Egg Allergy Research Articles

EAACI guidelines on the management of IgE-mediated food allergy.

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

Diagnostic Accuracy of Skin Prick Test, Food-Specific IgE and Component Testing for IgE-Mediated Peanut, Egg, Milk and Wheat Allergy.

Diagnostic Accuracy of Skin Prick Test, Food-Specific IgE and Component Testing for IgE-Mediated Peanut, Egg, Milk and Wheat Allergy.

Air pollution is associated with persistent peanut allergy in the first 10 years.

The role of air pollution in eczema and food allergy development remains understudied. We aimed to assess whether exposure to air pollution is associated with eczema and food allergies in the first 10 years of life. HealthNuts recruited a population-based sample of 1-year-old infants who were followed up at ages 4, 6, and 10 years. Annual average fine particulate matter (particulate matter with diameter of 2.5 μm or less, or PM2.5) and nitrogen dioxide (NO2) exposures were assigned to geocoded residential addresses. Eczema was defined by parent report. Oral food challenges to peanut, egg, and sesame were used to measure food allergy. Multilevel logistic regression models were fitted, and estimates were reported as adjusted odds ratios. Those exposed to high concentration of NO2 (<10 ppb) at age 1 year had higher peanut allergy prevalence at ages 1 (adjusted odds ratio [95% confidence interval], 2.21 [1.40-3.48]) and 4 (2.29 [1.28-4.11]) years. High exposure to NO2 at 6 years old were associated with higher peanut allergy prevalence at age 6 (1.34 [1.00-1.82] per 2.7 ppb NO2 increase) years. Similarly, increased PM2.5 at age 1 year was associated with peanut allergy at ages 4, 6, and 10 years (respectively, 1.27 [1.01-1.60], 1.27 [1.01-1.56], and 1.46 [1.05-2.04] per 1.2 μg/m PM2.5 increase) years. We found that increased concentrations of NO2 or PM2.5 at age 1 year were associated with persistent peanut allergy at later ages. Little evidence of associations was observed with eczema or with egg allergy. Early-life exposure to PM2.5 and NO2 was associated with peanut allergy prevalence and persistence. Policies aiming at reducing air pollution could potentially reduce presence and persistence of peanut allergy.

Gut microbiome features in pediatric food allergy: a scoping review.

Increasing evidence suggests that alterations in the gut microbiome (GM) play a pivotal role in the pathogenesis of pediatric food allergy (FA). This scoping review analyzes the current evidence on GM features associated with pediatric FAs and highlights the importance of the GM as a potential target of intervention for preventing and treating this common condition in the pediatric age. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we searched PubMed and Embase using the keywords (gut microbiome OR dysbiosis OR gut microbiota OR microbiome signatures) AND (food allergy OR IgE-mediated food allergy OR food protein-induced allergic proctocolitis OR food protein-induced enterocolitis OR non-IgE food allergy OR cow milk allergy OR hen egg allergy OR peanut allergy OR fish allergy OR shellfish allergy OR tree nut allergy OR soy allergy OR wheat allergy OR rice allergy OR food sensitization). We included 34 studies reporting alterations in the GM in children affected by FA compared with healthy controls. The GM in pediatric FAs is characterized by a higher abundance of harmful microorganisms (e.g., Enterobacteriaceae, Clostridium sensu stricto, Ruminococcus gnavus, and Blautia spp.) and lower abundance of beneficial bacteria (e.g., Bifidobacteriaceae, Lactobacillaceae, some Bacteroides species). Moreover, we provide an overview of the mechanisms of action elicited by these bacterial species in regulating immune tolerance and of the main environmental factors that can modulate the composition and function of the GM in early life. Altogether, these data improve our knowledge of the pathogenesis of FA and can open the way to innovative diagnostic, preventive, and therapeutic strategies for managing these conditions.

Baked Egg Oral Immunotherapy: Current State in Pediatric Age.

