Dietary baked egg accelerates resolution of egg allergy in children

doi:10.1016/j.jaci.2012.06.006

Journal of Allergy and Clinical Immunology

Volume 130, Issue 2, August 2012, Pages 473-480.e1

https://doi.org/10.1016/j.jaci.2012.06.006 Get rights and content

Background

Baked egg is tolerated by a majority of egg-allergic children.

Objective

To characterize immunologic changes associated with ingestion of baked egg and evaluate the role that baked egg diets play in the development of tolerance to regular egg.

Methods

Egg-allergic subjects who tolerated baked egg challenge incorporated baked egg into their diet. Immunologic parameters were measured at follow-up visits. A comparison group strictly avoiding egg was used to evaluate the natural history of the development of tolerance.

Results

Of the 79 subjects in the intent-to-treat group followed for a median of 37.8 months, 89% now tolerate baked egg and 53% now tolerate regular egg. Of 23 initially baked egg–reactive subjects, 14 (61%) subsequently tolerated baked egg and 6 (26%) now tolerate regular egg. Within the initially baked egg–reactive group, subjects with persistent reactivity to baked egg had higher median baseline egg white (EW)-specific IgE levels (13.5 kU_A/L) than those who subsequently tolerated baked egg (4.4 kU_A/L; P = .04) and regular egg (3.1 kU_A/L; P = .05). In subjects ingesting baked egg, EW-induced skin prick test wheal diameter and EW-, ovalbumin-, and ovomucoid-specific IgE levels decreased significantly, while ovalbumin- and ovomucoid-specific IgG₄ levels increased significantly. Subjects in the per-protocol group were 14.6 times more likely than subjects in the comparison group (P < .0001) to develop regular egg tolerance, and they developed tolerance earlier (median 50.0 vs 78.7 months; P < .0001).

Conclusion

Initiation of a baked egg diet accelerates the development of regular egg tolerance compared with strict avoidance. Higher serum EW-specific IgE level is associated with persistent baked and regular egg reactivity, while initial baked egg reactivity is not.

Section snippets

Participants

Subjects between 0.5 and 25 years of age with documented IgE-mediated egg allergy were recruited from the pediatric allergy clinics at the Mount Sinai Medical Center in New York, NY. Documented IgE-mediated egg allergy was defined by a positive EW SPT result and/or detectable (≥0.35 kU_A/L) serum EW-specific IgE level, and a recent history (within the past 6 months) of a type I hypersensitivity reaction to egg or a positive physician-supervised oral food challenge (OFC) to egg; or, if no history

Baseline clinical characteristics

Between June 2004 and September 2007, 117 subjects were enrolled in the study. Detailed baseline characteristics at the time of enrollment were previously described.¹⁴ Briefly, 79 subjects (71% males) were included in the intent-to-treat group, with a median age of 5.8 years (range, 1.6-15.8) and a median initial serum EW-specific IgE level of 2.5 (range, 0.2-101), and were followed for a median of 37.8 months (range, 7.6-69.7). At baseline challenge, 56 (71%) subjects in the intent-to-treat

Discussion

While avoidance continues to be the safest way to prevent symptoms of allergic food reactions, reports of food-sensitized eczema patients who developed systemic reactions after a period of avoidance and the recurrence of peanut allergy in former peanut-allergic patients who ingested peanut infrequently or in limited amounts have begun to change our way of thinking about tolerance.26, 27, 28, 29, 30 There is an increasing interest in OIT with native (unmodified) protein for the treatment of food

