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Eggs and Allergies

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Eggs and Allergies

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Prevalence of Egg Allergy in Australia 

In Australia, food allergy is common, affecting more than one in ten infants at 12 months of age.1 Cow’s milk, eggs and nuts are the most common food allergens.1 Raw egg allergy is very common, affecting 8.9% of 1 year old children, however many (80%) of these children can tolerate baked egg in their diets.1 By 4 years of age, the prevalence of challenge-confirmed egg allergy drops considerably, with just 1.2% remaining allergic to eggs at this stage of childhood.2 
 
Most egg allergy reactions occur in children between the ages of 6 and 15 months when egg is given for the first time. Fortunately, tolerance to egg usually develops between the ages of 3 and 4 years1 resulting in many children being able to eat eggs as they get older. Australian data from the HealthNuts cohort study of 5276 Australian infants found that in 47% of infants with egg allergy, egg allergy resolved by 2 years of age.3 Furthermore, infants who could tolerate baked egg at 12 months of age were more likely to have their allergy resolve by 2 years of age.4 By age 4, more than 85% of those who were allergic to eggs as an infant were able to tolerate eggs.2 For consumer-friendly information about feeding eggs to babies and children click here

Symptoms of Egg Allergy

Egg allergy may be IgE-mediated or non-IgE mediated.6,6 IgE-mediated reactions to egg are predominantly immediate reactions characterised by urticaria, angioedema, vomiting, diarrhoea and wheeze. Symptoms usually occur within 30 minutes or less of egg contact but may be delayed for 1–2 hours in a minority of cases.5 While cases of anaphylaxis to egg have been reported, this type of reaction is less common compared to peanut7and milk.8 Egg proteins are also being increasingly recognised as a trigger for non-IgE mediated gastrointestinal allergies.6 These gastrointestinal disorders are typically delayed in presentation after ingestion of the allergen and include food protein induced enterocolitis syndrome (FPIES), food-protein induced enteropathy or food protein induced allergic proctocolitis. An Australia-wide survey, published in 2017, found the incidence of FPIES in Australian infants (<24 months) was 15.4/100,000/year.9 
 

Allergens in Egg

Eggs are composed of many different individual proteins in both the egg white and the yolk. Six major egg allergens have been identified. Four of these are in the egg white and most children with an egg allergy react to these proteins. Less commonly children react to egg yolk allergens.10,11 

Common cooking processes, including heating, the addition of acid (such as lemon/lime juice or vinegar) and mixing can affect the allergenicity of proteins in foods.12 The differences in allergenicity are caused by disruption of the protein structure affecting the antibody binding sites. In addition, heating egg protein with wheat (for example in a cake) forms a matrix with the wheat protein, altering the digestibility of the egg protein,13 and provides an explanation for why children who react to raw egg may tolerate cooked egg and baked products containing egg.1,14  

Egg Allergy in At-Risk Children

Both genetic and environmental factors are likely to be responsible for the development of an allergy. The rapid increase over the past 20 years in incidence of food allergy and in variety of foods causing allergic reactions imply changing environmental influences on gene expression are probably the underlying cause of these recent trends.15 

Factors increasing the risk of IgE mediated food allergy, including egg allergy: 

  • Family history of allergies or asthma16,17 
  • Eczema as a baby17,18,19 
  • History of allergic disease in an immediate family member and having parents born in East Asia20
  • Insufficient vitamin D levels in infants21,22 

Factors decreasing the risk of IgE mediated food allergy, including egg allergy: 

  • Children with older siblings and those with a pet dog at home were less likely to develop egg allergy by 1 year of age12 
  • Earlier introduction of egg into the infants’ diet4  

Oral Immunotherapy (OIT)

Oral immunotherapy (OIT), involves exposing individuals with egg allergy to small amounts of egg allergen over time in order to build tolerance to the allergen. OIT is based on the hypothesis that exposing the immune system to small amounts of allergic protein over time helps ‘train’ the immune system, in effect ‘switching off’ the allergy. While evidence is building which suggests this process may help children out grow their allergy23,25 current trials are seeking to develop methods to maximise the benefit and reduce the risk of potential harm to people with severe food allergy. Currently there OIT is not approved for routine treatment in Australia and requires strict medical supervision.26 

Baked Egg and Tolerance

The Australian HealthNuts study also reported that in infants who could tolerate baked egg at age 1 year, frequent ingestion of baked egg (≥5 times per month) compared with infrequent ingestion (0-4 times per month) increased the likelihood of tolerance to other forms of egg.3 

As well as helping children outgrow their allergy, consumption of baked egg, when tolerated is associated with improved quality of life and improved nutritional status.27 Given these benefits, it is reasonable to consider including baked egg, when tolerated, in the diet of egg allergic children. Any challenges to baked egg, however, should only be carried out when recommended by a medical specialist. 

