The Egg Ladder; What It Is and How to Use It

The egg ladder was created following the success of the milk ladder. It starts with the most easily tolerated forms of egg-containing foods—those with low amounts of extensively-heated egg protein—and ends with raw egg (in a palatable form like mayonnaise or chocolate mousse). Although mild reactions are quite common when a child is introduced to a new food on the ladder, when the ladder is used correctly, the risk of severe reactions is incredibly small.

The potential rewards, however, are plentiful, even if a child does not reach the top of the ladder. Just being able to incorporate some egg into their diet improves their nutrition and makes it possible for them to enjoy more varied and diverse foods. It may also reduce the severity of any allergic reactions experienced by accidental exposure to egg, all of which improves the child’s quality of life and reduces the general level of anxiety in their household. Eating baked egg on a regular basis may even help an egg-allergic child to outgrow their allergy faster.

This page will answer the following questions:

What is the egg ladder?

The egg ladder is a method that allows children with egg allergy to reintroduce egg into their diets by following a series of steps that contain more egg protein in more allergenic forms as you go up the ladder, starting with extensively baked foods (e.g. biscuits and muffins), progressing onto to well-cooked forms of egg (e.g. pancakes and waffles), then less-cooked forms (e.g. lightly scrambled or soft-boiled egg) before ending with raw egg (e.g. in mayonnaise or cookie dough).

The aim of an egg ladder is to support a child’s development to full or at least partial tolerance of egg, thus enabling them to enjoy a less restricted diet.

Food ladders were originally designed in the UK as a way of dealing with non-IgE-mediated allergies to milk, based on evidence that the vast majority of milk-allergic children were able to tolerate extensively heated forms of milk in baked goods. Likewise, studies have shown that tolerance to baked egg develops before a child tolerates less-cooked egg, with a majority—between around two thirds and four-fifths—of egg-allergic children being able to eat baked egg (often in the form of a muffin) without symptoms.

In fact, researchers who have followed egg-allergic children over a number of years have observed that children tend to outgrow their allergy to well-cooked egg about twice as quickly as their allergy to uncooked egg.

Ireland was the first country to start using an egg ladder. The Irish Food Allergy Network (IFAN) started using one in 2011 and launched a website that made it available to the general public in 2013. The ladder is split into 3 stages (‘well-cooked egg’, ‘lightly cooked egg’ and ‘almost raw egg’) further subdivided into different foods that are supposed to be eaten in a certain order. The progression of foods within each stage ensures that a child gradually eats foods that contain slightly more egg that has been slightly less heated as they progress through the stage; the first stage starts with baked sponge cake and ends with pancake, the second stage starts with fresh egg pasta and ends with omelette, and the third stage starts with scrambled egg and ends with cracked eggshell.

The Irish egg ladder was probably inspired by guidelines from Britain, namely the 2010 guidelines published by the British Society for Allergy and Clinical Immunology (BSACI) that stated that children tend to grow out of their egg allergy gradually, first tolerating well-cooked egg (e.g. cake), then lightly cooked (e.g. scrambled eggs) before finally being able to eat raw egg. In 2021, BSACI published an official 9-step egg ladder based on this three-stage classification. Like the Irish ladder, it progresses through increasing amounts of less extensively cooked egg and includes typically British foods like Yorkshire pudding before ending with raw cake mix.

Canada also published an egg ladder in 2021. Their version is a simple, 4-step ladder which includes foods usually consumed in Canadian households—step 1 includes pastries and dried pasta, step 2; pancakes, waffles and fresh pasta, step 3; boiled egg, scrambled egg and French toast, and step 4 includes lightly cooked egg and raw egg in e.g. ice cream, meringue, cookie dough or mayonnaise.

In 2024, Germany got its own egg ladder, with 6 somewhat different steps that start with pastries/bread, followed by dried egg pasta, then pancakes, then meatballs/vegetable patties, then plain egg with different cooking times—hard-boiled, then soft-boiled, then scrambled/fried egg—before ending with various desserts that contain raw egg, such as cake dough, sorbet, meringue, Bavarian cream, Tiramisu, chocolate mousse and frosting. It also allows for the use of pre-packaged foods available on the German market.

Finally, in 2026, the US got its own version of an egg ladder designed explicitly for IgE-mediated allergy. This ladder is made up of 7 steps that have been carefully designed to contain a standardised amount of egg protein which progressively increases as you go up the ladder. The researchers used various scientific techniques to measure the micrograms of 2 major egg allergens (Gal d 1 and Gal d 2) as well as the milligrams in overall egg allergen per serving. The team included both a paediatric allergist and 2 paediatric dietitians to make sure that the food (cracker, bread, cookies, muffins, meatballs (including a veggie option) and pancakes) is easy to make and provides age-appropriate nutrition. Multiple recipes are available for each step of the ladder to provide more options for families.

Each egg ladder is slightly different and none demand the same level of exactitude as the milk ladder, with several not specifying the amount of egg to be included per step or even including recipes. This is probably because, as food allergens go, egg is generally less likely to provoke serious reactions than milk.

Although the egg ladder can be compared with egg immunotherapy, the two concepts are not the same.

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How does the egg ladder work?

The egg ladder works by starting with food containing a small amount of egg protein made less allergenic by extensive processing and progressing with steps that offer foods containing slightly more egg protein in a slightly less processed, more allergenic form, before ending with intact egg proteins.

Heating

The ladder capitalises on the fact that tolerance to extensively heated egg develops earlier than tolerance to raw egg (if it develops at all). This is largely due to the fact that baked egg has less potential to cause allergic reactions than less-heated forms of egg, and that’s because of what heat does to egg proteins.

