Food ladder use among ASCIA-affiliated clinicians in Australia and New Zealand: an exploratory descriptive survey

Background: Food ladders are clinician-guided graded dietary advancement tools used in selected patients with food allergy, but real-world implementation in Australia and New Zealand is not well described. Objective: To characterise respondent-reported food ladder use and implementation patterns among ASCIA-affiliated clinicians in Australia and New Zealand. Method: We conducted a cross-sectional online survey of ASCIA-affiliated healthcare professionals from 1 to 30 June 2024. Invitations were distributed via the ASCIA email distribution list. Analyses were descriptive, with percentages calculated using valid-response denominators. Results: Seventy clinicians participated: Australia 45/70 (64.3%) and New Zealand 25/70 (35.7%). Disciplines included allergy/immunology specialists (29/70, 41.4%), general paediatricians (13/70, 18.6%), nurses/nurse practitioners (10/70, 14.3%), dietitians (10/70, 14.3%), trainee doctors (7/70, 10.0%), and one general practitioner (1/70, 1.4%). Most primarily saw paediatric patients (53/70, 75.7%). Food ladder use was commonly reported among respondents (66/70, 94.3%). Among ladder users, most reported use in both IgE- and non-IgE-mediated contexts (47/66, 71.2%); milk (65/66, 98.5%) and egg (64/66, 97.0%) ladders predominated. Standardised ladders, recipes, and home introduction protocols were reported by 43/66 (65.2%), 43/66 (65.2%), and 45/66 (68.2%) respondents, respectively. Prior anaphylaxis to the proposed ladder food (51/66, 77.3%) and poorly controlled asthma (38/66, 57.6%) were the most frequently cited contraindications. In scenario responses, clinicians were least likely to recommend a ladder when there was prior anaphylaxis to the relevant food: milk 9/70 (12.9%) and egg 13/70 (18.6%). Conclusion: Among respondents, food ladder use was commonly reported, particularly for milk and egg allergy, with variability in implementation supports and in responses to higher-risk scenarios. These exploratory, self-reported findings are descriptive and hypothesis-generating. Together, they encourage further prospective evaluation and consensus-based standardisation.