Clinical Threshold for Reactions to Egg in Individuals with Egg Allergy

The amount of a food protein required to induce an allergic reaction is very important, as fatal accidents from trace amounts of food have been reported. Research published in 2013 found that the protein dose at which 5% of the allergic population is likely to respond with objective reactions is 1.5mg egg protein.28 
 

Current Recommendations for Inclusion of Egg in Infant Diets

Avoidance of Allergens During Pregnancy and Breastfeeding

Research does not support restriction of common allergenic foods (including peanut, egg, fish, soy and cow milk) during pregnancy and breastfeeding as a strategy for reducing the development of childhood allergies. The Australian Society of Clinical Immunology and Allergy (ASCIA) infant feeding advice states “exclusion of any particular foods (including foods considered to be highly allergenic) from the maternal diet during pregnancy or breastfeeding is not recommended, as this has not been shown to prevent allergies”.30 Eggs can therefore be included in the diet of pregnant and breastfeeding women as long as they are tolerated by the mother. 

Introducing Allergenic Solid Foods Including Eggs into the Infant’s Diet

Eggs are a good source of quality protein, iron and essential fatty acids and are nutritious foods to include in the diets of infants.31 Current evidence suggests that introduction of egg into the child’s diet before 12 months of age helps to develop tolerance to egg, even in infants who are at high risk of developing food allergies.19 

The 2020 ASCIA Infant feeding and Allergy Prevention guidelines recommends that “All infants should be given allergenic solid foods including peanut butter, cooked egg and dairy and wheat products in the first year of life. This includes infants at high risk of allergy”.30 When infants are ready, at around 6 months, but not before 4 months, a variety of solid foods should be introduced, starting with iron rich foods. At this stage, foods can be introduced according to what the family usually eats, regardless of whether the food is considered to be a common food allergen. 

There is evidence that early introduction of eggs may prevent allergy development,30,31,32,33 however further research is needed to clarify optimal timing and amount to introduce.30 

 In summary, the following recommendations regarding egg allergy can be made:

 Infant Feeding Advice for Prevention of Egg Allergy:

  • Recommendations are the same for all infants regardless of their family history of allergic diseases.
  • Restricting the mother’s egg intake during pregnancy and breast-feeding is not recommended.
  • Breastfeeding is recommended for at least 6 months.
  • Solid foods should be introduced at around 6 months, but not before 4 months.
  • Whole egg (along with other allergenic solid foods) should be introduced in the first year of life.

 For Children with Egg Allergy:

  • Egg is a common allergen, and may cause immediate IgE mediated allergies, and delayed non-IgE mediated allergies.
  • Most children outgrow their egg allergy before they start school, but a small number will still have their egg allergy in primary and high school.
  • The only treatment for egg allergy is complete avoidance of egg.  Many children with raw egg allergy will tolerate baked egg, and the timing of a baked egg challenge should be discussed with their allergist.

 This statement is for healthcare professionals only.

Useful Links

www.allergy.org.au

www.allergy.org.au/images/pcc/ASCIA_guidelines_infant_feeding_and_allergy_prevention.pdf

www.allergyfacts.org.au

FAQs

How many children are affected by egg allergy?

Australian data indicates that the prevalence of raw egg allergy in 12 month old infants is approximately 8.9%. Of these, 80% have been found to tolerate baked egg. It is also important to note that the majority of children grow out of their egg allergy with egg tolerance usually developing between the ages of 2 and 4 years. To find out more about feeding eggs to babies and children click here.

What are the symptoms of egg allergy?

In those with egg allergy, immediate reactions to egg ingestion can include hives (urticaria), angioedema, vomiting, diarrhoea and/or wheeze. Symptoms usually occur within 30 minutes of egg contact but may be delayed for 1-2 hours in a minority of cases. Severe life-threatening events and fatal anaphylaxis to egg in children are less common than to peanut and milk.

Are most children allergic to the egg-white or the yolk?