Food proteins provoke reactions when IgE antibodies recognise and latch onto certain parts of them—the epitopes. These epitopes come in 2 forms; they can be conformational, and depend on the shape of the protein, or they can be linear (aka sequential), and depend on the sequence of amino acids in the protein. Heat is able to change the shape of egg proteins—to ‘denature’ them. This makes the epitopes on the surface of the egg proteins ‘break up’, which means that egg-specific IgE antibodies can no longer recognise them.

Research suggests that the duration of the heating may matter more than the temperature itself when it comes to reducing the potential of egg to cause allergic reactions.

However, heating has no effect on the sequence of amino acids in a protein, so people who are allergic to linear epitopes are unlikely to be helped by cooking. People who are allergic to linear epitopes are more likely to have a more severe and persistent form of egg allergy, and are therefore less likely to be helped by the egg ladder.

Additionally, not all egg proteins are created equal; egg white contains several different known allergens and is considered more allergenic than egg yolk. Its two most important allergens are ovomucoid (Gal d 1), which makes up about 11% of the egg white, and ovalbumin (Gal d 2), which makes up about 54%. Although ovalbumun is the most abundant protein, it’s vulnerable to both heating and digestion, whereas ovomucoid is very resistant to both heat and digestion and, as a result, is considered the most potent.

Research has shown that 25 minutes of baking reduces the ability of ovalbumin to provoke an immune response, but not that of ovomucoid. But it’s just a matter of time; 30 minutes on 180°C/350°F reduces the bioavailability of both ovalbumin and ovomucoid, decreasing the concentration of ovalbumin and ovomucoid that IgE antibodies can bind to 1,942-fold and 72-fold, respectively. There is still some allergen left, though.

Although egg white allergens tend to get most of the attention, egg yolk matters too. So far, only 2 allergens have been officially recognised in egg yolk, and, while one (alpha livetin, Gal d 5) is vulnerable to heating, the other, (a glycoprotein, Gal d 6) is not (although it is somewhat vulnerable to digestion). Not outgrowing an allergy to egg yolk is often a sign that you will not outgrow your allergy to egg at all; research has found that children who still react to boiled egg yolk around the age of 2 tend to have persistent egg allergy.

The food matrix

Another thing that limits a protein’s ability to provoke reactions is the food matrix. The food matrix refers to the physical structure of a food and the way that the protein, fat and carbohydrates molecules inside it interact with each other. The food matrix affects how our bodies handle a food; it impacts a food’s nutritious value as well as its ability to provoke reactions. The presence of wheat in a food like muffin, for example, makes egg protein less able to bind to IgE antibodies and provoke a reaction.

In contrast to heating, baking egg into a wheat matrix seems to affect ovomucoid more than ovalbumin. Ovomucoid is one of the first proteins to be incorporated into the protein network formed during baking, and 30 minutes at 180°C (356°F) causes a remarkable decrease in its ability to bind to IgE antibodies. By contrast, the muffin matrix seems to ‘protect’ the ovalbumin from being destroyed by heating, at least initially.

Researchers have also found that egg allergen is undetectable in pasta that has been boiled for 15 min and subjected to simulated digestion. The intense mechanical action associated with kneading pasta dough for at least 30 minutes also seems to decrease the ability of ovomucoid to provoke allergic reactions.

Different ingredients in a food matrix affect egg allergens differently. For a start, it’s the wheat gluten in a baked cake that seems to affects the major egg allergen’s ability to provoke reactions, not the milk (or soybean) protein, and wheat replacers such as rice don’t seem to work as well.

Similarly, having fat in a food’s matrix doesn’t seem to weaken the ability of egg allergens to provoke a reaction in the same way that it does with peanut allergens, and cookies, with their high(er) sugar, low-water batter content, are not as good at disrupting the action of egg allergens as muffins, with their starch and gluten-rich matrix.

Adding ingredients like banana and chocolate chips to your egg-allergic child’s muffin also risks provoking reactions, including anaphylaxis. It’s thought that, because the wheat gluten is needed to form the protein networks that block IgE antibodies from binding with egg proteins, replacing wheat with an ingredient like banana means that there is less gluten available to make a matrix and more egg protein left free to provoke allergic reactions.

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Who is the egg ladder for?

Egg ladders are not suitable for everyone. Researchers have come up with a checklist of factors for doctors to use as a guide when deciding which children are suitable for this type of therapy, namely the four As; Age, active or poorly controlled Asthma, history of Anaphylaxis and Adherence.

Young children…

Egg ladders have been developed with preschool-aged children (i.e. younger than 6 years old) in mind. This is because the evidence from studies of children undergoing oral immunotherapy (for peanut) or ending up in hospital because of food-induced reactions shows that, the younger a child is, the less likely they are to suffer severe allergic reactions—involving the respiratory, cardiovascular or neurological systems—to food. Very young children are more likely to suffer from skin and gastrointestinal symptoms instead.

Just as importantly, the younger a person is, the more ‘plastic’ their immune system is, making it better able to respond to therapy; this has been demonstrated by the results of peanut immunotherapy (the most common and well-studied type of immunotherapy) which is more effective when it is carried out in infants and preschoolers than it is when carried out in older children.

… with a ‘mild form’ of egg allergy…

Children who are considered suitable candidates for the egg ladder are those whose previous reactions suggest a milder form of allergy;

• they have not had severe gastrointestinal, respiratory or cardiovascular symptoms during previous reactions
• they have not reacted to a trace amount of egg in a food before—i.e. they have a relatively high threshold and have experienced only mild skin symptoms when exposed to the equivalent of a mouthful of lightly cooked egg
• they can tolerate baked forms of egg

These characteristics are indicative of a child who is more likely to outgrow their egg allergy.

