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Severe reactions to baked egg and baked milk challenges

Published online: January 2021

Egg and milk allergies are the most common food allergies in young children. Most children tolerate baked egg (BE) and baked milk (BM) products, such as a cakes, cookies, and muffins, and regular ingestion of these foods can accelerate acquisition of tolerance (helping children to “outgrow” their egg or milk allergies sooner). However, up to 25-30% of children react to BE or BM. Consequently, these foods are initially given under medical supervision in a procedure called an oral food challenge (OFC) to determine whether or not a child is reactive. We observed delayed, and sometimes severe, reactions to BE and BM OFCs. Previous studies comparing BE and BM reactions to other OFC reactions were limited.

In a study recently published in The Journal of Allergy and Clinical Immunology: In Practice, Yonkof et al. retrospectively studied reactions to BE, BM, lightly cooked egg (CE), fresh cow’s milk (CM), peanut (PN), and tree nut (TN) OFCs performed at Nationwide Children’s Hospital from 6/1/2017 through 6/1/2019. OFCs involved giving children a standard serving of food divided into 5 or 6 doses, each of increasing amount. Eligibility for OFC was determined by subjects’ Allergist. Some children had a distant history of reacting to the challenge food, and some had never eaten it before but showed sensitization by skin or blood testing. When children displayed objective signs of an allergic reaction, the challenge was stopped, and treatment (if necessary) was given.

The researchers identified 174 OFCs conducted in 158 subjects, age 6 through 187 months (34 BE, 19 BM, 14 CE, 25 CM, 52 PN, 30 TN). TN reactors were older than BE (p 0.049) and PN (p<0.01) reactors and had a higher frequency of asthma than PN-reactive subjects (p 0.02).  Skin manifestations of allergic reactions (such as hives, rashes, and swelling) occurred less frequently during BE (56%) and BM (42%) OFCs compared to other OFCs (p<0.05). Lower respiratory reactions, like coughing and wheezing, were increased during BM (37%) versus BE, CM, and PN OFCs (p<0.05). Epinephrine was administered to more BE (44%) and TN (50%) than PN (17%) OFCs (p<0.01). New reaction manifestations developed >60 minutes after OFC termination during 29% BE and 21% BM vs. 0% PN OFCs (p<0.05). The median time from ingestion of the dose which elicited objective signs of an allergic reaction to the last new manifestation of reactivity was also longer for BE (25 minutes) compared to CM (0 minutes), PN (0 minutes), and TN (0 minutes) OFCs (p<0.02). One-third of anaphylactic reactions to BE began >60 minutes after OFC termination.

In summary, reactions to BE and BM OFCs can be severe. Nearly half of BE reactions were anaphylactic and required epinephrine; one-third of BM reactions caused respiratory problems. A subset of children reacting to BE and BM encountered delayed reactions occurring >60 minutes after the end of the OFC. Physicians can use this information to improve safety during BE and BM OFCs.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information the practicing clinician.

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