Pancake Oral Immunotherapy For Egg Allergy In Inducing Tolerance (POET)
Phase: NA
Conditions: Egg Allergy
Sponsor: KK Women's and Children's Hospital

 
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STUDY PROTOCOL 
 
PROTOCOL TITLE: 
Pancake Oral Immunotherapy For Egg Allergy In Inducing Tolerance (POET) 
 
PROTOCOL NUMBER:  
 
 
PROTOCOL VERSION:  
5.0 
PROTOCOL DATE:  
 15 Dec 2022 
 
PRINCIPAL INVESTIGATOR:  
Dr Chong Kok Wee, Consultant, Allergy Service, Paediatric Medicine, KKH 
 
 
 
 

 
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Table of Contents 
Contents 
1 
BACKGROUND AND RATIONALE ........................................................................................................................... 5 
1.1 
GENERAL INTRODUCTION .......................................................................................................................................... 5 
1.2 
RATIONALE AND JUSTIFICATION FOR THE STUDY ............................................................................................................. 6 
1.2.1 
RATIONALE FOR THE STUDY PURPOSE .......................................................................................................................... 6 
1.2.2 
RATIONALE FOR STUDY DESIGN .................................................................................................................................. 6 
1.2.3 
RATIONALE FOR STUDY POPULATION ........................................................................................................................... 7 
1.2.4 
RATIONALE FOR DOSES SELECTED ............................................................................................................................... 7 
2 
HYPOTHESIS AND OBJECTIVES .............................................................................................................................. 7 
2.1 
HYPOTHESIS ........................................................................................................................................................... 7 
2.2 
PRIMARY OBJECTIVES ............................................................................................................................................... 7 
2.3 
SECONDARY OBJECTIVES ........................................................................................................................................... 8 
2.4 
POTENTIAL RISKS AND BENEFITS: ................................................................................................................................ 8 
2.4.1 
POTENTIAL RISKS ..................................................................................................................................................... 8 
2.4.2 
POTENTIAL BENEFITS ................................................................................................................................................ 8 
3 
STUDY POPULATION ............................................................................................................................................. 9 
3.1 
LIST THE NUMBER AND NATURE OF SUBJECTS TO BE ENROLLED. ....................................................................................... 9 
3.2 
CRITERIA FOR RECRUITMENT AND RECRUITMENT PROCESS .............................................................................................. 9 
3.3 
INCLUSION CRITERIA ................................................................................................................................................. 9 
3.4 
EXCLUSION CRITERIA ................................................................................................................................................ 9 
3.5 
SUBJECT REPLACEMENT .......................................................................................................................................... 10 
4 
STUDY DESIGN .................................................................................................................................................... 10 
4.1 
RANDOMISATION AND BLINDING .............................................................................................................................. 12 
4.2 
CONTRACEPTION AND PREGNANCY TESTING ............................................................................................................... 13 
4.3 
STUDY VISITS AND PROCEDURES OVERVIEW ................................................................................................................ 13 
4.3.1 
SCREENING VISITS AND PROCEDURES ......................................................................................................................... 14 
4.3.2 
STUDY VISITS AND PROCEDURES ............................................................................................................................... 16 
4.3.2.1 BAKED EGG OPEN FOOD CHALLENGE (T0) ................................................................................................................. 16 
4.3.2.2 PANCAKE INITIAL ESCALATION PHASE (T1P) ............................................................................................................... 16 
4.3.2.3 PANCAKE BUILD-UP PHASE ..................................................................................................................................... 17 
4.3.2.4 COOKIE INITIAL ESCALATION (T1C) AND BUILD-UP PHASE ............................................................................................. 18 
4.3.2.5 HOME INSTRUCTIONS & CHECKLIST ........................................................................................................................... 19 
4.3.2.6 DESENSITISATION (DS) OPEN FOOD CHALLENGE (T3) .................................................................................................. 19 
4.3.2.7 SUSTAINED UNRESPONSIVENESS (SU) FOOD CHALLENGE (T4) ....................................................................................... 20 
4.3.2.8 CLINICAL ASSESSMENT AND PROCEDURES DURING OPEN FC (SCREENING FC, BAKED EGG FC, DS FC, SU  FC) ......................... 20 
4.3.2.9 QUALITY OF LIFE ASSESSMENTS ................................................................................................................................ 23 
4.3.2.10 LABORATORY ASSESSMENTS ..................................................................................................................................... 23 
4.3.3 
FINAL STUDY VISIT: ................................................................................................................................................ 24 
4.3.4 
POST STUDY FOLLOW UP AND PROCEDURES ............................................................................................................... 24 
4.4 
DISCONTINUATION/WITHDRAWAL ............................................................................................................................ 25 
4.4.1 
DISCONTINUATION CRITERIA .................................................................................................................................... 25 
4.4.2 
DISCONTINUATION VISIT AND PROCEDURES ................................................................................................................ 25 
5 
TRIAL MATERIALS ............................................................................................ ERROR! BOOKMARK NOT DEFINED. 
5.1 
TRIAL PRODUCT (S) ................................................................................................................................................ 26 

 
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5.1.1 
PANCAKE & COOKIE RECIPES ................................................................................................................................... 26 
5.1.2 
FOOD SAFETY........................................................................................................................................................ 28 
5.2 
STORAGE AND DRUG ACCOUNTABILITY ...................................................................................................................... 28 
6 
TREATMENT ....................................................................................................................................................... 29 
6.1 
RATIONALE FOR SELECTION OF DOSE ......................................................................................................................... 29 
6.2 
STUDY DRUG FORMULATIONS .................................................................................................................................. 30 
6.3 
STUDY DRUG ADMINISTRATION ................................................................................................................................ 30 
6.3.1 
IN THE EVENT OF A DOSE-RELATED ALLERGIC REACTION .................................................................................................. 31 
6.3.2 
IN THE EVENT OF OMITTED DOSES ............................................................................................................................. 31 
6.3.3 
IN THE EVENT OF SICK DAYS ...................................................................................................................................... 32 
6.3.4 
IN THE EVENT OF DOSE REDUCTION FOR OTHER REASONS ............................................................................................... 32 
6.4 
SPECIFIC RESTRICTIONS / REQUIREMENTS ................................................................................................................... 32 
6.5 
BLINDING ............................................................................................................................................................. 33 
6.6 
CONCOMITANT THERAPY ......................................................................................................................................... 33 
7 
SAFETY MEASUREMENTS .................................................................................................................................... 33 
7.1 
DEFINITIONS ......................................................................................................................................................... 33 
7.2 
CAUSALITY ........................................................................................................................................................... 35 
7.3 
COLLECTING, RECORDING AND REPORTING OF ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS TO CIRB ............................. 36 
7.4 
GRADING OF ADVERSE EVENTS ................................................................................................................................. 37 
7.5 
SAFETY MONITORING PLAN ..................................................................................................................................... 38 
7.6 
COMPLAINT HANDLING ........................................................................................................................................... 38 
8 
DATA ANALYSIS .................................................................................................................................................. 38 
8.1 
DATA QUALITY ASSURANCE ..................................................................................................................................... 38 
8.2 
DATA ENTRY AND STORAGE ..................................................................................................................................... 38 
9 
SAMPLE SIZE AND STATISTICAL METHODS ......................................................................................................... 38 
9.1 
DETERMINATION OF SAMPLE SIZE ............................................................................................................................. 38 
9.2 
STATISTICAL AND ANALYTICAL PLANS ......................................................................................................................... 38 
9.2.1 
ANALYSIS OF PRIMARY OUTCOME ............................................................................................................................ 39 
9.2.2 
ANALYSIS OF SECONDARY OUTCOMES ...................................................................................................................... 39 
10 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ................................................................................................ 40 
11 
QUALITY CONTROL AND QUALITY ASSURANCE .................................................................................................. 40 
12 
ETHICAL CONSIDERATIONS ................................................................................................................................. 40 
12.1 
INFORMED CONSENT .............................................................................................................................................. 40 
12.2 
CONFIDENTIALITY OF DATA AND PATIENT RECORDS ...................................................................................................... 40 
13 
PUBLICATIONS .................................................................................................................................................... 41 
14 
RETENTION OF TRIAL DOCUMENTS .................................................................................................................... 41 
15 
FUNDING AND INSURANCE................................................................................................................................. 41 
 
 
 
 

 
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PROTOCOL SIGNATURE PAGE 
 
 
 
Protocol Title: Pancake Oral Immunotherapy For Egg Allergy In Inducing Tolerance (POET) 
 
 
Protocol Number: 
 
 
Protocol Version/ Date: 5.0/15 Dec 2022 
 
 
 
 
 
Declaration of Investigator 
 
I confirm that I have read the above-mentioned protocol and its attachments. I agree to conduct the 
described trial in compliance with all stipulations of the protocol, regulations and ICH E6 Guideline 
for Good Clinical Practice (GCP) 
 
  
 
 
Principal Investigator Name:  __Chong Kok Wee___________________________ 
                                                            
 
Principal Investigator Signature:  ________________________ 
                                                            
 
Date:  _______________________________________ 
                                                            
 
 
 
 

 
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1 
BACKGROUND AND RATIONALE 
1.1 
General Introduction 
 
Food allergy is increasingly recognized as a growing public health burden, with prevalence of 
up to 10% of infants in some countries (1). Egg and cow’s milk allergies are the two 
commonest food allergies affecting young children worldwide. In Singapore, egg allergy is the 
most common food allergy seen in children younger than 2 years old, with a prevalence of 
1.8% at 12 months old (2). While most egg allergic patients naturally acquire tolerance to eggs 
by early to late childhood (about 50-73% by 6 years old) (3),(4), some continue to have 
persistent egg allergy as adolescents and adults.  
 
Most children with egg allergy (~70%) tolerate eggs in the baked form (5). Heat processing 
reduces the allergenicity of food proteins, presumably by changing the conformation of heat 
labile proteins that results in loss of conformational epitopes. Allergen interaction with a food 
matrix, such as wheat, can also make epitopes less accessible and decreases allergenicity. 
There is evidence that baked egg tolerant patients appear to develop tolerance to all forms 
of egg earlier than those reactive to baked egg. There is also some suggestion that introducing 
baked egg into the diet of a baked egg tolerant patient may accelerate resolution of egg 
allergy.  
 
