Paediatric Egg Allergy Guideline

Flowcharts

Egg Allergy in Children - Primary Care Guidance (Click to expand)
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Moderate Egg Allergy (Click to expand)
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Severe Egg Allergy (Click to expand)
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Introduction

​These guidelines are based on the BSACI 2021 guideline for the management of egg allergy
  • Egg allergy is a common paediatric allergy with 1 in 50 children presenting with this.
  • The majority of cases are mild, and the child is very likely to grow out of it.
  • Eczema is a risk factor for developing an immediate allergic reaction to egg, with severity of eczema increasing the risk
  • Most reactions occur to lightly cooked whole egg (eg scrambled egg), with reaction to baked egg with wheat (eg cake) being less common. The quantity eaten will also affect the severity of the reaction.
  • Most egg allergy presents on the first known exposure
  • Clinical diagnosis is made with rapid onset of typical symptoms. Clinical reactions typically show
    • 80-90% urticaria or urticaria/angioedema (within minutes)
    • 10-44% Gastrointestinal symptoms (within 2 hours)
  • A mild reaction is characterised by cutaneous symptoms (erythema, urticaria, angioedema) and/or a single vomit on significant exposure (eg teaspoon of scrambled egg)
  • A moderate to severe reaction includes
    • Hoarse cry/change in voice pitch
    • Persistent cough
    • Stridor
    • Wheeze
    • Appearing pale and floppy
  • Delayed hypersensitivity to egg can also occur, typically exacerbating eczema​
Definitions​
BSACI - British Society for Allergy and Clinical Immunology

AAI - Adrenaline Autoinjector

SPT - Skin Prick Test

OFC - Oral Food Challenge
Mild Egg Allergy
See Primary care chart
Moderate Egg Allergy
See Moderate Egg Allergy flow chart (child has not had anaphylaxis to egg)
In secondary care
  • SPT<=5mm Introduce baked egg at home and in 6 months introduce well-cooked whole egg – provide the home egg reintroduction leaflet
  • SPT>5mm continue to avoid all egg for a further year and then review with SPTs

If history consistent with other IgE allergies, complete SPT for these also.
  • If the child has severe eczema and is not yet eating peanuts, also carry out SPT to peanut.

Consider AAI if
  • Poorly controlled asthma
  • Moderate reaction to very small amount of food
  • Required for other IgE food allergies
  • Moderate reaction to baked egg

Consider hospital based challenges if:
  • Moderate poorly controlled asthma
  • Multiple off allergies
  • Anaphylaxis to other foods
  • Family anxiety
  • If AAI required
Severe Egg Allergy
See Severe Egg Allergy flow chart (child had anaphylaxis to egg)
  • These children should be seen in secondary care by a clinician experienced in the management of food allergies
  • In primary care information leaflets about egg allergy, egg reintroduction and weaning are linked to this document and should be given to the family (link on flow charts)
  • In primary care download and complete a BSACI Allergy Action Plan (link on flow chart)

In secondary care
  • SPT <=5mm with anaphylaxis to baked egg
    • If the severe reaction is within 2 years of this result – bring back for repeat SPT in 1 year before considering baked egg OFC
    • If the severe reaction occurred over 2 years ago – consider a hospital based baked egg OFC if SPT then <=5mm
  • SPT <= 5mm with anaphylaxis to well cooked whole egg
  • Hospital based baked egg challenge
  • SPT >5mm
    • Do not carry out OFC at this time
    • Review in 1 year
    • If SPT then <=5mm add baked egg with in hospital OFC

If history consistent with other IgE allergies, complete SPT for these also.
  • If the child has severe eczema and is not yet eating peanuts, also carry out SPT to peanut.

Once well baked egg has been introduced, it should be eaten regularly and skin prick tests repeated in 1 year.

When SPT<=3mm consider hospital based well-cooked whole egg OFC.

​Provide all children with anaphylaxis with
  • AAI 2 for home and 2 for childcare/school
  • BSACI Allergy Action Plan and AAI training
  • Egg Allergy Information leaflet
Home Egg Reintroduction
  • This is for children who have had a mild reaction to whole egg, eg scrambled egg, or following review in secondary care.
  • This starts with baked egg with a flour containing food such as cake. The leaflet linked in the flow chart about this gives the carer instructions and recipes about how to go about this
  • Egg reintroduction is carried out with baked egg in a flour containing food as it is highly unlikely that a child who has had a mild reaction to whole egg will have a severe reaction to this. The natural progression of mild egg allergy to whole egg is that initially baked egg can be tolerated and with time whole egg is tolerated again. This is why baked egg is initially introduced regularly to the diet and then well-cooked whole egg is introduced
  • Egg is reintroduced in a step-wise approach,
  • Once egg has been introduced, foods containing egg cooked to the same amount can be eaten
Baked Egg
Well-cooked Whole Egg
Raw Egg
​Plain cakes, sponge fingers, brioche, croissants, biscuits & cookies – remember no icing that contains egg
Boiled Egg
​‘Dippy’ uncooked boiled, fried or poached egg
​Dried egg pasta and noodles
Fried Egg
​Mousse
​Egg in shop bought sausages,  meatballs, gravy granules and gluten free bread
Omelette
​Mayonnaise
​Egg glaze on pastry
Poached Egg
​Ice cream especially fresh and luxury types
​Quorn products
Scrambled Egg
​Freshly made sorbet
​Shop bought precooked frozen Yorkshire puddings or ready-made pancakes and scotch pancakes
Quiche
​Royal icing (fresh and powdered icing sugar) & soft mallow
 
Batter made with egg
​Fondant icing inside a Cadbury’s crème egg®
 
Egg Custard
​Raw egg in cake mix and other dishes waiting to be cooked (children of all ages love to taste!)
 
Bread and Butter Pudding
​Carbonara sauce, Tartar sauce
 
Fresh Egg Pasta
​Chocolate bars containing egg in their filling eg Milky way, Mars bar 
 
Pancake cooked in a frying pan
 
 
Meringues
 
Vaccinations in Egg Allergic Children
MMR
It is safe for egg allergic children to have the MMR vaccination as per the Green Book

Influenza
Intranasal LAIV is safe in egg allergic children unless they have had anaphylaxis to egg requiring ITU admission.  These children require referral to secondary care for vaccination due to lack of safety data.
Most current IM vaccinations contain very low levels of ovalbumin (<0.12mcg/ml) and can be administered safely in primary care.  Public Health England publish the ovalbumin content of influenza vaccines for the forthcoming influenza season annually.

Yellow Fever
This vaccination contains egg and is contraindicated.  For patients where vaccination is absolutely necessary, a referral should be made to a tertiary allergy centre.
Document Version: 
1.0

Lead Authors: 
Cherry Alviani, Paediatric Registrar, UHS
Approving Network:
Wessex Allergy Network

Date of Approval: 
July 2023

Review Due:
July 2026