Strict Allergen Avoidance Research Articles

Eyelid Dermatitis: Common Patterns and Contact Allergens.

Eyelid dermatitis is a common dermatologic concern representing a broad range of inflammatory dermatoses. The most commonly reported cause of eyelid dermatitis is allergic contact dermatitis (ACD), a type IV delayed hypersensitivity reaction caused by exposure to external allergens that is diagnosed via epicutaneous patch testing. The most common contact allergens associated with eyelid dermatitis are metals, fragrances, preservatives, acrylates, and topical medications, which may be found in a variety of sources, including cosmetics, ophthalmic medications, nail lacquers, and jewelry. Management involves strict allergen avoidance with an emphasis on patient counseling. In this review, we discuss the clinical manifestation, evaluation, patch test considerations, and management of eyelid ACD to provide a valuable reference tool in the management of patients presenting with eyelid dermatitis.

Quality of Life in the Management of Anaphylaxis in Food-Allergic Adults.

Anaphylaxis is a life-threatening allergic reaction that can significantly affect the quality of life of those affected. Factors including undiagnosed allergies, lack of allergen information, and insufficient emergency training can impact the quality of life for food-allergic individuals. Well-informed patients are less likely to experience severe allergic responses, ensuring their safety and quality of life. This study aims to evaluate the effectiveness of following preventive behavior, focusing on routine counseling and training provided by healthcare professionals in preventing anaphylaxis and assessing the impact of strict adherence to an allergen avoidance regimen against anaphylaxis. This study was a descriptive, cross-sectional survey conducted in the Makkah region of Saudi Arabia. It involved adults aged 18 and above who had food allergies. A structured online questionnaire of seven items was developed and distributed to achieve the study's goals from October 2023 to January 2024. The data collected was automatically exported to Excel and then analyzed using the Statistical Package for the Social Sciences. The study involved 93 participants, 65.6% female and 34.4% male. Among those with food allergies, 34.4% had experienced anaphylaxis, with 50% allergic to eggs and seafood. The study found no significant association between specific food allergens and a history of anaphylaxis, but strict allergen avoidance was linked to lower anaphylaxis rates. Counseling or training for managing food allergy reactions also showed potential benefits. The research indicated that males were less likely to have anaphylaxis than females, and age increased the severity of anaphylaxis reactions regardless of gender. The study emphasizes the importance of preventive behaviors and healthcare professional support in reducing the risk of anaphylactic reactions for food-allergic adults. Future research could focus on improving their quality of life through education programs, policy development, and better access to emergency medications and psychosocial support strategies.

Practical issues of oral immunotherapy for egg or milk allergy.

Oral immunotherapy (OIT) has been recommended to reduce parental burden related to strict allergen avoidance and induce desensitization and immune tolerance for patients with long-lasting allergies to hen's eggs (HE) or cow's milk (CM). OIT should be monitored by pediatric allergists specializing in OIT and oral food challenge tests to manage allergic reactions. Although a previous history of anaphylaxis or multiple food allergies is not a contraindication to OIT, it is contraindicated if the patient has uncontrolled asthma, a malignancy, active systemic autoimmune disorders, or diseases requiring treatment with beta-blockers. A variety of OIT protocols have been de veloped to ensure better outcomes and safe up-dosing, including adjunctive therapies with biologics. This review provides insight into the practical issues of various immunotherapy options for children with HE or CM allergies.

Epicutaneous Sensitization and Food Allergy: Preventive Strategies Targeting Skin Barrier Repair-Facts and Challenges.

