Dietary Advancement Therapy using milk and egg ladders among children with a history of anaphylaxis

Background Anaphylaxis is 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 paediatric patients diagnosed with IgE-mediated milk and/or egg allergy between 2011-2021. Inclusion and exclusion criteria applied. Anaphylaxis defined as per the World Allergy Organisation amended criteria 2020. Data analysis utilised SPSS Version 28. Results 1552 patient charts reviewed, 1094 excluded (n=458). 70 infants had anaphylaxis at diagnosis (milk n=36, egg n=34). 77.8%-85.2% with anaphylaxis successfully completed the ladder, 88.9-92.9% without anaphylaxis were successful. Children who successfully completed the ladder did so at similar rates. 20.6-50% children presenting with anaphylaxis at diagnosis experienced allergic symptoms during treatment, compared to 17.3-40.7% 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. Conclusion 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.