Egg white is considered to be the most frequent source of allergens and most children with an allergy react to the proteins in the egg whites, though in some rare occasions reactions to egg yolk have been reported. While many egg-allergic children can tolerate baked egg, this should only be trialled under medical supervision.

Should patients avoid allergens during pregnancy and breastfeeding?

The Australian Society of Clinical Immunology and Allergy (ASCIA) does not recommend restricting the mother's diet during pregnancy in order to eliminate allergenic foods. The avoidance of eggs (and other allergenic foods) in pregnancy has not been shown to prevent allergy. Eggs can therefore be included in the diet of pregnant women as long as they are tolerated by the mother and well cooked. Avoidance, by breastfeeding women, of cow's milk, egg and fish does not protect against infant food allergy. To find out more about eggs and pregnancy click here.

References:

  1. Osborne, N.J., et al. Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. Journal of Allergy and Clinical Immunology 127, 668-676.e662 (2011). 
  2. Peters, R.L., et al. The prevalence of food allergy and other allergic diseases in early childhood in a population-based study: HealthNuts age 4-year follow-up. J Allergy Clin Immunol (2017). 
  3. Peters, R.L., et al. The natural history and clinical predictors of egg allergy in the first 2 years of life: a prospective, population-based cohort study. J Allergy Clin Immunol 133, 485-491 (2014). 
  4. Koplin, J.J., et al. Cohort Profile of the HealthNuts study: Population prevalence and environmental/genetic predictors of food allergy. International Journal of Epidemiology (2015). 
  5. Boyano-Martinez, T., Garcia-Ara, C., Diaz-Pena, J.M. & Martin-Esteban, M. Prediction of tolerance on the basis of quantification of egg white-specific IgE antibodies in children with egg allergy. J Allergy Clin Immunol 110, 304-309 (2002). 
  6. Nowak-Wegrzyn, A., Katz, Y., Mehr, S.S. & Koletzko, S. Non-IgE-mediated gastrointestinal food allergy. J Allergy Clin Immunol 135, 1114-1124 (2015). 
  7. Chan, J.C., et al. Food Challenge and Community-Reported Reaction Profiles in Food-Allergic Children Aged 1 and 4 Years: A Population-Based Study. J Allergy Clin Immunol Pract 5, 398-409 e393 (2017). 
  8. Allen, C.W., Campbell, D.E. & Kemp, A.S. Egg allergy: Are all childhood food allergies the same? J Paediatr Child Health 43, 214-218 (2007). 
  9. Mehr, S., Frith, K., Barnes, E.H., Campbell, D.E. & Group, F.S. Food protein-induced enterocolitis syndrome in Australia: A population-based study, 2012-2014. J Allergy Clin Immunol (2017). 
  10. Poulsen, L.K., et al. Allergens from fish and egg. Allergy 56 Suppl 67, 39-42 (2001). 
  11. Eigenmann, P.A. Anaphylactic reactions to raw eggs after negative challenges with cooked eggs. J Allergy Clin Immunol 105, 587-588 (2000). 
  12. Mine, Y. & Yang, M. Recent advances in the understanding of egg allergens: basic, industrial, and clinical perspectives. Journal of Agricultural and Food Chemistry 56, 4874-4900 (2008). 
  13. Mine, Y. & Zhang, J.W. Comparative studies on antigenicity and allergenicity of native and denatured egg white proteins. Journal of Agricultural and Food Chemistry 50, 2679-2683 (2002). 
  14. Romeira, A.M., et al. Egg allergy--to be or not to be boiled. Allergy 58, 533-534 (2003). Page 6 of 6 Position Statement: Eggs and Allergies www.enc.org.au 
  15. Rudders, S.A., Banerji, A., Vassallo, M.F., Clark, S. & Camargo, C.A., Jr. Trends in pediatric emergency department visits for foodinduced anaphylaxis. J Allergy Clin Immunol 126, 385-388 (2010). 
  16. Prescott, S.L. & Tang, M.L. The Australasian Society of Clinical Immunology and Allergy position statement: Summary of allergy prevention in children. Med J Aust 182, 464-467 (2005). 
