Egg Desensitization and Induction of Tolerance in Children
Phase: NA
Conditions: Egg Protein Allergy
Sponsor: McGill University Health Centre/Research Institute of the McGill University Health Centre

Version 3 
March 15, 2018 
1
Egg Desensitization and induction of tolerance in Children 
Principal Investigator: Moshe Ben-Shoshan MD 
  
 
 
         McGill University Health Center 
 
Sub-Investigators: Bruce Mazer MD 
  
 
 
 McGill University Health Center 
 
  
 
 
 Christine McCusker MD 
  
 
 
 McGill University Health Center 
 
 
1 
Proposed Research Questions 
1. What is the rate of desensitization in children allergic to egg? 
2. What are the predictors associated with success or failure of desensitization in   
     children? 
3. What are the molecular mechanisms involved in desensitization? 
2 
Research Objectives and Significance 
We are proposing to initiate a study assessing desensitization for egg  
This study would enable us to better determine the potential benefit of 
desensitization in individuals with egg allergy. 
More specifically, we will address the following research objectives: 
Objectives 
A. To determine the rate of desensitization to egg.. 
B. To characterize predictors of successful desensitization.   
C. To characterize molecular mechanisms involved in the process of desensitization. 
 
3. Gaps and Unmet Needs in Existing Knowledge on food desensitization  

Version 3 
March 15, 2018 
2
3.i Why do we need trials on food desensitization. 
Foods are reported to be primary inciting allergens for anaphylaxis and account for 
33.2% to 56% of all anaphylaxis cases.(1-4) Further, food-induced anaphylaxis hospital 
admissions are reported to have increased, mainly in the first 2 decades of life.(5;6) 
At present, the only treatment for food allergy is to avoid the allergy-causing food, while 
the only treatment for an allergic reaction is prompt administration of intramuscular 
epinephrine. (7;8)  Primary anaphylaxis prevention is based on allergen desensitization 
through immunotherapy and until recently was not available for food allergies. Although 
there are a few recent research protocols exploring desensitization for foods and although 
these have so far been largely successful, (9;10)  up to this point  there are no  known 
guidelines describing the optimal candidate for desensitization nor are there criteria for 
the safest and most effective dosing schedule. Further, many of these studies have a very 
small sample size and do not use a control group. Hence, the efficacy of these protocols is 
hard to interpret (11-14) and additional larger scale randomized control studies are required.  
3.ii Why Egg. 
Cow milk allergy (CMA) and egg allergies are the most common food allergies in 
children and recent reports suggest that rates of resolution are considerably lower than 
previous estimates. (15-17) Further, both CMA and egg allergy are associated with severe 
anaphylaxis(18;19) and due their ubiquitous use in our diet are almost impossible to strictly 
avoid.(20-22) In line with these, several studies suggest that quality of life of patients  with 
milk/egg allergy and their families is severely impaired.(23-25)  
With the support of AllerGen NCE and CIHR we have initiated in 2014 the first cross 
Canada study to assess milk desensitization. This study now includes almost 50 patients, 

Version 3 
March 15, 2018 
3
and our preliminarily results reveal an almost 80% success rate .  We are now proposing 
to initiate an egg desensitization study based on the expertises, recruitment skills and data 
collected in our first 2 years of milk desensitization.   
We hypothesize that there will be at least 50% improvement in the ability to tolerate egg. 
E.g. a child that was able to tolerate only 40 mg of merengue will be able to tolerate at 
least 60 mg subsequent to desensitization  
 
The trial design is an RCT aiming to demonstrate superiority of the desensitization 
protocol  to an avoidance strategy regarding the tolerated quantity of egg . The ratio of 
patients to control is 1:1 . Patients will be block randomized in groups of 2 according to 
age and sex.   
 
Egg allergy is the most common IgE mediated food allergy in children. Approximately 
30% of children suffering from moderate to severe atopic dermatitis present an associated 
food allergy and egg is reported to be the  major food allergen triggering IgE mediated 
allergic reactions in those with atopic dermatitis.(26) The major allergens in egg are known 
as Gal d 1-5 and include  Ovomucoid which is the dominant egg allergen,( Gal d 1) and is 
a protease inhibitor, Ovalbumin (Gal d 2) & Ovotransferrin (Gal d3) and lysozyme (Gal 
d4).(27) Egg allergens are altered by heat and gastric enzymes and 55%-73% of those with 
egg allergy will be able to ingest cooked egg.(28;29) However, ovomucoid, the main egg 
allergen, is not affected by heating.(30) Different egg whites (e.g, goose , duck and turkey)  
were all found to contain proteins cross-reacting with most of the allergens in hen's egg 
white. (31) Presence of egg allergy has also major implications regarding safe 
administration of vaccines. Several vaccines are manufactures on egg containing media 
including yellow fever and Q fever and may induce an allergic reaction in those that are 
egg allergic.(32-35)Hence, use of rapid and effective desensitization to egg   may be 
extremely beneficial prior to travel to yellow fever endemic areas. In addition,  although 

Version 3 
March 15, 2018 
4
it was reported that the median age for tolerance to egg is 6 years + 6 months, (36) recent 
studies suggest a  lower resolution  rate of 68% by age 16 years.(17) 
 
Given the importance of egg allergy, protocols aiming to induce desensitization were 
recently explored.(37;38) These protocols reveal encouraging results with significantly 
increased thresholds to food-induced allergic reactions after oral immunotherapy in 100% 
of those with egg allergy. (12) Recently rush(11;13) and modified  rush protocols(12) were 
suggested for egg  but again  studies exploring these protocols are limited by small 
sample size and by lack of controls as well as  absence of methodologies assessing the 
molecular processes underlying these successful desensitization.  It is suspected that the 
nature of this increased threshold is transient and reflects desensitization rather than true 
tolerance given that avoidance of these foods was shown to increase sensitization as well 
as to lower the threshold of subsequent reactivity.(39;40)  In conclusion, the efficacy of the 
immunotherapy, extent of desensitization versus tolerance, the quantity/ frequency of 
allergen consumption required to maintain this effect and molecular mechanisms 
involved in the desensitization process are currently unknown. 
3. iii. Do we achieve only desensitization or do we induce also tolerance. 
Desensitization refers to a change in the amount of food antigen needed to cause 
allergic symptoms; this state is dependent on regular antigen exposure. In contrast, 
tolerance refers to long-term immunologic changes associated with the ability to ingest a 
food without symptoms and without ongoing therapy. Desensitization is a worthwhile 
therapeutic goal as it allows individuals freedom from the risk of accidental ingestion in 
everyday settings; achieving long-term clinical tolerance would allow safe food ingestion 

Version 3 
March 15, 2018 
5
without ongoing therapy by inducing lasting immunologic changes.(41) Trials so far 
suggest that there might be  loss of tolerance within 48 h following elimination of the 
food from the diet. (42) However, these trials are flawed by their small sample size (3 
patients). (42) Given that more recent trials suggest that  as long as participants ingested 
the maintenance dose of  at least twice a week  no allergic reactions are likely to occur(13) 
and given the abundance of egg products in our diet , it is crucial, to explore such an 
approach in  a large scale clinical trial.  
 