Children who can tolerate baked egg have a better prognosis than those who can’t. Various studies have shown that children are more likely to outgrow their egg allergy if they can already tolerate and regularly eat baked egg products from a young age.

For example, data from the Australian HealthNuts cohort showed that, of the children who could tolerate baked egg at the age of 1, just over half (56%) had outgrown their allergy by the age of 2, whereas only 13% of those who could not eat baked egg at the age of 1 had become tolerant a year later. More pertinently, in the group of infants who were tolerant to baked egg at the age of 1, eating baked egg at least 5 times a month increased the likelihood of developing tolerance to regular egg.

Similarly, children who experience more severe initial reactions to egg are less likely to outgrow their allergy than those who experience predominantly skin or gastrointestinal symptoms.

… including mild FPIES…

Although the egg ladder is mostly used for children with IgE-mediated allergy to egg and immediate symptoms, the egg ladder has also been used for children with the non-IgE-mediated condition food protein-induced enterocolitis syndrome, thanks to evidence showing that many children with FPIES to egg are able to tolerate baked egg and should therefore be able to use the egg ladder safely.

One retrospective review of cases seen an at Italian allergy clinic reported that around three quarters of the 61 children seen with egg-induced acute FPIES were tolerant to cooked egg when they were around 30 months old. About half of those were shown to tolerate raw egg just over a year later. Importantly, no serious reactions had been reported to baked egg in children with FPIES.

Having atypical FPIES (i.e. also having an IgE sensitisation to egg) was not a hindrance to achieving tolerance. In fact, the children with atypical FPIES reached tolerance to cooked egg around 7 months earlier than children with classical FPIES, although they achieved tolerance to raw egg about 4 months later. The percentage of the 52 children with classical FPIES to reach tolerance was higher than that of the 9 children with atypical FPIES (cooked egg: 69% vs 44%, raw egg: 52% vs 44%) but the difference was not statistically significant.

… whose asthma is under control…

Children whose asthma is inadequately controlled (even when they are on medium dose inhaled steroid therapy) or who have experienced a recent severe asthma exacerbation are not considered suitable candidates for the egg ladder because they run a higher risk of experiencing very severe symptoms should they react to an egg ladder food.

BSACI guidelines also recommend not undertaking egg ladder therapy if a child has severe eczema covering over 40% of their body, either.

… and with motivated families who are able to follow the procedure

Parents whose children are following an egg ladder need to be able understand the doctor or dietician so that when the details, benefits and risks of the protocol are explained to them, they understand what the egg ladder is supposed to accomplish what they need to do to make it work.

This includes being able to commit to feeding their child the required doses of egg (-containing food) on a daily basis. Parents need to be able to make or buy the required food for the step they are currently on and they need to have the time to measure the right portion and feed it to their child, at least 3 to 5 times a week.

Parents need to know not to administer the dose if potential cofactors are involved; for example, not if their child is ill, or has taken medication, or has just exercised or had a hot bath.

Parents need to be able to recognise the symptoms of an allergic reaction and to be able to deal with it, which includes being prepared to use an adrenaline autoinjector. Children who have a delayed allergy may have an accompanying IgE sensitisation to egg proteins and parents of those children must learn about the symptoms of early and delayed type allergic reactions so that they can recognise both types if necessary.

Parents also have to be able to keep their child’s asthma or eczema under control and know to stop the dosing if it gets out of control.

Parents need to know when to access healthcare support—i.e. when to ask their doctor or dietician for help—and they should also be able to access emergency services in the unlikely event that their children require them which requires not living in a remote location. And they must be able to keep their medical appointments.

All of these things—including the risks and benefits that are applicable in your child ‘s specific case, so you can make an informed choice about whether you want to go ahead with this therapy in the first place!—should be discussed with you before your child undertakes home reintroduction. If you don’t understand something, you should never be afraid to ask for clarification!

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When is the egg ladder introduced?

The best time to implement the egg ladder is when an infant starts to outgrow their egg allergy, which tends to be around the age of 1. This is seen as a ‘window of opportunity’ to reintroduce egg into their diet, to a) help speed up the resolution of the allergy, and b) avoid a prolonged and unnecessary exclusion diet.

The British Society for Allergy and Clinical Immunology (BSACI) recommends reintroducing egg into a (previously) egg-allergic child’s diet from the age of 12 months, or 6 months after the last reaction. Caution is advised when it comes to older children, especially when they have been on a long elimination diet, because a long time practicing strict avoidance puts people with a history of mild reactions at risk of developing severe symptoms when their trigger foods are reintroduced into their diet.

A doctor will typically make a decision on when to begin with an egg ladder based on a child’s history of symptoms and their lab test results. Children who are likely to outgrow their egg allergy and are therefore suitable candidates for egg reintroduction will have relatively small skin prick test responses and/or low levels of egg-specific IgE antibodies in their blood.

However, lab tests are not infallible. Researchers have reported that tests for egg‐specific IgE antibodies cannot definitely predict who will pass a challenge with baked egg and who will eventually be able to tolerate raw egg. As such, many experts recommend that children be given the chance to undergo a challenge with baked egg regardless of the outcome of their lab test results, because ‘such consumption might affect the natural course of allergy to egg’.