Food allergy represents a growing public health and socio-economic problem with an increasing prevalence over the last two decades. Despite its substantial impact on the quality of life, current treatment options for food allergy are limited to strict allergen avoidance and emergency management, creating an urgent need for effective preventive strategies. Advances in the understanding of the food allergy pathogenesis allow to develop more precise approaches targeting specific pathophysiological pathways. Recently, the skin has become an important target for food allergy prevention strategies, as it has been hypothesized that allergen exposure through the impaired skin barrier might induce an immune response resulting in subsequent development of food allergy. This review aims to discuss current evidence supporting this complex interplay between the skin barrier dysfunction and food allergy by highlighting the crucial role of epicutaneous sensitization in the causality pathway leading to food allergen sensitization and progression to clinical food allergy. We also summarize recently studied prophylactic and therapeutic interventions targeting the skin barrier repair as an emerging food allergy prevention strategy and discuss current evidence controversies and future challenges. Further studies are needed before these promising strategies can be routinely implemented as prevention advice for the general population.

Successful management of chronic urticaria and food allergies in a pediatric population using integrative traditional Chinese medicine therapy: a case series

BackgroundFood allergy is becoming increasingly common among the pediatric population. Despite strict avoidance of food allergens, a subgroup of sensitive individuals still develops frequent, persistent, and difficult to treat hives (FPDTH) for which there is no curative therapy. Although these cases are rare, these patients are in most need of therapy.Case presentationsThis is a retrospective review of 3 pediatric patients with highly sensitive food allergies who initially presented with hives daily or every other day, or multiple times a day, but achieved marked remission after traditional Chinese medicine (TCM) therapies. Patient 1 (P1) is a 5-year-old who has experienced 140 reactions in his lifetime. Reactions were mostly hives with 4 episodes of anaphylaxis. P1 had used Prednisone 20 times, had an Epinephrine injection 4 times, and had 3 emergency room (ER) visits. Patient 2 (P2) is a 12-year-old who had experienced hives since age 3. Despite daily antihistamine use, P2 had > 730 reactions in his lifetime at the time of presentation including 2 episodes of anaphylaxis. He had been prescribed prednisone 4 times, an Epinephrine injection 2 times, and had 1 ER visit. Patient 3 (P3) is a 20-month-old girl who had experienced > 120 reactions including 1 episode of anaphylaxis. She was on daily desonide and frequently used an antihistamine, yet still had required a course of prednisone once, an Epinephrine injection once, and had 1 ER visit to manage her reaction. After presenting to our clinic, patients received internal and external TCM treatments, including herbal baths and creams (Remedy A-D) as basic remedies to reduce food reactions, including but not limited to frequent hives. Within 7–9 months of TCM treatment, remarkably all patients had complete remission of atopic symptoms. All three patients also experienced an improvement in other conditions including food intolerance, diarrhea, anxiety, eczema, and environmental allergies. After 1 year of treatment, all three patients had reductions in food-specific IgE levels that had been previously elevated, and additionally, P1 and P3, who initially had high total IgE levels, experienced a marked decrease in total IgE levels as well. All three patients continued to introduce foods into their diet that they previously had reactions to, and all 3 patients remain symptom-free.ConclusionsThree pediatric patients with a known history of multiple food sensitivities and physician-diagnosed food allergies that presented with FPDTH underwent a TCM regimen and experienced dramatic improvement in symptoms and reduction in their IgE levels. This regimen appears to be effective in FPDTH population although a further study in a controlled clinical setting is required.

Intestinal Uptake and Tolerance to Food Antigens.

Food allergy is a growing concern due to its increasing world-wide incidence. Strict avoidance of allergens is a passive treatment strategy. Since the mechanisms responsible for the occurrence and development of food allergy have not yet been fully elucidated, effective individualized treatment options are lacking. In this review, we summarize the pathways through which food antigens enter the intestine and review the proposed mechanisms describing how the intestine acquires and tolerates food antigens. When oral tolerance is not established, food allergy occurs. In addition, we also discuss the contribution of commensal bacteria of the gut in shaping tolerance to food antigens in the intestinal tract. Finally, we propose that elucidating the mechanisms of intestinal uptake and tolerance of food antigens will provide additional clues for potential treatment options for food allergy.

