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Gallagher A, Cronin C, Heng TA, McKiernan A, Tobin C, Flores L, McGinley AM, Loughnane C, Velasco R, O'B Hourihane J, Trujillo J. Dietary Advancement Therapy Using Milk and Egg Ladders Among Children With a History of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2135-2143. [PMID: 38729302 DOI: 10.1016/j.jaip.2024.04.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Anaphylaxis has been increasing in recent years, with common triggers in infants being milk and eggs. Currently, the mainstay of treatment for milk and/or egg allergy is strict avoidance. Recently, new therapies have emerged including stepwise introduction of allergens via a ladder approach. The suitability of infants for the ladders is debated. OBJECTIVE This study aims to focus on the use of food ladders in children with anaphylaxis to egg or milk. METHODS Retrospective review of pediatric patients diagnosed with immunoglobulin E-mediated milk and/or egg allergy between 2011 and 2021. Inclusion and exclusion criteria were applied. Anaphylaxis was defined as per the World Allergy Organization-amended criteria 2020. Data analysis utilized SPSS Version 28. RESULTS We reviewed 1,552 patient charts, and excluded 1,094, leaving a total sample size of 458. Seventy infants had anaphylaxis at diagnosis (milk n = 36; egg n = 34). A range of 77.8% to 85.2% of infants with anaphylaxis successfully completed the ladder, 88.9% to 92.9% without anaphylaxis were successful. Children who successfully completed the ladder did so at similar rates. A range of 20.6% to 50% children presenting with anaphylaxis at diagnosis experienced allergic symptoms during treatment, compared with 17.3% to 40.7% without anaphylaxis. Reactions were mild, mostly cutaneous and not requiring medical attention. Patients experiencing allergic symptoms while on the ladder were less likely to successfully complete treatment. CONCLUSIONS Milk and egg ladders are a safe and effective way of inducing tolerance in infants, including those with a history of anaphylaxis at diagnosis. There are no obvious predictors for who will experience allergic reactions while on the ladder; however, these children are less likely to complete the ladder, so parents should be educated in management of mild allergic reactions at home.
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Affiliation(s)
- Aoife Gallagher
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Department of Paediatrics, Cork University Hospital, Cork, Ireland; Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland
| | - Caoimhe Cronin
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland
| | - Tessa Ah Heng
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Anne McKiernan
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland
| | - Ciara Tobin
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Laura Flores
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | | | - Conor Loughnane
- Cork University Business School, University College Cork, Cork, Ireland
| | - Roberto Velasco
- Paediatric Emergency Unit, Parc Tauli Hospital, Barcelona, Spain
| | | | - Juan Trujillo
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Department of Paediatrics, Cork University Hospital, Cork, Ireland; Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland.
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Anagnostou A, Mack DP, Johannes S, Shaker M, Abrams EM, DeSanto K, Greenhawt M. The Safety and Efficacy of Baked Egg and Milk Dietary Advancement Therapy: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00639-1. [PMID: 38901613 DOI: 10.1016/j.jaip.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Cow's milk and egg allergy affect approximately 1.9% and 0.9% of children, respectively. Dietary advancement therapies (DATs), including milk (ML) and egg (EL) ladders, and baked milk (BM-OIT) and baked egg (BE-OIT) oral immunotherapy, are potential therapeutic options for these patients. OBJECTIVE To perform systematic review and meta-analysis of the safety and efficacy of DATs in children with IgE-mediated milk or egg allergy. METHODS A systematic literature review was conducted, exploring 22 potential outcomes, with meta-analysis performed where ≥3 studies reported data. The GRADE approach was used to determine the certainty of evidence for each outcome, and the Johanna Briggs Institute tools were used for determining risk of bias. RESULTS Twenty-nine studies met inclusion criteria among 9946 titles screened. Tolerance occurred in 69% of EL, 58% of ML, 49% of BE-OIT, and 29% of BM-OIT patients. All-severity allergic reactions occurred in 21% of EL, 25% of ML, 20% of BE-OIT, and 61% of BM-OIT patients, with epinephrine use in 3% of EL, 2% of ML, and 9% of BM-OIT patients. At-home reactions occurred in 19% of BE-OIT and 10% of BM-OIT patients. Discontinuation occurred in 14% of EL, 17% of ML, 17% of BE-OIT, and 20% of BM-OIT patients. The mean time to BE egg and BE-OIT tolerance was 13.25 months (4 studies) and 19.1 months (3 studies). Certainty of evidence was very low, and risk of bias high. Study heterogeneity was high, attributable to multiple factors. CONCLUSIONS There is very low certainty of evidence supporting DAT safety and efficacy. We cannot conclude that DAT accelerates tolerance development.