3. iv Gaps regarding the roles of mast cells in desensitization. 
Given that food desensitization is a relatively rapid process, mast cell are implicated to 
have a key role in this process. Compared to activated cells, desensitized Mast cells were 
shown to have  had impaired degranulation, calcium flux, secretion of arachidonic acid 
products.(43) However, the effect of food desensitization on mast cells was not explored 
so far in clinical trials.   
3v. Gaps regarding the role of T regulatory cells in desensitization. 
Although several studies in humans report that food allergens induce specific effector T 
cells, there are significant controversies between studies regarding the T cell phenotype 
dominating that response.  Some  studies  report  a Th2 dominated response in children  
with food allergies whereas Th1- responses underlie oral tolerance  (44). Other studies 
suggest that food antigens induce a Th2 response  regardless of the presence of food 
allergy(45). Further, it is proposed that Treg cells may be crucial to control food related 
allergic reactions. A potential suppressive role of Treg in food allergies was exemplified 
in both animal models (46-48) and in human studies. Increased numbers of Treg cells in 

Version 3 
March 15, 2018 
6
peripheral blood in children who outgrew milk allergy was reported (49;50) and decreased 
Treg suppression was associated with egg allergy in neonates (51). Cord blood from 
offspring of atopic mothers showed fewer innate induced Treg cells and impaired 
suppression(52). In line with these, an association with severe food allergy was described 
in patients with profound dysfunction of T reg cells that characterizes IPEX syndrome 
(immunodysregulation polyendocrinopathy enteropathy X-linked syndrome)(53).   
In contrast 1 study looking at the number of Tregs in 10 children undergoing milk 
desensitization reports no enhancement of CD4+CD25+Foxp3+ T(reg) levels in 
peripheral blood and suggests that there is unlikely a role for long-lasting systemic 
immunologic changes in desensitization. However, this study is limited by a small sample 
size and relatively short period of follow up (6 months). (54) Additionally, data now 
suggests that Foxp3-ve Tregs may also play a role in tolerance. 
3.vi  Gaps regarding the role of demethylation in desensitization. 
The rising incidence of food allergies  is occurring more rapidly than changes to the 
genome sequence would allow(55) and epigenetic regulation (heritable changes in gene 
expression that occur in the absence of alterations in DNA sequences) may in part 
mediate the complex gene-by-environment interactions that can lead to asthma.(56) 
Experimental studies provide substantial in vitro data indicating that DNA methylation of 
genes critical to T-helper cell differentiation may induce polarization toward or away 
from an allergic phenotype. Methylation of DNA and resulting changes in chromatin 
structure have been shown to initiate the process by which the Th cells lose their 
plasticity and differentiate productively toward the Th1 versus the proallergic Th2 pattern 

Version 3 
March 15, 2018 
7
of cytokine gene expression.(57-59) So far no studies have explored the role of DNA 
methylation in short term processes such as desensitization for food allergens. 
3.vii. Gaps in role of allergen specific salivary IgA.  
We hypothesize that development of an enhanced antigen specific mucosal IgA response 
is associated with reduced responses to oral antigen challenge in food allergy in children. 
Antigens delivered to the gastrointestinal mucosa are subject to a variety of barriers 
before they come into contact with effector cells such as mast cells, loaded with antigen 
specific IgE, that may trigger an adverse allergic reaction. Since the majority of allergic 
effector cells within the intestinal tract are below the epithelial barrier, and IgA is in 
much higher concentration than IgE, we may enhance blockade against allergic reactions 
in previously sensitized individuals through increases in mucosal IgA, and especially 
through an increased IgA:IgE ratio. While this has been examined experimentally in 
mice, the relationship between mucosal IgA and desensitization in the clinical setting is 
not defined. 
4. Methodological Approach/Study Design 
Thirty four boys and girls with between 6 to 18 years of age, diagnosed with egg allergy 
will be approached by our study group. Participants will be recruited from the allergy 
clinic at the Montreal Children’s Hospital. 
Inclusion criteria:  Children 6 years and older who satisfy all the following criteria 
will be included: 
a. A history suggestive of immediate allergy to egg. A convincing clinical history of 
an IgE mediated reaction to a specific food will be defined as a minimum of 2 mild 
signs/symptoms or 1 moderate or 1 severe sign/symptom that was likely IgE mediated 

Version 3 
March 15, 2018 
8
and occurred within 120 minutes after ingestion or contact (or inhalation in the case of 
fish and shellfish).  Reactions will be considered mild if they involve pruritus, urticaria, 
flushing, or rhinoconjunctivitis; moderate if they involve angioedema, throat tightness, 
gastrointestinal complaints, or breathing difficulties (other than wheeze); and severe if 
they involve wheeze, cyanosis, or circulatory collapse.(64-67) 
b. The presence of at least one of the following confirmatory tests: 
 
(a)  Positive SPT to egg or its proteins (weal diameter 3 mm larger than that of the 
normal saline control). The allergens used will be commercial extracts of egg (Omega 
Labs, Toronto, Ontario). 
 
(b)  Detection of serum specific IgE (>0.35 kU/L) to egg or any of its proteins 
(ovalbumin, ovomucoid, lysozyme and conalbumin), measured by fluorescence enzyme 
immunoassay (Phadia, CAP System, Uppsala, Sweden). 
 
(c)  Positive oral challenge test to egg. Oral challenges will be performed with 
Meringue Powder according to the recommendations of the position paper of the 
European Academy of Allergology and Clinical Immunology (68)and in an open manner 
(appendix C). When subjective symptoms will appear (oral pruritus, abdominal 
discomfort), the challenge tests will be blinded. 
  
Informed consent form signed by the parents or legal guardian (appendix B). 
Exclusion criteria.  
1. Patients who are unstable from a respiratory point of view . 
2. Patients who  present with  intercurrent disease at the time of starting 
desensitization. 

Version 3 
March 15, 2018 
9
4. Non-IgE-mediated or non-immunological adverse reactions to egg. 
5. Malignant or immunopathological diseases and/or severe primary or secondary 
immune deficiencies. 
6. Patients receiving immunosuppressor therapy. 
7. Patients receiving β-blockers (including topical formulations). 
8. Associated diseases contraindicating the use of epinephrine: cardiovascular disease 
or severe hypertension. 
 
Subject Recruitment and Retention 
Consent will be obtained by the study coordinator 
Potential participants are referred to the study team by their treating allergist.  They 
are given information about the study and a follow-up conversation - to review the 
study aims and procedures - with the study coordinator is scheduled.  Typically, 
families of the potential participants will be given a week to review the study 
information.  Following this, if potential participants are still interested in 
participating, they will meet with one of the investigators to review the potential 
benefits and risks of participation  
 
 It has been our experience that with this highly motivated group of participnats, it has 
not been necessary to implement procedures to monitor compliance. 
 
Through a process of stratified randomization (according to sex), participants will be 
randomly assigned to one of 2 study groups. The first group will receive active 
desensitization , and the second group will not receive any treatment but will be followed 
up ( appendix B protocols ) .  
The desensitization protocol will be performed at the Center of Innovative medicine 
(CIM ) as is currently done for our milk and peanut desensitization study, under the direct 
supervision of the medical and nursing staff, and with full cardiopulmonary resuscitation 
measures available for the treatment of possible allergic reactions that could occur during 

Version 3 
March 15, 2018 
10
the procedure. Oral and intravenous doses of diphenhydramine and intramuscular 
epinephrine were at the bedside at all times.  
Desensitization to egg  .(12) 
Desensitization will begin with combined challenge/rush desensitization.  After 
placement of an intravenous catheter, 20 ml blood samples will be collected, skin prick 
test (SPT) to egg will be performed and 5 ml of saliva will be collected.  These samples 
will be used to establish participants’ baselines for the various biological markers being 
examined during the study.  The modified challenge will begin with a first single dose of 
0.1 mg of placebo, alternating with powdered egg white in the form of Meringue powder. 
After the initial dose, subjects will receive approximately doubling doses every 30 
minutes until the highest tolerated single dose will be determined (see Appendix B for 
Challenge/Rush doses). For doses of 25 mg and greater, powdered meringue will be 
dispensed from individual preweighed containers..  After the initial dose, subjects will 
receive approximately doubling doses every 30 minutes until the highest tolerated single 
dose was determined. All doses will be mixed with an acceptable vehicle food chosen by 
the subject and his or her parent.  Subjects treated for reactions will be observed for 2 
hours, and if there is no evidence of an allergic reaction, they will be discharged home. 
Self-administered epinephrine will be  provided to all patients' caregivers, along with 
instructions and indications for administration and education about the nature of possible 
reactions to OIT. To ensure there were no ill effects of the daily dosing, each subject will 
return  to the CIM  on the second day for an observed administration of the starting daily 
dose. 
 

