Our study demonstrated that the Canadian Egg Ladder can safely guide the advancement of egg-containing foods in patients with mild-to-moderate FPIES to egg. Most patients successfully completed the Canadian Egg Ladder, tolerating a serving size of cooked egg. No patients required healthcare presentation. Three of the four patients who experienced mild symptoms had accidental exposure to a higher step of the ladder, highlighting the importance of counselling on the hidden forms of egg in common foods. All four of these patients successfully completed the ladder. These promising results provide support for using food ladders, which may reduce the healthcare burden associated with OFCs and increase access to treatment for patients. Gradual introduction of egg-containing foods may also be safer than consuming large doses at once in OFCs. The rate of acute, adverse reactions requiring intervention for hospital-based OFCs has been reported to range from 10 to 41%, although these studies include patients with severe FPIES [6, 10,11,12]. Furthermore, reducing the need for strict dietary elimination may alleviate stress and improve quality of life for families [13].

The literature reports variable median age of acquiring tolerance to the FPIES trigger food ranging from 18 to 63 months [14,15,16]. Sopo et al. demonstrated earlier rate of resolution to cooked egg compared to raw egg and proposed a shorter duration between last reaction and OFC for cooked egg [9]. Similarly, participants regularly consumed cooked egg in this case series andthe median age of resolution was 17 months, which is earlier compared to the current literature. Furthermore, there were no severe adverse reactions to baked egg in both our case series and the study led by Sopo et al. .

Study limitations include recall bias; however, patients were followed every 3–6 months, limiting the reporting timeframe. Excluding patients with a history of severe FPIES reaction may have impacted participants’ tolerance and degree of reactions while undergoing treatment with the Canadian Egg Ladder. Lastly, results were based on a small sample size of participants from a single Canadian province and may not be generalizable to patients in other regions. Further evidence is required to support daily allergen exposure in the management of FPIES.

This novel approach encourages safe expansion of the diet, minimizes the duration and burden of food avoidance, eliminates the need for costly and time consuming OFCs, and may contribute to earlier delabelling of FPIES.