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Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Division of Allergy and immunology, Baylor College of Medicine, Houston, Texas
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Stephanie Johannes
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Marcus Shaker
- Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, NH
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Kristen DeSanto
- University of Colorado Strauss Health Sciences Library, Aurora, Colo
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
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Saravanabavan S, Upton J. Practical tips for the use of the Canadian milk ladder for paediatricians. Paediatr Child Health 2024; 29:72-73. [PMID: 38586484 PMCID: PMC10996459 DOI: 10.1093/pch/pxad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/20/2023] [Indexed: 04/09/2024] Open
Affiliation(s)
| | - Julia Upton
- Division of Immunology and Allergy, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Cronin C, Salzberg N, Woon Y, Wurttele JT. Primary, secondary and tertiary prevention of food allergy: current practices and future directions. Allergol Immunopathol (Madr) 2024; 52:32-44. [PMID: 38459888 DOI: 10.15586/aei.v52i2.1023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/27/2023] [Indexed: 03/11/2024]
Abstract
The incidence of food allergies has risen around the globe, and experts have been exploring methods of preventing such allergies in young children to ease the burden of disease and reduce the morbidity and mortality caused by anaphylaxis to food allergens. Such preventative measures can be categorised as primary, secondary and tertiary prevention, which are discussed in detail in this review. Primary prevention is defined as the prevention of becoming sensitised towards specific allergens. The evidence suggests that avoiding common allergenic foods during pregnancy and breastfeeding is not protective against food allergies, and guidelines recommend weaning from 4 to 6 months of age, with recent studies supporting the early introduction of peanuts at 4 months to prevent peanut allergy. Secondary prevention targets patients who are already sensitised and aims to halt the progression of sensitisation, with evidence for high rates of success and safety in trials of early introduction to milk and peanuts using oral immunotherapy in sensitised infants. Tertiary allergy prevention focuses on reducing the risk of a patient having anaphylaxis, with oral immunotherapy being the most common method of promoting tolerance in allergic children. Several studies have demonstrated successful reintroduction for milk, egg and peanut; however, no such guidelines are recommended for other foods. Finally, dietary advancement therapy in the form of milk and egg ladders has been employed as a method of primary, secondary and tertiary prevention of allergies, particularly in Ireland, the UK and Canada.
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Affiliation(s)
- Caoimhe Cronin
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
- Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland
| | - Noah Salzberg
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Yuxin Woon
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
| | - Juan Trujillo Wurttele
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
- Cork University Hospital, Irish Centre for Maternal and Child Health Research (INFANT), HRB Clinical Research Facility Cork (CRF-C), Cork, Ireland;
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Barzylovych V, Umanets T, Barzylovych A, Hilenko H, Stelmah V, Besh L, Nedelskaya S, Abaturov O, Ditiatkovsky V, Kasianenko H, Khomenko V, Lapshyn V, Antipkin Y. The Ukrainian Milk Ladder: Enhancing diet for children with cow's milk allergy. Clin Exp Allergy 2024; 54:222-224. [PMID: 38380708 DOI: 10.1111/cea.14460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Vladyslava Barzylovych
- SI "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O.M. Lukyanova, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
- National Medical University named after O.O. Bogomolets, Kyiv, Ukraine
| | - Tetiana Umanets
- SI "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O.M. Lukyanova, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
- National Medical University named after O.O. Bogomolets, Kyiv, Ukraine
| | | | - Hanna Hilenko
- Taras Shevchenko National University of Kyiv, Ukraine
- Allergy Clinic Aclinic, Odesa, Ukraine
| | | | - Lesya Besh
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Svetlana Nedelskaya
- Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
| | | | | | - Hanna Kasianenko
- Allergy Clinic Aclinic, Odesa, Ukraine
- Odesa National Medical University, Odesa, Ukraine
| | | | - Volodymyr Lapshyn
- SI "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O.M. Lukyanova, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
| | - Yurii Antipkin
- SI "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O.M. Lukyanova, National Academy of Medical Sciences of Ukraine", Kyiv, Ukraine
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Upton JEM, Wong D, Nowak-Wegrzyn A. Baked milk and egg diets revisited. Ann Allergy Asthma Immunol 2024; 132:328-336.e5. [PMID: 38151097 DOI: 10.1016/j.anai.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/29/2023]
Abstract
Most children with milk and egg allergy are nonreactive to modified forms of milk and egg in bakery products such as muffins because of conformational changes in proteins. These baked milk (BM) and baked egg (BE) diets have become commonplace in the management of milk and egg allergy, respectively. Current laboratory- and skin test-based diagnostic approaches remain limited in their ability to predict BM/BE tolerance, resulting in various approaches to introduce these foods. One approach to introduce BM/BE is to offer a medically supervised oral food challenge and then advise dietary introduction of baked products for children who have tolerance. Another approach is adapted from a home-based protocol of graded ingestion of BM or BE originally intended for non-IgE mediated allergy, often referred to as a "ladder." The ladder advises home ingestion of increasing amounts of BM or BE. For children who have allergy to BM or BE, the ladder is essentially oral immunotherapy, although not always labeled or recognized as such. Risk assessment and education of patients suitable for home introduction are essential. A home approach that may be called a ladder can also be used to escalate diets after demonstrated tolerance of baked forms by introducing lesser cooked forms of milk or egg after tolerating BM or BE. A randomized controlled trial provided clear evidence that baked diets can hasten the resolution of IgE-mediated milk allergy. Moreover, BM/BE foods have an emerging role in the treatment of non-IgE-mediated allergy. There is tangential evidence for BM and BE diets in the prevention of IgE-mediated allergy.