Management of food allergy is primarily allergen avoidance; however, given the ubiquity of 
egg in food, strict avoidance is difficult and accidental reactions do occur. The psychosocial 
impact in the quality of life of food allergic patients, as a result of dietary restrictions, has 
been well-described. Oral immunotherapy (OIT) refers to feeding an allergic individual an 
increasing amount of an allergen in the attempt to induce desensitisation, sustained 
unresponsiveness (SU) or ideally oral tolerance. Desensitisation is defined as a temporary 
increase in the reaction threshold to an allergen while receiving active therapy while SU is the 
lack of clinical reaction to an allergen after active therapy has been discontinued for a period 
of time. Egg OIT using various forms of egg (pasteurized raw egg white, scrambled eggs, hard-
boiled egg etc) has been successful in desensitizing egg-allergic children, with rates ranging 
from 55% to 100% (6). On the other hand, rates of SU following egg OIT have been much 
lower ranging from 28-50% although it has been postulated that longer durations of OIT may 
improve SU rates.  Furthermore, the occurrence of frequent allergic reactions (including 
anaphylaxis) together with a treatment failure rate of around 20% has limited OIT largely to 
research settings. 
 
The use of baked egg OIT in baked egg reactive children has been reported in very few studies 
(7),(8), with published rates of desensitisation to cooked/ lightly cooked egg (hard boiled/ 
scrambled) at ~50%. The safety profile of baked egg OIT in these studies were favourable, 
with all reactions recorded as mild and none requiring adrenaline. Using baked egg which is 
the least allergenic form of egg and presumably less immunogenic, as a form of OIT, can 
explain the lower rates of desensitisation as well as severe adverse events.  
 
  

 
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1.2 
Rationale and Justification for the Study 
The aim of this study is to assess the efficacy, safety and feasibility of using pancakes as a 
form of OIT in desensitising egg allergic children.  
 
1.2.1 Rationale for the Study Purpose 
OIT using raw/ cooked egg has good desensitisation outcomes but is associated with 
frequent and sometimes severe adverse events (anaphylaxis is not uncommon). OIT using 
baked egg is less effective at inducing desensitisation but has a better safety profile. The 
compliance to daily consumption of baked egg products (muffins/ biscuits) after a negative 
baked egg challenge in egg allergic patients has also been reported to be poor, secondary 
to taste fatigue in children and need for frequent baking.  A study using baked egg OIT had 
38% withdrawal due to difficulties in ingesting the baked egg product daily (8). Pancakes, 
traditionally described as a flat cake prepared from a starch-based batter containing egg 
and milk and cooked on a hot surface for 5-7 minutes, is likely to be less allergenic than 
cooked egg because of the wheat matrix but more allergenic than baked egg. To date, there 
are no published studies investigating the use of pancakes in egg OIT. We hypothesize that 
pancakes are more effective than baked eggs in inducing desensitisation and sustained 
unresponsiveness while reducing the risk of adverse events associated with egg OIT. 
 
1.2.2 Rationale for Study Design  
This is a randomised controlled study exploring the efficacy, safety and feasibility of a novel 
form of egg OIT using pancakes to induce desensitisation and sustained unresponsiveness 
in egg allergic patients. The control group receiving current standard care of egg avoidance, 
will be used to control for the incidence of natural resolution of egg allergy over the study 
period. Safety of OIT and its impact on quality of life measures will also be compared against 
the risk of accidental reactions among controls who continue strict egg avoidance. 
Allocation ratio of 2:1 (active:control) allows for more patients to be given a chance to 
receive OIT. 
 
This is an open label study as we wish to assess a pragmatic approach to OIT with home 
preparation of pancakes and cookies using store bought eggs, in which blinding will not be 
feasible nor practical. 
 
Subjects randomised to the active arm will undergo an open baked egg food challenge (FC) 
to determine their baseline baked egg tolerance. Baked egg tolerant (BET) patients will 
directly undergo OIT using pancakes. Baked egg reactive (BER) patients will commence OIT 
with baked egg (cookies), to first achieve desensitisation to baked egg before transitioning 
to pancakes. Desensitisation will be assessed by an open cooked egg FC at the end of 
treatment while SU will be assessed by an open cooked egg FC after stopping OIT for 
approximately 6 weeks. 
 
Updosings for cookies will be done at home under the guidance of the study team based on 
the safety profile of other home-based baked egg OIT protocols (7),(8). Updosings for 
pancakes will be performed in the hospital as this has not been evaluated previously.  

 
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Subjects randomised to the control arm will continue strict egg avoidance and undergo an 
open cooked egg FC between 12 and 18 months.  
 
1.2.3 Rationale for Study Population 
Egg allergy is one of the commonest food allergies affecting children. Most published egg 
OIT trials include patients above 4-5 years of age as these patients are believed to have a 
lower chance of acquiring natural tolerance without intervention. Given that OIT may 
potentially accelerate tolerance acquisition in younger children, we have chosen to include 
subjects between 2-15 years old in this study. Furthermore, recruiting children of a wider 
age range will allow us to better assess the safety and feasibility of using pancakes for OIT 
in children of various ages, particularly the acceptability of pancake in the younger cohort.  
 
1.2.4 Rationale for Doses Selected 
The BET group will undergo a 4-dose initial escalation with pancakes in hospital (37.5mg, 
75mg, 150mg, 300mg egg protein) to determine the home starting dose of pancake. Those 
reacting at 37.5mg or 75mg will not begin OIT with pancakes but instead begin with cookies, 
as the amount of pancake required to begin OIT in these patients will be too small for 
practical home measurement. The home starting dose will be 1 step below the dose 
tolerated during initial escalation to minimise risk of allergic reactions at home, particularly 
as the presence of co-factors may decrease reaction threshold. Dose increments during the 
pancake build-up phase will occur every 4 weeks until a target maintenance dose of 2500mg 
egg protein is achieved.   This maintenance dose was selected for reasons of safety and 
practicality as this translates to 1 pancake which is easier to consume on a daily basis.  
 
The BER group who tolerate at least 3mg of muffin in the baseline baked egg FC will undergo 
initial escalation with cookies in hospital. The first dose to be administered during the initial 
escalation will be individualised based on the outcomes of the baseline baked egg FC while 
the home starting dose will be the last dose tolerated during initial escalation. Subsequent 
dose increments will occur every 2 weeks at home until a target of 2500mg egg protein (the 
amount tolerated in a baked egg FC) is tolerated before transitioning to pancake OIT. 
 
2 
HYPOTHESIS AND OBJECTIVES 
2.1 
Hypothesis 
        Oral immunotherapy (OIT) using pancake is safe and effective in desensitising egg-allergic 
children to cooked egg.  
 
2.2 
Primary Objectives 
To evaluate the efficacy of pancake OIT in inducing desensitisation in egg-allergic children. 
 

 
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2.3 
Secondary Objectives 
1. 
To evaluate the efficacy of pancake OIT in inducing sustained unresponsiveness in egg-
allergic children. 
2. 
To evaluate the safety and feasibility of using pancake as OIT for egg-allergic children. 
3. 
To compare immunological outcomes (skin prick test to egg white, serum IgE to egg white, 
ovomucoid, ovalbumin) at baseline and end of OIT program. 
4. 
To assess the impact of OIT on health-related quality of life. 
5. 
To compare the immune cell profiles at baseline and end of OIT program. 
6. 
To identify the mechanistic basis of resistance, desensitisation and SU to OIT. 
 
2.4 
Potential Risks and Benefits:  
2.4.1 Potential Risks 
Allergic reactions are expected during baseline challenges to cooked egg and baked egg and 
they also frequently occur through the course of OIT. The risk of experiencing an allergic 
reaction is higher in those undergoing OIT than those who are avoiding the allergen (9). 
Most adverse events are expected to be mild and local reactions (itch in mouth, rashes, 
abdominal pain or nausea). However, systemic reactions including anaphylaxis can occur, 
either in the hospital during FC/ updosings or with home doses.  
 
It has been reported that small number of patients (~2%) undergoing OIT can develop 
eosinophilic oesophagitis (EoE), which is almost always reversible by stopping OIT, without 
long-term sequelae.  
 
Risks from venepuncture are low and mainly associated with transient discomfort which can 
be mitigated by the use of local anaesthetics.  
 
2.4.2 Potential Benefits 
OIT aims to induce desensitisation in food allergic patients, hence reducing the risk of an 
(unpredictable) allergic reaction to egg through accidental exposure. This is despite the 
increase in frequency of allergic reactions during OIT, which are often controlled and 
predictable.  This can reduce parental anxiety when they are eating out or travelling, 
potentially improving their quality of life. Successful desensitisation to egg can also broaden 
their dietary variety by introducing egg-containing foods and also reduce social limitations 
such as exclusion from birthday parties in the younger age group. 
 
Participating in the study will contribute to existing evidence of OIT as a potential disease-
modifying intervention in food allergic patients. 
 

 
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3 
STUDY POPULATION 
3.1       List The Number and Nature of Subjects to be Enrolled.  
Children aged 2-15 years with current egg allergy will be identified from the KKH Paediatric 
Allergy Service. A total of 33 egg-allergic patients will be recruited and randomised 2:1 to 
active (n=22) or control (n=11) groups.  
 
3.2       Criteria for Recruitment and Recruitment Process 
Potential participants in outpatient clinics will be approached by the study team and existing 
patients may be contacted by their attending allergists (part of the study team) to be invited 
to participate in this study. Study Participant Information Sheet and Consent Form will be 
provided to participants prior to screening visit. The consent form will describe the purpose 
of the study, the procedures to be followed and the risks and benefits of participation. 
Patients contacted through phone/email, who are keen to participate will have a separate 
screening visit. Informed consent will be obtained from parents/ legal guardian, and assent 
will be obtained from children 6 years old and above prior to gathering study specific 
personal information and performing study specific procedures (eg. skin prick tests, food 
challenge).   
 