Indeed, the authors of the Canadian egg ladder propose that food ladders be considered a form of oral immunotherapy for children with high levels of IgE antibodies in their blood, and even older children, with the hope that regularly consuming very small amounts of their food allergen will enable them to outgrow their allergy in time.

Some children with severe egg allergy tolerate baked egg products, despite having experienced anaphylaxis to eggs in the past, which is why some experts recommend an egg ladder approach for these children regardless of the severity of their past reactions. Studies have reported that the egg ladder can be a safe and effective tool for children with severe forms of egg allergy, including those with a history of anaphylaxis.

And some children who start off unable to tolerate baked egg still end up tolerating baked egg and even raw egg. In one study, around two thirds of the children who initially reacted during a baked egg challenge were eventually able to tolerate baked egg, while around a quarter were eventually able to tolerate regular egg. Which is why most young children who initially react to baked egg benefit from undergoing regular testing (e.g. every 6 months) to see whether their responses are decreasing and when they might benefit from a new challenge to baked egg.

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How should I use the ladder?

If your child has a diagnosed egg allergy, you should get support from a healthcare professional in the form of advice and instructions on how to use the ladder, as well as appropriate medication with which to treat reactions that don’t resolve by themselves. If you are following the procedure under medical guidance, someone should be in regular contact with you and you should be able to get in touch with them with any questions that you may have.

Starting the process

Most children will start on step 1 of the ladder. However, some children may already be eating some forms of processed egg in their diet, such as small portions of baked egg in muffins, pancakes or waffles, or small amounts of scrambled eggs, in which case they can start on the step that corresponds to the foods that they can tolerate.

The ladder is a guide and not an absolute prescription and, in some cases, the doctor/dietician will propose something slightly different; for example, if your child has had moderate to severe reactions to egg in the past, you may be advised to start the ladder with very small quantities of a ladder food, such as a few crumbs of muffin, before building up to a full muffin.

Children who already tolerate baked egg and/or have had only mild symptoms in the past to relatively large amounts of egg (i.e. have high thresholds) can start the egg ladder with small amounts of baked egg at home. If a child has a history of moderate to severe reactions, has poorly controlled asthma or has ever reacted to trace amounts of egg in their food, an initial challenge to an egg-containing product under medical supervision will probably be advised.

The first feeding of a new food (or a larger amount of the same food) at any level of the egg ladder must always be done when your child is feeling well and is free of symptoms associated with their egg allergy, and their asthma and/or eczema is under control.

Progressing up the ladder

There is no consensus on how long a child should spend on each step of the egg ladder before going on to the next one. Each step can be conducted over any length of time, it completely depends on how your child is progressing.

Both the experts behind the British egg ladder and those behind the Canadian egg ladder advise feeding your child a pea-sized amount of baked egg every day and gradually increasing it until it reaches an age-appropriate serving. The Canadians specify that your child should keep eating a regular serving of the food for 1 to 3 months before advancing to the next step. They note that any kind of progress, even if it’s very slow, is good, as simply feeding your child baked goods from the first step of the ladder on a regular basis has been shown to promote tolerance.

A Belgian study compared a slow escalation (staying on the first 2 steps for 9 months and the last 2 for 6 months) with a faster escalation (staying on the first 2 steps for 6 months and the last 2 for 3 months) using a simple 4-step ladder on a group of children with mild egg allergy who were tolerant to baked egg.

The ladder started with cake, step 2 was hard-boiled egg, step 3 included omelet/waffle/pancake, and step 4 included soft-boiled egg, before the child finally tried chocolate mousse or mayonnaise to see if they were raw egg tolerant. The initial introduction of the cake was performed under medical supervision, but all of the foods on the next steps of the ladder were introduced at home, unless a pediatrician considered a food challenge to be necessary. Children were asked to build up to an age-appropriate serving of the food(s) in each step and aim to eat the food(s) 2 or 3 times a week before moving up to the next step.

39 children around the age of 3 were assigned to a shorter protocol (lasting around 18 months) and 39 children around the age of 2 were assigned to a longer one (lasting around 30 months). By the end of the study period, 31 children in the short arm and 27 in the long arm were able to eat raw egg. The average time to raw egg tolerance was 2 years in the short arm and 2.5 years in the long arm.

11 children had to repeat a step because of their symptoms, 7 following the short protocol and 4 following the long one. 46 children (23 in each group) reported accidental exposure, but only 16 of them experienced reactions, all of which were mild or moderate, and all of the children continued with the ladder. 22 of the children even used the accidental exposure and lack of reaction as a reason to speed up their progress and even skip a step.

4 children following the shortened protocol developed complete tolerance within 5–12 months instead of the predefined 18 months, and 11 children following the longer protocol became tolerant to raw egg within 5–29 months instead of the predefined 30 months.

In the end, both the short and long protocols were deemed equally safe and effective. The children following the shortened protocol did achieve tolerance a little faster, but they were a bit older and had been allergic to egg a little longer than those assigned to the longer protocol (2 years vs 1.2 years) so they might have been a little closer to achieving natural tolerance. Most of the children who achieved tolerance went on to eat egg-containing food on a daily basis.