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2024, Annals of Allergy, Asthma and Immunology
Most children with milk and egg allergy are nonreactive to modified forms of milk and egg in bakery products such as muffins because of conformational changes in proteins. These baked milk (BM) and baked egg (BE) diets have become commonplace in the management of milk and egg allergy, respectively. Current laboratory- and skin test-based diagnostic approaches remain limited in their ability to predict BM/BE tolerance, resulting in various approaches to introduce these foods. One approach to introduce BM/BE is to offer a medically supervised oral food challenge and then advise dietary introduction of baked products for children who have tolerance. Another approach is adapted from a home-based protocol of graded ingestion of BM or BE originally intended for non-IgE mediated allergy, often referred to as a “ladder.” The ladder advises home ingestion of increasing amounts of BM or BE. For children who have allergy to BM or BE, the ladder is essentially oral immunotherapy, although not always labeled or recognized as such. Risk assessment and education of patients suitable for home introduction are essential. A home approach that may be called a ladder can also be used to escalate diets after demonstrated tolerance of baked forms by introducing lesser cooked forms of milk or egg after tolerating BM or BE. A randomized controlled trial provided clear evidence that baked diets can hasten the resolution of IgE-mediated milk allergy. Moreover, BM/BE foods have an emerging role in the treatment of non–IgE-mediated allergy. There is tangential evidence for BM and BE diets in the prevention of IgE-mediated allergy.
Partial Egg Consumption Modifies the Diagnostic Performance of Allergy Tests to Predict Outcome of Double-Blind Placebo-Controlled Food Challenges to Egg
2024, Journal of Allergy and Clinical Immunology: In Practice
Many children are consuming some egg when they are diagnosed with egg allergy. We hypothesized that egg consumption could modify the diagnostic performance of allergy tests.
To stratify diagnostic performance of tests according to egg consumption status.
The BAT2 study (NCT03309488) participants underwent oral food challenge (OFC), food-frequency questionnaires, skin prick test (SPT), specific immunoglobulin E (sIgE) and specific immunoglobulin G4 (sIgG4) and basophil activation test (BAT).
At study entry, 45% of participants reported partial egg consumption (“consumers”) and 55% were avoiding egg strictly (“avoiders”). Avoiders had larger SPT (P < .001), higher BAT to egg (P < .001), sIgE to egg white (EW; P = .001) and to ovalbumin (OVA; P = .001), but not to ovomucoid (P = .231). Consumers had higher levels of sIgG4 to all egg allergens (P < .001) than avoiders. In consumers, the test with the best diagnostic performance was BAT (area under the curve [AUC] = .912) followed by SPT to raw egg (AUC = 0.805), EW-sIgE (AUC = 0.738), and OVA-sIgE (AUC = 0.732). In avoiders, the best tests were BAT (AUC = 0.834) and EW-sIgE (AUC = 0.833) followed by OVA-sIgE (AUC = 0.793) and SPT to EW (AUC=0.789). Using 100% sensitivity and 100% specificity cut-offs, the proportion of patients requiring OFC were 33% for BAT, 53% for SPT to raw egg, 61% for OVA-sIgE, and 73% for EW-sIgE for consumers; and 73% for BAT, 79% for EW-sIgE, and 93% for SPT to EW for avoiders.
The diagnostic performance of tests is influenced by the immunomodulatory effect of egg consumption. BAT is the most reliable test and reduced the need for OFC, particularly in partial egg consumers.
Baked Milk and Baked Egg Survey: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee
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Most milk- and egg-allergic children can tolerate milk and egg in baked forms. Some allergists have extended the use of baked milk (BM) and baked egg (BE) to advocating for the stepwise introduction of small amounts of BM and BE to children who are reactive to larger amounts of BM and BE. Little is known about the practice of introducing BM and BE and existing barriers to this approach. The purpose of this study was to gather a current assessment of the implementation of BM and BE oral food challenges and diets for milk- and egg-allergic children. We conducted an electronic survey of North American Academy of Allergy, Asthma & Immunology members offering BM and BE introduction in 2021. The response rate was 10.1% of distributed surveys (72 of 711). Surveyed allergists had a similar approach to both BM and BE introduction. Demographic features of time in practice and region of practice were significantly associated with the odds of introducing BM and BE. A wide variety of tests and clinical features guided decisions. Some allergists determined BM and BE to be appropriate for home introduction and offered this for BM and BE more often than other foods. The use of BM and BE as a food for oral immunotherapy was endorsed by almost half of respondents. Less time in practice was the most significant factor associated with offering this approach. Published recipes were used and written information was widely provided to patients by most allergists. The wide practice variabilities reveal a need for more structured guidance about oral food challenges, in-office versus home procedures, and patient education.
Retail Food Equivalents for Post–Oral Immunotherapy Dosing in the Omalizumab as Monotherapy and as Adjunct Therapy to Multi-Allergen Oral Immunotherapy in Food-Allergic Children and Adults (OUtMATCH) Clinical Trial
2023, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Even if foods have equivalent allergenic protein content, processing may have an impact on allergenicity. There is extensive research on the impact on allergenicity of heating food proteins such as milk and egg.27–29 Unbaked milk products may also contain varying quantities of milk proteins; cheese and yogurt typically contain more casein than whey compared with fluid milk.
Patients with food allergy may be advised to introduce specific foods into their diets, both to increase tolerance gradually and as next steps after completing oral immunotherapy or other therapeutic interventions. However, the safe use of retail foods depends on the ability to establish the specific allergen protein content of these foods.
To develop a systematic approach to estimate the protein content of peanut, milk, egg, wheat, cashew, hazelnut, and walnut in a variety of retail food equivalents for each allergen and associated patient education materials.
We created an algorithm that used a multistep process with information from product food labels, nutrient databases, independent weighing and measuring of foods, and information provided by manufacturers, including certificates of analysis, and e-mail communication to estimate the allergen protein content of multiple retail foods for each of seven allergens. Once a variety of retail food equivalents for each allergen and allergen serving size was determined, we developed participant education handouts, which were reviewed by study teams at 10 food allergy centers, the National Institute of Allergy and Infectious Diseases, and the Consortium for Food Allergy Research coordinating center. After 1 year of use, multiple queries were addressed and the retail food equivalents and educational materials were reviewed and edited.
We identified a variety of retail food equivalents for seven allergens at six serving sizes, and created 48 unique patient education materials.
Our results provide extensive guidance on a variety of retail equivalents for seven foods, and a method to estimate retail food protein equivalents systematically with ongoing reassessment.
Home Introduction of Baked Egg After Oral Food Challenge
2023, Journal of Allergy and Clinical Immunology: In Practice
Baked egg (BE) introduction may accelerate resolution of egg allergy. Long-term data regarding the safety and success of BE introduction in the real world are limited.
To identify predictors of future egg consumption and barriers to advancement based on characteristics during and after BE oral food challenges (OFCs).
We performed a retrospective review of consecutive BE OFCs with a minimum 24-month follow-up. Goal doses ranged from 1/16 to 1/4 egg. Outcomes were categorized as pass (no reaction), fail (but allowed BE introduction), or fail (avoid). Status of egg introduction and reactions were recorded.
A total of 243 patients were included; 134 passed and 109 failed (70 of whom were instructed to introduce BE). At follow-up (median, 47 months), 90 (37%) were consuming direct egg, 26 (11%) lightly cooked egg, 39 (16%) BE, and 88 (36%) avoiding; 58% who failed versus 81% who passed were consuming some form of egg. Median egg white IgE level was significantly higher among avoiders versus introducers (8.7 vs 5.8; P = .008). Lower egg white IgE level and younger age were predictors of egg consumption in some form at follow-up (median IgE, 5.8 vs 8.4; P = .03; median age, 4.0 vs 8.0 years; P < .001). A total of 94 patients had a total of 136 reactions (132 mild, 4 severe); 22 (16.2%) were accidental exposures, 42 (30.9%) planned escalations, and 72 (52.9%) with previously tolerated doses.
Most patients who underwent a BE OFC continued to consume some form of egg, often advancing to direct egg. However, many reverted to avoidance and adverse reactions were common.
Avoiding avoidance in milk and egg allergy
2022, Annals of Allergy, Asthma and Immunology

