“Food, milk and egg ladders look the same, but they’re not the same.”

– Dr. Juan Trujillo

Ladders are close to standard in some clinics now. The evidence that they change the course of anything is still thin. So families are climbing, clinicians are advising, and nobody has settled the question underneath: is a ladder modifying the disease, or is it keeping everyone busy while a child outgrows it on schedule? On this episode, Dr. Mariam Hanna puts that to someone who has lived with the question longer than most.

Dr. Juan Trujillo is a consultant paediatric allergist at Cork University Hospital and a senior lecturer at University College Cork. He is careful not to oversell. There isn’t much literature to go on, he says, so ladder practice ends up tracking something else: how many appointments a clinic can offer. In a stretched service, a ladder can mean fewer visits rather than more. When it comes to egg and milk allergies, different ladders, different timelines, different success rates. Clinics tend to treat them as one thing. Trujillo doesn’t.

On this episode, they discuss:

• The evidence base is incomplete. Practice moved ahead anyway, largely because indefinite avoidance is not a neutral default.
• In resource-limited systems, ladders can reduce appointments rather than generate them.
• Milk and egg are not interchangeable and should not be presented to families as though they are.
• Skin testing, specific IgE and components will diagnose the allergy. They will not give you the threshold, and they will not tell you who is going to climb.
• Counting milligrams of protein overcomplicates what is, for most young children, dietary advancement.
• Age matters. The younger the child, the better the prospects. Older than five, Trujillo approaches with caution.
• Patient selection is doing more of the work than any step-by-step protocol.

In young children, selected carefully and supported properly, ladders are worth doing on practical grounds, whether or not they turn out to be disease modifying.

Posted on August 4, 2026.