Provider Recommendations and Maternal Practices When Providing Breast Milk to Children With Immunoglobulin E-Mediated Food Allergy

To evaluate health care provider recommendations and the breastfeeding dietary practices of mothers with a child who has immunoglobulin E (IgE)-mediated food allergy.The study participants were recruited from online social media groups for breastfeeding mothers or mothers of children with food allergies.The study included a Web-based survey with the following initial questions as inclusion criteria: having a child diagnosed with an IgE-mediated food allergy by a health care provider before 2 years of age, confirmation of food allergy with blood or skin testing, listing of specific food(s) to which the child is allergic in the survey, confirmation of food allergy by an allergist, and consumption of breast milk before the child’s diagnosis. With the survey, the researchers then explored the mother’s consumption of food to which the child has an allergy (while breastfeeding), and, if present, reported possible allergic reactions were rated by a board-certified allergist on a scale of 1 (highly inconsistent) to 5 (highly consistent) with an IgE-mediated reaction.A total of 133 mothers completed the survey. A total of 47.4% (n = 63) of mothers reported their health care provider encouraged them to continue breastfeeding without dietary restrictions, 17.3% (n = 23) were advised to continue breastfeeding but avoid eating the food(s) their child has an allergy to, and 28.6% (n = 38) stated this issue was not addressed. A total of 88% (n = 117) of mothers noticed no allergic reaction in their child while consuming the food their child has an allergy to, and 12% (n = 16) believed their child had a possible allergic reaction. Of the 16 who reported reactions, only 4 were “likely consistent” with an IgE-mediated reaction, most of which were mild. The remaining reported reactions were inconsistent with an IgE-mediated reaction. All 4 mothers completely eliminated the food(s) from their own diet while continuing to breastfeeding their child.This study reveals the inconsistencies in counseling provided by health care providers to breastfeeding mothers of children with IgE-mediated food allergy. Most mothers were able to consume the food their child was allergic to while breastfeeding without adverse sequelae.With this study, the authors highlight the need for further research and unification of recommendations provided to breastfeeding mothers of children with food allergies. Strict avoidance of food allergens by breastfeeding mothers may not be warranted. If reactions are reported, a thorough history should be performed to determine if it is consistent with an IgE-mediated reaction before recommending avoidance in the mother’s diet.

Exploring barriers to commercial peanut oral immunotherapy treatment during COVID-19

Among children in the United States, the prevalence of peanut allergy has continued to rise and contributes substantially to the mortality and morbidity associated with food allergies.1-3 Although the standard of care for peanut allergy is strict allergen avoidance in addition to early use of rescue medications, accidental ingestions often occur and can result in severe allergic reactions across the life span.4,5 Despite significant patient and caregiver motivation to reduce the risk for these accidental reactions, treatment options for peanut allergy have not been widely accessible until recently.

White paper on peanut allergy- part1: Epidemiology, burden of disease, health economic aspects.

Peanuts are Leguminosae, commonly known as the legume or pea family, and peanut allergy is among the most common food allergies and the most common cause of fatal food reactions and anaphylaxis.The prevalence of peanut allergy increased 3.5-fold over the past two decades reaching 1.4–2% in Europe and the United States. The reasons for this increase in prevalence are likely multifaceted. Sensitization via the skin appears to be associated with the development of peanut allergy and atopic eczema in infancy is associated with a high risk of developing peanut allergy.Until recently, the only possible management strategy for peanut allergy was strict allergen avoidance and emergency treatment including adrenaline auto-injector in cases of accidental exposure and reaction.This paper discusses the various factors that impact the risks of peanut allergy and the burden of self-management on peanut-allergic children and their caregivers.

Food-Induced Anaphylaxis in Infants: Can New Evidence Assist with Implementation of Food Allergy Prevention and Treatment?

