Egg Ladder Protocol Remains Underused Despite Safety Data

Every child with a food allergy carries some chance of resolution, even peanut allergy, historically considered unlikely to resolve, according to Mahboobeh Mahdavinia, MD, PhD, a board-certified allergist/immunologist from The University of Texas Health Science Center at Houston.¹ Mahdavinia said the message for practicing allergists is straightforward: discuss the possibility of resolution at diagnosis regardless of allergen, and recheck IgE levels or offer an oral food challenge at least yearly, since a year or 2 of surveillance can change a family's dietary reality.

Mahdavinia said early, unpublished follow-up data from a subset of the FORWARD cohort suggest yearly surveillance may meaningfully raise peanut resolution rates above the 3.8% seen at initial enrollment, though the finding has not yet been published or peer-reviewed. The latest FORWARD data reported that resolution rates varied greatly by allergen: 35% for milk, 32% for soy, 27% for wheat, 3.8% for peanut, and 3.5% for shellfish. ¹ The analysis also identified socioeconomic and racial disparities in food allergies, with resolution lower in Black or Hispanic children and children with lower household income, lower parental health literacy scores, and higher area deprivation index. ¹

Why the Egg Ladder Protocol Sits Unused

A separate area of focus for Mahdavinia's group is an egg ladder protocol being presented as an abstract at the 2026 American Academy of Allergy, Asthma & Immunology (AAAAI) conference in Pheonix. She said the graded, at-home introduction protocol is published and freely available but rarely used in practice, largely because of the counseling burden it places on clinicians and families.

"It's not a pill to prescribe. It's lots of talking," Mahdavinia said.

The first visit alone can take close to an hour, she said, and providers need full confidence in the protocol before introducing it, since hesitancy is easily picked up by anxious parents managing reactions at home.

More Food-Specific Papers on the Way

Mahdavinia said her group is preparing 6 additional food-specific resolution papers covering milk, egg, fish, shellfish, and tree nut allergy, alongside milk and egg ladder abstracts for the same AAAAI meeting. FORWARD is led by principal investigator Ruchi Gupta, MD, with Mahdavinia serving as a site PI.²

“This [FORWARD] project is really working on how to help [the] resolution of food allergy,” Mahdavinia said. “We are grateful to [Gupta] for her leadership. That's why we can get to do all these beautiful studies.”

Read more from this interview series:

• Socioeconomic, Racial Disparities Linked to Food Allergy Resolution
• Racial Gap in Food Allergy Resolution Traced to Access, Not Biology
• Closing the Food Allergy Resolution Gap Needs More Than Specialist Access

Editor’s note: Reported disclosures for Mahdavinia include Eli Lilly and Company, GENZYME CORPORATION, Blueprint Medicines Corporation, Regeneron Healthcare Solutions, AstraZeneca Pharmaceuticals LP, Takeda Pharmaceuticals U.S.A., Inc., Grifols USA, CSL Behring, Pharming Healthcare, Inc., Novartis Pharmaceuticals Corporation, and Paratek Pharmaceuticals.

References

1. Dileep A, Bilaver LA, Warren C, et al. Factors associated with outgrowing food allergies: insights from a large food allergy cohort. Ann Allergy Asthma Immunol. Published online August 12, 2026. doi:10.1016/j.anai.2026.08.004

2. Derman C. Race, income, and health literacy tied to food allergy resolution. HCPLive. Published August 17, 2026. Accessed August 31, 2026. https://www.hcplive.com/view/race-income-health-literacy-food-allergy-resolution