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: This project has been supported by National Institutes of Health–National Institute of Allergy and Infectious Diseases grant AI 059318 to A.N.-W. and grant no. UL1-RR-029887 from the National Center for Research Resources, a component of the National Institutes of Health.

: Disclosure of potential conflict of interest: H. A. Sampson has consultant arrangements with Allertein Therapeutics, LLC; serves on advisory boards for ImmusanT and Novartis; received research support from the Food Allergy Initiative and the National Institutes of Health–National Institute of Allergy and Infectious Diseases; is a consultant/scientific advisor for the Food Allergy Initiative; is a medical advisor for the Food Allergy & Anaphylaxis Network; is a scientific advisor for the University of Nebraska–Food Allergy Research and Resource Program and for the Asthma & Allergy Foundation of America; and is 45% owner of Herb Springs, LLC. S. H. Sicherer has consultant arrangements with the Food Allergy Initiative; has received research support from the National Institute of Allergy and Infectious Diseases; and is a medical advisor for the Food Allergy & Anaphylaxis Network. The rest of the authors declare that they have no relevant conflicts of interest.

^∗: S. A. Leonard is currently with the Division of Pediatric Allergy and Immunology, University of California, San Diego, Calif.

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Food, drug, insect sting allergy, and anaphylaxisDietary baked egg accelerates resolution of egg allergy in children

Background

Objective

Methods

Results

Conclusion

Section snippets

Participants

Baseline clinical characteristics

Discussion

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Pediatr

J Allergy Clin Immunol

Food, drug, insect sting allergy, and anaphylaxis
Dietary baked egg accelerates resolution of egg allergy in children