3.3       Inclusion Criteria 
Subjects must meet all the inclusion criteria listed below to participate in this study. 
 
a. Age 2-15 years at time of consent. 
b. Allergic to 4.443g egg protein or less, at baseline egg open food challenge OR 
Convincing clinical reaction to egg within past 6 months (or failed a clinical egg food 
challenge in last 6 months) AND evidence of current sensitization (positive SPT or 
egg-specific IgE performed within the last 3 months) 
c. Written, informed consent of parent/legal guardian and patient assent (for those 6 
years old and above).  
 
3.4      Exclusion Criteria 
Subjects meeting any of the exclusion criteria at baseline will be excluded from 
participation. 
 
• Required previous admission to an intensive care unit for management of an allergic 
reaction. 
• Children with a past history of egg allergy currently consuming egg-containing 
products other than extensively-heated egg in baked foods (e.g. biscuits, cakes).  
• Developed severe anaphylaxis to egg or egg-containing products requiring more 
than 2 adrenaline auto-injectors or intravenous adrenaline infusion.  

 
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• Poorly controlled asthma within the previous 3 months (as defined by clinician 
judgement with reference to the ICON guidelines). 
• Moderate-severe eczema despite appropriate use of emollients (eczema is not 
otherwise an exclusion criteria). 
• Clinically significant chronic illness (other than asthma, rhinitis or eczema). 
• History of symptoms of eosinophilic oesophagitis, irrespective of cause. 
• Undergoing specific immunotherapy to another allergen and within the first year of 
treatment. 
• Receiving anti-IgE therapy, oral immunosuppressants, beta-blocker or ACE inhibitor. 
• Pregnancy. 
• Unwilling or unable to fulfil study requirements.  
 
3.5      Subject Replacement 
Subjects who drop out will not be replaced. 
 
4      STUDY DESIGN 
This is a single site, open label interventional, randomised controlled trial evaluating the 
efficacy, safety and feasibility of pancake OIT, in inducing desensitisation and sustained 
unresponsiveness in egg allergic children between 2-15 years old. Participants will be 
recruited from the Allergy Department at KK Women’s and Children’s Hospital and 
assessed for eligibility based on the inclusion/ exclusion criteria listed. Those fulfilling 
criteria will be invited for an open FC to cooked egg (hard boiled), to confirm the diagnosis 
of an egg allergy (TS). *Children with a history of convincing clinical reaction to egg or 
failed a clinical egg food challenge within the last 6 months AND evidence of egg 
sensitisation on either skin prick test (SPT) or egg-specific IgE within the last 3 months will 
be exempted from this baseline FC. Those with a confirmed diagnosis of egg allergy will 
then be randomised 2:1 to active OIT or control.   
 
Subjects randomised to the active arm will undergo a baked egg FC on a separate day in 
the unit (T0). This will be in the form of muffin baked by parents using standardised recipes 
(2 eggs in 6 muffins). *Children who have failed a baked egg FC within the last 6 months 
can be exempted from this baked egg FC. Depending on the outcome of the baked egg FC, 
they will be allocated to baked egg tolerant (BET) group (tolerating 2.5g baked egg) or 
baked egg reactive (BER) group (failing baked egg FC at any stage).  
 
The BET group will undergo a 4-dose initial escalation with pancakes in hospital (37.5mg, 
75mg, 150mg, 300mg egg protein) to determine the home starting dose of pancake (T1P). 
Those reacting at 37.5mg or 75mg will not begin OIT with pancakes but instead begin with 
cookies (Table 6 Step 11). The starting pancake dose will be administered at home daily for 
4 weeks (minimum 3 weeks) before the next updosing to be performed in hospital. When 

 
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participants have successfully reached the target maintenance dose (Table 5 Step 7), they 
will remain on this maintenance dose for a minimum of 16 weeks (or total OIT duration of 
18 months, whichever earlier). 
 
The BER group who tolerate at least 3mg of muffin in the baseline baked egg FC will undergo 
initial escalation with cookies in hospital (T1C). The first dose to be administered during the 
initial escalation will be individualised based on the outcomes of the baseline baked egg FC 
while the home starting dose will be the last dose tolerated during initial escalation. The 
starting cookie dose will be administered daily at home for a minimum of 2 weeks. 
Subsequent updosings will be done at home on a 2-weekly basis. When participants have 
successfully reached the target dose (Table 6 Step 11), they will remain on this dose for a 
minimum of 2 weeks before undergoing pancake initial escalation to begin pancake OIT 
(T2P). Those reacting at 37.5mg or 75mg will not begin OIT with pancakes but instead 
resume cookie OIT Step 11 for another minimum 4 weeks before re-attempting pancake 
initial escalation. 
 
All participants who have completed at least 16 weeks of maintenance pancake OIT will 
undergo an open cooked egg FC at the end of treatment to assess for desensitisation (T3). 
Participants who tolerate 4443mg of cooked egg and deemed successfully desensitised will 
then stop OIT for approximately 6-8 weeks prior to returning for a repeat cooked egg FC to 
assess for sustained unresponsiveness (T4).  
 
Participants who tolerate 4443mg of cooked egg at SU FC will be allowed ad libitum cooked 
egg consumption post study. Participants who develop allergic reactions at SU FC will 
resume previous maintenance dose. 
 
Control subjects will receive the current best standard care, i.e. strict egg avoidance with 
provision of rescue medication and training. They will then undergo an open cooked egg FC 
between 12 and 18 months to assess for cooked egg tolerance. 
 
Approximate time to complete study recruitment is 12 months. Total OIT duration from 
initial escalation to desensitisation FC is a minimum of 12 months and maximum of 18 
months. 
 
 

 
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Figure 1: POET Study Design 
 
4.1 
Randomisation and Blinding 
 
OIT outcomes have been reported to be affected by a range of variables, including age, 
baseline egg-specific IgE, baseline reaction threshold and the presence of asthma (10). It is 
therefore essential to maintain balance between treatment groups with respect to these 
predictors. However, stratified randomisation using several variables is not effective in small 
trials. Minimisation is a valid alternative to ordinary randomisation, and has the advantage 
that there will be only minor differences between groups in baseline variables which are 
used in the allocation process (11). With minimisation, the treatment allocated to the next 
participant enrolled in the trial depends on the characteristics of those participants already 
enrolled, with an element of weighted randomisation – typically 80% chance – of each 
participant getting the allocation that minimises any imbalance. Randomisation with 2:1 
allocation ratio will be performed using an online free, open-source, desktop minimization 
program with a random element using a weighting probability of 0.8 (MinimPy Program 
0.3).  

 
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Baseline variables included in the minimisation will be: 
• Age (<5, ≥5 years) 
• Egg-specific serum IgE (<10 kU/L, ≥10 kU/L)  
• Asthma on inhaled corticosteroids (No, Yes) 
 
This is an open label study and blinding will not be performed.  
 
4.2 
Contraception and Pregnancy Testing 
Females of childbearing age will be tested for pregnancy using serum HCG if they are 
reported to be sexually active.  
 
4.3 
Study Visits and Procedures Overview 
There will be 9-10 hospital visits for the BET group, 10-11 hospital visits for the BER group 
over the entire study duration. There will be 2 hospital visits for the control group. 
 
 
Figure 2: POET Study Timeline 
 
 
 
 
 
 
 
 
 
 

 
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Study Timepoints 
TS 
T0 
T1C 
 
T1P/ 
T2P 
 
T3 
T4 
 
Screening & 
Cooked Egg FC 
Baked Egg FC 
Cookie Initial 
Escalation 
Home Cookie 
Build-up 
Pancake Initial 
Escalation 
Hospital Pancake 
Build-up 
Exit Cooked Egg 
FC 
 SU FC 
Informed consent 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Concomitant medications 
X 
X 
X 
 
X 
X 
X 
X 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
Spirometry 
 
(X) 
 
 
 
 
(X) 
 
Asthma control test 
X 
(X) 
 
 
 
 
(X) 
 
SCORAD 
X 
 
 
 
 
 
 
 
POEM 
X 
 
 
 
 
 
 
 
Skin Prick Test 
X* 
 
 
 
 
 
X 
X 
Blood test 
X* 
 
 
 
 
 
X 
X 
HRQL Assessments 
X 
 
X 
 
X 
 
X 
X 
Table 1: Study Procedures 
(X) may be performed, depending on clinical need;   X* - Results from SPT/ IgE performed within 3 
months prior will be used and need not be repeated 
X are procedures applicable to control subjects 
FC – Food Challenge; SU – Sustained Unresponsiveness 
 
4.3.1 Screening Visits and Procedures 
Informed consent and screening procedures listed below can be performed on the day of 
patient’s scheduled allergy outpatient visit or on the day of screening FC, or at a separate 
clinic visit. Once the subject fulfils all eligibility criteria, he/she will be randomised 2:1 to 
active OIT or control arms.  
 
The following will take place at the first screening visit (TS): 
• Written informed consent and participant assent. 
• Clinical history and directed physical examination. 
• For children with asthma, current asthma status will be assessed by the clinician and 
completion of a validated asthma control test. 
• For children with eczema, eczema will be assessed using the SCORAD system (which 
provides an objective measure of eczema severity) as well as the POEM 
questionnaire, a validated patient-based symptom assessment. 

 
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• Skin prick test (SPT) to commercial extracts of egg (accepted if it was performed 
within 3 months prior to screening visit). 
• Blood test - Serum IgE to egg white, ovomucoid and ovalbumin (accepted if it was 
performed within 3 months prior to screening visit) and immunoprofiling tests. 
• Health-related quality of life (HRQL) assessment. 
• Females of childbearing age will be tested for pregnancy using serum HCG if they are 
reported to be sexually active.  
• Screening open FC to cooked egg. (*Except those with convincing clinical reaction to 
egg or failed a clinical egg food challenge in last 6 months) AND evidence of current 
sensitization - positive SPT or egg-specific IgE performed within the last 3 months) 
Subjects assigned to the active arm will undergo an open baked egg FC in KKH outpatient 
Allergy unit. OIT should commence (initial escalation) at soonest possible date after baked 
egg FC. 
 
Subjects assigned to the control arm will have baseline SPT and blood test (serum IgE to 
egg white, ovomucoid, ovalbumin) performed during screening visit. 
 