Ultimately, the length of time that your child will spend on each step basically depends on 3 things:

1. Why the ladder is being used in the first place:

• If it’s being used to determine whether or not your child can tolerate the foods on the egg ladder, the time spent on each step will be relatively short
• If it’s being used to induce tolerance, the time spent on each step will be longer

2. What type of allergy your child has:

• If your child has a low-risk form of egg allergy with a history of mild reactions, the interval between each step will be relatively short, perhaps between 1 week to 1 month, whatever time it takes to make sure that they can tolerate each food in that step without reacting before moving on
• If your child has a high-risk form of egg allergy with a history of moderate to severe reactions, a schedule which involves starting with small doses of each food and building up to an age-appropriate serving is safer, and therefore intervals between steps will be longer

3. Whether cofactors like exercise or illness get in the way:

If your child has a tendency to suffer from infections or a tendency to run around a lot, this can lower their tolerance to their food trigger, in which case they may suffer from symptoms that will require you to lower the dose and build up the amount of protein that they eat during each step of the ladder more slowly. Some families also experience problems in building up the dose because, for example, they have busy schedules and cannot always take the time that’s needed to make and measure out the next food on the ladder, or they can’t get their hands on the right ingredients.

The important thing to remember is that, if your child is able to incorporate any kind of egg into their diet on a regular basis, you are already helping them on their way, either to tolerance or the ability to weather accidental exposures.

If your child can tolerate the food(s) allocated to a certain step of the ladder, they should keep eating it (them) while also trying the food allocated to the next step.

According to the BSACI guidelines, once your child can tolerate baked egg, it should be included in their diet 2 to 3 times a week. Once they can tolerate ‘loosely cooked egg’ (e.g. scrambled egg), you can assume that they have outgrown their egg allergy and egg can be included as part of the normal diet.

When your child develops symptoms

Symptoms are most likely to occur when your child tries a new ladder food or transitions from one step of the ladder to the next one.

The procedure for dealing with symptoms generally involves either going back to eating previously tolerated foods or, if symptoms happen when your child was eating more of a certain food, going back to the amount that they tolerated before.

The experts behind the Canadian egg ladder advise that, if your child develops symptoms to a new food on the ladder, they should go back to eating the food(s) that they do tolerate for at least 1 month before ‘cautiously attempting to advance on the ladder.’

The experts behind the British egg ladder suggest going back to the previously tolerated food(s) for 3 to 6 months before progressing further up the ladder.

If your child developed symptoms to a food that they previously tolerated, check for the presence of cofactors; were they feeling unwell when they ate their dose of milk-containing food? Had they been exercising? Had they just taken a hot bath? Have they been sleeping badly? If any of these apply, only give them the food that provoked reactions when that cofactor no longer applies; e.g. when they feel better, have/will not be running around, etc.

If they unwell but are several steps up the ladder by then, try giving them less allergenic foods; e.g. if they react to egg in an omelette, try giving them some pancake or muffin instead. It’s important that they keep eating some form of egg-containing food on a regular basis, if at all possible.

The decision on whether to postpone introducing a new food or trying a larger amount of a new food should also depend on how severe the reactions are and why they are happening. Mild symptoms like localised hives or flushing, coughing, sneezing or a runny nose should not impede progress too much; you may consider, for example, trying a smaller portion of the food on the same step. For more severe reactions, going back a step for a few weeks is warranted. If you are trying the egg ladder under the supervision of a healthcare professional, always report symptoms (write them down if you think you will forget them before your next contact with the doctor) and never be afraid to ask for advice on what steps to take and how long to wait before trying to advance up the ladder again.

In the case of non-IgE-mediated allergies, recognising the symptoms of a reaction may be more difficult because they can easily be confused with other signs that are common during feeding time in infancy (like spit up or a reluctance to eat something), and it’s even more difficult when you’re dealing with an infant who’s not able to tell you what they’re experiencing. When symptoms are ambiguous, experts recommend repeating the last step again—i.e. trying the same food or amount of food—when the symptoms have resolved rather than unnecessarily delaying the introduction process because of teething problems or a runny nose caused by a cold.

In the study run by the experts referenced above, around half of the parents whose children ended up completing the ladder had to try more than once to see whether their child was able to tolerate a certain egg-containing food because of their confusing symptoms, and parents whose children were only partially tolerant or still allergic made even more attempts at reintroduction before figuring out their child’s allergic status. (But no serious reactions were reported during the study.)

Always get in touch with your doctor if you are unsure how to proceed.

After completing the ladder process

When children outgrow their allergies, they must include the food that they have become tolerant to in their diets on a regular basis, otherwise there’s a risk that the allergy will return. So, if your child tolerates egg in any form, whether it’s just muffins or less heated forms of egg, be sure to include it in their diet at least once or twice a week.

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How effective has the egg ladder been for other children?

IgE-mediated allergy

Research on the egg ladder suggests that it helps the majority of the children who are considered suitable candidates; preschoolers with a high likelihood of outgrowing their egg allergy.

In 2019, a team of Israelis were the first to publish a study that showed that following an egg ladder is more likely to help baked egg-tolerantchildren to outgrow their egg allergy than avoiding egg entirely. In the study, 39 children under the age of two with a mild egg allergy and a known tolerance for baked eggs followed a ‘structured graduated protocol’ involving heated egg, first eating cookies then pancakes then omelette/fried eggs, with each step up preceded by an oral food challenge under medical supervision. Most of the children were followed until just after their third birthday.

The progress of the children following the egg ladder was compared to that of a control group of 80 children with the same characteristics (including a tolerance for baked egg) who had been advised to strictly avoid egg until the age of two (or earlier, if they outgrew their allergy). Most of these children were followed until around their sixth birthday.

At the time of the last follow-up, 32 (82%) of the 39 children who’d followed the ladder approach were tolerant to lightly cooked eggs, compared to 43 (54%) of the 80 children who had been avoiding egg and had been followed for a longer period of time. All of the children in the first group were able to tolerate some form of egg, with 22 of the 39 (76%) children able to eat raw eggs without symptoms and 10% managing baked eggs. In the control group, 27.5% of the children did not eat any eggs at all and 17.5% ate only baked eggs.

