METHODS: We performed a search of currently published food allergen ladders and obtained published information and clinical expertise to summarize current knowledge and suggest future standardized approaches for using food allergen ladders.
RESULTS: There are currently a limited number of published milk, egg, wheat and soy ladders. We suggest the following points should be considered when developing food ladders: 1) Food allergen: dose, time and temperature of heating of the food allergen, simplicity of the ladder and recipes, the possible role of the wheat matrix and testing for allergenic protein levels to standardize doses; 2) Nutritional factors: health and nutritional value of the foods in the ladder, taste, texture and cultural appropriateness of foods should be considered; 3) Medical aspects: consideration of which patients are safe to undergo ladders outside of the clinical setting, other safety aspects and risk factors for severe reactions, number of days suggested per steps and availability and provision of rescue medication. Written instructions and recipes should be provided to families who wish to use food allergen ladders.
CONCLUSIONS: Food allergen ladders used for gradual reintroduction of food allergens into a food allergic individual\'s diet are increasingly being used internationally. Standardization regarding the foods included in the ladder and medical considerations are required to practice patient-centered care, best assist patients and families, and ensure safety.