Version 3 
March 15, 2018 
11
All challenges and escalation doses will take place in the Center of Innovative 
medicine (CIM ) as is currently done for our milk and peanut desensitization study . The 
CIM services include equipment and medications required to monitor and treat potential 
reactions . The CIM nurse that will assist in the desensitization protocol is a nurse that 
has been trained to work in an intensive care unit. The patients will not be admitted, but 
will remain under observation for 7 h each day, with the possibility for increasing this 
period if required. 
SPT with the allergens listed above will be performed on all patients before starting 
desensitization, and the tests will be  repeated at 3, 6 and 12 months. Blood tests will be 
also  performed to measure sIgE and sIgG, T cell phenotypes (including regulatory 
Tcells), salivary IgA and DNA methylation before  desensitization, at 3 weeks and at 3, 6 
and 12 months. 
Reactions during the desensitization protocol will be  classified according to the 
categories proposed by Perry et al.(69): mild reactions are defined when symptoms are  
limited to the  oral mucosa or the skin; severe reactions include cardiovascular or 
respiratory symptoms or involvement of any four systems; all other reactions will 
classified as moderate, although we  will consider isolated abdominal discomfort as mild 
when it lasted for 30 min or less (appendix C protocols ). 
Build-up phase 
Subjects will begin daily home dosing based on the highest dose tolerated during the 
modified rushof powdered egg white in 1 to 2 tablespoons of baby food or other 
acceptable vehicle food. Home doses will be provided in individual pre-weighed 
containers, and subjects will be instructed to ingest 1 dose daily for 2 weeks. As long as 

Version 3 
March 15, 2018 
12
subjects tolerate current doses, the doses will be increased every 2 weeks (see dosing 
schedule Appendix B) until reaching 150 mg and then increased by 50 mg at each visit 
until reaching maintenance (300 mg). Dose escalations will be made at visits in the 
research unit to ensure that subjects tolerate increases, and subjects will be observed for 
at least 2 hours after increases for signs of clinical reactions.  Subjects will be given 
diaries to track their dose-related symptoms during the study  
 
The protocol will be individualized according to each patient's tolerance to egg: 
 
 Mild allergic reactions will be treated when necessary and the regimen will be 
continued when the patient becomes asymptomatic. The previously tolerated dose will be 
repeated before resuming the process. 
 
Moderate reactions will be treated and desensitization would be restarted on the 
following day at the previously tolerated dose. 
 
Severe reactions will be treated with the necessary measures and in the 
appropriate department, followed by an assessment of whether to interrupt desensitization 
or reduce the dose on the following day to 1/10 of the dose that caused the reaction. 
The patients' parents will be instructed verbally and in writing about the 
recommendations to be followed after desensitization and how to treat possible allergic 
reactions. They will also given a direct telephone line for consultation. Patients will be  
instructed not to perform physical exercise (70;71) for 2 h after eating egg and not to take 
non-steroidal anti-inflammatory drugs for 3 h before or after ingestion. No special 
recommendations will be  given for viral infections.(11)  Participants will be given 

Version 3 
March 15, 2018 
13
symptom diaries and instructed to complete it daily to keep track of their allergic 
symptoms during the desensitization process. 
Participants who are not able to achieve desensitization (desensitization defined as being 
able to tolerate the 300 mg maintenance dose) by 18 months following the initiation of 
the desensitization process will be considered treatment failures and discontinued from 
the study. 
 
 
Maintenance/ Follow-up Phase 
 
Once subjects reached the daily dose of 300 mg, they will be instructed to take this 
daily for the length of the study (12 months). The subjects will be also instructed to 
otherwise continue an egg-elimination diet for the duration of the study.Subjects and 
families will be asked to complete daily home diaries to document that daily doses were 
taken, as well as to report accidental ingestions, problems with dose administration, or 
related symptoms. Follow-up visits in addition to and in conjunction with the biweekly 
visits for dose escalation will be planned at 3, 6, 9, 12 months from the second egg 
challenge. Each visit will involve a medical history and physical examination. egg 
specific skin prick testing (SPT), a blood draw similar to that at the challenge to measure 
serum egg-specific IgE and IgG concentrations, T cell penotyping and DNA methylation.  
A 5 ml saliva sample will be collected to assess salivary IgA 
 
 

Version 3 
March 15, 2018 
14
 
 
 
 
Food challenges 
One month after subjects reach the 300 mg dose, they will undergo a second food 
challenge to determine his or her allergenic reactivity to egg protein. Subjects will 
continue OIT dosing through the day before the challenge. The challenge will consist of 
10 doses of powdered egg white given every 10 to 20 minutes in increasing amounts up 
to a total of 8 g of powdered egg white (6 g of egg protein). 
After their year in the control arm, , oral desensitization will be offered to the control 
patients  
 
Variables measured. The following variables will be measured in each patient: 
A. The primary study variable will be the presence of desensitization defined by the 
ability to tolerate egg 1 year after the start of the trial. This is a qualitative variable with 
three categories: total desensitization ( 300mg of egg); partial desensitization ( 30-300mg 
of egg); and failed desensitization (<30 mg of egg). Only patients presenting total 
desensitization were regarded as being successfully desensitized. 
B. Secondary variables will be:  
1. 
Number and severity of adverse reactions occurring after oral exposure to 
egg /milk during the desensitization and follow-up phases. 
 

Version 3 
March 15, 2018 
15
2. 
Minimum dose of egg white that triggered symptoms during the 
desensitization protocols or challenge tests. 
3. 
Days until desensitization was achieved, excluding weekends. 
4. 
Indices of desensitization : 
SPT weal size and levels of sIgE and sIgG before desensitization, during follow-up 
and at the end of the study. 
 
5. 
Mast cell activation. 
Mast cell activation will be assessed through a proxy measure: the basophil activation 
test. This test is based on the percentage of CD63-expressing basophils detected by 
flowcytometry . This test is done by incubating basophils from highly sensitized atopic 
donors or preferably after priming them with Il3 (regardless of basophil source ) (72;73) 
with sera from patients . We will assess the expression of CD63 on basophils after 
addition of egg/milk antigens respectively as well as an irrelevant antigen (gliadin and 
tetnus toxoid) The expression of CD63 on these cells is compared to values acquired after 
incubation with healthy controls and the same antigens. Values above the mean of 
CD63+ cells + 2 SD induced will be considered as positive. (74)   
 
6. 
Indices of T cell tolerance  :  
Levels of Treg and cytokine release at base line and uring desensitization. In order to 
characterise molecular pathways associated with desensitization , we will draw 
approximately 20 ml cc of blood from each participant and check their T cell phenotype 
including their Treg cells and the response to egg and milk proteins. As control the 

Version 3 
March 15, 2018 
16
response to an irrelevant antigen (gliadin) and to tetanus toxoid will be MEDICed.  We 
will invite participants for annual follow ups in the first 5 years after study entry. We will 
also offer the desensitization to the control group at the end of the study. 
 