Half of the children who used the egg ladder had had an initial anaphylactic reaction to egg, compared to a third of the children in the control group. The children who were avoiding egg took much longer to achieve tolerance than the children using the egg ladder, outgrowing their egg allergy at a median age of 169 months compared to 29 months in the latter group.

In 2021, a review of cases seen at an Irish paediatric allergy clinic was published. The review included 29 children with a confirmed or suspected egg allergy who undertook the Irish egg ladder. The development of tolerance to raw egg was tested after 6 and 12 months on the ladder. 20 (69%) of the children achieved tolerance to ‘almost raw’ egg products (like mayonnaise) within a year of their first appointment, and 12 of the children completed the ladder within 6 months. 2 of the children made no progress on the ladder, which the researchers put down to their parents’ reluctance to use it (probably because their children’s initial reaction to egg was quite severe) rather than the child’s physical inability to tolerate any form of egg.

The children took an average of 8 months to achieve tolerance, but those with other food allergies (except peanut, which is closely linked to egg allergy) took longer (around 11 months). Other atopic diseases—eczema, asthma and hay fever—played no role in the development of tolerance, however.

In Turkey, some experts use an egg ladder that gives priority to egg yolk. The thinking is that, because the majority of egg-allergic infants are sensitised to egg white but not necessarily to egg yolk, starting a ladder with egg yolk will be more tolerable for children with egg allergy. A 2024 review evaluated this concept.

This study included 85 children with different forms of egg allergy, some of whom had had anaphylaxis in the past, and 25 of whom had FPIES. According to their protocol, a food challenge was first performed with egg yolk and, if the child passed, they were asked to eat a 2-egg yolk cake at home daily for 7 to 10 days. Then they underwent a challenge to egg white and, if they passed that, they ate cake made with 2 whole eggs. The procedure was continued with boiled egg yolk, then boiled egg white, then lightly scrambled egg.

Of the 80 children who undertook the protocol, 70 achieved tolerance to lightly cooked egg, 6 to baked egg and 4 remained tolerant only to baked egg yolk. 5 children were unable to follow the treatment because they were found to be allergic to egg yolk. In total, 76 (89%) of the 85 children included in the study were able to include at least some form of egg in their diet, 4 of whom would not have been helped by a treatment that focused solely on whole egg. Tolerance to baked egg yolk was confirmed around the age of 1 for the average child (with a range of 5 to 32 months), tolerance to baked egg white around a month later, and tolerance to whole scrambled egg at around 20 months old (with a range of 6 to 48 months).

Factors that were found to affect whether (and when) a child outgrew their allergy included having a more severe form of allergy with a history of anaphylactic reactions, which was more common in children who did not outgrow their allergy, and having been delivered by caesarian section, which delayed the acquisition of tolerance (a link has been shown between being delivered by caesarian section and developing allergies, although the causes, and indeed the link itself, are still under debate).

Several studies have shown that the egg ladder can help children with a severe form of egg allergy.

In 2024, Spanish researchers published the results of a study involving 19 children over the age of 1 with high levels of egg-specific IgE antibodies—associated with a low chance of being able to tolerate baked egg—11 of whom also had a history of anaphylactic reactions, 8 of whom has asthma and 7 of whom had reacted to traces of egg in food.

The researchers reported that the use of a 4-step ladder including local foods (such as breaded chicken and battered courgette) with in-hospital challenges to each new food was both safe and effective. 17 of the 19 children were able to complete the ladder, and only 2 of them suffered a very mild reaction during the process (oral allergy syndrome). The other 2 children withdrew from the study for unrelated reasons.

In the same year, a review of the medical records of children seen at at allergy clinic in Ireland was published. The review included 287 children under the age of 3 who undertook the Irish egg ladder, 34 of whom had a history of anaphylaxis to egg. Although parents were encouraged to get in touch with the clinic if they had questions, the entire implementation of the ladder took place at home and in-person appointments were only scheduled every 6 months.

On average, the children needed just over 23 months to achieve tolerance to ‘almost raw egg’ in the form of meringue or mayonnaise. Children with histories of anaphylactic reactions were not significantly more likely to react to the ladder food than children without anaphylaxis and the reactions were generally mild (skin or GI symptoms). No child required unscheduled medical care for their symptoms. 2 children experienced anaphylaxis because of accidental exposure to an egg in a food that was not included in the egg ladder.

Children with a history of anaphylaxis were just as likely to be successful in achieving tolerance; 29 (85%) of the children who had had anaphylactic reactions in the past completed the ladder, compared to 237 (93%) of the children who had had milder forms of egg allergy, and they all took about 2 years to do so.

In Poland, a 2025 study involving 23 ‘high risk’ children—with a history of severe allergic symptoms and/or asthma and/or elevated egg-specific IgE levels—reported that undertaking a 4-step egg ladder at home after an initial challenge to baked egg enabled 3 of the children to develop tolerance to raw egg, while 14 ended up being able to eat some form of processed egg after 11 to 17 months on the ladder. No serious reactions were reported.

Non-IgE-mediated allergy

There hasn’t been a lot of research involving children with non-IgE-mediated forms of egg allergy. A 2021 study describes a trial carried out by a team of British doctors who used a ladder approach to establish a home introduction protocol for a range of allergens (milk, egg, wheat and soy) for a group of 114 children aged between 1 month of 16 years old, most of whom were toddlers.

