Food allergen ladders: A need for standardization

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.

Food allergy—A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review

“…Another controversial issue is the use of “ladders” for safe baked egg/baked milk introduction, through which foods are introduced in a step‐wise approach starting with more highly processed forms. The benefits and harms of using such ladders needs to be formally evaluated, especially as their use is increasing and they can have the potential to liberate patients from dietary restrictions earlier than the course of natural resolution would do 47 …”

“…The benefits and harms of using such ladders needs to be formally evaluated, especially as their use is increasing and they can have the potential to liberate patients from dietary restrictions earlier than the course of natural resolution would do. 47…”

Tolerance to heated egg in egg allergy: Explanations and implications for prevention and treatment

“…These food ladders could be considered as a form of OIT, but they still lack standardization and a sound scientific underpinning of their efficacy. 127,128 Summary:…”

Non-IgE mediated food allergies in breastfed children: A clinical challenge

“…The iMAP guidelines provide a consensus-based milk ladder, which has been constructed on the existing data that heating and fermentation reduces the allergenicity of cow’s milk [ 50 , 51 , 52 ]. This step-wise reintroduction approach has gained popularity and, from what is known, is safe [ 53 ], but there is to date no data on efficacy and there is a need for standardization [ 54 ]. For other allergens (i.e., egg, soya, wheat) there is only one study by Meyer et al [ 55 ] describing the re-introduction using a ladder approach.…”