7.  Egg specific salivary IgA  
At the initial visit and at all follow-up visits, participants will be asked to produce 5 ml 
of saliva.  Our work in previous desensitization studies has demonstrated that even 
children as young as 6 years can produce this volume of saliva.  Egg-specific salivary 
IgA will be determined by ELISA 
 
 
5.   Statistical Considerations  
Given that previous studies in adults have attributed at least 50% improvement in the 
ability to tolerate egg  ,(75) with an α  of 0.05 and a power (1- β ) of 0.80, a sample of 17 
cases and 17 controls will be recruited. Statistical analyses will be performed using paired 
t-tests. A P value of <0.05 will be considered significant. 
Descriptive statistics of the variables including means, standard deviations and 
frequencies were computed for all study variables. The concentrations of egg -sIgE and 
sIgG , the weal size , Mast cell, salivary IgA, T cell and DNA  methylation status at the 
different study time-points will be  compared with their baseline values using the one-
sample paired t-test  and to the control using a 2 sample t-test . 
Multiple regression models will be used to assess factors associated with response to 
desensitization (i.e. baseline demographic characteristics; gender; age; baseline basophile 

Version 3 
March 15, 2018 
17
activation; T cell status, baseline SPT and specific IgE, salivary IgA, and DNA 
methylation status,). 
 
6.   Ethical Considerations   
In the consent form given at study enrolment, participants will be advised that they 
will be randomly assigned to either desensitization treatment or observation alone for one 
year, (appendix B). Participants will also be advised that their data will be shared only 
among the study members. Participants who will be at the control group will be told that 
they will be offered the desensitization protocol one year after study entry. 
 
7. Participant Confidentiality and Record Retention 
All participants will be assigned a unique study code that will be used on all study 
documents.  The link between the participants’ code and their name will be stored on a 
password protected computer in the MUHC’s Centre for Innovative Medicine, which is a 
restricted access unit.  All study documents will be kept in a locked filing cabinet in the 
Centre for Innovative Medicine.  Only members of the study team, and authorized 
oversight bodies will be allowed access to the study documents. 
Study documents will be kept at the Centre for Innovative Medicine for two years 
after the end of the study, then transferred to Iron Mountain for long-term storage off-site.  
All study documents will be stored for 25 years 
 
8.  Research Deliverables and Milestones 
Timeframe 
Deliverables 
Milestones 

Version 3 
March 15, 2018 
18
 
 
 
9. Requirement for networking across Disciplines and Sites 
 
Our researchers have a legacy of working across disciplines, across sites, and 
across sectors.  For this study, we have assembled a multi-institutional research team with 
cross-disciplinary expertise Dr Ben-Shoshan (Montreal Children’s Hospital, McGill 
University) and Dr Mazer  (Montreal Children’s Hospital  ) and Dr Stuart Carr  (f 
Department of Pediatrics, University of Alberta, Edmonton, Canada)bring expertise in 
clinical immunology to the research team. Dr. Ann Clarke (Montreal General Hospital) 
will bring expertise in the field of clinical allergy and together with the co-investigator, 
Dr. Joseph, a biostatistician, will assisted with the study design and will supervise the 
statistical analyses. Dr Ciriaco Piccirillo (Departments of Microbiology & Immunology 
and Medicine, McGill University, Montreal, Quebec ) will contribute their expertise in 
the areas of T cell phenotyping and DNA methylation status. Epidemiologic and 
011/17 – 03/ 18 
 
Develop sampling frame; ethics approval;  
Ready to recruit participants 
 
03/18 –07/20 
Collect data from participants  
12 weeks of data collection in 
treated participants  completed 
07/20– 12/24 
Knowledge translation activities: 
dissemination workshops & manuscript 
preparation 
 
Preparation of abstracts and 
manuscript 

Version 3 
March 15, 2018 
19
biostatistician skills are essential to undertaking this program of research and are 
represented in the persons of Moshe Ben-Shoshan (McGill) and Mr .Duncan Lejtenyi 
(both Msc in Epidemiology). Mr Duncan Lejtenyi will also be responsible for the 
laboratory evaluation of CD63 levels. Finally, as incorporated in our protocol, we will 
share the results of this research with representatives of key constituencies involved in 
the data collection –patients with food allergies and their families, physicians and allied 
professionals (e.g. nurses) through scientific meetings, our website and publications in 
medical journals.   
 
 
10. Organization of Research Team 
The nominated principal applicant, Dr. Moshe Ben-Shoshan, and co-principal 
applicants, Dr. Bruce Mazer, will oversee all aspects of the proposed research.   The 
collaborators, Dr Stark, Dr Piccirillo will aid in the recruitment of patients and the 
assessment T cells and DNA methylation status respectively.   
Mr Duncan Lejtenyi, who had worked with our team in numerous studies will serve as 
research coordinator. 
 
11. External Research Partnerships and funding 
 
As indicated above, external research partnerships are considered essential to the 
activities of our research team.  We will apply to receive substantial financial support 
from the CIHR and from AllerGen (appendix D budget).  We will work closely with 
client organizations such as the Anaphylaxis Canada , AAIA ( allergy/Asthma 
Information Association ) , and the AQAA (Association québécoise des allergies 

Version 3 
March 15, 2018 
20
alimentaires ). These support a cyber-society of people with food allergies and will 
provide support for our research activities from their limited budgets, again indicating the 
relevance of our research efforts to their needs. 
Name of Partner 
Nature of participation 
Contribution (CA$) 
Letter 
yes /no 
 
 
Cash 
In-kind 
 
Anaphyalxis 
Canada  
 
 
1000 
Y 
AAIA 
 
 
1000 
Y 
AQAA 
 
 
1000 
Y 
Total value of partnerships  
 
 
 
References 
 
 
(1)  Decker WW, Campbell RL, Manivannan V, Luke A, St Sauver JL, 
Weaver A et al. The etiology and incidence of anaphylaxis in Rochester, 
Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin 
Immunol 2008; 122(6):1161-5. 
 
(2)  Bohlke K, Davis RL, DeStefano F, Marcy SM, Braun MM, 
Thompson RS. Epidemiology of anaphylaxis among children and adolescents 
enrolled in a health maintenance organization. J Allergy Clin Immunol 2004; 
113(3):536-42. 
 
(3)  Sheikh A, Alves B. Hospital admissions for acute anaphylaxis: 
time trend study. BMJ 2000; 320(7247):1441. 
 
(4)  Gold MS. EpiPen epidemic or good clinical practice? J Paediatr 
Child Health 2003; 39(5):376-7. 
 
(5)  Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and 
admissions in Australia. J Allergy Clin Immunol 2009; 123(2):434-42. 
 
(6)  Lin RY, Anderson AS, Shah SN, Nurruzzaman F. Increasing 
anaphylaxis hospitalizations in the first 2 decades of life: New York State, 1990 -
2006. Ann Allergy Asthma Immunol 2008; 101(4):387-93. 

Version 3 
March 15, 2018 
21
 
(7)  Gold MS, Sainsbury R. First aid anaphylaxis management in 
children who were prescribed an epinephrine autoinjector device (EpiPen). J 
Allergy Clin Immunol 2000; 106(1 Pt 1):171-6. 
 
(8)  Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine 
absorption in children with a history of anaphylaxis. J Allergy Clin Immunol 1998; 
101(1 Pt 1):33-7. 
 
(9)  Plaut M, Sawyer RT, Fenton MJ. Summary of the 2008 National 
Institute of Allergy and Infectious Diseases-US Food and Drug Administration 
Workshop on Food Allergy Clinical Trial Design. J Allergy Clin Immunol 2009; 
124(4):671-8. 
 
(10)  Ben Shoshan M, Clarke AE. Anaphylaxis: past, present and 
future. Allergy 2010. 
 
(11)  Garcia RR, Urra JM, Feo-Brito F, Galindo PA, Borja J, Gomez E 
et al. Oral rush desensitization to egg: efficacy and safety. Clin Exp Allergy 2011; 
41(9):1289-96. 
 
(12)  Buchanan AD, Green TD, Jones SM, Scurlock AM, Christie L, 
Althage KA et al. Egg oral immunotherapy in nonanaphylactic children with egg 
allergy. J Allergy Clin Immunol 2007; 119(1):199-205. 
 