Previous guidance on infant anaphylaxis largely relied on data from older children and adults. Infants are a unique subgroup, which presents specific challenges because infants are unable to verbalize symptoms, although the magnitude of underrecognition is not well studied. Data show that strict avoidance of allergens is difficult to achieve in the infant age group and a source of stress and anxiety for their caregivers. Recent studies suggest that infant anaphylaxis is less severe than in older children, which could greatly assist with implementation of food allergy prevention and treatment. New evidence from clinical trials and observational and real-world studies show that infant anaphylaxis is rare on first ingestion of a new food and typically not severe when it occurs, which parents may not be aware of when preparing to introduce peanut or other common food allergens to infants for the purpose of prevention. The better safety and efficacy of oral immunotherapy in infants and preschoolers could help prevent undesired psychosocial consequences of longstanding food allergy such as anxiety, bullying, and poor quality of life. Evidence from recent years on the lower risk of infant anaphylaxis and its severity could move allergy practice toward the confidence that regular, long-term ingestion provides.

Assessment of the effects of a work-related allergy to seafood on the reduction of earning capacity in the context of BK No. 5101.

Fish, crustaceans, and mollusks are among the most potent allergenic foods of animal origin and are thus important triggers of work-related immediate-food allergies. In Germany, work-related seafood allergies are of great importance in the fishing and processing industries as well as in the areas of food preparation, food control, and food sales. There is no causal therapy of seafood allergy, only the strict and lifelong avoidance of allergens remains. The following recommendations serve to assess the impact of a seafood allergy with regard to the work opportunities ended by it for the assessment of the reduction of earning capacity (MdE (German for Minderung der Erwerbsfähigkeit)) in the context of the occupational disease number 5101 of the Annex to the German regulation for occupational diseases. As a special feature of work-related seafood allergy with regard to insurance law aspects, it must be taken into account that there is a potential risk of systemic reaction with subsequent multi-organ involvement. For the estimation of MdE in the general labor market, the impact of a seafood allergy can therefore be assessed, depending on its clinical severity, as generally “mild” to “severe” in justified individual cases.

Assessing Parental Anxiety in Pediatric Food Allergy: Development of the Worry About Food Allergy Questionnaire.

Food allergies (FAs) in children are increasingly common, and strict allergen avoidance and safety concerns place parents at risk for anxiety (Lau et al. in Pediatr Allergy Immunol 25:236-242, 2014). Assessing parental anxiety with generic instruments may not capture the unique experience of parents managing children's FAs. This study developed and preliminarily validated the 13-item Worry About Food Allergy (WAFA) questionnaire, a measure of FA-specific parental anxiety, in an online sample of 265 parents aged 22-66 (M = 40.25) of children with FAs. The WAFA showed good internal reliability (Cronbach's α = .89) and moderate convergent validity with other anxiety measures, indicating support for a reliable measure of a discrete, specific construct. Exploratory factor analysis indicated a single factor structure. Criterion validity was established through significant, small, positive correlations with relevant allergy variables. A coherent single factor measure, the WAFA, shows promise as a screening tool for parental anxiety in pediatric practice and FA management.

Food allergy among university students: uncharted territory

BackgroundFood allergy is a growing global health concern, with limited studies conducted in developing countries. High-risk behavior regarding allergies is common among young adults, making them prone to severe allergic reactions. This study aimed to estimate the prevalence of food allergies among Imam Abdulrahman Bin Faisal University (IAU) students and to determine the rate of high-risk behaviors in this group.MethodsAn online survey was conducted among IAU students enrolled between the academic years of 2008 and 2018. The survey addressed food allergies with respect to age of onset, allergy testing, self-injectable epinephrine (SIE) prescription, associated allergic conditions, and attitude and behavior of university students regarding food avoidance and epinephrine use.ResultsIn total, 5497 completed surveys were analyzed; 526 participants were clinically diagnosed with allergies to at least one food item. A SIE device was prescribed for only 129 (24.5%) of the diagnosed individuals, of which only 4.7% carried the device at all times. Thirty-nine individuals (30.2%) reported that they and their family members know the proper epinephrine device technique. Strict avoidance of food allergens was reported by 30.2% of the individuals. Associated allergic conditions were observed in 69.3% of the clinically diagnosed individuals.ConclusionFood allergies are prevalent among IAU students, with under-prescription of SIE devices. A high rate of high-risk behaviors with respect to food avoidance and carrying SIE was noted. Interventional strategies are needed to mitigate the risk of severe reactions among these university students.