Screening Food Challenge to Cooked Egg 
Dose 
Egg Protein (mg) 
Equivalent serving of 
cooked egg (g) 
1 
3 
0.02 
2 
10 
0.08 
3 
30 
0.24 
4 
100 
0.8 
5 
300 
2.4 
6 
1000 
8 
7 
3000 
24 
Cumulative dose 
4443 
35.54 
Table 2: Dosing protocol for Screening Open FC to cooked egg 
 
For subjects who pass the screening FC (ie. tolerate up to dose 7), the investigator may 
elect to give participant an 8th dose - 3000g egg protein, to confirm tolerance. Subjects 
who tolerate up to dose 7 would have failed screening and inclusion criteria.  
 

 
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4.3.2 Study Visits and Procedures 
FC visits, initial escalation visits and pancake updosing visits will be conducted in the Allergy 
Unit, with staff fully trained in the management of allergic reactions including anaphylaxis 
and with emergency equipment and medication available. 
 
4.3.2.1 Baked Egg Open Food Challenge (T0) 
All eligible participants assigned to the active arm will undergo a separate day visit for baked 
egg FC (T0). This should be performed at soonest possible date after consent and screening 
FC. The baked egg FC will be in the form of muffin baked by parents using standardised 
recipes (2 eggs in 6 muffins). 
 
The following will take place at the T0 visit (for active arm): 
• Spirometry for subjects 8 years old and older, with a diagnosis of asthma/ suspected 
asthma. A recent spirometry (performed within the past 6 months) is acceptable if 
the control has been stable and there is no clinical concerns.  
• Baked Egg Open Food Challenge (*Children who have failed a baked egg FC within 
the last 6 months can be exempted from this baked egg FC.) 
 
Baked Egg (2 eggs in 6 muffins) Food Challenge 
Dose 
Egg Protein (mg) 
Equivalent serving of 
muffin (g) 
1 
3 
0.07 
2 
10 
0.24 
3 
30 
0.72 
4 
100 
2.4 
5 
300 
7.2 
6 
1000 
24 
7 
1057 
25.4 
Cumulative dose 
2500 
1 muffin 
Table 3: Dosing protocol for Baked Egg Open FC 
 
4.3.2.2 Pancake Initial Escalation Phase (T1P) 
The baked egg tolerant (BET) group will undergo a 4-dose initial escalation with pancakes in 
hospital on a separate day (T1P) to determine the home starting dose of pancake. This 
should be performed at soonest possible date after baked egg FC.  
 
Pancake Initial 
Escalation 
Pancake Recipe A – 1 egg in 6 pancakes 
If dose tolerated, 
commence build-up at:  
Time Point (min) 
Pancake amount 
Egg Protein (mg) 
0 
~1/32 
37.5 
NA* 

 
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20 
1/16 
75 
Step 1: 37.5mg 
40 
1/8 
150 
Step 2: 75mg 
60 
1/4 
300 
Step 3: 150mg 
Table 4: Dosing protocol for Pancake Initial Escalation 
*Those reacting at 37.5mg or 75mg will not begin OIT with pancakes but instead begin 
with cookies (Table 6 Step 11).  
 
BET subjects will commence pancake initial escalation at 37.5mg with increments every 20-
30 minutes to a maximum of 300mg unless symptoms develop. The dose tolerated is one 
which results in no more than mild transient (not lasting more than 20 minutes) symptoms 
(e.g. itchy mouth) - transient Grade 1 symptoms based on the CoFAR specific grading 
symptoms for allergic reactions (Table 8). The home starting dose will be one step below 
the tolerated dose during initial escalation to minimise risk of allergic reactions at home, 
particularly as the presence of co-factors may decrease reaction threshold.  
 
4.3.2.3 Pancake Build-Up Phase 
Each dose increment for pancake will be performed in the Allergy Unit under medical 
supervision, to confirm tolerance before the new dose is given at home daily for 4 weeks 
(minimum 3 weeks). Mild transient symptoms (e.g. itchy mouth) to the dose - transient (not 
lasting more than 20 minutes) Grade 1 symptoms (Table 8) - might be acceptable. If the 
updosing is not tolerated (i.e. more than mild transient symptoms), the participant will stay 
on the previously tolerated dose for another 4 weeks (minimum 3 weeks) before returning 
for repeat updosing.  
 
Pancake 
Build-up 
Phase 
Protocol 
Pancake Recipe A – 1 egg in 6  
Pancake Recipe B – 2 eggs in 6 
Min. no. of 
months on 
this step 
Cumulative 
no. of 
months 
(minimum)  
STEP 
Pancake 
Recipe 
Pancake 
amount 
Egg Protein 
(mg) 
1 
A 
1/32 
37.5 
1 
1 
2 
A 
1/16 
75 
1 
2 
3 
A 
1/8 
150 
1 
3 
4 
A 
1/4 
300 
1 
4 
5 
A 
1/2 
625 
1 
5 
6 
A 
1 
1250 
1 
6 
7 
B 
1 
2500 
4 
10 
Table 5: Pancake Build-up Phase Protocol  
When participants have successfully reached the target maintenance dose (Step 7), they will 
remain on this maintenance dose for a minimum of 16 weeks (or total OIT duration of 18 
months, whichever earlier).  
 

 
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4.3.2.4 Cookie Initial Escalation (T1C) and Build-up Phase 
The baked egg reactive (BER) group who tolerate at least 3mg of muffin will undergo initial 
escalation with cookies under medical supervision in the hospital on a separate day (T1C) to 
determine the home starting dose of cookie. This should be performed at soonest possible 
date after baked egg FC. The first dose to be administered during initial escalation will be 
individualised based on the outcome of the baseline baked egg FC. The NOAEL (No Observed 
Adverse Event Level) – defined as highest dose triggering none or transient Grade 1 
symptoms) will be used for this purpose. Subsequent increments will be administered every 
20-30 minutes and the maximum number of doses to be administered during the initial 
escalation is stipulated in Table 6 below. If a given dose triggers symptoms that causes 
discomfort to the participant or is deemed significant by the research team, no further doses 
will be administered on that day. Participants will be observed for at least one hour after 
dosing (2 hours if participant has previously experienced a delayed reaction). Participants 
will be instructed to have the last well-tolerated dose at home daily for a minimum of 2 
weeks, until the next updosing is performed.  
Subsequent updosings will be performed at home by the parents once every 2 weeks.  The 
study team will conduct a phone call 2 weeks after the initial escalation and then monthly 
phone calls, to check on the progress of home updosing, ensure compliance and review any 
adverse events.  When participants successfully reach the target dose (Step 11), they will 
remain on this dose for a minimum of 2 weeks before undergoing initial escalation with 
pancake (T2P). Subjects who react at 37.5mg or 75mg during pancake initial escalation will 
not continue with pancake OIT but instead resume cookie OIT Step 11 for a minimum of 
another 4 weeks before re-attempting pancake initial escalation. 
 
Cookie Initial Escalation (IE) and Build-up Phase Protocol 
NOAEL at Baseline 
BE FC (mg) 
STEP 
Cookie 
Recipe 
Cookie 
Amount 
Egg Protein 
(mg) 
Max Egg Protein 
at IE (mg) 
Max no. of 
doses at IE 
3 
1 
C 
1 
1.25 
5 
3 
- 
2 
C 
2 
2.5 
- 
- 
- 
3 
C 
4 
5 
- 
- 
10 
*3.5 
D 
0.5 
6.25 
37.5 
3 
30 
4 
D 
1 
12.5 
75 
3 
- 
5 
D 
3 
37.5 
- 
- 
100 
6 
E 
1 
75 
150 
2 
300 
7 
E 
2 
150 
300 
2 
- 
8 
E 
4 
300 
- 
- 
1000 
9 
F 
1 
625 
1250 
2 
- 
10 
F 
2 
1250 
- 
- 
- 
11 
F 
4 
2500 
- 
- 
Table 6: Cookie Initial Escalation and Build-up Phase Protocol 
* Step 3.5 is only for initial escalation for subjects with NOAEL of 10mg 

 
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Egg Content in Cookie Recipes: 
C: 1ml egg in 100 cookies (1.25mg egg protein per cookie) 
D: 10ml egg in 100 cookies (12.5mg egg protein per cookie) 
E: 1 egg in 100 cookies (75mg egg protein per cookie) 
F: 1 egg in 12 cookies (625mg egg protein per cookie) 
4.3.2.5 Home Instructions & Checklist 
Prior to discharge post initial escalation (pancake or cookie), each family will be provided 
with:  
• A symptom advice sheet including instructions in the prompt recognition of allergic 
reactions.  
• A food allergy action plan. Subjects and their families will be instructed in the use of 
adrenaline auto-injectors, antihistamines and salbutamol (if known to be asthmatic). 
The expiry date of medications will be checked, and a prescription for replacements 
provided if needed. 
• A daily dosing diary and instruction sheet which will include the following: 
• Contact information for the team, which will include a dedicated mobile 
phone number with 24/7 access to a member of the medical team for urgent 
queries, and an email address which will be checked daily by the research 
team from Monday to Friday for non-urgent queries. 
• Information to GP / Children’s Emergency in writing that the patient is 
undergoing OIT and that allergic reactions may occur during administration. 
• Instructions on study dose administration including the dose to give their 
child and advice to avoid intense physical exercise up to 2 hours before and 
after the dose intake. Subjects will be asked to log all doses taken at home 
and any resulting adverse events. In the event of any symptoms, the family 
needs to contact the study team for advice and record all symptoms, 
duration, timing in relation to immunotherapy dose and any exacerbating 
factors (e.g. exercise, excessive tiredness, viral illness  
• Dietary advice on egg avoidance (See Section 6.4).  
All control subjects will receive a food allergy action plan, instructions on use of adrenaline 
auto-injectors, antihistamines and salbutamol if needed, as well as dietary advice on strict 
egg avoidance.  
 
4.3.2.6 Desensitisation (DS) Open Food Challenge (T3) 
All participants who have completed at least 16 weeks of maintenance pancake OIT (Table 
5 Step 7) will undergo an open cooked egg challenge at the end of treatment (T3) to assess 
for desensitisation. This is subjected to a total OIT duration (from initial escalation to exit 
challenge) of a minimum 12 months and maximum 18 months. All control subjects will 
undergo an open cooked egg challenge between 12 and 18 months (T3). 
 