(13)  Itoh N, Itagaki Y, Kurihara K. Rush specific oral tolerance 
induction in school-age children with severe egg allergy: one year follow up. 
Allergol Int 2010; 59(1):43-51. 
 
(14)  Zapatero L, Alonso E, Fuentes V, Martinez MI. Oral 
desensitization in children with cow's milk allergy. J Investig Allergol Clin 
Immunol 2008; 18(5):389-96. 
 
(15)  Fiocchi A, Schunemann HJ, Brozek J, Restani P, Beyer K, 
Troncone R et al. Diagnosis and Rationale for Action Against Cow's Milk Allergy 
(DRACMA): a summary report. J Allergy Clin Immunol 2010; 126(6):1119-28. 
 
(16)  Steinke M, Fiocchi A, Kirchlechner V, Ballmer-Weber B, Brockow 
K, Hischenhuber C et al. Perceived food allergy in children in 10 European 
nations. A randomised telephone survey. Int Arch Allergy Immunol 2007; 
143(4):290-5. 
 
(17)  Savage JH, Matsui EC, Skripak JM, Wood RA. The natural history 
of egg allergy. J Allergy Clin Immunol 2007; 120(6):1413-7. 
 
(18)  Calvani M, Cardinale F, Martelli A, Muraro A, Pucci N, Savino F et 
al. Risk factors for severe pediatric food anaphylaxis in Italy. Pediatr Allergy 
Immunol 2011. 

Version 3 
March 15, 2018 
22
 
(19)  Silva R, Gomes E, Cunha L, Falcao H. Anaphylaxis in children: A 
nine years retrospective study (2001-2009). Allergol Immunopathol (Madr ) 2011. 
 
(20)  Boyano-Martinez T, Garcia-Ara C, Pedrosa M, Diaz-Pena JM, 
Quirce S. Accidental allergic reactions in children allergic to cow's milk proteins. J 
Allergy Clin Immunol 2009; 123(4):883-8. 
 
(21)  Maiello N, Del Giudice MM, Capristo C, Decimo F, Santaniello F, 
Perrone L et al. Severe allergic reaction to lactulose in a child with milk allergy. 
Ann Allergy Asthma Immunol 2011; 107(1):85. 
 
(22)  Nowak-Wegrzyn A, Shapiro GG, Beyer K, Bardina L, Sampson 
HA. Contamination of dry powder inhalers for asthma with milk proteins 
containing lactose. J Allergy Clin Immunol 2004; 113(3):558-60. 
 
(23)  Leung TF, Yung E, Wong YS, Li CY, Wong GW. Quality-of-life 
assessment in Chinese families with food-allergic children. Clin Exp Allergy 2009; 
39(6):890-6. 
 
(24)  Gupta RS, Springston EE, Smith B, Kim JS, Pongracic JA, Wang 
X et al. Food allergy knowledge, attitudes, and beliefs of parents with food-
allergic children in the United States. Pediatr Allergy Immunol 2010. 
 
(25)  Kemp AS, Allen CW, Campbell DE. Parental perceptions in egg 
allergy: does egg challenge make a difference? Pediatr Allergy Immunol 2009; 
20(7):648-53. 
 
(26)  Breuer K, Heratizadeh A, Wulf A, Baumann U, Constien A, Tetau 
D et al. Late eczematous reactions to food in children with atopic dermatitis. Clin 
Exp Allergy 2004; 34(5):817-24. 
 
(27)  Heine RG, Laske N, Hill DJ. The diagnosis and management of 
egg allergy. Curr Allergy Asthma Rep 2006; 6(2):145-52. 
 
(28)  Urisu A, Ando H, Morita Y, Wada E, Yasaki T, Yamada K et al. 
Allergenic activity of heated and ovomucoid-depleted egg white. J Allergy Clin 
Immunol 1997; 100(2):171-6. 
 
(29)  Des RA, Nguyen M, Paradis L, Primeau MN, Singer S. Tolerance 
to cooked egg in an egg allergic population. Allergy 2006; 61(7):900-1. 
 
(30)  Bernhisel-Broadbent J, Dintzis HM, Dintzis RZ, Sampson HA. 
Allergenicity and antigenicity of chicken egg ovomucoid (Gal d III) compared with 
ovalbumin (Gal d I) in children with egg allergy and in mice. J Allergy Clin 
Immunol 1994; 93(6):1047-59. 
 
(31)  Langeland T. A clinical and immunological study of allergy to 
hen's egg white. VI. Occurrence of proteins cross-reacting with allergens in hen's 

Version 3 
March 15, 2018 
23
egg white as studied in egg white from turkey, duck, goose, seagull, and in hen 
egg yolk, and hen and chicken sera and flesh. Allergy 1983; 38(6):399-412. 
 
(32)  Tey D, Heine RG. Egg allergy in childhood: an update. Curr Opin 
Allergy Clin Immunol 2009; 9(3):244-50. 
 
(33)  Schuler JE, King WJ, Dayneka NL, Rastelli L, Marquis E, Chad Z 
et al. Administration of the adjuvanted pH1N1 vaccine in egg-allergic children at 
high risk for influenza A/H1N1 disease. Can J Public Health 2011; 102(3):196-9. 
 
(34)  RUBIN SS. An allergic reaction following typhus-fever vaccine 
and yellow-fever vaccine due to egg yolk sensitivity. J Allergy 1946; 17:21-3. 
 
(35)  Munoz-Cano R, Sanchez-Lopez J, Bartra J, Valero A. Yellow 
fever vaccine and egg allergy: really a problem? Allergy 2010; 65(4):533-4. 
 
(36)  Cantani A, Micera M. Natural history of cow's milk allergy. An 
eight-year follow-up study in 115 atopic children. Eur Rev Med Pharmacol Sci 
2004; 8(4):153-64. 
 
(37)  Ibanez MD, Escudero C, Sanchez-Garcia S, Rodriguez del RP. 
Comprehensive Review of Current Knowledge on Egg Oral Immunotherapy. J 
Investig Allergol Clin Immunol 2015; 25(5):316-28. 
 
(38)  Escudero C, Rodriguez del RP, Sanchez-Garcia S, Perez-Rangel 
I, Perez-Farinos N, Garcia-Fernandez C et al. Early sustained unresponsiveness 
after short-course egg oral immunotherapy: a randomized controlled study in 
egg-allergic children. Clin Exp Allergy 2015; 45(12):1833-43. 
 
(39)  Jones SM, Pons L, Roberts JL, Scurlock AM, Perry TT, Kulis M et 
al. Clinical efficacy and immune regulation with peanut oral immunotherapy. J 
Allergy Clin Immunol 2009; 124(2):292-300, 300. 
 
(40)  Morisset M, Moneret-Vautrin DA, Guenard L, Cuny JM, Frentz P, 
Hatahet R et al. Oral desensitization in children with milk and egg allergies 
obtains recovery in a significant proportion of cases. A randomized study in 60 
children with cow's milk allergy and 90 children with egg allergy. Eur Ann Allergy 
Clin Immunol 2007; 39(1):12-9. 
 
(41)  Varshney P, Jones SM, Scurlock AM, Perry TT, Kemper A, Steele 
P et al. A randomized controlled study of peanut oral immunotherapy: clinical 
desensitization and modulation of the allergic response. J Allergy Clin Immunol 
2011; 127(3):654-60. 
 
(42)  Rolinck-Werninghaus C, Staden U, Mehl A, Hamelmann E, Beyer 
K, Niggemann B. Specific oral tolerance induction with food in children: transient 
or persistent effect on food allergy? Allergy 2005; 60(10):1320-2. 

Version 3 
March 15, 2018 
24
 
(43)  Sancho-Serra MC, Simarro M, Castells M. Rapid IgE 
desensitization is antigen specific and impairs early and late mast cell responses 
targeting FcepsilonRI internalization. Eur J Immunol 2011; 41(4):1004-13. 
 