After an elimination diet of around 4 to 8 weeks, the children were given a shortened protocol to follow in order to try and introduce the trigger foods into their diets in about 2 weeks, although this sometimes took longer because of ongoing symptoms or general health problems.

61 of the children were allergic to egg although, at the time of the home introduction, about a third were able to tolerate some form of processed egg. By the end of the study period, 34 (56%) of the children were considered fully tolerant (they could eat an age-appropriate amount of loosely cooked egg), 18 (29%) were partially tolerant (they tolerated some form of heated egg in their diet) and 9 (15%) were still allergic, having not managed the first step of the ladder. Those who achieved full tolerance did so around the age of 18 months (with an age range of 9 to 25 months), those who achieved partial tolerance did so around the age of 24 months (their ages ranged from 17 to 28 months) and those who were considered still allergic were categorised as such around the age of 23 months (between 21 and 27 months).

The authors of the study also note that, although over 98% of the children showed overall symptom improvement, not all of the children were left symptom-free; in particular, there were lingering gastrointestinal symptoms, notably gas and stomach pain with back arching, and some of the children still showed food aversion.

A 2023 review of cases involving 21 Canadian children younger than 5 (most of whom were around 10 months old) with mild-moderate FPIES to egg (defined as no history of lethargy or need for intravenous fluid administration at any point) reported more success. In this group of children, 11 were already known to tolerate some form of extensively cooked egg before starting the ladder, and 5 had had a reaction to extensively egg.

19 (90.5%) of the children were able to complete the ladder and achieve tolerance to egg, most of whom managed this in around 7 months (with a range of 4 to 9 months) and were around 17 months old when they did so. The other two children remained on step 2 of the ladder, so at least able to include some form of cooked egg in their diet.

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What are the risks associated with the egg ladder?

Food ladders entail offering a child their trigger food, so they inevitably come with inherent risk, notably for children with IgE-mediated allergy. Even when children who undertake the egg ladder only have a history of mild reactions, having a history of mild reactions doesn’t mean that your future reactions will be mild, so the risk of anaphylaxis remains. Other factors—that is, cofactors like illness, fatigue and exercise, or poorly controlled asthma or eczema—can lower a child’s tolerance or put them at risk of experiencing worse reactions.

On top of that, current egg ladders are quite inconsistent; for example, whereas the Canadian milk ladder puts pancakes after waffles, the corresponding egg ladder puts waffles after pancakes. While that may be because there of there is more allergenic milk protein present in pancakes than in waffles but vice versa for egg, that does mean that a child who is allergic to both may have problems with that progression.

Happily, serious reactions involving baked egg are rare. One study involving 236 children with egg allergy who underwent a food challenge with baked egg reported that only 12 experienced anaphylaxis and, of those, only 5 required treatment with adrenaline. Another study involving 95 infants who underwent a total of 181 challenges reported no serious reactions to well-cooked egg at all.

Bearing in mind that people who are selected to undergo hospital-based food challenges normally have more serious forms of allergy than the average child undertaking the egg ladder at home, and the starting dose of egg for hospital-based challenges is considerably higher than the dose proposed on the first step of the egg ladder, the risk of anaphylaxis to baked egg in infants and young children who are using an egg ladder to build up the amount of egg protein in their diet is minimal.

That said, it pays to be careful.

If you have a child who has been diagnosed with egg allergy, consult a doctor before beginning on the egg ladder, if at all possible. A doctor can give you guidance and, most importantly, rescue medication if necessary. Doctors can also (order or) carry out tests to see whether or not your child is ready to get started with the egg ladder and, if yes, on which step.

Proceed with caution. Stick to the foods allowed on the step of the ladder you’re on. If your child has reacted to foods on previous steps, take each step slowly and introduce them to very small amounts before building up to the whole portion.

Follow the guidance carefully. Use the correct baking times and temperatures and don’t add any extras to the food, like banana which, as well as disrupting the beneficial wheat matrix, is a ‘wet’ ingredient that will make it more difficult to ensure that the middle of the muffin is baked properly.

The German egg ladder experts advise using pasteurised eggs for food being fed to young children who reach the last (almost raw) step of the ladder, as their developing immune systems make them more vulnerable to food poisoning from bacteria like Salmonella (people living in the UK can use eggs with a red lion stamp on them).

Be careful with processed foods because recipes for similar products can differ in the quantity of egg protein used per portion, as well as the length of time and temperature at which they are cooked. When trying a new brand, try a smaller amount of it first. That said, according to experts, people who can tolerate baked milk or egg should be able to eat dry goods containing milk or egg ‘if listed as the third ingredient or lower’.

What research says about the safety of the egg ladder

IgE-mediated allergy

Most children who undertake the egg ladder do not experience any symptoms, but when they do, this generally happensw hen they are going up a step and trying a new ladder food. For example, a Turkish study involving 85 children, some with a severe form of IgE-mediated egg allergy and some with non-IgE-mediated allergy (notably FPIES), introduced the children to different forms of egg under medical supervision before sending them home to continue eating that food for a week or two before the next challenge; none of the children had an allergic reaction at home.

Serious reactions are extremely rare, but when they happen, they tend to affect older children. A 2021 study from Australia explored the performance of a ladder introduced to 47 children aged around 3.5 years old with a mild egg allergy, half of whom were known to tolerate baked egg, were included in the study.

A mild reaction (rash or hives) was reported in 18 (38%) of the children. 2 families reported serious reactions and one of the children was given adrenaline. This child was 6 years old. Both of the children who’d had the severe reactions were moving from one step to another and simply went back to eating the dose of egg they tolerated, later progressing up the ladder to Step 5 or 6 (raw egg).