 
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Desensitisation Open Food Challenge to Cooked Egg 
Dose 
Egg Protein (mg) 
Equivalent serving of cooked egg (g) 
1 
3 
0.02 
2 
10 
0.08 
3 
30 
0.24 
4 
100 
0.8 
5 
300 
2.4 
6 
1000 
8 
7 
3000 
24 
 
 
 
Cumulative dose 
4443 
35.54 
Table 7: Dosing protocol for DS Open FC to cooked egg 
 
Successful desensitisation is defined as passing the FC to cooked egg, tolerating 4443mg of 
egg protein.  
4.3.2.7 Sustained Unresponsiveness (SU) Food Challenge (T4) 
Desensitised subjects in the active arm (tolerating 4443mg of cooked egg at T3) will be asked 
to stop OIT and all baked egg products (if they had been taking them) for approximately 6-
8 weeks prior to returning for a repeat FC to assess for sustained unresponsiveness. The 
dosing protocol for SU FC will be the same as that of DS FC (Table 7). 
 
Participants who tolerate 4443mg of cooked egg at SU FC will be allowed ad libitum cooked 
egg consumption post study. Participants who develop allergic reactions at SU FC will 
resume previous maintenance dose.   
 
4.3.2.8 Clinical assessment and procedures during open FC (screening FC, baked egg FC, DS FC, SU 
 
FC) 
All challenges will be conducted in the Allergy outpatient unit, with staff fully trained in the 
management of allergic reactions including anaphylaxis. Emergency equipment (including 
oxygen and suction) and medication will be checked beforehand, as per local protocol and 
international criteria for performance of FC.  
 
All subjects will be assessed prior to FC to determine suitability for a challenge, as follows: 
• No intercurrent illness  
• No exacerbation in allergic symptoms (eczema, asthma, food allergy) in the preceding 
week. 
• No short-acting β2 agonists used in the past 12 hours 
• No recent antihistamine exposure (e.g. cetirizine, loratadine) in the past 48 hours (72 
hours for fexofenadine, 5 days for long-acting antihistamine (e.g. chlorphenamine, 
desloratadine). 

 
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• No oral steroids have been taken in the past 2 weeks 
• Baseline observations (temperature, blood pressure, heart and respiratory rate, oxygen 
saturations,) within the normal range.  
• Baseline physical examination must not reveal any significant acute findings. 
The clinical team may elect to secure intravenous access by cannulation as an additional 
safety precaution at challenge. This will allow treatment to be easily and rapidly 
administered in the event of a significant allergic reaction, and also allows blood to be 
collected without further venepuncture. 
Participants will be monitored including heart rate, blood pressure and oxygen saturations. 
Clinical manifestations will be assessed throughout the challenge. 
 
Dose intervals should be between 20-30min but may be extended up to one hour at the 
investigator’s discretion, where the participant may be experiencing an evolving reaction 
(as a safety measure, to limit the dose which might in turn moderate the symptoms 
experienced at challenge). A 2-hour observation period will follow the last dose to monitor 
for signs of reaction. For safety reasons, families will be asked to provide their child with a 
snack/ lunch to eat one hour after the last dose has been given or the challenge has been 
stopped due to reaction. Participants will then be observed for a second hour prior to 
leaving the unit. 
 
Symptoms will be monitored during the challenge, with detailed assessment prior to each 
challenge dose, according to Figure 3. 
• Green symptoms: Not generally sufficient to consider a challenge positive. 
• Orange symptoms: Symptoms that recur on 3 doses or persist (e.g. 40 minutes) are more 
likely indicative of a reaction than when such symptoms are transient and not reproducible. 
3 or more scoring areas in orange, more likely represent a true response. 
• Red symptoms: A single red symptom is likely to indicate a true response, and if present 
the challenge should be halted. 
The outcome of the challenge (positive or negative) and the apparent eliciting threshold 
dose will be recorded in the participant record. Challenge outcome will be determined as 
per the PRACTALL Consensus criteria, as shown in Figure 3; where possible, challenges 
should be stopped on the basis of at least one objective symptom. 
Any allergic reaction occurring during in-hospital food challenge will be managed according 
to our unit’s established protocol.  

 
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Figure 3: PRACTALL consensus stopping criteria for food challenges 

 
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4.3.2.9 Quality of Life Assessments 
The impact of OIT on participants’ health-related quality of life (HRQL) will be assessed both 
from parents’ and participants’ perspective using disease-specific validated “food-allergy 
quality of life questionnaire” (FAQL-Q) in its parental, child and teenager forms. The FAQLQ-
PF (parent form) will be administered to all parents; FAQLQ-CF (child form) administered to 
patients age 8-12 years at commencement of study; FAQLQ-TF (teenager form) 
administered to patients age 13-18 years at commencement of study. To ensure the ability 
to compare responses consistently during the 12 months of OIT, children who are age 12 at 
study commencement will be asked to complete the Teenage version unless there are 
difficulties with comprehension which preclude this. 
 
These will be performed for subjects in the active arm at the following points during the 
study: 
i. 
baseline, at screening (TS). 
ii. 
prior to cookie initial escalation (T1C). 
iii. 
prior to pancake initial escalation (T1P/ T2P) 
iv. 
prior to the DS FC (T3). 
v. 
prior to SU FC (T4). 
 
Subjects in the control arm will be assessed at baseline (TS) and prior to DS FC (T3). 
 
4.3.2.10 Laboratory Assessments 
The development of tolerance in immunotherapy is associated with several immunological 
changes, including decreases in egg-specific IgE levels with concomitant increases in IgG4 
levels. Serum IgE to egg white, ovomucoid and ovalbumin will be performed at baseline 
screening (TS) and at the end of study (T3) for all subjects and additionally for active subjects 
who have a visit at T4. 
 
Other than serum immunoglobins assay, 3 mL of Ethylenediaminetetraacetic acid anti-
coagulated blood will be concurrently collected (TS, T3 and if applicable, T4) and sent to a 
core laboratory for peripheral blood mononuclear (PBMC) preparation. We expect 3 mL of 
blood to yield approximately 6 million PBMCs. These following experiments will be 
performed: 
i. 
DNA-human leukocyte antigen (HLA) genotypes: DNA will be isolated from 0.2 mL of 
blood to perform HLA typing to determine the appropriate candidates for major 
histocompatibility complex (MHC) tetramers analysis and genome sequencing if new 
data arises that indicates the importance of other non-HLA genetic variants for 
allergy manifestation.    
ii. 
Multi-parametric immune cell profiling: We will utilise multi-parametric cytometry 
to holistically characterise the immunome and determine the differences between 
non-responders and those with SU to identify immune signatures that confer 
resistance to OIT. Absolute counts of B, T, natural killer and dendritic cell subsets will 
be characterised.  

 
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iii. 
Transcriptomic analysis: This will be done either at the immune cell subset or single 
cell level depending on the immune cell profiling data to identify the pathways 
responsible for the differences in response to OIT. 
iv. 
Multi-parametric cytokines/chemokines profiling: This will be done on the plasma 
stored after PBMC preparation if the cytometry data indicates the involvement of 
specific cytokines/chemokines in allergy manifestation. 
 
 
 
 
4.3.3 Final Study Visit: 
The final study visit will be on the day of DS challenge (T3) for controls and for active subjects 
who did not achieve desensitisation.  The final study visit will be on the day of SU challenge 
(T4) for those successfully desensitised at T3. 
 
 
4.3.4 Post Study Follow up and Procedures 
Subjects will be followed up by the Allergist in the clinical service and the monitoring and 
treatment of adverse events will be done during regular outpatient visits with the allergy 
team.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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4.4 
Discontinuation/Withdrawal 
 
4.4.1 Discontinuation Criteria 
 
Subjects will be free to withdraw from the study at any time without affecting their future 
medical care.  
The safety of study participants is paramount: subjects who are assessed as having 
anaphylaxis to OIT dose at home but who have not administered IM adrenaline as per the 
management plan will have further updosing suspended until the family undergo retraining 
on the recognition and management of allergic symptoms. 
A participant may be withdrawn from the study under the following circumstances: 
• If, in the opinion of the study team, compliance with study procedures is suboptimal such 
that it compromises the patient’s safety. 
• If, in the opinion of the study team, further participation would adversely affect the 
participant’s health. 
• A child develops an exclusion criteria during the updosing phase of the study e.g. a new 
medication (which would normally be a contra-indication) is commenced. 
• If consent is withdrawn or the subject fails to return for a study visit. 
  
4.4.2 Discontinuation Visit and Procedures 
 
All subjects withdrawn from study will be given appropriate care under medical supervision 
until the symptoms of any adverse event resolve or the subject’s condition becomes stable. 
Subjects withdrawn from study will be invited to a final discontinuation visit and if willing, 
the following will take place: 
• Skin prick test (SPT) to commercial extracts of egg. 
• Blood test - Serum IgE to egg white, ovomucoid and ovalbumin and immunoprofiling 
tests (4.3.2.10) 
• Health-related quality of life (HRQL) assessment (4.3.2.9) 
Withdrawn subjects will be offered continued follow up in the Allergy clinical service as per 
current clinical practice.  
 
 
 
 
 
 
 
 
 

 
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5.1 
Trial Product (s) 
5.1.1 Pancake & Cookie Recipes – A set of standardised baking tools including baking tray, 
measuring cup, measuring spoons, digital weighing scale, frying pan, syringes will be 
provided to subjects in the active arm, to ensure uniformity in the cookies and pancake. 
 