(44)  Turcanu V, Maleki SJ, Lack G. Characterization of lymphocyte 
responses to peanuts in normal children, peanut-allergic children, and allergic 
children who acquired tolerance to peanuts. J Clin Invest 2003; 111(7):1065-72. 
 
(45)  Thottingal TB, Stefura BP, Simons FE, Bannon GA, Burks W, 
HayGlass KT. Human subjects without peanut allergy demonstrate T cell-
dependent, TH2-biased, peanut-specific cytokine and chemokine responses 
independent of TH1 expression. J Allergy Clin Immunol 2006; 118(4):905-14. 
 
(46)  Takayama N, Igarashi O, Kweon MN, Kiyono H. Regulatory role 
of Peyer's patches for the inhibition of OVA-induced allergic diarrhea. Clin 
Immunol 2007; 123(2):199-208. 
 
(47)  van Wijk F, Wehrens EJ, Nierkens S, Boon L, Kasran A, Pieters R 
et al. CD4+CD25+ T cells regulate the intensity of hypersensitivity responses to 
peanut, but are not decisive in the induction of oral sensitization. Clin Exp Allergy 
2007; 37(4):572-81. 
 
(48)  Cardoso CR, Teixeira G, Provinciatto PR, Godoi DF, Ferreira BR, 
Milanezi CM et al. Modulation of mucosal immunity in a murine model of food-
induced intestinal inflammation. Clin Exp Allergy 2008; 38(2):338-49. 
 
(49)  Karlsson MR, Rugtveit J, Brandtzaeg P. Allergen-responsive 
CD4+CD25+ regulatory T cells in children who have outgrown cow's milk allergy. 
J Exp Med 2004; 199(12):1679-88. 
 
(50)  Shreffler WG, Wanich N, Moloney M, Nowak-Wegrzyn A, 
Sampson HA. Association of allergen-specific regulatory T cells with the onset of 
clinical tolerance to milk protein. J Allergy Clin Immunol 2009; 123(1):43-52. 
 
(51)  Smith M, Tourigny MR, Noakes P, Thornton CA, Tulic MK, 
Prescott SL. Children with egg allergy have evidence of reduced neonatal 
CD4(+)CD25(+)CD127(lo/-) regulatory T cell function. J Allergy Clin Immunol 
2008; 121(6):1460-6, 1466. 
 
(52)  Schaub B, Liu J, Hoppler S, Haug S, Sattler C, Lluis A et al. 
Impairment of T-regulatory cells in cord blood of atopic mothers. J Allergy Clin 
Immunol 2008; 121(6):1491-9, 1499. 
 
(53)  Torgerson TR, Linane A, Moes N, Anover S, Mateo V, Rieux-
Laucat F et al. Severe food allergy as a variant of IPEX syndrome caused by a 
deletion in a noncoding region of the FOXP3 gene. Gastroenterology 2007; 
132(5):1705-17. 

Version 3 
March 15, 2018 
25
 
(54)  Mori F, Bianchi L, Pucci N, Azzari C, De MM, Novembre E. 
CD4+CD25+Foxp3+ T regulatory cells are not involved in oral desensitization. Int 
J Immunopathol Pharmacol 2010; 23(1):359-61. 
 
(55)  Tan TH, Ellis JA, Saffery R, Allen KJ. The role of genetics and 
environment in the rise of childhood food allergy. Clin Exp Allergy 2011. 
 
(56)  Miller RL, Ho SM. Environmental epigenetics and asthma: current 
concepts and call for studies. Am J Respir Crit Care Med 2008; 177(6):567-73. 
 
(57)  Lee DU, Agarwal S, Rao A. Th2 lineage commitment and efficient 
IL-4 production involves extended demethylation of the IL-4 gene. Immunity 
2002; 16(5):649-60. 
 
(58)  Jones B, Chen J. Inhibition of IFN-gamma transcription by site-
specific methylation during T helper cell development. EMBO J 2006; 
25(11):2443-52. 
 
(59)  Tykocinski LO, Hajkova P, Chang HD, Stamm T, Sozeri O, 
Lohning M et al. A critical control element for interleukin-4 memory expression in 
T helper lymphocytes. J Biol Chem 2005; 280(31):28177-85. 
 
(60)  Camargo CA, Jr., Clark S, Kaplan MS, Lieberman P, Wood RA. 
Regional differences in EpiPen prescriptions in the United States: the potential 
role of vitamin D. J Allergy Clin Immunol 2007; 120(1):131-6. 
 
(61)  Mullins RJ, Clark S, Camargo Jr CA. Regional variation in infant 
hypoallergenic formula prescriptions in Australia. Pediatr Allergy Immunol 2009. 
 
(62)  Mullins RJ, Clark S, Camargo CA, Jr. Regional variation in 
epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin 
D-anaphylaxis hypothesis. Ann Allergy Asthma Immunol 2009; 103(6):488-95. 
 
(63)  Milner JD, Stein DM, McCarter R, Moon RY. Early infant 
multivitamin supplementation is associated with increased risk for food allergy 
and asthma. Pediatrics 2004; 114(1):27-32. 
 
(64)  Ben-Shoshan M, Kagan RS, Alizadehfar R, Joseph L, Turnbull E, 
St.Pierre Yvan et al. Is the prevalence of peanut allergy increasing? A five-year 
follow-up study on the prevalence of peanut allergy in primary school children in 
Montreal. Journal of Allergy and Clinical Immunology 123[4], 783-8. 2009.  
Ref Type: Journal (Full) 
 
(65)  Hourihane JO, Kilburn SA, Dean P, Warner JO. Clinical 
characteristics of peanut allergy. Clin Exp Allergy 1997; 27(6):634-9. 
 
(66)  Brown SG. Clinical features and severity grading of anaphylaxis. J 
Allergy Clin Immunol 2004; 114(2):371-6. 

Version 3 
March 15, 2018 
26
 
(67)  Sicherer SH, Burks AW, Sampson HA. Clinical features of acute 
allergic reactions to peanut and tree nuts in children. Pediatr 1998; 102(1):e6. 
 
(68)  Bindslev-Jensen C, Ballmer-Weber BK, Bengtsson U, Blanco C, 
Ebner C, Hourihane J et al. Standardization of food challenges in patients with 
immediate reactions to foods--position paper from the European Academy of 
Allergology and Clinical Immunology. Allergy 2004; 59(7):690-7. 
 
(69)  Perry TT, Matsui EC, Conover-Walker MK, Wood RA. Risk of oral 
food challenges. J Allergy Clin Immunol 2004; 114(5):1164-8. 
 
(70)  Calvani M, Sopo SM. Exercise-induced anaphylaxis caused by 
wheat during specific oral tolerance induction. Ann Allergy Asthma Immunol 
2007; 98(1):98-9. 
 
(71)  Caminiti L, Passalacqua G, Vita D, Ruggeri P, Barberio G, Pajno 
GB. Food-exercise-induced anaphylaxis in a boy successfully desensitized to 
cow milk. Allergy 2007; 62(3):335-6. 
 
(72)  Wedi B, Novacovic V, Koerner M, Kapp A. Chronic urticaria 
serum induces histamine release, leukotriene production, and basophil CD63 
surface expression--inhibitory effects ofanti-inflammatory drugs. J Allergy Clin 
Immunol 2000; 105(3):552-60. 
 
(73)  Gentinetta T, Pecaric-Petkovic T, Wan D, Falcone FH, Dahinden 
CA, Pichler WJ et al. Individual IL-3 priming is crucial for consistent in vitro 
activation of donor basophils in patients with chronic urticaria. J Allergy Clin 
Immunol 2011. 
 