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Affiliation(s)
- Julia E M Upton
- SickKids Food Allergy and Anaphylaxis Programme, Division of Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Division of Clinical Immunology and Allergy, Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Dennis Wong
- SickKids Food Allergy and Anaphylaxis Programme, Division of Immunology and Allergy, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada; Division of Clinical Immunology and Allergy, Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU R. Grossman School of Medicine, New York, New York; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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Hicks A, Fleischer D, Venter C. The future of cow's milk allergy - milk ladders in IgE-mediated food allergy. Front Nutr 2024; 11:1371772. [PMID: 38496796 PMCID: PMC10941844 DOI: 10.3389/fnut.2024.1371772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Cow's milk allergy (CMA) is one of the most common and complex presentations of allergy in early childhood. CMA can present as IgE and non-IgE mediated forms of food allergy. Non-IgE mediated CMA includes food protein-induced enterocolitis syndrome (FPIES), eosinophilic gastrointestinal disorders (EGIDs), and food protein-induced proctocolitis (FPIAP). There are recent guidelines addressing CMA diagnosis, management, and treatment. Each of these guidelines have their own strengths and limitations. To best manage CMA, individualized avoidance advice should be given. Cow's milk (CM) can be replaced in the diet by using hypoallergenic formulas or plant-based milk, depending on factors such as the child's age and their current food intake. Oral and epicutaneous immunotherapy is used to increase tolerance in children with CMA but is not without risk, and the long-term outcome of sustained unresponsiveness is still unclear. The allergenicity of CM proteins are affected differently by different forms of heating, leading to the use of baked milk or milk ladders in the management of CMA, most likely the most promising option for future management and treatment of CMA. Future management of children with CMA will also include discussion around the immunomodulatory potential of the child's dietary intake.
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Affiliation(s)
| | | | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
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Mack DP. Standardization of food allergen ladders for optimal effectiveness and patient safety. JOURNAL OF FOOD ALLERGY 2023; 5:49-54. [PMID: 39022756 PMCID: PMC11250552 DOI: 10.2500/jfa.2023.5.230013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
The use of extensively heated (EH) milk and egg products, and dietary advancement therapies such as milk and egg ladders is increasingly common for the management of milk and egg allergies. Although the majority of patients with milk and egg allergies will outgrow their allergies, the ability to tolerate extensively hydrolyzed forms of these allergens is an early indicator of developing long-term tolerance. The denaturation of conformational epitopes during the heating process reduces the allergenicity of these proteins, which makes patients who are EH tolerant more likely to tolerate progressively more of these proteins.
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Affiliation(s)
- Douglas P Mack
- From the Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Chomyn A, Chan ES, Yeung J, Cameron S, Chua GT, Vander Leek TK, Williams BA, Soller L, Abrams EM, Mak R, Wong T. Safety and effectiveness of the Canadian food ladders for children with IgE-mediated food allergies to cow's milk and/or egg. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:94. [PMID: 37932826 PMCID: PMC10629013 DOI: 10.1186/s13223-023-00847-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/05/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Food ladders are tools designed to facilitate home-based dietary advancement in children with food allergies through stepwise exposures to increasingly allergenic forms of milk and egg. Several studies have now documented safety and efficacy of food ladders. In 2021, we published a Canadian adaptation of the previously existing milk and egg ladders originating in Europe using foods more readily available/consumed in Canada. Our study adds to the growing body of evidence supporting food ladder use and provides safety and effectiveness data for our Canadian adaptation of the milk and egg ladders. METHODS Surveys were distributed to families of children using the Canadian Milk Ladder and/or the Canadian Egg Ladder at baseline, with follow up surveys at 3 months, 6 months, and 12 months. Data were analyzed using REDCap and descriptive and inferential statistics are presented. RESULTS One hundred and nine participants were started on milk/egg ladders between September 2020 and June 2022. 53 participants responded to follow up surveys. Only 2 of 53 (3.8%) participants reported receiving epinephrine during the study. Severe grade 4 reactions (defined according to the modified World Allergy Organization grading system) were not reported by any participants. Minor cutaneous adverse reactions were common, with about 71% (n = 10/14) of respondents reporting cutaneous adverse reactions by 1 year of food ladder use. An increasing proportion of participants could tolerate most foods from steps 2-4 foods after 3, 6, and 12 months of the food ladder compared to baseline. CONCLUSION The Canadian food ladders are safe tools for children with cow's milk and/or egg allergies, and participants tolerated a larger range of foods with food ladder use compared to baseline.