Pancake Recipe 
Recipe A 
Makes 
Amount of pancake 
to be consumed 
Egg protein (mg) 
Plain Flour 
Baking Powder 
Baking Soda 
Salt 
Sugar 
Butter 
Milk 
Egg (65g) 
Vanilla Essence 
55g 
1 tsp 
1/8 tsp 
1/8 tsp 
15g 
15g 
60ml 
1 
½ tsp 
6 pancakes 
(30ml or 1/8 
cup per 
pancake) 
1/32 
37.5 
1/16 
75 
1/8 
150 
¼  
300 
½  
625 
1 
1250 
Recipe B 
Makes 
Amount of pancake 
to be consumed 
Egg protein (mg) 
Plain Flour 
Baking Powder 
Baking Soda 
Salt 
Sugar 
Butter 
Milk 
Egg (65g) 
Vanilla Essence 
110g 
2 tsp 
¼ tsp 
¼ tsp 
30g 
30g 
120ml 
2 
1 tsp 
6 pancakes 
(60ml or ¼ 
cup per 
pancake) 
1 
2500 
Method  
1. Microwave the butter for 20-30 seconds to melt it. 
2. Combine the flour, baking powder, baking soda, salt and sugar in a large-sized bowl. Make 
a well in the centre and add the cooled melted butter, milk, egg(s) and vanilla essence. 
3. Use a wire whisk and mix the wet and dry ingredients together until smooth. The batter 
should be thick and creamy in consistency. 
4. Set the batter aside and allow to rest while heating up your pan. 
5. Heat the  non-stick pan over medium heat for 2 minutes then turn heat down to low. 
6. Pour 30ml of Recipe A or 60ml of Recipe B onto the pan.  
7. Cook for 3 minutes. Bubbles should appear on the surface and the edge of the pancake 
should peel off easily to reveal a golden underside. 
8. Flip with a spatula and cook for another 3 minutes.  
9. Repeat with remaining batter to make a total of 6 pancakes. 
*tsp = teaspoon 

 
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Cookie Recipe 
 
Amount of 
egg used 
Makes 
Amount of cookies to be 
consumed daily 
Egg protein 
(mg) 
150g Plain Flour 
100g Sugar 
100g Butter/ Milk-
free margarine 
½ tsp Baking soda 
Recipe C 
 
 
1ml 
 
100 cookies 
1 
1.25 
2 
2.5 
4 
5 
Recipe D 
 
 
10ml 
100 cookies 
1 
12.5 
3 
37.5 
Recipe E 
 
 
1 whole (65g) 
100 cookies 
1 
75 
2 
150 
4 
300 
Amount of 
egg used 
Makes 
Amount of cookies to be 
consumed daily 
Egg protein 
(mg) 
100g Plain Flour 
50g Sugar  
50g Butter/ Milk-
free margarine 
¼ tsp Baking soda  
Recipe F 
 
 
2 whole (65g 
each) 
24 cookies 
1 
625 
2 
1250 
4 
2500 
Method 
1. Preheat oven to 180oC. Microwave the butter or milk-free margarine for 30-40 seconds 
to melt it.  
2. Using a whisk, beat the melted butter with sugar until creamy. Add the egg and continue 
beating until just incorporated. Avoid beating the egg for too long as cookies will be stiff.  
3. Add the flour and baking soda. Mix well together into a dough.  
4. Line the square baking tray with baking paper. Roll the dough evenly onto the baking 
tray.  
5. Bake in the oven for 15 minutes at 180oC. 
6. Once out of the oven, immediately cut into 10x10 squares (Recipe C-E) or 6x4 rectangles 
(Recipe F) before the cookies cool.  
 
 
 
 
 
 
 
 
 
 

 
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5.1.2 Food Safety  
Raw Ingredients  
• Eggs 
• Salmonella bacteria can be present on egg shells and the interior of normal-looking 
eggs.  
• Proper handling of eggs reduces the risk of Salmonella contamination. This includes 
storing eggs in the refrigerator until they are needed, and ensuring adequate personal 
hygiene and cleanliness of utensils during food preparation. 
 
Cookies and Pancakes 
• Baked and cooked products are subject to microbiological spoilage. This is influenced by 
factors such as storage temperature, relative humidity, initial contamination and moisture 
content of the product. 
• Water activity, aw, which is an indicator of moisture content, allows recognition of the spoilage 
and safety potential of baked goods. Cookies have a low moisture content (aw <0.6) while 
pancakes have a high moisture content (aw >0.85).  
• Low moisture baked products such as cookies are less likely to be affected by microbiological 
spoilage. In high moisture cooked products like pancakes, almost all bacteria, yeasts and 
moulds are capable of growth.  
• To control microbiological spoilage, the following strategies should be taken:  
• Cookies and pancakes should be cooled completely prior to storage.  
• Stored in airtight container. 
• Store at room temperature (if consumed within 2 weeks for cookies, and within 2 hours 
for pancakes) or in the freezer to prolong storage life.  
 
5.2 
Storage and Drug Accountability 
Storage Requirements and Stability (Temperature, Duration) 
 
 Shelf Stable Ingredients  
 
Shelf (unopened) 
Shelf (opened) 
Plain flour  
Use by date 
6 months* 
Sugar  
Use by date 
18 – 24 months  
Oil 
Use by date 
3 – 5 months  
Baking powder  
Use by date 
3 – 6 months  
    * Opened flour packets should be stored in air-tight containers. 
 
     Perishable ingredients 
 
Refrigerator 
Eggs, in shell  
3 – 5 weeks OR Use by date 
Butter/ 
Milk-free margarine  
1 – 2 months  
6 months  
Fresh cow’s milk  
Use by date (unopened) 
3 days (opened) 
      

 
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Baked Products 
 
Room Temperature 
(~25oC) 
Refrigerator  
(0 – 4oC)  
Freezer 
Cookies 
2-3 weeks 
2 months 
8-12 months 
Pancakes 
2 hours  
2 – 3 days  
2 months  
 
• Pancake batter must be cooked within 2 hours upon preparation.  
• General safe food preparation and handling practices apply. 
 
 
6 
TREATMENT 
6.1 
Rationale for Selection of Dose 
Current OIT regimens typically involve the daily consumption of an allergen, commencing at 
a very low dose followed by dose increments over several hours during initial escalation 
phase and periodically (usually every 2-4 weeks) during build-up phase until the target 
maintenance dose is achieved (12) This maintenance dose is then continued on a daily basis 
for months to years. There is considerable variation between studies regarding starting and 
target maintenance doses.  
 
Egg OIT (using eggs in various forms such as lyophilized egg, dehydrated egg white, 
pasteurized raw egg white, lightly cooked eggs or hard-boiled eggs) has been reported with 
much heterogeneity in desensitisation rates ranging from 55% to 100%. Furthermore, the 
ability of current protocols to induce SU appear to be even more limited (~30%).  It is 
possible that longer duration and higher doses of treatment resulting in higher cumulative 
dose of allergen may lead to higher rates of allergy remission but this would have to be 
balanced against the risk of allergic reactions. Safety of egg OIT, just like other OIT, is a 
concern with early discontinuation due to adverse events reported in 12.5%‐36% of children 
(13).  
 
Only 2 studies have evaluated using baked egg in OIT and both used different doses 
administered over different durations of time. In the study by Bravin et al, biscuits 
containing varying amounts of egg protein were administered to baked egg allergic subjects, 
starting at 125µg and increased daily over 60 days to a target maximum dose of 6.25g after 
which an open FC to 1 boiled egg was performed to assess for desensitisation. Of the 15 
patients recruited, 12 (80%) completed the OIT program and all adverse reactions were 
mild. The second study by Bird et al. did not report the starting OIT dose but baked egg-
allergic subjects underwent an initial escalation phase up to 125mg in hospital followed by 
home up-dosing to a maintenance dose of 3.8g which was continued for 1 year. This was 
followed by an open FC to 6g of lightly cooked egg to assess for desensitisation. Again, 
dosing was well tolerated with only 77 adverse reactions reported of 5605 total recorded 
doses (1.37% of total doses) and none requiring adrenaline.    
 

 
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Pancakes are expected to be less allergenic than cooked egg because of the wheat matrix 
but more allergenic than baked egg. In our study, all subjects assessed to be baked egg 
tolerant will have ingested and tolerated 2.5g of egg protein during the baseline baked egg 
open FC. BET subjects will hence commence pancake OIT at 37.5mg (1.5% of the 2.5g 
cumulative dose tolerated during the baked egg FC) with increments every 30minutes to a 
maximum of 300mg during the initial escalation phase (Table 4). The starting dose of the 
build-up phase will be 1 step below the dose tolerated during the initial escalation phase to 
minimise risk of allergic reactions at home, particularly as the presence of co-factors may 
decrease reaction threshold (see Section 6.4). Dose increments during the build-up phase 
will occur every 4 weeks (minimum 3 weeks) until a target maintenance dose of 2500mg is 
achieved (Table 5). Subjects will then remain on the daily maintenance dose for a minimum 
of 16 weeks or total OIT duration of 18 months, whichever is achieved earlier.                   
 
BER subjects who tolerate at least 3mg of muffin will commence OIT with cookies to first 
desensitise them to baked egg before transitioning to OIT with pancakes.  The first dose to 
be administered during the initial escalation will be individualised based on the outcome of 
the baseline baked egg FC. Subsequent dose increments during the cookie build-up phase 
will occur every 2 weeks at home until the target of 2500mg egg protein (the amount 
tolerated in a baked egg FC) is tolerated. When participants successfully reach the target 
dose (Table 6 Step 11), they will remain on this dose for a minimum of 2 weeks before 
undergoing initial escalation with pancake.   
 
All participants who have completed at least 16 weeks of maintenance pancake OIT (Table 
5 Step 7) will undergo exit cooked egg FC to assess for desensitisation to cooked egg.  
 
6.2 
Study Drug Formulations 
Standardised recipes for pancakes and cookies will be given to participants. Recipes are 
clearly labelled and clear updosing instructions (including change of recipe) are given to 
subjects at commencement of OIT, and with reminders by the study team at updosing 
intervals.  All ingredients will be weighed where possible. Standardised frying pans and 
scoops will be used for pancakes. Doses of egg protein consumed daily will be determined 
by the quantity of pancake/cookie consumed following the dosing Tables 5 and 6.    
 
6.3 
Study Drug Administration 
Initial escalation phase and all dose increments during the pancake build-up phase will be 
administered in the Allergy Unit under medical supervision.   Dose increments during the 
cookie build-up phase will be performed at home as previous studies have reported very 
low risks of severe allergic reactions. This will reduce the number of hospital visits required. 
All doses (pancake and cookie) must be taken for a minimum of 1 week before the next 
updosing.      

