Helping Kids Move Beyond Egg Allergy: A New Clinician Tool

Key Takeaways:

• Egg allergy affects about 1% of children in the U.S. It can limit food choices and impact quality of life.
• Baked egg may help build tolerance. For children who can tolerate baked egg, eating it regularly may support faster progress toward outgrowing the allergy.
• The egg ladder offers a step-by-step path forward. This new tool helps healthcare providers guide egg reintroduction while expanding food options.

Approximately 1% of all children in the US and about 12% of children with food allergies are allergic to eggs [1] . For these children, egg allergy can impact nutrient intake [2] and quality of life [3]. The good news is that egg allergies are considered to have a high rate of resolution in childhood [4, 5], and now, there is a new tool to help. The new U.S.-focused egg ladder is a standardized tool that can help clinicians support their patients in re-introducing eggs to the diet, with the goal of outgrowing an egg allergy[6].

It has been observed that approximately 70-80% of children with egg allergy can tolerate extensively baked egg in foods like muffins (as opposed to lightly cooked eggs like scrambled) [5, 7, 8]. Several studies have suggested that for children who can tolerate baked egg, eating these foods may help them outgrow an egg allergy sooner [5, 8-10], with some studies showing better tolerance with more frequent intake [11]. These data support the rationale for using an egg ladder, which provides a stepwise progression from extensively heated to less heated commonly consumed foods [6].

The new egg ladder for IgE-mediated egg allergy considers age-appropriate foods, allergen content, ease of preparation, and nutrition [6]. There are seven steps in the egg ladder, which ranks egg-containing foods based on laboratory-verified ovalbumin, ovomucoid, and total egg protein content [6]. Ovalbumin is a protein in egg white that is sensitive to heat, which results in denaturation of the protein and decreased allergenicity.  Ovomucoid is the primary allergen found in egg white, as this protein can retain antibody-binding activity after heating [7].  However, in the case of extensively baked food products, heating and interactions with the food matrix (e.g., wheat gluten) can alter protein structure and as a result, decrease antigenic activity of egg proteins, including ovomucoid [6, 7, 12].

Children who can tolerate extensively heated baked egg are more likely to outgrow their food allergy, potentially because exposure to the allergen in the baked food products alters the course of allergy resolution [10, 13-15]. Tolerance of baked egg could also be an indicator of phenotypes less likely to be persistent [8]. Either way, the egg ladder is a valuable tool that can support progress toward outgrowing an egg allergy and expanding food choices [6]. While further research is required to evaluate which types of patients this egg ladder is best suited for, with clinician guidance, this tool is a positive step forward in supporting families with egg allergies. For clinicians interested in more information about the egg ladder, including supplemental materials with recipes and instructions for families, please see the publication in Pediatric Allergy and Immunology. Importantly, the most recent recommendations from leading health authorities focus on prevention, with early introduction around 6 months of age to reduce the risk of egg allergy [16, 17]. For more information on the early introduction of eggs, please see our early introduction education materials.