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Affiliation(s)
- Alanna Chomyn
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada.
| | - Edmond S Chan
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Joanne Yeung
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Scott Cameron
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Timothy K Vander Leek
- Pediatric Allergy & Asthma, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brock A Williams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
- Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada
| | - Lianne Soller
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
- Department of Pediatrics and Child Health, Section of Allergy and Immunology, University of Manitoba, Winnipeg, Canada
| | - Raymond Mak
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada
| | - Tiffany Wong
- Department of Pediatrics, Division of Clinical Immunology & Allergy, University of British Columbia, BC Children's Hospital, Room 1C31B 4480 Oak Street, V5Z 4H4, Vancouver, BC, Canada.
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Ye L, Wong T, Lavine E, Cook VE, Erdle SC. Using the canadian egg ladder in children with food protein-induced enterocolitis syndrome: a case series. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:87. [PMID: 37803461 PMCID: PMC10557249 DOI: 10.1186/s13223-023-00843-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Current management of food protein-induced enterocolitis syndrome (FPIES) involves strict avoidance of the offending food for 12-18 months, followed by oral food challenge (OFC) under physician supervision. OFCs are resource-intensive and there is a lack of a universal standardized protocol for FPIES. Prolonged avoidance may increase the risk of IgE-mediated allergy, particularly in atopic patients. Food ladders have shown success in promoting accelerated tolerance in patients with IgE-mediated allergy. Our case series evaluated the safety of use of the Canadian Egg Ladder in patients with mild-to-moderate FPIES to egg. METHODS From May 2020 to November 2021, patients with mild-to-moderate FPIES to egg, defined as no history of lethargy or intravenous fluid administration, were started on the Canadian Egg Ladder. Instructions for advancing up the ladder were identical to using the Canadian Egg Ladder in patients with IgE-mediated allergy. Patients were followed every 3-6 months, at which time information was collected regarding progression up the ladder, symptoms while on treatment and interventions required. Treating allergists completed a survey to capture baseline demographic characteristics and prior tolerance to egg. Descriptive statistics were analyzed using MS Excel. RESULTS Twenty-one patients with mild-to-moderate FPIES were started on the Canadian Egg Ladder. Median age at initiation of the ladder was 10 months (IQR, 9-11). Nineteen (90.5%) patients completed the ladder, tolerating a serving size amount of cooked egg, over a median duration of 7 month (IQR, 4-9 months). Four patients (19.0%) had mild symptoms including vomiting (9.5%), pallor (9.5%), belching (4.8%), irritability (4.8%) and small spit up (4.8%). In three of the four patients, symptoms were the result of accidental exposure to a higher step of the ladder. There were no reports of lethargy. No patients required health care presentation or intravenous fluid administration. No patients discontinued the ladder. CONCLUSIONS The Canadian Egg Ladder can safely guide the dietary advancement of egg-containing foods in patients with mild-to-moderate FPIES to egg, without the need for prolonged avoidance and resource-intensive OFCs.
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Affiliation(s)
- Linlei Ye
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Tiffany Wong
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
| | - Elana Lavine
- Department of Pediatrics, University of Toronto, Humber River Hospital, Toronto, ON, Canada
| | - Victoria E Cook
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
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Hosaagrahara Ramakrishna S, Shah N, Acharyya BC, Durairaj E, Verma L, Sankaranarayanan S, Wadhwa N, Venter C. The Need for Culturally Appropriate Food Allergy Management Strategies: The Indian Milk Ladder. Nutrients 2023; 15:3921. [PMID: 37764705 PMCID: PMC10535525 DOI: 10.3390/nu15183921] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Cow's milk allergy (CMA) is one of the most common and complex food allergies affecting children worldwide and, with a few exceptions, presents in the first few months of life. Baked-milk-containing diets are well tolerated in the majority of milk-allergic children and allow dietary restrictions to be relaxed. In addition, the early introduction of tolerated forms of allergenic foods to an infant's diet in small amounts may enhance the outgrowth of their milk allergy through oral tolerance induction. The methods of milk introduction vary widely across the globe. METHODS We convened an expert group to develop a comprehensive milk ladder based on the calculated milk protein content of Indian foods. To validate the milk ladder, the foods chosen for the ladder were analyzed and the ladder was re-evaluated based on the cooked milk protein content. RESULTS Combining expert consensus and validation of milk protein content, we created the world's first milk ladder containing Indian foods. This is the first ladder that provides information on the timing and temperature of cooking, with validated milk protein content. CONCLUSIONS This is the first milk ladder based on the unique features of Indian food habits built by the consensus of Indian experts along with international collaboration with laboratory quantification of milk protein in each step. We believe the "The Indian Milk Ladder" will be a very helpful tool for pediatricians helping manage CMA in children as well as their parents and caregivers, not only in India, but in countries world-wide where these foods are commonly consumed.