 
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6.3.1 In the event of a dose-related allergic reaction  
In the event of an allergic reaction to a dose of immunotherapy within 2 hours of a dose, 
either at updosing in hospital or after a dose given at home, families will be instructed to 
follow their Allergy Action Plan, and to contact the study team. 
Anaphylaxis reactions at home 
• Where a child is having objective symptoms consistent with possible anaphylaxis (e.g. 
wheeze, persistent cough, difficulty breathing, stridor or marked swallowing difficulties), 
families will be instructed to administer the adrenaline auto-injector pen, contact the study 
team on the Emergency number and call 995 for the child to be brought to KKH Children’s 
Emergency for further evaluation and admission 
Following resolution of symptoms, the previous tolerated dose will be given the next 
possible day, under medical observation.  
Persistent/ bothersome symptoms at home 
• For persistent symptoms that last >3days (within 2 hours of the immunotherapy dose) 
consisting of abdominal pain, rhinoconjunctivitis or skin symptoms (Table 8 Grade 1), the 
investigator should consider a dose reduction to the previous tolerated dose for at least 3 
days or until symptoms have mostly resolved. 
• In the event of other symptoms that prove bothersome to the child, the dose can be 
reduced at investigator’s discretion. 
• In cases of dose reduction due to persistent/ bothersome symptoms, the original dose 
should be resumed once symptoms are deemed to have mostly resolved. Upon resumption 
of original dose, subjects should be on the dose for at least 1 week before the next updosing.  
• For recurrent symptoms where dose reduction has not on its own been effective, the 
investigator may elect to offer participants an oral second-generation antihistamine, prior 
to OIT dosing, to reduce allergic symptoms to immunotherapy doses. If started, the use of 
these medications should be minimized, and then discontinued at the earliest opportunity. 
Antihistamines should not be taken on the day of updosing.  
Mild symptoms at home 
• For mild skin symptoms, itchy mouth, rhinoconjunctivitis or mild abdominal symptoms 
(Table 8 Grade 1), reassurance to families will be provided and the current dose will be 
continued, with contact with the study team as needed. 
 
6.3.2 In the event of omitted doses 
• If 1-2 days of immunotherapy is missed, the subject can continue with the current dose at 
home with the next scheduled updose to proceed as planned 
• If 3-7 days of immunotherapy are missed,  

 
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• for pancake build-up phase - the previous dose will be given until the subject can 
attend the Allergy unit for repeat updosing. Upon resumption of original dose, 
subjects should be on the dose for at least 1 week before the next updosing. 
• for cookie build-up phase - the previous dose will be given for a week before repeat 
updosing at home. Upon resumption of original dose, subjects should be on the dose 
for at least 1 week before the next updosing. 
• If more than 7 days of immunotherapy are missed, dosing should stop until the subject can 
attend the Allergy unit for repeat updosing of the previous dose.  
 
6.3.3 In the event of sick days  
Families will be requested to contact the study team in the event of an intercurrent illness, 
to discuss reducing the dose depending on symptoms and intensity. 
In the event of subject having an intercurrent illness, the investigator may pre-emptively 
reduce the OIT to the previous dose for the duration of the illness. Upon resumption of 
original dose, subjects should be on the dose for at least 1 week before the next updosing. 
 
6.3.4 In the event of dose reduction for other reasons 
Subjects are expected to be compliant to doses and will be encouraged to adhere to the 
protocol. In the event the subject is unable to take the current dose for reasons other than 
allergic reactions and sick days (eg. refusal from taste fatigue), the previous dose will be 
given until the original dose is resumed.  Upon resumption of original dose, subjects should 
be on the dose for at least 1 week before the next updosing. If the subject is taking less than 
the previous dose, subsequent dosing will be managed as per omitted doses (Section 6.3.2).  
 
6.4 
Specific Restrictions / Requirements  
Subjects in the control arm will be advised strict egg avoidance including all baked egg 
products. However for those who were already previously tolerating baked egg products, 
they will be allowed to continue consumption of baked egg products outside of study, up to 
a maximum of 2.5g baked egg protein (approximately equivalent to a slice of cake or one 
muffin) per week. 
 
Subjects in the BER group undergoing cookie OIT will be counselled for strict egg avoidance 
including all baked egg products outside of the study treatment.  Subjects in the BET group 
who had tolerated baked egg products prior to study will be allowed to continue the 
consumption of baked egg products outside of study, up to a maximum of 2.5g baked egg 
protein (approximately equivalent to a slice of cake or one muffin) per week. This limit is 
placed because baked egg consumption in BET subjects may enhance desensitisation to 
cooked egg, and subjects taking larger quantities of baked egg outside of pancake OIT may 
have better rates of desensitisation. However, as pancake OIT outcomes should be assessed 

 
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in a real-world setting, this will include allowing baked egg consumption in egg allergic 
children who are already tolerating baked egg.  
 
Subjects who are receiving anti-IgE therapy, oral immunosuppressants, beta-blocker, ACE 
inhibitor or immunotherapy for other allergens will fall under the study’s exclusion criteria 
and be withdrawn from study.  
 
Subjects will be advised to avoid intense physical exercise up to 2 hours before and after 
each OIT dose intake. 
 
6.5 
Blinding 
This is an open label study. Blinding will not be performed. 
6.6 
Concomitant therapy 
 
Participants may continue usual medications, including those taken for asthma, rhinitis, and 
eczema during the study. Antihistamines must not be taken on the day of updosing and 
must be stopped prior to FC visits as per Section 4.3.2.8. Participants (or their parents) will 
be asked to document any use of medication (including rescue medication) in home diary 
cards.  
All medications (prescription and over the counter) taken by the participant should be 
documented. 
 
7 
SAFETY MEASUREMENTS 
7.1 
Definitions 
An adverse event (AE) is any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and which does not 
necessarily have a causal relationship with this treatment. 
A serious adverse event (SAE) or reaction is any untoward medical occurrence that at any 
dose: 
• results in or contributes to death 
• is life-threatening 
• requires inpatient hospitalisation or prolongation of existing hospitalisation 
• results in or contributes to persistent or significant disability/incapacity or 
• results in or contributes to a congenital anomaly/birth defect 
• results in such other events as may be prescribed  
 
Important Notes Relating to Definition of SAE: 
• Hospitalisation refers to the requirement for overnight admission to hospital. 
Observation in hospital following an allergic reaction that is not immediately life 
threatening does not constitute a hospital admission. 

 
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• A subject who experiences an anaphylaxis reaction (e.g. hoarse voice, cough, wheeze, 
stridor not requiring intubation, transient hypotension) is not at “immediate risk of 
death” and such events will not be classified as SAE unless they fulfil SAE criteria.  
The following criteria will constitute an SAE: 
• Anaphylaxis occurring at in-hospital challenge requiring more than two doses of 
intramuscular adrenaline 
• Anaphylaxis occurring in response to a dose of OIT outside the hospital environment, 
requiring more than one dose of intramuscular adrenaline.  
• Clinician-confirmed diagnosis of eosinophilic oesophagitis (with positive histology). 

 
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7.2 
Causality 
The adverse event can be described as ‘expected’ if it caused symptoms and/or signs that 
could be reasonably described as a consequence of an allergic reaction to allergen exposure 
within the protocol. Symptoms of an allergic reaction are defined as any described within 
this protocol. An adverse event is considered “unexpected” when its nature or severity is 
not consistent with the investigator’s protocol.  
An adverse event is defined as “related” when it has resulted from the administration of 
any of the research procedures. Related adverse events are defined as “adverse reactions”. 
All episodes of anaphylaxis occurring in response to a dose of OIT will be treated as an AE 
“of interest”.  
 
In this study, the following may be used as a guide to aid consistency in classification of the 
relationship to study treatment. The descriptors outlined below are not intended to be 
prescriptive and the Site Investigator should classify each event according to the specific 
circumstances involved.  
 
Probably related:  
• Objective signs of an IgE mediated allergic reaction (hives, angioedema, vomiting, 
anaphylaxis) occurring within 1 hour of the study treatment in the absence of other 
known allergic triggers for that subject; AND 
• Symptoms cannot be reasonably explained by subject’s clinical state, environmental or 
toxic factors or other treatments taken by the participant. 
 
Possibly related:  
• Objective signs of an IgE mediated allergic reaction (hives, angioedema, vomiting, 
anaphylaxis) occurring more than 1 hour but less than 4 hours after taking the study 
treatment; AND  
• Symptoms cannot be reasonably explained by subject’s clinical state, environmental 
toxic factors or other treatments taken by the participant. 
 
Unlikely to be related:  
• Allergic symptoms occurring more than 4 hours after taking study treatment; or 
• Symptoms can be reasonably explained by the subjects’ clinical state, environmental or 
toxic factor or other therapies taken by the participant. e.g. exacerbation of asthma or 
eczema; or 
• Symptoms do not follow a known pattern of response for the study treatment. 
 
Unrelated:  
• Any event where an alternate cause is identified – e.g. allergic reaction following 
exposure to another food allergen in a subject with known allergy to that allergen; or  
• The AE does not meet the criteria for the other categories above. 
 
 
Not assessable: 
• There is insufficient or incomplete evidence to make a clinical judgement of the causal 
relationship. 

 
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7.3 
Collecting, Recording and Reporting of Adverse Events and Serious Adverse Events to CIRB  
 
All adverse events will be recorded on a subject’s diary from the time the participant 
provides consent until the time the event resolves or until 30 days after the participant 
completes study treatment. Adverse events may be discovered through observing and 
questioning the participant or receiving an unsolicited complaint and questioning the 
participant in an objective manner. All adverse events will be recorded, regardless of their 
severity or relation to study medication or procedures. 
 
Reporting of adverse events involves the PI submitting to the approving CIRB the completed 
SAE Reporting Form within the stipulated timeframe. PI is responsible for informing the 
institution representative (local SAE resulting in death), sponsor or regulatory bodies as 
required and appropriate. 
 
Reporting timeline to CIRB:  
 
• SAE that result in death, regardless of causality, should be reported immediately - 
within 24 hours of the PI becoming aware of the event.  
• All “related” SAE (definitely / probably / possibly) irrespective of severity or 
expectedness, need to be reported to CIRB within 24 hours of the PI becoming aware 
of the event. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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7.4 
Grading of Adverse Events 
Allergic reactions will be graded according to the CoFAR Grading System for Allergic Reactions, 
with additional modification to Grade 1 symptoms as shown in Table 8. 
 