Emerging Food Allergy Treatments.

Immunoglobulin E (IgE)-mediated food allergy affects up to 8% of the pediatric population and occurs when a person develops antibodies to specific food proteins resulting in immediate reaction upon ingestion of the food in question. Current treatment revolves around strict allergen avoidance and prompt treatment of systemic, anaphylactic reactions with injectable epinephrine. However, despite strict avoidance, unexpected reactions are a significant problem. Therefore, therapeutic options for treatment of food allergy are in high demand. This article focuses on emerging therapies including oral immunotherapy, sublingual immunotherapy, epicutaneous immunotherapy, and possible adjunct therapies for the treatment and desensitization of IgE-mediated food allergy. [Pediatr Ann. 2019;48(12):e468-e472.].

Current perspectives on peanut allergy.

Peanut allergy is increasingly prevalent and for most patients is a life-long condition, with the potential to cause life-threatening reactions. Accurate diagnosis and appropriate management are essential to minimise risks due to accidental peanut exposure. Current management strategies focus on strict allergen avoidance and access to emergency medicines to treat potential reactions; however, active approaches are an area of intense research. Promising new methods of food allergen immunotherapy are set to change the approach to managing peanut allergic patients in the near future.

Oral Immunotherapy for Peanut Allergy (PACE): A Systematic Review and Meta–analysis of Efficacy and Safety

To systematically review the efficacy and safety of peanut oral immunotherapy (OIT) compared with allergen avoidance or placebo OIT for peanut allergy.The population included individuals with peanut allergy (61% male, 39% female), the majority of whom were children (median age: 8.7 years; interquartile range [IQR]: 5.9–11.2 years) participating in peanut OIT trials in North America, Australia, and Western Europe.This systematic review and meta-analysis included a comprehensive search of international health care databases from the United States, Latin America, Europe, and China through December 2018. Authors performed searches for randomized controlled trials comparing peanut OIT to no OIT for the treatment of peanut allergy. The authors screened studies, extracted data, assessed risk of bias, and assessed quality of evidence by the Grading of Recommendations Assessment, Development, and Evaluation approach. The main outcomes included treatment efficacy (ie, proportion of patients passing an oral food challenge), anaphylaxis, allergic or adverse reactions, epinephrine use, and quality of life.Twelve randomized controlled trials were included, with 1041 participants in total undergoing peanut OIT for a median follow-up of 1.0 year (IQR: 0.8–1.4), achieving a median target dose of 2000 mg of peanut protein (IQR: 375–4000). Passing a supervised, in-clinic oral food challenge was more likely in the OIT group. Subjects undergoing peanut OIT had increased anaphylaxis risk (risk ratio: 3.12 [95% confidence interval (CI): 1.76–5.55]), anaphylaxis frequency (incidence rate ratio: 2.72 [95% CI: 1.57–4.72]), and epinephrine use (risk ratio: 2.21 [95% CI: 1.27–3.83]). Peanut OIT increased serious adverse events and nonanaphylactic reactions. These findings were irrespective of OIT protocol, proprietary formulation or not, and phase of OIT (build-up versus maintenance). Quality of life was not different between groups.High-quality evidence shows that current peanut OIT regimens effectively achieve a modest level of desensitization but clinically result in a net increase in anaphylaxis and other allergic reactions compared with avoidance or placebo, rather than preventing them, as intended. These data support the need for improved food allergy treatment approaches with an enhanced safety profile.Hesitancy to implement OIT in routine clinical practice centers around concerns for safety, standardization of approach, practicality of long-term therapy maintenance, and identification of patients who will respond best with the fewest side effects. Although most adverse effects from OIT are mild and do not prevent patients from continuing therapy, the potential for life-threatening anaphylaxis exists. Despite the safety concerns outlined in this report, OIT is being offered in some clinical practices and is expected be available on a larger scale in the near future. It is important to remember that OIT may not be the best fit for many food-allergic patients, and as we near the likely acceptance of a US Food and Drug Administration–approved peanut OIT product, patients will seek advice from their pediatrician before talking to an allergist to help them navigate the pros and cons of interventional therapy versus the traditional approach of maintaining strict allergen avoidance. Salient points for the pediatrician to remember include the following. (1) OIT and all other products currently under investigation for treatment of food allergy provide benefit while on therapy but do not appear to induce sustained remission for the majority of allergic patients. (2) There are no surrogate biomarkers to identify which patients will receive the greatest benefit with the fewest side effects. (3) Anaphylaxis while on therapy is a potential side effect, and patients must continue to carry autoinjectable epinephrine at all times. Shared decision-making and an open and honest discussion with families considering therapeutic options are necessary in providing comprehensive care of our patients with food allergy and their families.