Hen's egg allergy is one of the most common food allergies in the Western world, with an increase in recent years. It affects about 9.5% of the pediatric population, and the onset most often occurs before the first year of life. The occurrence of spontaneous oral tolerance acquisition varies among studies, but it is generally high by school age. Nowadays, allergen immunotherapy may represent the only therapeutic strategy able to modify the natural history of hen's egg allergy. Specifically, many children with hen's egg allergy may tolerate baked eggs. Food processing, specifically high temperatures, alters the allergenicity of hen's egg proteins by causing conformational changes in allergen epitopes, which makes them less allergenic. This review aims to discuss the scientific evidence in the field of baked egg oral immunotherapy in hen's egg-allergic children, with a meticulous examination of the pertinent literature surrounding the subject matter.

Characteristics of childhood anaphylaxis in different age groups.

Anaphylaxis is a severe systemic hypersensitivity reaction that usually has a rapid onset and can be fatal. Presentations of childhood anaphylaxis vary widely in accordance with the triggers and the patient's age, geographical region and dietary and lifestyle habits. The medical records of 177 paediatric patients diagnosed with anaphylaxis between January 2021 and January 2024, whose disease progression was monitored at a single tertiary care centre, were reviewed retrospectively. The study included 177 patients diagnosed with anaphylaxis (107 males and 70 females with a median age of 48 months). The most common allergen responsible was food (53.7%). Egg allergy was the most common source of anaphylaxis, afflicting 35 patients (19.3%), while beta-lactam provoked the most common drug allergy, affecting 24 patients (13.6%). The most common organ involved was the skin (92.7%). When the patients were analysed by age group, there were more males in the infancy, preschool and school age groups, while there were more females in the adolescent group (p = 0.44). Food-induced anaphylaxis became less common with increasing age, whereas the rate of drug-induced anaphylaxis increased (p = 0.01 and p = 0.01, respectively). Cardiovascular system findings were observed more frequently in adolescents compared to other age groups (p = 0.003). Most cases stemming from a food allergy were mild, whereas most drug-induced cases were moderate or severe (p < 0.05). When severity was analysed by age group, mild cases in infants were more common than moderate to severe cases. The aetiological and clinical manifestations of childhood anaphylaxis vary among different age groups.

The self-assembly mechanism of ovotransferrin fibrils induced by subtilisin A and Ca2+ ions and their application in nutrient delivery and texture optimization for liquid food

The self-assembly behavior of proteins and peptides has been widely studied due to their ability to construct various nanostructures, such as nanotubes and nanofibrils. Understanding the self-assembly mechanism is of great significance for developing functional nanomaterials. Herein, we adopt a novel method to construct ovotransferrin (OVT) fibrils by subtilisin A hydrolysis and Ca2+ ions induced self-assembly with mild reaction conditions. The kinetic process of OVT fibrils formation contains lag, growth, and plateau stage. During the growth stage, OVT peptides self-assemble into precursor structures, which undergo morphological changes of twisted ribbons, helical ribbons, and nanotubes, ultimately closing to form mature fibrils. Ca2+ ions likely coordinate with the carboxyl groups of OVT peptides, aiding in the self-assembly process. And the secondary conformation is manifested as a β-sheet stacking. The mature OVT fibrils have distinct hollow and left-handed structures. Then OVT fibrils successfully encapsulate zeaxanthin (Zea) and improve its solubility and stability. Besides, OVT fibrils exhibit no in vitro cytotoxicity, and significantly reduce allergenicity to egg allergy patients compared to OVT. OVT fibrils delivery Zea into milk to develop Zea fortified dairy beverage and improve the viscosity of dairy beverage. OVT fibrils show a great potential as nutrient delivery and texture optimization for food application.