  17. Fleischer DM, Chan ES, Venter C, Spergel JM, Abrams EM, Stukus D, Groetch M, Shaker M, Greenhawt M. A Consensus Approach to the Primary Prevention of Food Allergy Through Nutrition:Guidance from the American Academy of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; and the Canadian Society for Allergy and Clinical Immunology. J Allergy Clin Immunol Pract. 2021 Jan; 9(1): 22-43. e4. 
  18. Miceli Sopo, S., et al. Risk of adverse IgE-mediate reaction at the first egg ingestion in children with atopic dermatitis. Results of a case-control study. Allergol Immuniopathol (Madr) [Epub ahead of print] (2012). 
  19. Palmer, D.J., et al. Early regular egg exposure in infants with eczema: A randomized controlled trial. J Allergy Clin Immunol 132, 387-392 e381 (2013).  
  20. Koplin, J.J., et al. Environmental and demographic risk factors for egg allergy in a population-based study of infants. Allergy 67, 1415-1422 (2012). 
  21. Allen KJ, Koplin JJ, Ponsonby AL, Gurrin LC, Wake M, Vuillermin P, Martin P, Matheson M, Lowe A, Robinson M, Tey D, Osborne NJ, Dang T, Tina Tan HT, Thiele L, Anderson D, Czech H, Sanjeevan J, Zurzolo G, Dwyer T, Tang ML, Hill D, Dharmage SC. Vitamin D insufficiency is associated with challenge-proven food allergy in infants. J Allergy Clin Immunol. 2013 Apr;131(4):1109-16, 1116.e1-6. 
  22. Molloy J, Koplin JJ, Allen KJ, Tang MLK, Collier F, Carlin JB, Saffery R, Burgner D, Ranganathan S, Dwyer T, Ward AC, Moreno-Betancur M, Clarke M, Ponsonby AL, Vuillermin P; BIS Investigator Group. Vitamin D insufficiency in the first 6 months of infancy and challenge-proven IgE-mediated food allergy at 1 year of age: a case-cohort study. Allergy. 2017 Aug;72(8):1222-1231. 
  23. Burks, A.W., et al. Oral immunotherapy for treatment of egg allergy in children. N Engl J Med 367, 233-243 (2012). 
  24. Dello Iacono, I., et al. Specific oral tolerance induction with raw hen's egg in children with very severe egg allergy: A randomized controlled trial. Pediatr Allergy Immunol [Epub ahead of print](2012). 
  25. Caminiti, L., et al. Oral Immunotherapy for Egg Allergy: A Double-Blind Placebo-Controlled Study, with Postdesensitization Follow-Up. J Allergy Clin Immunol Pract (2015). 
  26. ASCIA 2021. Oral Immunotherapy for Food Allergy Frequently Asked Questions. https://www.allergy.org.au/patients/allergy-treatment/oral-immunotherapy-for-food-allergy 
  27. Robinson ML, Lanser BJ. The Role of Baked Egg and Milk in the Diets of Allergic Children. Immunol Allergy Clin North Am. 2018 Feb;38(1):65-76. 
  28. Blom, W.M., et al. Threshold dose distributions for 5 major allergenic foods in children. J Allergy Clin Immunol 131, 172-179 (2013). 
  29. Appelt, G.K., et al. Breastfeeding and food avoidance are ineffective in preventing sensitization in high risk children [abstract]. J Allergy Clin Immunol 113, S99 (2004). 
  30. ASCIA 2020. ASCIA Guidelines – Infant feeding and Allergy Prevention. https://www.allergy.org.au/hp/papers/infant-feeding-and-allergy-prevention 
  31. Yakaboski E, Robinson LB, Arroyo A, Espinola JA, Geller RJ, Sullivan AF, Rudders SA, Camargo CA. Early Introduction of Food Allergens and Risk of Developing Food Allergy. Nutrients. 2021; 13(7):2318. https://doi.org/10.3390/nu13072318 
  32. Dai NN, Li XY, Wang S, et al. Timing of food introduction to the infant diet and risk of food allergy: a systematic review and Meta-analysis. Chinese Journal of Pediatrics. 2021 Jul;59(7):563-569. DOI: 10.3760/cma.j.cn112140-20201130-01064. PMID: 34405638. 
  33. Martone, G. M., Lehman, H. K., Rideout, T. C., Choudhary, D., Cameron, C. E., Oken, E., Rifas-Shiman, S. L., Camargo, C. A., Jr, Gold, D. R., & Wen, X. (2022). Delayed egg introduction beyond infancy and increased egg allergy risk in childhood. Journal of paediatrics and child health, 10.1111/jpc.16234. Advance online publication. https://doi.org/10.1111/jpc.16234 

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