Comparative evaluation of seven severity grading systems in pediatric oral food challenges: Distinctions between anaphylactic and non-anaphylactic reactions

Background Multiple severity scoring systems exist for classifying reactions during OFCs; however, the lack of uniformity among them results in inconsistent identification and management of anaphylaxis. Objective This study aimed to evaluate the clinical characteristics and severity of anaphylactic and non-anaphylactic reactions during oral food challenges (OFCs) in children and to compare the concordance and discrepancies among 7 different severity scoring systems. Methods In this single-center, retrospective, and observational study, positive OFCs were retrospectively graded using 7 different severity classification systems. The concordance and discrepancies among the classification systems, including the World Allergy Organization (WAO) 2024 criteria, the International Classification of Diseases 11th Revision (ICD-11), and the European Academy of Allergy and Clinical Immunology (EAACI) classifications, were evaluated. Results Of the 1901 OFCs performed on 855 patients, 344 (18.1%) were positive, and among these, 61 (17.7%) were classified as anaphylactic reactions. Patients with anaphylactic reactions were significantly older than those with non-anaphylactic reactions (median age: 27 months vs. 15 months; p < 0.001). Using the WAO2024 criteria as the reference standard, both ICD-11 and EAACI classifications showed 100% sensitivity, while specificity for all systems ranged from 86.2% to 99.3%. Discrepancies among severity scoring systems were primarily due to differences in the interpretation of gastrointestinal manifestations. EAACI showed the most favorable balance between sensitivity and specificity, whereas CoFAR and Dribin demonstrated the highest specificity. Conclusion The findings emphasize the need for a harmonized severity classification system that is applicable in both clinical practice and research. Such standardization would enhance diagnostic accuracy and improve the management of food allergies in children.