Exploring Cross-Reactivity Among Hen, Duck, and Quail Eggs in Children with Hen’s Egg Allergy

Exploring Cross-Reactivity Among Hen, Duck, and Quail Eggs in Children with Hen’s Egg Allergy

No Yellow Fever Vaccine Reactions in IgE-Mediated Egg Allergic Patients

Introduction: Egg allergy usually manifests during the initial 2 years of life, a period in which most vaccinations are administered. This often leads to delays in the application of some vaccines in patients with egg allergies, exposing them to a risk of contracting preventable infections. The aim of the study was to describe the frequency of reactions after applying the yellow fever vaccine (YFV) within a population with egg allergy. Methods: This was a cohort study with retrospective, multicenter data (2014–2023). Patient records diagnosed with egg allergy were gathered from their initial egg-related reactions until their YFV administration. Information was also collected about hypersensitivity tests conducted for egg and YFV such as the skin prick test (SPT) and intradermal test (IDT). Results: Among the 171 records analyzed, 23.9% of patients had a history of egg anaphylaxis. Out of these, 5 patients had a positive SPT and 21 IDT with the YFV. All patients tolerated the application of YFV without developing hypersensitivity reactions, regardless of the results of the YFV tests, the severity of egg reactions, the number of egg reactions, or the time since the last egg reaction. Out of the total patient cohort, 46.1% (79 individuals) encountered delays in receiving the YFV, and in this subset, 14% faced delays lasting longer than 12 months. Conclusion: The risk of allergic reactions with the YFV remains low. YFV tests generate delays in the vaccine application without providing high diagnostic accuracy. YFV should not be deferred even in patients with a history of severe egg reactions.

Component diagnosis of food allergy: precise identification of allergenic components in egg and milk

Food allergy are triggered by an abnormal immune response to specific food components, with milk and eggs being the most common food allergens, especially in children. Food allergy can cause various symptoms such as rashes, difficulty breathing, and digestive issues. Allergen component diagnostics is a technique used to identify specific allergenic proteins, aiding doctors in providing more precise treatment and management recommendations for patients. This article analyzes the latest research developments and clinical significance of milk and egg allergen components based on the " Molecular Allergology User's Guide 2.0 (MAUG 2.0)" issued by the European Academy of Allergy and Clinical Immunology (EAACI), including their applications in clinical diagnosis, treatment, and management. This article aims to enhance healthcare professionals' understanding of milk and egg allergies, offering new perspectives and practical guidelines for research and clinical practice to promote accurate diagnosis and personalized treatment strategies.

Physical Properties, Nutritional Composition and Sensory Acceptance of Eggless Pumpkin Muffin Prepared using Plant-Based Ingredients

Eggs play a crucial role in the production of muffins by contributing to their moistness and tenderness. However, several issues arise with using eggs in muffin formulation, such as egg allergies and the sustainability of egg supply in the market. Therefore, this study aimed to determine the effect of incorporating plant-based ingredients (chia seeds, flaxseeds and mashed banana) in eggless pumpkin muffin formulations on physical properties, nutritional composition and sensory acceptance. Four samples were prepared as follows: Control (muffin with egg), F1 (muffin with chia seeds), F2 (muffin with flaxseeds) and F3 (muffin with mashed banana). The samples were analysed for batter density, muffin height, texture profile analysis, muffin crumb colour, nutritional composition and sensory preference using a nine-point hedonic scale. Generally, muffins prepared with plant-based ingredients showed a decrease in height (3.97–3.83 cm) and water activity (0.88–0.89) compared to the control muffins (4.37 cm and 0.90, respectively). On the contrary, the batter density of wet batter eggless pumpkin muffins increased compared to those prepared with egg. The replacement of egg with plant-based ingredients resulted in muffins with a harder texture, as indicated by the increased hardness values compared to the control muffin. The use of plant-based ingredients in pumpkin muffin formulations produced muffins with a lighter colour due to the absence of colour pigments in chia seeds, flaxseeds and mashed banana. The inclusion of plant-based ingredients in eggless pumpkin muffin formulations increased the ash, fibre and carbohydrate content while decreasing the fat content. Overall, the preference test revealed that eggless pumpkin muffins prepared using chia seeds (6.93) and mashed banana (7.58) rated higher for overall acceptance attribute as compared to the control pumpkin muffin.