(74)  Gyimesi E, Sipka S, Danko K, Kiss E, Hidvegi B, Gal M et al. 
Basophil CD63 expression assay on highly sensitized atopic donor leucocytes-a 
useful method in chronic autoimmune urticaria. Br J Dermatol 2004; 151(2):388-
96. 
 
(75)  Shertzer CL, Lookingbill DP. Effects of relaxation therapy and 
hypnotizability in chronic urticaria. Arch Dermatol 1987; 123(7):913-6. 
 
(76)  Skripak JM, Nash SD, Rowley H, Brereton NH, Oh S, Hamilton 
RG et al. A randomized, double-blind, placebo-controlled study of milk oral 
immunotherapy for cow's milk allergy. J Allergy Clin Immunol 2008; 122(6):1154-
60. 
 
(77)  Caminiti L, Passalacqua G, Barberi S, Vita D, Barberio G, De 
Luca R et al. A new protocol for specific oral tolerance induction in children with 
IgE-mediated cow's milk allergy. Allergy Asthma Proc 2009; 30(4):443-8. 

Version 3 
March 15, 2018 
27
 
(78)  Martorell A, De la Hoz B, Ibanez MD, Bone J, Terrados MS, 
Michavila A et al. Oral desensitization as a useful treatment in 2-year-old children 
with cow's milk allergy. Clin Exp Allergy 2011; 41(9):1297-304. 
 
(79)  Enrique E, Malek T, Pineda F, Palacios R, Bartra J, Tella R et al. 
Sublingual immunotherapy for hazelnut food allergy: a follow-up study. Ann 
Allergy Asthma Immunol 2008; 100(3):283-4. 
 
(80)  Fernandez-Rivas M, Garrido FS, Nadal JA, Diaz dD, Garcia BE, 
Gonzalez-Mancebo E et al. Randomized double-blind, placebo-controlled trial of 
sublingual immunotherapy with a Pru p 3 quantified peach extract. Allergy 2009; 
64(6):876-83. 
 
(81)  Vassallo MF, Banerji A, Rudders SA, Clark S, Mullins RJ, 
Camargo CA, Jr. Season of birth and food allergy in children. Ann Allergy 
Asthma Immunol 2010; 104(4):307-13. 
 
(82)  Pali-Scholl I, Jensen-Jarolim E. Anti-acid medication as a risk 
factor for food allergy. Allergy 2010. 
 
(83)  Gourbeyre P, Denery S, Bodinier M. Probiotics, prebiotics, and 
synbiotics: impact on the gut immune system and allergic reactions. J Leukoc 
Biol 2011; 89(5):685-95. 
 
(84)  Poole JA, Barriga K, Leung DY, Hoffman M, Eisenbarth GS, 
Rewers M et al. Timing of initial exposure to cereal grains and the risk of wheat 
allergy. Pediatrics 2006; 117(6):2175-82. 
 
(85)  Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki SJ, Fisher HR et 
al. Early consumption of peanuts in infancy is associated with a low prevalence 
of peanut allergy. J Allergy Clin Immunol 2008; 122(5):984-91. 
 
(86)  Katz Y, Rajuan N, Goldberg MR, Eisenberg E, Heyman E, Cohen 
A et al. Early exposure to cow's milk protein is protective against IgE-mediated 
cow's milk protein allergy. J Allergy Clin Immunol 2010; 126(1):77-82. 
 
(87)  Joseph CL, Ownby DR, Havstad SL, Woodcroft KJ, Wegienka G, 
Mackechnie H et al. Early complementary feeding and risk of food sensitization in 
a birth cohort. J Allergy Clin Immunol 2011. 
 
(88)  Koplin JJ, Osborne NJ, Wake M, Martin PE, Gurrin LC, Robinson 
MN et al. Can early introduction of egg prevent egg allergy in infants? A 
population-based study. J Allergy Clin Immunol 2010; 126(4):807-13. 
 
(89)  DesRoches A, Infante-Rivard C, Paradis L, Paradis J, Haddad E. 
Peanut allergy: is maternal transmission of antigens during pregnancy and 
breastfeeding a risk factor? J Investig Allergol Clin Immunol 2010; 20(4):289-94. 

Version 3 
March 15, 2018 
28
 
(90)  Sicherer SH, Wood RA, Stablein D, Lindblad R, Burks AW, Liu 
AH et al. Maternal consumption of peanut during pregnancy is associated with 
peanut sensitization in atopic infants. J Allergy Clin Immunol 2010; 126(6):1191-
7. 
 
(91)  Chung SY, Butts CL, Maleki SJ, Champagne ET. Linking peanut 
allergenicity to the processes of maturation, curing, and roasting. J Agric Food 
Chem 2003; 51(15):4273-7. 
 
(92)  Liu GM, Cheng H, Nesbit JB, Su WJ, Cao MJ, Maleki SJ. Effects 
of boiling on the IgE-binding properties of tropomyosin of shrimp (Litopenaeus 
vannamei). J Food Sci 2010; 75(1):T1-T5. 
 
(93)  Samson KT, Chen FH, Miura K, Odajima Y, Iikura Y, Naval RM et 
al. IgE binding to raw and boiled shrimp proteins in atopic and nonatopic patients 
with adverse reactions to shrimp. Int Arch Allergy Immunol 2004; 133(3):225-32. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Version 3 
March 15, 2018 
29
 
 
 
 
 
 
 
 
 
 
 
 

Version 3 
March 15, 2018 
30
 
 

Version 3 
March 15, 2018 
31
Appendix A : Disease burden and gaps. 
Table 2. Primary and secondary prevention measures for food allergiesa 
 
Trigg
er 
Primary 
prevention 
Route of 
desensitization 
Reference number 
Secondary prevention 
Refere
nce 
number 
Foods 
Milk 
PO, SL 
(14;76-78) 
Avoidance of allergenic food; 
education of allergic individuals and 
their care-givers on importance of 
avoidance, improved labeling of 
prepackaged foods for allergens, 
wearing of Medic-Alert bracelet stating 
specific food allergy 
154,15
5 
Egg 
PO 
(11-13) 
Peanut 
PO 
(39) 
Tree nut 
SL 
(79) 
Peach 
SL 
(80) 
a only the most common foods , drugs and insect desensitization approaches are mentioned.  
PO, Per os; SL, Sublingual; SC,  
 

Version 3 
March 15, 2018 
32
 
 
 
Table 2.Environmental factors associated with food allergy. 
Factor 
study 
Type of study 
Effect 
Reference 
number 
Season 
Vassallo 
MF  
Case control 
Children younger than 5 years born in fall or winter had a 53%  higher odds of 
food allergy compared with controls. 
(81) 
Drugs 
Palli-
Scholl  
Case control 
The relative risk to develop food-specific IgE after anti-acid therapy was 10.5 
(95% CI,1.44,76.48).  
(82) 
Microbia
l exposure 
Gourbeyr
e  
Review of case 
control and cohort 
studies 
No clear conclusion regarding probiotic beneficial effects on the prevention or 
treatment of allergy .  
(83) 
 
Food 
consumption 
(quantity 
and timing) 
Poole JA  
Cohort 
After adjusting for breastfeeding duration, introduction of rice cereal, family 
history of allergy, and history of food allergy before 6 months of age, age at initial 
exposure to cereal grains continued to be strongly associated with wheat allergy 
( 7 months: adjusted OR: 3.8; 95% CI, 1.18,12.28) 
(84) 

