Food ladders in infants with anaphylaxis

Published online May 8, 2024

Anaphylaxis is a severe, potentially life-threatening allergic reaction that is particularly common among infants with allergies to milk and eggs. These allergies are increasing globally, affecting up to 3% of children in developed countries. Standard management for these allergies includes strict avoidance of the allergens and the use of epinephrine autoinjectors for accidental exposures. This approach, however, can be burdensome and negatively impact the quality of life of children and their families. Recent developments in allergy management, such as the milk and egg “ladders” offer a gradual introduction of allergens starting with forms of food that have potentially reducing allergenicity.

This study by Gallagher et al., published in The Journal of Allergy and Clinical Immunology: In Practice, investigates the safety and efficacy of these ladders in children under three years old who were diagnosed with IgE-mediated milk or egg allergies, focussing on those who presented with anaphylaxis at diagnosis. Gallagher et al. conducted a retrospective analysis of 458 children under three years old diagnosed with IgE-mediated milk and/or egg allergy over a ten-year period. The study aimed to evaluate the effectiveness and safety of the milk and egg ladders, particularly in children who had experienced anaphylaxis at diagnosis. The study population was identified from allergy clinic referrals, and included cases where symptoms ranged from skin reactions to gastrointestinal and respiratory symptoms. Parents were trained to use the ladders, which involved a stepwise introduction of the allergens starting with minimal amounts in baked forms. The primary outcome was the successful introduction of unrestricted cow’s milk or almost raw egg into the child’s diet. Secondary outcomes included the time taken to complete the ladder and any medical interventions required due to allergic reactions during the process.

The study found that 77.8% of children with milk anaphylaxis and 85.2% of those with egg anaphylaxis successfully completed the respective ladders. Success rates were slightly higher in children without anaphylaxis, but the differences were not statistically significant. The time to completion was similar across all groups, averaging around 20-24 months. Safety was a key focus, and the study found that no child experienced anaphylaxis while following the milk or egg ladder, despite having anaphylaxis at diagnosis. Most ladder-related symptoms were mild, such as skin reactions and gastrointestinal symptoms, which were successfully managed by parents at home without the need for unscheduled medical care. This underscores the feasibility and safety of using the milk and egg ladders even in infants with a history of severe allergic reactions. The authors concluded  that despite initial anaphylaxis, children can safely undergo the ladder reintroduction process, providing a promising alternative to strict avoidance and enhancing the quality of life for affected families. This research underscores the importance of further prospective studies to refine these protocols and optimize allergy management in young children.

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

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