Food allergy-From food avoidance to active treatment.

The prevalence of food allergy (FA) has increased too rapidly, possibly due to environmental factors. The guidelines recommend strict allergen avoidance, but FA is still the main cause of anaphylaxis in all age groups. Immunotherapy is the only treatment able to change the course of allergic disease, and oral immunotherapy (OIT) is the more effective route in FA. However, it carries the risk of adverse reactions, including anaphylaxis. To improve OIT safety, adjuvant therapy with the immunoglobulin E (IgE) monoclonal antibody omalizumab has been extensively used. Results suggest particular benefit in patients with high risk of fatal anaphylaxis. An alternative approach is to use omalizumab instead of OIT to prevent severe allergic reactions upon accidental exposure. This paper reviews current evidence regarding IgE-mediated FA, focusing on natural tolerance and food sensitization acquisition, and on avoidance measures and their limitations.

Personalized Nutrition Approach in Food Allergy: Is It Prime Time Yet?

The prevalence of food allergy appears to be steadily increasing in infants and young children. One of the major challenges of modern clinical nutrition is the implementation of individualized nutritional recommendations. The management of food allergy (FA) has seen major changes in recent years. While strict allergen avoidance is still the key treatment principle, it is increasingly clear that the avoidance diet should be tailored according to the patient FA phenotype. Furthermore, new insights into the gut microbiome and immune system explain the rising interest in tolerance induction and immunomodulation by microbiota-targeted dietary intervention. This review article focuses on the nutritional management of IgE mediated food allergy, mainly focusing on different aspects of the avoidance diet. A personalized approach to managing the food allergic individual is becoming more feasible as we are learning more about diagnostic modalities and allergic phenotypes. However, some unmet needs should be addressed to fully attain this goal.

Food allergy and anaphylaxis.

Anaphylaxis is a severe and potentially life-threatening allergic reaction. There are numerous potential causes, with food allergy being the leading cause in children and the focus of this review. Most reactions involve an IgE-mediated mechanism, although non-IgE-mediated and nonimmunologic reactions can occur. Various cofactors to be discussed can place certain individuals at an increased risk of severe or fatal anaphylaxis. The clinical manifestations of anaphylaxis are broad and may involve multiple body systems. Diagnosis of food-related anaphylaxis is primarily based on signs and symptoms and supported, wherever possible, by identification and confirmation of a culprit food allergen. First-line treatment of anaphylaxis is intramuscular administration of epinephrine. Long-term management is generally focused on strict allergen avoidance and more recently on food desensitization using immunotherapy. This review provides an overview of anaphylaxis with a specific focus on food allergy.