Trajectories of egg sensitization in childhood: Two birth cohorts in Asia and Europe.

Hen's egg exposure through impaired skin barrier is considered a major mechanism of sensitization to eggs. However, the impact of filaggrin (FLG) gene loss-of-function mutations on the natural history of egg sensitization lacks consensus among studies. To evaluate the association between the natural course of egg sensitization and FLG mutations. We used Japanese and the UK birth cohorts (CHIBA and MAAS) to identify the longitudinal patterns of egg sensitization until mid-school age and examined the relationship between the identified patterns and FLG mutations. Sensitization was assessed using egg white-specific IgE levels or skin prick tests (SPTs). Egg allergy was confirmed by parental reports and sensitization. Latent class growth analysis identified longitudinal patterns. Three similar patterns of egg sensitization (persistent, early-onset remitting, and no/low grade classes) were identified in both cohorts, with differing prevalence estimates. The proportion of children with egg allergy in the persistent class at 7 or 8 years of age was 23% (CHIBA) and 20% (MAAS). Consistently in both cohorts, FLG mutations were significantly associated only with the persistent class. Children with FLG mutations had an approximately four-fold increased risk of being in the persistent sensitization class (RRRs: 4.3, 95%C.I. (1.2-16.0), p = .03 in CHIBA; 4.3 (1.3-14.7), p = .02 in MAAS). FLG loss-of-function mutations are associated with persistent egg sensitization in both Japanese and European ethnicities, and the mutations might be a potential biomarker for identifying the risk of persistent egg sensitization/allergy in early infancy. Future studies should incorporate oral food challenges to confirm this relationship.

Immunological and molecular study in children with combined immunodeficiency.

Background. Severe combined immunodeficiency (SCID) is a form of immunodeficiencies (PID), caused by molecular defects. These defects can restrict the development and function of lymphocytes. Early diagnosis and treatment of SCID can lead to disease-free survival. This study aims to investigate some of the possible underlying genetic defects in a group of Egyptian infants and children with clinical and immunological profiles suggestive of SCID. Methods. This study included eighty patients who showed clinical warning signs of immunodeficiency. Subjects were thoroughly examined clinically. Laboratory evaluation included immunoglobulins serum levels and flow cytometric assessment of immune cells. This testing showed an altered immune profile in thirty patients. They had decreased T and/or B lymphocytes or natural killer cells. DNA extraction was done for those cases. The coding regions of the RAG1 gene and RAG2 gene was investigated for hot spot mutations by sequencing technique guided by the patient clinical evaluation, inheritance pattern, immunophenotyping by flow cytometric analysis of lymphocyte subsets, and serum immunoglobulins level detection. Results. Results showed novel and previously reported variants (mutation, polymorphism), they were found in 18 cases which include variants in the RAG1 gene (E880K, A960A, H249R, S913R, K820R, V782G), and variants in the RAG2 gene (P501T, L514M, rs10836573, cDNA.2129A>T). Conclusions. To evaluate SCID patients completely, mutation gene analysis is highly required and recommended.

Milk and egg allergy are associated with increased risk of peanut allergy at age 1 in Australia

Milk and egg allergy are associated with increased risk of peanut allergy at age 1 in Australia

Efficacy of very-low-dose oral food challenge in children with severe hen egg allergy: A retrospective, single-center case series

