{"http:\/\/dx.doi.org\/10.14288\/1.0420748":{"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool":[{"value":"Land and Food Systems, Faculty of","type":"literal","lang":"en"},{"value":"Medicine, Faculty of","type":"literal","lang":"en"},{"value":"Pediatrics, Department of","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider":[{"value":"DSpace","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#identifierCitation":[{"value":"Allergy, Asthma & Clinical Immunology. 2022 Jun 12;18(1):51","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/contributor":[{"value":"Children's Hospital (Vancouver, B.C.). Research Institute","type":"literal","lang":"en"},{"value":"University of British Columbia. Food, Nutrition and Health Program","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#rightsCopyright":[{"value":"The Author(s)","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/creator":[{"value":"Chua, Gilbert T.","type":"literal","lang":"en"},{"value":"Chan, Edmond S.","type":"literal","lang":"en"},{"value":"Yeung, Joanne","type":"literal","lang":"en"},{"value":"Cameron, Scott B.","type":"literal","lang":"en"},{"value":"Soller, Lianne","type":"literal","lang":"en"},{"value":"Williams, Brock","type":"literal","lang":"en"},{"value":"Chomyn, Alanna","type":"literal","lang":"en"},{"value":"Vander Leek, Timothy K.","type":"literal","lang":"en"},{"value":"Abrams, Elissa M.","type":"literal","lang":"en"},{"value":"Mak, Raymond","type":"literal","lang":"en"},{"value":"Wong, Tiffany","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/issued":[{"value":"2022-09-27T18:55:15Z","type":"literal","lang":"en"},{"value":"2022-06-12","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/description":[{"value":"A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity from extensively heated forms, such as baked goods, to less processed products. While widely considered safe, the food ladder is not risk-free and most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies, and with no or well-controlled asthma. We propose a Food Ladder Safety Checklist to assist with patient selection using \u201c4 A's\u201d based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence.","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO":[{"value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/82768?expand=metadata","type":"literal","lang":"en"}],"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note":[{"value":"Chua\u00a0et\u00a0al. Allergy, Asthma & Clinical Immunology           (2022) 18:51  https:\/\/doi.org\/10.1186\/s13223-022-00696-wLETTER TO THE EDITORPatient selection for\u00a0milk and\u00a0egg ladders using a\u00a0food ladder safety checklistGilbert T. Chua1,2,3*  , Edmond S. Chan4,5, Joanne Yeung4, Scott B. Cameron4,6, Lianne Soller4,5, Brock A. Williams4,7, Alanna Chomyn4, Timothy K. Vander Leek8, Elissa M. Abrams4,9, Raymond Mak4 and Tiffany Wong4,5 Abstract A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity from extensively heated forms, such as baked goods, to less processed products. While widely considered safe, the food ladder is not risk-free and most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies, and with no or well-controlled asthma. We propose a Food Ladder Safety Checklist to assist with patient selection using \u201c4 A\u2019s\u201d based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence.Keywords: Food ladders, Milk allergy, Egg allergy, Safety\u00a9 The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article\u2019s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article\u2019s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:\/\/ creat iveco mmons. org\/ licen ses\/ by\/4. 0\/. The Creative Commons Public Domain Dedication waiver (http:\/\/ creat iveco mmons. org\/ publi cdoma in\/ zero\/1. 0\/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.To the\u00a0Editor,In May 2021, a young girl in Ontario, Canada, with a history of milk allergy and long-standing asthma, passed away while undergoing a therapy that some have described as a milk ladder, although media reports suggest she did not increase beyond tiny amounts of milk-containing muffin [1, 2]. This tragic incident deeply saddens the allergy community, and underscores the need for careful patient selection and close monitoring of patients undergoing all forms of dietary advancement therapy. This article discusses the benefits, risks, and precautions of food ladders as a form of dietary advancement therapy, as well as how to help our patients and families decide whether ladders are an appropriate treatment option through a shared decision-making process. We propose a Food Ladder Safety Checklist to assist with patient selection.What is\u00a0a\u00a0food ladder?A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food. Egg and milk ladders are the two typical forms of food ladders used clinically. The goal of the food ladder is to facilitate the development of natural tolerance through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity through different cooking processes, typically with gradual progression from baked products (e.g., biscuits, muffin), to well-cooked forms (e.g., pancakes, waffles, hard-boiled eggs) and finally to less processed products (e.g., fresh mousse, fresh ice cream) [3]. It has been widely used in Europe and was initially designed to manage non-IgE-mediated food allergies [4, 5]. Subsequently, application of the food ladder has been extrapolated to management of IgE-mediated milk and egg allergy, which has been generally safe and effective [6\u20138].Open AccessAllergy, Asthma & Clinical Immunology*Correspondence:  cgt560@hku.hk1 Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1\/F, New Clinical Building, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong,, SAR, ChinaFull list of author information is available at the end of the articlePage 2 of 5Chua\u00a0et\u00a0al. Allergy, Asthma & Clinical Immunology           (2022) 18:51 What are the\u00a0benefits and\u00a0risks of\u00a0the\u00a0food ladder?The primary benefits of home-based treatments such as milk and egg ladders include the demedicalization of food (by providing a structured approach which still allows flexibility in options and pace at which individuals proceed), and reduction in health care utilization. For example, they allow practitioners the ability to allocate limited in-person appointments for oral food challenges and oral immunotherapy to other