Milk & egg ladders: Patient selection, safety, and shared decision-making

The clinical approach of administering extensively heated milk and egg products, and of using dietary advancement therapies (DAT) such as milk and egg ladders is a progressive intervention to manage milk and egg allergies. Tolerance to baked and hydrolyzed versions of allergens often indicates the potential for patients to outgrow these allergies. The heating process alters the proteins' structure, reducing allergenicity and increasing the likelihood of tolerance to larger quantities over time. This paper reviews the use of DATs for managing non‐immunoglobulin E (IgE) mediated and IgE-mediated allergies by emphasizing recent guidelines, reviews, and limited clinical trial evidence. The effectiveness of ladders in hastening allergy resolution is still debated, with inconsistent evidence to suggest that they expedite tolerance development. These methods' long-term effectiveness and safety are still uncertain, and the potential risk of adverse reactions must be considered. Selecting appropriate patients is key to the success and safety of these therapies, and this article highlights potential phenotypic factors linked to positive outcomes. Standardizing protocols is necessary for consistent long-term evaluation of DATs, especially given the variability in allergen doses, which results from different food preparations. Safe clinical practice also relies on thorough patient education and counselling about the process, risk reduction, and management of comorbid health conditions. Future research should aim to establish the best age for starting ladders, the precise measurements of allergenic proteins for progressive tolerance, and enhanced communication with caregivers and medical professionals. Ultimately, clinicians should consider whether ladders may simply provide an organized structure to a naturally occurring phenomenon.