Likewise, a 2021 survey evaluating the performance of the 4-step Canadian milk and egg ladders reported that few children had experienced symptoms, most of which were limited to the skin. However, 2 of the children had needed adrenaline because of anaphylaxis to egg ladder foods. One had experienced coughing, a runny nose and stomach pain on the first day of using the ladder, and the other had experienced a cough, wheeze, hives, swelling and hay fever-like symptoms. The children were aged 9 and 14, and one of them had a history of anaphylactic reactions to egg.

To be clear, the medical definition of anaphylaxis may not be what you think it is.

The studies that have been carried out have shown that having reactions does not prevent a child from completing the egg ladder, with the vast majority of children who have experienced reactions eventually being able to progress up the ladder after an initial period of time spent eating the egg ladder food from the previous step. However, when reactions are responsible for a lack of progress, it tends to be the stress and anxiety experienced by both the child and the parents which blocks further progress, rather than the physical ability of the child, or the fact that the child just doesn’t like eating egg.

Egg ladders that have been implemented at home by parents with little support from doctors have also proven effective, with one Australia study noting that almost 8 in 10 of the parents using the ladder with minimal medical assistance were either ‘satisfied or very satisfied’ with it, with the remaining families being neutral and none dissatisfied. Parents ‘valued the structured approach of introducing egg which helped identify their child’s level of tolerance, and allowed them to progress at their own pace.’ Those whose children did not like eating egg were able to find ways of including egg in their child’s diet regularly as in ingredient in cooked or baked food, as shown by the ladder.

Research carried out in Ireland, where there is a shortage of qualified healthcare personnel to deal with child allergy, has effectively demonstrated the safety and effectiveness of the egg ladder, even in when the only medical help available is over the phone or online. The ladder approach has proven to be so safe and effective that is has enabled Irish clinics to scrap most of their food challenges in favour of letting parents manage their child’s egg allergy at home.

Non-IgE-mediated allergy

The small amount of research carried out focussing on children with mild-to-moderate FPIES suggests that the egg ladder is a safe way to reintroduce egg into the diet of children with non-IgE-mediated allergy. A 2023 review of cases involving 21 Canadian children reported mild symptoms (vomiting, pallor, belching, irritability and small spit up) in 4 of the children. Three of these incidents were due to accidental exposure to egg-containing foods that were not ladder foods. None of the incidents caused any of the children to stop using the egg ladder. The 2021 study carried out in British children with mild FPIES reported ‘no serious adverse events’.

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What are the benefits of the egg ladder?

Although egg ladders do seem to help the majority of children to eventually tolerate raw egg, a child does not have to reach the last step of the egg ladder in order to reap the benefits of being able to incorporate some egg, in any form, into their diet.

Research suggests that an egg-allergic child is more likely to outgrow their allergy if they can include baked egg in their diet in early childhood.

Eating baked egg regularly seems to produce positive immunological changes that resemble those that occur as a child naturally outgrows their allergy, namely a reduction in egg-specific IgE antibodies and an increase in antibodies associated with tolerance to food (IgG4). It may also provide protection against anaphylaxis from accidental exposure to egg-containing foods.

Additionally, food allergies are associated with nutritional deficiencies and progress to any step above the first on the egg ladder will allow your child to eat a more varied and nutritious diet.

The ability to eat at least some egg also improves the quality of life of both children and parents, because it reduces food-related anxiety, including the fear of accidental exposure, partly thanks to the fact that more sensitive children and parents get to experience what allergic reactions are actually like and how they can be managed, a positive consequence that is also seen after people undergo food challenges and/or oral immunotherapy.

Additionally, being able to tolerate egg protein in some form also means that dietary restrictions can be loosened at school and when children go to friends’ and relatives houses, which improves their social lives. It also makes it somewhat easier to do the grocery shopping.

Incorporating baked egg into a young child’s diet on a regular basis may even help them to outgrow their allergy faster. This was first demonstrated in a 2012 study involving 79 egg-allergic children between the ages of 1 and 16. Those who were already tolerant to baked egg were advised to eat some every day and their ability to eat less cooked forms of egg was evaluated after 6 months or so. Those who could still not eat baked egg were advised to keep avoiding egg but were given challenges to baked egg after 12 months or so to see if their allergic status had changed.

By the end of the study period, 70 (89%) of the 79 children could eat baked egg and 42 had outgrown their allergy altogether. Of the 56 children who initially tolerated baked egg, 36 (64%) outgrew their allergy. Of the 23 children who initially reacted to baked egg, 14 (61%) were able to eat baked egg and 6 (26%) could eat regular egg. Being able to tolerate baked egg initially meant that a child was able to outgrow their allergy faster, with the former group outgrowing their allergy after about 3 and a half years and the latter group after about 4 and three quarter years. But once a child who initially reacted to baked egg was able to eat it, they were just as likely to outgrow their allergy as a child who initially tolerated baked egg.

More pertinently, the children who’d eaten baked egg regularly were compared to a group of children with similar characteristics who’d continued to avoid any form of egg; those in the former group were were 20.9 times more likely to tolerate baked egg and 18.3 times more likely to tolerate regular egg, and they were able to outgrow their allergy faster (50 months versus 78.7 months, respectively). These numbers may even be an underestimation considering the fact that the children in the comparison group were followed for a significantly longer period of time, giving them more chance to naturally outgrow their egg allergy.

Since then, several studies have produced results that support the idea that regularly eating baked egg accelerates the resolution of egg allergy, but others have not and some experts remain unconvinced. The debate continues.

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