Oral and sublingual immunotherapy for egg allergy.

Clinical egg allergy is a common food allergy. Current management relies upon strict allergen avoidance. Oral immunotherapy might be an optional treatment, through desensitization to egg allergen. To determine the efficacy and safety of oral and sublingual immunotherapy in children and adults with immunoglobulin E (IgE)-mediated egg allergy as compared to a placebo treatment or an avoidance strategy. We searched 13 databases for journal articles, conference proceedings, theses and trials registers using a combination of subject headings and text words (last search 31 March 2017). We included randomized controlled trials (RCTs) comparing oral immunotherapy or sublingual immunotherapy administered by any protocol with placebo or an elimination diet. Participants were children or adults with clinical egg allergy. We retrieved 97 studies from the electronic searches. We selected studies, extracted data and assessed the methodological quality. We attempted to contact the study investigators to obtain the unpublished data, wherever possible. We used the I² statistic to assess statistical heterogeneity. We estimated a pooled risk ratio (RR) with 95% confidence interval (CI) for each outcome using a Mantel-Haenzel fixed-effect model if statistical heterogeneity was low (I² value less than 50%). We rated the quality of evidence for all outcomes using GRADE. We included 10 RCTs that met our inclusion criteria, that involved a total of 439 children (oral immunotherapy 249; control intervention 190), aged 1 year to 18 years. Each study used a different oral immunotherapy protocol; none used sublingual immunotherapy. Three studies used placebo and seven used an egg avoidance diet as the control. Primary outcomes were: an increased amount of egg that can be ingested and tolerated without adverse events while receiving allergen-specific oral immunotherapy or sublingual immunotherapy, compared to control; and a complete recovery from egg allergy after completion of oral immunotherapy or sublingual immunotherapy, compared to control. Most children (82%) in the oral immunotherapy group could ingest a partial serving of egg (1 g to 7.5 g) compared to 10% of control group children (RR 7.48, 95% CI 4.91 to 11.38; RD 0.73, 95% CI 0.67 to 0.80). Fewer than half (45%) of children receiving oral immunotherapy were able to tolerate a full serving of egg compared to 10% of the control group (RR 4.25, 95% CI 2.77 to 6.53; RD 0.35, 95% CI 0.28 to 0.43). All 10 trials reported numbers of children with serious adverse events (SAEs) and numbers of children with mild-to-severe adverse events. SAEs requiring epinephrine/adrenaline presented in 21/249 (8.4%) of children in the oral immunotherapy group, and none in the control group. Mild-to-severe adverse events were frequent; 75% of children presented mild-to-severe adverse events during oral immunotherapy treatment versus 6.8% of the control group (RR 8.35, 95% CI 5.31 to 13.12). Of note, seven studies used an egg avoidance diet as the control. Adverse events occurred in 4.2% of children, which may relate to accidental ingestion of egg-containing food. Three studies used a placebo control with adverse events present in 2.6% of children. Overall, there was inconsistent methodological rigour in the trials. All studies enrolled small numbers of children and used different methods to provide oral immunotherapy. Eight included studies were judged to be at high risk of bias in at least one domain. Furthermore, the quality of evidence was judged to be low due to small numbers of participants and events, and possible biases. Frequent and increasing exposure to egg over one to two years in people who are allergic to egg builds tolerance, with almost everyone becoming more tolerant compared with a minority in the control group and almost half of people being totally tolerant of egg by the end of treatment compared with 1 in 10 people who avoid egg. However, nearly all who received treatment experienced adverse events, mainly allergy-related. We found that 1 in 12 children had serious allergic reactions requiring adrenaline, and some people gave up oral immunotherapy. It appears that oral immunotherapy for egg allergy is effective, but confidence in the trade-off between benefits and harms is low; because there was a small number of trials with few participants, and methodological problems with some trials.