Cow's milk and egg protein threshold dose distributions in children tolerant to beef, baked milk, and baked egg

Abstract

Background The use of eliciting doses (EDs) for food allergens is necessary to inform individual dietary advice and food allergen risk‐management. The Eliciting Dose 01 (ED01) for milk and egg, calculated from populations of allergic subjects undergoing oral food challenges (OFCs), are 0.2 mg total protein. The respective Eliciting Dose 05 (ED05) is 2.4 mg for milk and 2.3 mg for egg. As about 70% children allergic to such foods may tolerate them when baked, we sought to verify the EDs of that subpopulation of milk and egg‐allergic children. Methods We retrospectively assessed consecutive OFC for fresh milk and egg between January 2018 and December 2020 in a population of baked food‐tolerant children. Results Among 288 children (median age 56 ‐ IQR 36–92.5 months, 67.1% male) included, 87 (30.2%) returned positive OFC results, 38 with milk and 49 with egg. The most conservative ED01 was 0.3 mg total protein (IQR 0.03–2.9) for milk and 14.4 mg total protein (IQR 3.6–56.9) for egg. The respective ED05 was 4.2 (IQR 0.9–19.6) mg for milk and 87.7 (IQR 43–179) mg for egg. Such thresholds are, respectively, 1.5 (milk ED01), 1.75 (milk ED05), 72 (egg ED01), and 38.35 (egg ED05) times higher than the currently used thresholds. Conclusions The subpopulation of children allergic to milk and egg, but tolerant to baked proteins, displays higher reactivity thresholds than the general population of children allergic to milk and egg. Their risk stratification, in both individual and population terms, should consider this difference. In baked milk‐tolerant children, milk causes reactions at lower doses than egg in our group of egg‐tolerant children. This could be associated with the relative harmlessness of egg compared with milk in the determinism of fatal anaphylactic reactions in children.

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

“…The data demonstrate the huge disparity in the quantity, which will elicit a reaction for different foods; the ED5 discrete dose for cashew nut is 0.8 mg, compared to 1.5 mg for celery, 2.3 mg for egg, and 12.1 mg for fish, with mustard having the lowest ED5 (0.4 mg) and shrimp the highest (280 mg) 54 . Although one study found that the threshold dose did not differ significantly between children tolerant or not tolerant of baked milk and/or egg, another study reported that tolerance of baked milk/egg was associated with a higher ED to milk and egg 55,56 . The amount of food eaten does not always correspond to symptom severity, some ED doses may result in subjective symptoms rather than objective and those experiencing anaphylaxis do not seem to react at a lower dose than those who have only mild‐to‐moderate symptoms 57 .…”

Food-labeling issues for severe food-allergic consumers

“…The absence of international consensus regarding reference doses affects its reproducibility, and the use of the VITAL system remains nonmandatory. Recently, the reference doses for the subpopulation of egg-allergic children tolerating baked egg were found higher than those reported in VITAL [40 ▪▪ ]. Similarly, reference doses for milk allergy sufferers were also higher than in VITAL, although the differences were smaller.…”

Relationship between eliciting doses and the severity of allergic reactions to food

“…During milk OFCs, the ED05 was reported at 2-7 mg of protein [13][14][15][16]; however, a previous systematic review showed that approximately 5% of individuals with a cow's milk allergy react to less than 2.9 mg of protein and that 5% of those with allergic reactions will experience anaphylaxis [15 && ]. Furthermore, children who are allergic to raw milk or egg but are tolerant to baked products containing milk or egg have higher thresholds than those who cannot tolerate baked products [17]. Other reports have provided updates of the ED01 or ED05 for peanuts and other foods [18][19][20].…”