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Affiliation(s)
| | - Neil Shah
- The Portland Hospital, London W1W 5AH, UK
- Reckitt Nutrition, Slough SL1 3UH, UK
| | - Bhaswati C Acharyya
- Department of Paediatric Hepatology & Gastroenterology, AMRI Hospitals, Kolkata 700028, India
- Department of Paediatric Hepatology & Gastroenterology, Institute of Child Health, Kolkata 700017, India
| | - Emmany Durairaj
- Department of Clinical Nutrition, Mazumdar Shaw Medical Centre, Narayana Health City, Bengaluru 560099, India
| | - Lalit Verma
- Department of Paediatric Hepatology & Gastroenterology, Global Hospitals, Mumbai 400012, India
| | - Srinivas Sankaranarayanan
- Department of Paediatric Hepatology & Gastroenterology, Kanchi Kamakoti CHILDS Trust Hospital, Chennai 600024, India
- Department of Paediatric Hepatology & Gastroenterology, Apollo Children Hospital, Chennai 600006, India
| | - Nishant Wadhwa
- Institute of Child Health, Division of Paediatric Gastroenterology, Hepatology & Nutrition, Sir Gangaram Hospital, New Delhi 110060, India
| | - Carina Venter
- Paediatrics, Section of Allergy & Immunology, Denver School of Medicine, University of Colorado, Denver, CO 80204, USA
- Paediatrics, Section of Allergy & Immunology, Children's Hospital Colorado, Denver, CO 80218, USA
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Upton JEM, Lanser BJ, Bird JA, Nowak-Węgrzyn A. Baked Milk and Baked Egg Survey: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2335-2344.e4. [PMID: 37236351 DOI: 10.1016/j.jaip.2023.04.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 05/28/2023]
Abstract
Most milk- and egg-allergic children can tolerate milk and egg in baked forms. Some allergists have extended the use of baked milk (BM) and baked egg (BE) to advocating for the stepwise introduction of small amounts of BM and BE to children who are reactive to larger amounts of BM and BE. Little is known about the practice of introducing BM and BE and existing barriers to this approach. The purpose of this study was to gather a current assessment of the implementation of BM and BE oral food challenges and diets for milk- and egg-allergic children. We conducted an electronic survey of North American Academy of Allergy, Asthma & Immunology members offering BM and BE introduction in 2021. The response rate was 10.1% of distributed surveys (72 of 711). Surveyed allergists had a similar approach to both BM and BE introduction. Demographic features of time in practice and region of practice were significantly associated with the odds of introducing BM and BE. A wide variety of tests and clinical features guided decisions. Some allergists determined BM and BE to be appropriate for home introduction and offered this for BM and BE more often than other foods. The use of BM and BE as a food for oral immunotherapy was endorsed by almost half of respondents. Less time in practice was the most significant factor associated with offering this approach. Published recipes were used and written information was widely provided to patients by most allergists. The wide practice variabilities reveal a need for more structured guidance about oral food challenges, in-office versus home procedures, and patient education.
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Affiliation(s)
- Julia E M Upton
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Bruce J Lanser
- Department of Pediatrics, Division of Allergy and Clinical Immunology, National Jewish Health and University of Colorado School of Medicine, Denver, Colo
| | - J Andrew Bird
- Department of Pediatrics, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anna Nowak-Węgrzyn
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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13
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Loke P, Vickery BP, Jones SM, Peters RL, Roberts G, Koplin JJ. Food Allergen Immunotherapy in Preschool Children: Do We Have the Evidence? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1028-1035. [PMID: 36649799 DOI: 10.1016/j.jaip.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
Standard care for the management of food allergies previously centered on allergen avoidance and the treatment of adverse reactions after allergen exposure. An increase in the development of immunotherapy treatments for food allergy has occurred over the past 2 decades, with many centers now offering immunotherapy. Previous studies mainly focused on school-age children in whom food allergies are likely to be persistent. However, there is increasing evidence that delivering immunotherapy for food allergy to preschool-age children may deliver higher rates of success, and that peanut allergen immunotherapy leads the way. Conversely, the natural resolution of food allergies occurs primarily in these younger age groups, resulting in challenges to selecting patients who will ultimately benefit from these treatments. Both immunotherapy and natural history studies reveal the inherent plasticity of the immune system in early life, which may be more amenable to intervention, but this raises a delicate yet unknown balance between the optimal timing of intervention versus waiting for natural resolution of the food allergy. Here we review the evidence for early food allergen immunotherapy in preschoolers, and present the pros and cons of this approach while acknowledging important research gaps in this age group.