BackgroundTo avoid complete elimination of hen eggs (HE) from diet, we introduced a very-low-dose (VLD) oral food challenge (OFC) in patients with severe HE allergy in 2019. Herein, we investigated the efficacy of VLD HE OFC for achieving the full dose OFC. MethodsPatients with an overt allergic reaction to LD (1/32 HE [≤100 mg]) or less, egg white (EW) protein within 6 months were included. In the VLD group, patients not achieving full-dose OFC (1/2 HE: 1600 mg EW protein) within 2 years were excluded. We retrospectively compared the rate of passing a full-dose OFC between patients who underwent a LD OFC before 2019 (LD group) and those who underwent a VLD OFC (1/100 HE: 32 mg EW protein) after 2019 (VLD group). The period for passing the full-dose OFC was evaluated using Kaplan–Meier survival analysis. ResultsWe enrolled 411 and 111 patients in the LD and VLD groups, respectively. The median age at OFC initiation was 2.2 [1.5–3.6] and 2.1 [1.4–3.2] years in the LD and VLD groups, respectively. EW- and ovomucoid-specific IgE levels were 38.3 (12.5–72.9) and 21.0 (8.3–46.2) kUA/L in the LD group and 49.8 [18.8–83.9] and 32.1 [15.6–67.8] kUA/L in the VLD group, respectively. Over 4 years, the LD and VLD groups passed the full-dose OFC at rates of 70 and 95%, respectively, with significant differences (log-rank test, P < 0.001). ConclusionsVLD HE OFC may contribute to passing a full-dose OFC in patients with severe HE allergies.

The Safety and Efficacy of Baked Egg and Milk Dietary Advancement Therapy: A Systematic Review and Meta-Analysis

BackgroundCow’s milk and egg allergy affect approximately 1.9% and 0.9% of children, respectively. Dietary advancement therapies (DAT), including milk (ML) and egg (EL) ladders, baked milk (BM-OIT) and baked egg (BE-OIT) oral immunotherapy are potential therapeutic options for these patients. ObjectiveTo perform systematic review and meta-analysis of the safety and efficacy of DAT in children with IgE-mediated milk or egg allergy. MethodsA systematic literature review was conducted, exploring 22 potential outcomes, with meta-analysis performed where >3 studies reported data. The GRADE approach was used to determine the certainty of evidence for each outcome, and the Johanna Briggs Institute tools for determining risk of bias. ResultsTwenty-nine studies met inclusion criteria among 9946 titles screened. Tolerance occurred in 69% of EL, 58% of ML, 49% of BE-OIT and 29% of BM-OIT patients. All-severity allergic reactions occurred in 21% of EL, 25% of ML, 20% of BE-OIT and 61% of BM-OIT patients, with epinephrine use in 3% of EL, 2% of ML, and 9% of BM-OIT patients. At-home reactions occurred in 19% of BE-OIT and 10% of BM-OIT patients. Discontinuation occurred in 14% of EL, 17% of ML, 17% of BE-OIT and 20% of BM-OIT patients. Mean time to BE egg and BE-OIT tolerance was 13.25 months (4 studies) and 19.1 months (3 studies). Certainty of evidence was very low, and risk of bias high. Study heterogeneity was high, attributable to multiple factors. ConclusionsThere is very low certainty of evidence supporting DAT safety and efficacy. We cannot conclude DAT accelerates tolerance development.

The advances on oral tolerance induction for prevention of egg allergy in infants

The prevalence of food allergy is increasing worldwide and seriously affects the living quality of patients and their families. Egg allergy is one of the commonest forms of food allergy. The traditional regimen is to delay the introduction of eggs to infant complementary foods, which is not able to reduce the prevalence of egg allergies and causes negative effects on infants' physical and psychological conditions. Oral tolerance therapy is an approach to establish immune tolerance by the active suppression of specific immune responses to antigens in the gastrointestinal tract. The development of oral tolerance through early introduction of eggs to infant complementary has proven effective in randomized controlled trials, which has been incorporated into infant feeding guidelines in many countries. This article focuses on the mechanism, efficacy and safety of oral tolerance induction in the prevention of egg allergy.

