR 2.6 [95% CI, 1.1-6.2]; P = .03), symptoms of diarrhea (OR 4.5 [95% CI, 1.4-14.0]; P = .024), and wheezing (OR 2.6 [95% CI, 1.4-8.9]; P = .029). Patients with a history of prior anaphylaxis, an unknown precipitant, or who present with symptoms of diarrhea or wheezing may be at increased risk for a biphasic reaction.
    05/2014; 2(3):281-7. DOI:10.1016/j.jaip.2014.01.012
  • [Show abstract] [Hide abstract]
    ABSTRACT: Food allergy affects up to 10% of preschool children, and continues to increase in prevalence in many countries, resulting in a major public health issue, with practical implications for the food industry, educational establishments and healthcare systems. The need to distinguish between food allergen sensitization and true clinical reactivity remains crucial in diagnosis, often requiring formal food challenge to avoid unnecessary dietary elimination. Epicutaneous exposure in the absence of oral tolerance induction during infancy may be an important risk factor for food allergy. Mounting evidence suggests that for milk and egg allergens, many children are able to tolerate the food when heat-modified, and that this may hasten resolution of the allergy. These developments will hopefully result in a lower adverse impact on quality of life for food-allergic individuals and their families.
    03/2014; 17(3). DOI:10.1097/MCO.0000000000000052