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Affiliation(s)
- Paxton Loke
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Monash Children's Hospital, Melbourne, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Australia.
| | - Brian P Vickery
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Ga
| | - Stacie M Jones
- Department of Pediatrics, Allergy, and Immunology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Rachel L Peters
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Graham Roberts
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; David Hide Asthma and Allergy Centre, St Mary's Hospital, Isle of Wight, United Kingdom
| | - Jennifer J Koplin
- Murdoch Children's Research Institute, Melbourne, Australia; Child Health Research Centre, University of Queensland, Brisbane, Australia
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14
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‘Early Introduction’ of Cow’s Milk for Children with IgE-Mediated Cow’s Milk Protein Allergy: A Review of Current and Emerging Approaches for CMPA Management. Nutrients 2023; 15:nu15061397. [PMID: 36986127 PMCID: PMC10057913 DOI: 10.3390/nu15061397] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023] Open
Abstract
IgE-mediated cow’s milk protein allergy (CMPA) is one of the most prevalent food allergies in early childhood. Though the cornerstone of management involves the strict avoidance of milk products while awaiting natural tolerance, research increasingly shows that the rates of resolution are slowing down. Therefore, there is a need to explore alternative pathways to promote tolerance to cow’s milk in pediatric populations. This review aims to combine and appraise the scientific literature regarding the three CMPA management methods: avoidance, the milk ladder, and oral immunotherapy (OIT) and their outcomes in terms of efficacy, safety, and immunological effects. Cow’s milk (CM) avoidance virtually protects against allergic reaction until natural tolerance occurs, with hypoallergenic substitutes available in the market, but accidental ingestion represents the main issue for this strategy. Introduction to baked milk using the milk ladder was designed, with most CMPA patients successfully completing the ladder. Similar to baked milk treatment, many OIT protocols also demonstrated decreased IgE and increased IgG4 levels post protocol, as well as a reduction in wheal size diameter. Though these strategies are shown to be safe and effective in CMPA, future clinical trials should compare the safety and effectiveness of these three management strategies.
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15
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Lloyd M, Loke P, Mack DP, Sicherer SH, Perkin MR, Boyle R, Yin Leung AS, Lee BW, Levin M, Blumchen K, Fiocchi A, Ebisawa M, Oliveira LCLD, Tang MLK. Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1010-1027.e6. [PMID: 36805346 DOI: 10.1016/j.jaip.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.
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Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Agnes Sze Yin Leung
- Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Hub of Paediatric Excellence, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic Fibrosis, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Allergy Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Lucila Camargo Lopes de Oliveira
- Department of Paediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, VIC, Australia.
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16
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Mediterranean Milk Ladder: Integrating a Healthy Eating Plan While Reintroducing Cow's Milk. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020234. [PMID: 36832362 PMCID: PMC9954599 DOI: 10.3390/children10020234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/21/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
The process of gradually reintroducing food allergens into an individual's diet is referred to as a food allergen "ladder", and the most recent edition of the original Milk Allergy in Primary (MAP) Care Guidelines, as well as the International Milk Allergy in Primary Care (IMAP), includes a shortened, improved, and international version with specific recipes, indicating the exact milk protein content, as well as the duration of heating and the temperature for each step of the ladder. Food allergen ladders are being used increasingly in clinical practice. The aim of this study was to develop a Mediterranean milk ladder based on the principles of the Mediterranean eating pattern. The protein content delivered in a portion of the final food product in each step of the ladder in the Mediterranean version corresponds to that provided in the IMAP ladder. Different recipes for the various steps were provided to increase acceptability and variety. Quantification of the total milk protein, casein content, and beta-lactoglobulin by Enzyme-linked immunosorbent assay (ELISA) could detect the gradual increase in concentrations, but the accuracy of the method was affected by the presence of the other ingredients in the mixtures. When developing the Mediterranean milk ladder, a key consideration was to reduce the amount of sugar by using limited amounts of brown sugar and substituting sugar with fresh fruit juice or honey for children aged older than one year. The proposed Mediterranean milk ladder includes principles of (a) healthy eating based on the Mediterranean diet and (b) the acceptability of foods across different age groups.