Grade 1 - 
Transient 
Grade 1 – 
Mild  
Grade 2 – 
Moderate 
Grade 3 – 
Severe 
Grade 4 – 
Life Threatening 
Grade 5  
Death 
Transient 
mild 
discomfort 
(<20mins). 
No limitation 
in activity 
Mild 
discomfort 
(< 48 hours). 
No limitation 
in activity 
Symptoms 
produce mild 
to moderate 
limitation in 
activity. 
Marked limitation 
in activity. 
Extreme 
limitation 
in activity. 
Death 
No 
assistance or 
medical 
intervention
/ therapy 
required. 
 
No 
assistance or 
medical 
intervention/ 
therapy 
required. 
 
Some 
assistance may 
be needed; no 
or minimal 
intervention/ 
therapy is 
required. 
Hospitalization 
is possible but 
unlikely. 
Assistance usually 
required; Medical 
intervention is 
required 
(Parenteral 
medication(s) are 
usually indicated) 
Hospitalisation is 
possible. 
Significant 
assistance and 
medical 
intervention is 
required; 
hospitalisation is 
probable. 
 
Symptoms may include 
pruritus, periorbital or facial 
angioedema, swelling or 
rash, mild abdominal 
discomfort, or other 
transient symptoms. 
Symptoms 
may 
include 
persistent 
hives, 
wheezing 
without 
dyspnea, 
abdominal 
discomfort 
/ increased 
vomiting, or 
other 
symptoms 
Symptoms may 
include 
bronchospasm 
with dyspnoea, 
severe 
abdominal pain, 
throat tightness 
with hoarseness, 
transient 
hypotension 
among others.  
Symptoms may 
include 
persistent 
hypotension 
and/or hypoxia 
with 
resultant 
decreased 
level of 
consciousness 
associated 
with collapse 
and/ 
or incontinence 
or other life-
threatening 
symptoms. 
 
Table 8: CoFAR Specific Grading System for Allergic Reactions 
 

 
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7.5 
Safety Monitoring Plan 
The PI will perform regular data and safety monitoring. Safety data including side effects 
and adverse reactions will be monitored from time of enrolment to completion of study. 
The PI will report AE/ SAE to CIRB as per guidelines stipulated above.  
 
7.6 
Complaint Handling  
Complaints will be handled by the PI and dealt with according to the institution’s guidelines.  
 
8 
DATA ANALYSIS 
8.1 
Data Quality Assurance 
The PI and co-I (at least 2 persons) will independently and regularly check each other's data 
collection forms, data entry, to ensure accurate and complete data collection and data 
entry, in accordance to the protocol. Any disagreements will be discussed together with the 
third co-I for consensus.  
 
8.2 
Data Entry and Storage 
Data will be first entered into hardcopy data collection forms (DCF). These forms will be 
stored under lock and key in access-controlled Paediatric office, only accessible to the study 
team. Data will then be transcribed from DCF to electronic forms (Microsoft Excel/ SPSS). 
Coded data will be stored on password-protected files on password-protected computers' 
shared folders, and all identifying information will only be available to the researchers in a 
file separate from the coded data that is also password-protected.  
 
9 
SAMPLE SIZE AND STATISTICAL METHODS 
9.1 
Determination of Sample Size  
The incidence of natural resolution of egg allergy over 12 month period is about 15% 
(4),(10). The efficacy for desensitisation using raw/cooked eggs is about 80% (ranging 
between 55% -100%) whilst that for OIT using baked egg products is about 50%. As there 
are no prior studies using pancake to desensitise egg-allergic patients, we are estimating 
the efficacy to be in between that of raw/cooked eggs and baked eggs, at about 65%. We 
plan to recruit 33 egg-allergic children to the study, who will be randomised 2:1 to active 
(n=22) or control (n=11) groups. This will allow us to detect a difference in rates of 
desensitisation of 50%, with 80% power using a two-sided significance level of 0.05, whilst 
allowing for a 30% attrition rate. Sample size calculation was performed using PASS 14 
(Power Analysis and Sample Size Software (2015). NCSS, LLC. Kaysville, Utah, USA, 
ncss.com/software/pass.). 
 
9.2 
Statistical and Analytical Plans 
The primary analysis will be performed on an intention to treat basis: all subjects allocated 
to each arm will be analysed together as representing that treatment arm, irrespective of 
compliance and whether or not they have completed the prescribed regimen. A secondary 

 
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analysis will also be performed on a per protocol basis. Statistical analysis was performed 
using SAS software version 9.4 for Windows (Cary, NC: SAS Institute Inc.). Statistical 
significant is set at p < 0.05. 
 
 
9.2.1 Analysis of Primary Outcome 
The primary analysis will compare the proportion of subjects who can tolerate 4443mg or 
more of egg protein in the active and control groups, using a two‐sided Fisher's exact test. 
 
9.2.2 Analysis of Secondary Outcomes 
The following secondary analyses will be performed: 
 
• Proportion of subjects who tolerate 4443mg or more of egg protein in the active and 
control groups, following cessation of all egg intake for 6 weeks (sustained 
unresponsiveness), using a two‐sided Fisher's exact test. 
 
• The incidence of adverse events experienced between active and control groups. 
Statistical differences will be determined using two-sided Fisher’s exact test for 
proportions; non parametric tests for graded reactions. Logistic regression will be 
used to assess the association of age, gender, asthma status and prior history of 
anaphylaxis with incidence of adverse events. 
 
• Completion rates in the active and control groups will be compared using a two-‐‐
sided Fisher's exact test.  
 
• Change in quality of life assessments before and after OIT, as assessed by FAQL-Q in 
children, teenagers and their parents – between the active and control groups using 
two independent sample t test (or Mann-Whitney U test if normality assumption is 
not tenable). The changes within each group will be assessed using paired t test (or 
Wilcoxon signed rank test if normality assumption is not tenable). 
 
• Immunological outcome measures pre- and post‐ of OIT, using paired t test (or 
Wilcoxon signed rank test if normality assumption is not tenable) within each group. 
 
 

 
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10 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
 
The investigators will permit study-related monitoring, audits and/or IRB review and 
regulatory inspection(s), providing direct access to source data/document. 
 
11 
QUALITY CONTROL AND QUALITY ASSURANCE 
 
The PI and co-I (at least 2 persons) will independently and regularly check each other's data 
collection forms, data entry, to ensure accurate and complete data collection and data 
entry, in accordance to the protocol. Any disagreements will be discussed together with the 
third co-I for consensus.  
 
 
12 
ETHICAL CONSIDERATIONS 
 
This study will be conducted in accordance with the ethical principles that have their origin 
in the Declaration of Helsinki and that are consistent with the Good Clinical Practice and the 
applicable regulatory requirements. 
 
This final study protocol, including the final version of the Patient Information and Informed 
Consent Form, must be approved in writing by the Centralised Institutional Review Board 
(CIRB), prior to enrolment of any patient into the study. 
 
The principle investigator is responsible for informing the CIRB of any amendments to the 
protocol or other study-related documents, as per local requirement. 
 
12.1 
Informed Consent 
 
Prior to study enrolment, written informed consent will be obtained from at least one of 
the parents, or legal representative of the participating subject. The PI/ co-I will obtain this 
written informed consent after adequate explanation to the parents/ legal representative, 
of the aims, methods, anticipated benefits and potential risks of the study and the 
discomfort it may entail. Written informed consent will be obtained prior to screening, with 
the understanding that consent may be withdrawn at any time without prejudice. Child 
assent forms will be signed for children above 6 years of age. Two copies of the informed 
consent and assent will be signed: one set is given to the subject’s parents, and one set is 
retained on site by the investigator.  In obtaining and documenting informed consent, the 
investigators will comply with the GCP guidelines and to the ethical principles that have their 
origin in the Declaration of Helsinki.  
 
12.2 
Confidentiality of Data and Patient Records 
Coded data will be stored on password-protected files on password-protected electronic 
storage devices (thumbdrives), and all identifying information will only be available to the 
researchers in a file separate from the coded data that is also password-protected. The 
password-protected thumbdrives will be stored under lock and key in access-controlled 

 
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Paediatric office. Primary research data will only be available to the entire study team; the 
analysed or tabulated results without identifying features would be made available to the 
institution as required. 
 
13 
PUBLICATIONS 
Study findings will be submitted to a peer-review journal for publication and authorship will 
be accorded based on contributions. 
 
14 
RETENTION OF TRIAL DOCUMENTS 
Records for all participants, including data collection forms, all source documentation 
(containing evidence to study eligibility, history and physical findings, laboratory data, 
results of consultations, etc.) as well as IRB records and other regulatory documentation 
should be retained by the PI in a secure storage facility. The records should be accessible for 
inspection and copying by authorized authorities. The records will be retained and stored 
for a minimum of 7 years after completion of research study or date of publication of the 
research using the research data, whichever is later. 
 
15      FUNDING and INSURANCE 
Funding has been obtained from Paeds ACP/ Tan Cheng Lim (TCL) Fund Grant 2021 for the 
operational costs of the study.  Subjects will be paying for the costs involved in consultations, 
investigations and management.  
 
 

 
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References 
 
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Tham EH, Lee BW, Chan YH, Loo EXL, Toh JY, Goh A, et al. Low Food Allergy Prevalence 
Despite Delayed Introduction of Allergenic Foods—Data from the GUSTO Cohort. J Allergy 
Clin Immunol Pract. 2018;6(2):466-475.e1.  
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Sicherer SH, Wood RA, Vickery BP, Jones SM, Liu AH, Fleischer DM, et al. The natural history 
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Vazquez-Ortiz M, Alvaro M, Piquer M, Dominguez O, Machinena A, Martín-Mateos MA, et al. 
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Altman DG, Bland JM. Treatment allocation by minimisation. BMJ. 2005;330(7495):843.  
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Wood RA. Food allergen immunotherapy: Current status and prospects for the future. Vol. 
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Machinena A, Lozano J, Piquer M, Gereda D, Mauledoux J, Riggioni C, et al. Oral 
immunotherapy protocol for hen’s egg allergic children: Improving safety. Vol. 30, Pediatric 
Allergy and Immunology. Blackwell Publishing Ltd; 2019. p. 760–3.