Dietary Intake, Diet Diversity, and Weight Status of Children With Food Allergy

BackgroundAdoption of allergen avoidance diets may increase the risk of nutritional deficiencies and affect growth in children with food allergy (FA). How these dietary restrictions have an impact on diet diversity, a health-promoting eating behavior, remains unclear. ObjectiveTo evaluate diet diversity, dietary intake, and weight status of children with FA. DesignObservational study. Participants/settingOne hundred children with immunoglobulin E (IgE)-mediated milk, egg, or nut FA or multiple FAs and 60 children with perennial respiratory allergies (RA) matched as controls, aged 3 to 18 years, were consecutively recruited into the study. Main outcome measuresDietary intake and diet diversity (number of different foods consumed/day) were assessed through 4 24-hour recalls. Weight status (underweight, healthy weight, overweight, or obesity) was also evaluated. Statistical analyses performedChi-squared test and 2-sample independent t test were used to test differences between groups. Adjustment for sex, age, and energy intake was made using linear regression. ResultsThe percentage of underweight was higher in children with FA (19.6%) compared with children in the control group (5.1%). Children with FA compared with children in the control group consumed more servings of meat (1.7, 95% CI, 1.6, 1.9 vs. 1.5, 95% CI, 1.3, 1.7 servings/day [Padj = 0.031]). No difference was observed in the diet diversity between the 2 groups (11–12 different foods/day). Within the FA group, children with allergy to milk proteins had lower energy intake from protein, lower intake of calcium, lower consumption of commercially prepared sweets, and higher consumption of eggs, compared with children with nut or egg allergy, but no difference in diet diversity was observed. ConclusionsDiet diversity did not differ between children with FA and children with no FA, despite some differences in the intake from specific food groups. However, the higher percentage of underweight in children with FA suggests the need for targeted nutrition intervention as early as possible after FA diagnosis.

Traditional cooking methods decreased the allergenicity of egg proteins.

Egg allergy is one of the most common food allergies globally. This study aimed to assess the impact of four traditional cooking methods on the allergenicity of egg proteins using a comprehensive strategy, including simulated gastrointestinal digestion in vitro, serology experiments, a rat basophilic leukemia (RBL)-2H3 cell degranulation model, and a passive cutaneous anaphylaxis (PCA) mice model, and the structure changes were detected by circular dichroism (CD)spectra and ultraviolet (UV) spectra. The results showed that the processed egg proteins were more readily digested compared to raw egg proteins. The serological experiments revealed a significant reduction in immunoglobulin E binding of egg proteins after thermal treatments (p<0.05), particularly after frying. Subsequently, the RBL-2H3 cell degranulation experiment demonstrated a marked decrease in the level of egg allergens-induced β-hexosaminidase release after cooking (p<0.05). Moreover, the results from the PCA mice model indicated that the increase in vascular permeability was effectively relieved in the treated groups, especially in frying group (p<0.05). Additionally, the α-helix and β-turn contents of processed egg proteins were significantly decreased (p<0.05) compared with native egg proteins. The UV spectra findings showed that all cooking treatments caused significant alterations in the tertiary structure, and fluorescence analysis indicated that cooking decreased the surface hydrophobicity of egg proteins. In conclusion, four traditional cooking methods reduced the allergenicity of egg proteins, particularly frying, and this reduction was associated with structural changes that could contribute to the destruction or masking of epitopes of egg allergens. PRACTICAL APPLICATION: Egg allergy has a serious impact on public health, and there is no ideal treatment method at present. This study demonstrated that four traditional cooking methods (boiling, steaming, baking, and frying) reduced the allergenicity of egg proteins, especially frying, and the results will provide a basis for the development of hypoallergenic egg products.

Dietary Advancement Therapy Using Milk and Egg Ladders Among Children With a History of Anaphylaxis

BackgroundAnaphylaxis 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. ObjectiveThis study aims to focus on the use of food ladders in children with anaphylaxis to egg or milk. MethodsRetrospective 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. Results1552 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. ConclusionMilk 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.