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17
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Théolier J, Vatin G, Barrère V, Dominguez S, Godefroy SB. Spent fowl as a source of unintentional egg proteins exposure in Canadian food products. Poult Sci 2022; 101:102003. [PMID: 35841641 PMCID: PMC9289861 DOI: 10.1016/j.psj.2022.102003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/30/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022] Open
Abstract
The occurrence of egg proteins in products containing spent fowl manufactured under current practices was studied to assess the risk these food products may pose to egg-allergic consumers and to determine if Precautionary Allergen Labelling (PAL) was recommended. Spent fowl slaughtering and processing operations in 2 Canadian facilities were observed. Raw hen pieces (n = 134), coming from 2 facilities, and intermediate and processed products containing spent fowl (n = 57), coming from one facility, were analyzed using ELISA. All samples tested positive for egg proteins. Raw pieces were tested using a qualitative method (i.e., swabbing); estimated egg proteins concentrations suggest the presence of highly contaminated samples (>600 mg/kg in 2 hen wing samples). Swabbing was found to be efficient for rapid detection of eggs in raw hen pieces, but not for quantification. A comparison between swab and grind results showed that egg proteins concentration is underestimated by at least a factor 2 for whole carcasses and a factor 10 for breast, wings and drumsticks, when using the swab protocol. For intermediate and processed products, quantitative measurements indicate that egg protein levels were below 16 mg/kg. Additionally, 88 water samples from chiller tanks were analyzed and indicate that this step could be the cause of the global contamination observed with an increase in egg protein concentrations overtime during the production schedule. As egg contamination is not adequately controlled under the current good production practices, the use of PAL would be recommended for raw spent fowl products.
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Affiliation(s)
- Jérémie Théolier
- Food Risk Analysis and Regulatory Excellence Platform, Institute of Nutrition and Functional Foods, Laval University, Québec, Canada.
| | - Gabrielle Vatin
- Food Risk Analysis and Regulatory Excellence Platform, Institute of Nutrition and Functional Foods, Laval University, Québec, Canada
| | - Virginie Barrère
- Food Risk Analysis and Regulatory Excellence Platform, Institute of Nutrition and Functional Foods, Laval University, Québec, Canada
| | - Silvia Dominguez
- Food Risk Analysis and Regulatory Excellence Platform, Institute of Nutrition and Functional Foods, Laval University, Québec, Canada
| | - Samuel Benrejeb Godefroy
- Food Risk Analysis and Regulatory Excellence Platform, Institute of Nutrition and Functional Foods, Laval University, Québec, Canada
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18
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De Vlieger L, Nuyttens L, Matton C, Diels M, Verelst S, Leus J, Coppens K, Sauer K, Dilissen E, Coorevits L, Matthys C, Schrijvers R, Raes M, Bullens DMA. Guided Gradual Egg-Tolerance Induction in Hen's Egg Allergic Children Tolerating Baked Egg: A Prospective Randomized Trial. FRONTIERS IN ALLERGY 2022; 3:886094. [PMID: 35769568 PMCID: PMC9234941 DOI: 10.3389/falgy.2022.886094] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Background Over the last few years, studies have shown that the majority of egg allergic children tolerate baked egg (e.g., cake), and that consuming baked egg accelerates the resolution of egg allergy. However, few prospective studies demonstrate the step-wise reintroduction of egg at home after developing baked egg tolerance. Although this could have a positive impact on the children's quality of life and nutrition. Additionally, research supporting the theoretical concept that heating in the presence or absence of wheat causes reduced allergenicity of egg proteins is limited. Objective To investigate the clinically most favorable duration of gradual egg-tolerance induction in baked egg tolerant children at home, with regard to complete raw egg tolerance. Methods Baked egg tolerant children above 12 months of age were randomly assigned to a short- or long arm protocol. In the short arm, egg-tolerance induction was studied over 18 months compared to 30 months in the long arm. Children were guided through this protocol involving the step-wise introduction of increasingly allergenic forms of egg starting with baked egg offered as cake, followed by hard-boiled egg, omelet/waffle/pancake, soft-boiled egg, and finally raw egg. We hereby designed this protocol based on the influence of thermal processing in the presence or absence of wheat on egg proteins, as investigated by ELISA, SDS-PAGE, and immunoblotting. At inclusion, children either passed an in-hospital cake challenge or had ovomucoid sIgE ≤1.2 kUA/L, which was considered safe for introduction at home. Results Gel electrophoresis revealed that the ovalbumin band became weaker with heating, while the ovomucoid band remained stable. In accordance, the IgE-binding to ovalbumin decreased with extensive heating, as opposed to ovomucoid. However, heating in the presence of wheat led to a decreased IgE reactivity to ovomucoid. Of the 78 children in the intention-to-treat group, 39 were randomized to each arm. Fifty-eight children reached the raw egg tolerance endpoint, of which 80% were in the short arm and 69% in the long arm. Within the short arm, the median time to raw egg tolerance was 24 months (95% CI, 21–27 months) compared to 30 months (95% CI, 28–32 months) in the long arm (p = 0.005). No grade IV reactions or cases of eosinophilic esophagitis were observed. The short arm was considered to be non-inferior to the long arm. Conclusion Our gradual short arm protocol appears to be safe and allows clinicians to guide baked egg tolerant children toward raw egg tolerance at home. The allergenicity of the egg proteins was affected by heating temperature and duration, as well as the presence of wheat.