Version 3 
March 15, 2018 
33
Du Toit  
Case control 
After adjustment for atopy, other food allergies, age, and sex, the RR for 
peanut allergy in the UK vs Israel is  5.8 (95% CI, 2.8,11.8), and  largest and most 
significant difference in weaning between the UK and Israel was observed in the 
age of introduction of peanut (P < .0001). By 9 months of age, 69% of Israelis 
were eating peanut compared with only 10% of UK infants. 
(85) 
Katz   
Cohort 
The OR was 19.3 (95% CI, 6.0,62.1) for development of IgE mediated CMA 
among infants with exposure to cow milk protein at the age of 15 days or more (P 
< .001) vs those introduced to cow milk protein before 15 days.  
(86) 
Joseph   
Cohort 
Early feeding reduced the risk of peanut sensitization among children with a 
parental history [adjusted OR, 0.2 (95% CI, 0.1,0.7); P = .007]. The relationship 
also became significant for egg when a cutoff for IgE of ≥0.70 IU/mL was used 
[adjustedOR, 0.5 (95% CI, 0.3,0.9)]. 
(87) 
Koplin  
Case control 
Introduction of cooked egg at age 4 to 6 months, vs later exposure  reduced 
the risk of egg allergy [OR, 0.2 (95% CI, 0.06-0.71)]. 
(88) 
Des 
Roches  
Case control 
The reported consumption of peanuts during pregnancy and breastfeeding was 
higher in the case group (those who developed peanut allergy and associated with 
an increased risk of peanut allergy in offspring [OR, 4.22 (95%CI, 1.57,11.30) 
and OR, 2.28 (95% CI, 1.31,3.97) for pregnancy and breastfeeding, respectively]. 
(89) 

Version 3 
March 15, 2018 
34
Sicherer  
Case control 
Multivariate analysis including clinical, laboratory, and demographic variables 
showed frequent peanut consumption during pregnancy {OR, 2.9( 95% CI, 
1.7,4.9)] to be associated with peanut IgE ≥5 kUA/L. 
(90) 
Food 
processing 
Chung  
Laboratory analysis 
After curing and roasting, mature peanuts exhibited approximately 20% higher 
levels of advanced glycation end adducts and higher IgE binding   vs immature 
peanuts. 
(91) 
Yadzir  
Laboratory analysis 
Extracts from raw shrimp bound higher IgE than extracts from boiled shrimp, 
but the purified boiled tropomysoin (the main shrimp allergen) demonstrates 
higher IgE binding vs raw shrimp. 
(92) 
Samson  
Laboratory  
analysis 
Thermal processing can lead to the formation of new antigenic structures. 
(93) 
Vitamin 
D 
Milner  
Cohort  
Early vitamin D use (within the first 6 months of life) was associated with a 
higher risk for food allergies in the exclusively formula-fed population [OR,1.63( 
95% CI,1.21,2.20)]. Vitamin use at 3 years of age was associated with increased 
risk for food allergies but not asthma in both breastfed [OR,1.62(95% 
CI,1.19,2.21) ]and exclusively formula-fed infants [OR, 1.39( 95% CI,1.03,1.88)]. 
 
(63) 
Cramago  
Ecologic  study 
Strong north-south gradient for the prescription of EpiPens in the United 
(60) 

Version 3 
March 15, 2018 
35
States, with the highest rates found in New England. [adjusted β for New England 
vs the rest of the US, 4.07 (95%CI, 2.77,5.36)] 
Mulins et 
al  
Ecologic  study 
Using multivariate analysis , EpiPen prescription rates were higher in southern 
latitudes (less sunlight) compared with northern regions [β, −19.22( 95% CI, 
−26.71 , −11.73)]. 
(61) 
Mulins et 
al 
Ecologic  study 
Southern latitudes were associated with higher hypoallergenic formulae 
prescription rates [beta, -147.98( 95% CI,-281.83 , -14.14)]. 
(62) 
OR, odds ratio;RR, Relative Risk; CI,confidence interval ;CMA, Cow’s Milk Allergy 
 

Version 3 
March 15, 2018 
36
 
 
Appendix B. protocols. 
Initial Egg Challenge/Desensitization doses (12)*: 
Dose (n:0) 
Mg egg protein 
Dosage form 
1 
0.1 
Excipient microcrystalline cellulose 
 
2 
0.2 
   _”_ 
3 
0.4 
_”_ 
4 
0.8 
_”_ 
5 
1.5 
_”_ 
6 
3 
_”_ 
7 
6 
_”_ 
8 
12 
Dose of the powder 
 
9 
25 
_”_ 
10 
50 
_”_ 
11 
75 
_”_ 
12 
100 
_”_ 
13 
125 
_”_ 
14 
150 
_”_ 
15 
200 
_”_ 
16 
250 
_”_ 

Version 3 
March 15, 2018 
37
17 
300 
_”_ 
Increasing doses are given approximately every 30 minutes. If the subject does not 
tolerate a given dose and symptoms are mild, then that dose or the previously tolerated 
one is repeated, and the protocol proceeds as outlined. If the subject experiences 
significant symptoms, then the protocol is stopped, and the highest tolerated dose is used 
as the starting daily dose. 
 
Post – Escalation Egg challenge (Egg Protein): 
 
Number of dose  
Egg protein mg at 
each challenge 
dose  
Cumulative dose  
1 
1mg 
1 
2 
3mg 
4 
3 
10mg 
14 
4 
30mg 
44 
5 
100mg 
144 
6 
300mg 
443 
7 
600mg 
1043 
8 
1000mg 
2043 
9 
2000mg 
4043 
10 
2000mg 
6043 
 

Version 3 
March 15, 2018 
38
10 doses of powdered Meringue given every 10 to 20 minutes in increasing 
amounts up to a total of 10 g of powdered egg white (6.04 g of egg protein which 
is equivalent to 1 egg). 
Scale for Grading Reaction Severity and management  
Score  
Symptom 
Action 
Mild 
Pruritus, 
Urticaria, 
Flushing, 
Rhinoconjunctivitis 
Observe 
May 
give 
Antihistamine 
(e.g. 
Benadryl or Reactin as prescribed 
Call Research Team  
Research team will evaluate if dose 
adjustment is needed and if next dose 
will be given at home or in hospital.  
Moderate  
Angioedema, 
 Throat tightness, 
 Gastrointestinal complaints (cramping, 
. pain,vomiting,diarrhea) 
 Respiratory symptoms (Cough, Mucous 
production)  
Give epinephrine IM as per protocol  
Give Antihistamine (e.g. Benadryl or 
Reactin as prescribed 
Seek urgent care  (hospital emergency 
room) 
Call Research team 
To give next adjusted dose in hospital 
research unit (CIM) 
Severe 
Wheeze, Respiratory Distress 
Hypoxia, 
Cyanosis,  
Hypotension 
Circulatory collapse (Shock) 
Give epinephrine IM as per protocol  
Give Antihistamine (e.g. Benadryl or 
Reactin as prescribed 
Call 911 
Seek urgent care (transfer to hospital 
emergency room) 
Call Research team; if the symptoms 
are not improving within 10 minutes 
of the first dose, instructions will be 
given from the team regarding use of 
a second dose of epinephrine.  
 
 
 
 
Appendix C. Budget 
Total budget estimate: 78,000CAD per year including: 
 
 
 
Estimate (CAD) 
comment 

Version 3 
March 15, 2018 
39
Yearly salary for an 
undergraduate student for expenses 
related to training in Lab evaluation 
mechanisms for auto-immune 
urticaria detection 
35,000 
 
Study coordinator 
40,000 
Yearly salary with 
benefits 
Paediatric test center (70CAD 
for each blood sample) 
3000 
 
Staining with monoclonal Abs 
3000 
 
Use of FACS 
3000 
 
CBA 
3500 
 
Culture materials and stimulating 
material 
3500 
 
Travel expenses for presentation 
of results in scientific conferences  
5000 
 
 
78,000 
yearly 
 
 
Appendix D Study Schema 

Version 3 
March 15, 2018 
40
 
Oral food challenge/  
Rush desensitization 
Randomized 
to  
treatment 
Randomized 
to 
 Control 
1 year 
Re- Challenge 
Enter Treatment 
Escalation 
phase 
300 mg for 1 
month 
Challenge 
Follow-up for 1 
year