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Affiliation(s)
- Liselot De Vlieger
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
- *Correspondence: Liselot De Vlieger
| | - Lisa Nuyttens
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | - Marianne Diels
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Sophie Verelst
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, Jessa Hospital, Hasselt, Belgium
| | - Jasmine Leus
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, AZ Maria Middelares, Ghent, Belgium
| | - Katrien Coppens
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, Imelda Hospital, Bonheiden, Belgium
| | - Kate Sauer
- Department of Pediatrics, AZ Sint-Jan Hospital, Bruges, Belgium
| | - Ellen Dilissen
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Lieve Coorevits
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Christophe Matthys
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marc Raes
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatrics, Jessa Hospital, Hasselt, Belgium
| | - Dominique M. A. Bullens
- Department of Microbiology, Immunology and Transplantation, Allergy and Immunology Research Group, KU Leuven, Leuven, Belgium
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
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Nagendran S, Patel N, Turner PJ. Oral immunotherapy for food allergy in children: is it worth it? Expert Rev Clin Immunol 2022; 18:363-376. [PMID: 35285356 DOI: 10.1080/1744666x.2022.2053675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Oral immunotherapy (OIT) is effective at inducing desensitization in food-allergic individuals, and is a valid therapeutic option for those allergic to peanut, cow's milk and egg. However, there is a high rate of dose-related adverse events, and at least one fatality to OIT has been reported. AREAS COVERED We provide an update on the broader framework of issues which will impact on the availability and uptake of OIT. EXPERT OPINION The need for standardized products remains controversial. A licensed product exists for peanut-OIT, but OIT can also be safely achieved using peanut-containing foods at much lower cost. For other allergens, OIT can only be done with non-pharma products - something which has been done safely for over 2 decades. There is a need to develop personalized protocols for OIT, particularly for the 20% of patients unable to tolerate standard OIT. Cost-effectiveness is dependent on improved quality of life, but evidence for this is currently lacking, and is a key evidence gap. OIT is likely to be cost-effective, particularly if noncommercial products are used. There may be a trade-off: in patients with lower reaction thresholds, a commercial product may be needed for initial updosing, until a level of desensitization is achieved when they can be switched to natural food products.
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Affiliation(s)
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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20
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Venter C, Meyer R, Ebisawa M, Athanasopoulou P, Mack DP. Food allergen ladders: A need for standardization. Pediatr Allergy Immunol 2022; 33:e13714. [PMID: 34882843 DOI: 10.1111/pai.13714] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The process of gradually reintroducing food allergens into an individual's diet is referred to as food allergen "ladders". There remain many questions regarding the foods chosen, structure and composition of the ladder, and medical and safety considerations. The COVID-19 pandemic has propelled us into an era where medicine is increasingly practiced via online platforms, highlighting the need for standardized food allergen ladder approaches for successful and safe introduction of food allergens. METHODS We performed a search of currently published food allergen ladders and obtained published information and clinical expertise to summarize current knowledge and suggest future standardized approaches for using food allergen ladders. RESULTS There are currently a limited number of published milk, egg, wheat, and soy ladders. We suggest the following points should be considered when developing food ladders: (1) Food allergen: dose, time, and temperature of heating of the food allergen, simplicity of the ladder and recipes, the possible role of the wheat matrix, and testing for allergenic protein levels to standardize doses; (2) Nutritional factors: health and nutritional value of the foods in the ladder, taste, texture, and cultural appropriateness of foods should be considered; and (3) Medical aspects: consideration of which patients are safe to undergo ladders outside of the clinical setting, other safety aspects and risk factors for severe reactions, number of days suggested per steps, and availability and provision of rescue medication. Written instructions and recipes should be provided to families who wish to use food allergen ladders. DISCUSSION Food allergen ladders used for gradual reintroduction of food allergens into a food allergic individual's diet are increasingly being used internationally. Standardization regarding the foods included in the ladder and medical considerations are required to practice patient-centered care, best assist patients and families, and ensure safety.
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Affiliation(s)
- Carina Venter
- Children's Hospital Colorado, University of Colorado, AuRoRa, Colorado, USA
| | - Rosan Meyer
- Department of Paediatrics, Imperial College, London, UK
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | | | - Douglas Paul Mack
- Department of Paediatrics, Paediatric Allergy, Asthma, and Immunology, McMaster University, Hamilton, Ontario, Canada
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