patients who are too high-risk for home-based treatments. While some practitioners offer a starting dose in the office, home-based therapies typically involve fewer in-office visits. Studies have shown that even home-based oral immunotherapy for IgE-mediated food allergy can be feasible and safe with very carefully selected patients [9, 10], which offers hope for facilitating early commencement of dietary advancement therapy where resources are limited with long waiting times, especially during the COVID-19 pandemic when there were limited non-emergency elective services and lack of regular in-office visits [11, 12].Ball et\u00a0al. retrospectively studied 86 children with mild milk allergies who started home-based milk introduction between 8 to 33\u00a0months of age; 68 of 86 subjects (79.1%) reached the top of the milk ladder at the two-year mark and two additional subjects tolerated all dairy products at the fourth review. None developed anaphylaxis or required epinephrine autoinjector [6]. Gotesdyner et\u00a0 al. studied 39 children under two years old with mild egg allergy and treated them using a structured graduated exposure protocol, and compared with a matched group of 80 children who were advised to strictly avoid egg at least until two years old or earlier natural resolution and followed to a median age of 69\u00a0 months. The age of egg allergy resolution in the treatment group was significantly younger than the control group (median age 24\u00a0months vs. 78\u00a0 months, p < 0.001), and 82% of children in the treatment group were able to tolerate lightly cooked eggs, versus 54% in the control group (p = 0.001) [8]. Thomas et\u00a0al. retrospectively reviewed 98 children with a median age of 40\u00a0months with mild egg allergy and were managed with egg ladder. 43% were managed with an egg ladder over an average of 15.5\u00a0months. Only two children had severe reactions, and one required adrenaline; those with severe reactions resumed the ladder and progressed to the last two steps (lightly cooked whole egg or raw egg) successfully. A high proportion (78.7%) of the parents felt satisfied or very satisfied with the egg ladder [7] (Table\u00a01).Patient selection for\u00a0milk and\u00a0egg\u2011allergic patientsLike any other dietary advancement therapy, the food ladder should be considered a form of oral immunotherapy and therefore not risk-free. Most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies without a history of anaphylaxis (who have a high likelihood of outgrowing their food allergy), together with well-controlled or no asthma, and families who could follow food allergy management and anaphylaxis action plans [6\u20138] (Table\u00a01). Other studies limited the inclusion of egg and milk allergic subjects who had passed a baseline oral food challenge to baked egg or milk, and used the food ladder as a tool to facilitate the desensitization process [5].Emerging real-world evidence has demonstrated that performing oral immunotherapy for food allergy early, especially during infancy and preschool age (< 6\u00a0 years old), is significantly safer, more effective, and more likely to result in sustained unresponsiveness, compared to starting later in older children [13\u201319]. It is also known that infants and toddlers have fewer allergic reactions involving the respiratory, cardiovascular, and neurological systems compared to older children [20\u201322]. Evidence on the safety of using food ladders to desensitize older children and adolescents with persistent allergy to baked egg and milk is also lacking. Therefore, patients with persistent higher-risk phenotypes such as those with older age (> 6\u00a0years old), previous anaphylactic reactions to extensively baked forms of food (especially involving the respiratory and cardiovascular systems), a prior history of allergic reaction at a very low trigger threshold, poor asthma control, or psychosocial factors (e.g. families unable to adhere to instructions or follow-up) are not suitable candidates for food ladders [6, 7].Pre\u2011requisites for\u00a0administering food ladders safelyThe food ladder should be administered by well-trained and experienced healthcare professionals with the necessary expertise and experience in food allergy and anaphylaxis management, performance of oral food challenges, and careful selection of patients for food immunotherapy [2]. Patient informed consent should be obtained, and patients should be aware of cofactors that could lower reaction threshold while on any dietary advancement therapy, including febrile illnesses, exercise, hot baths, dosing on an empty stomach, and an increase in total allergen exposure such as dust mite and pollen [23, 24]. Allergists should be readily available to address patient concerns and reactions,and to ensure families are confident and competent at treating anaphylaxis before offering ladders. Allergists should also be aware of conditions where using food ladders as a dietary advancement therapy could be risky and less effective. On-going close follow-up with the allergist administering the food ladders is essential to ensure the safety, ongoing Page 3 of 5Chua\u00a0et\u00a0al. Allergy, Asthma & Clinical Immunology           (2022) 18:51  Table 1 Summary of studies using egg and milk ladders to treat IgE-mediated egg and milk allergyIgE Immunoglobulin E, IQR interquartile range, OFC oral food challenge, SPT skin prick testingAuthor\/Year\/Study Type\/LadderInclusion criteriaExclusion criteriaNo of subjects in active treatment groupAgeMain outcomes% of any adverse reactionsAnaphylaxisRisk factors for anaphylaxisBall et al.\/2019 [6]Retrospective chart review\/Milk LadderIgE-mediated cow\u2019s milk allergy based on clinical history and positive SPT\u2013 Cow\u2019s milk allergic reactions occurring with trace baked milk ingestion\u2013 Allergic reactions involving the respiratory or cardiovascular systems\u2013 History of recurrent wheeze\u2013 SPT > 8 mm86Median 13 months (range 8\u201433 months)\u2013 68 subjects (79.1%) reached the top of the milk ladder by the two-year mark\u2013 2 subjects tolerated all dairy products at the fourth review80%NoneN\/AGotesdyner et al.\/2019 [8]Case Control Study\/Egg Ladder-Children < 2 years old-IgE\u2010mediated egg allergy diagnosed by OFC or by positive SPT and\/or positive IgE along with a clinical history of an immediate allergic reaction after exposure to cooked or fried eggs in the past yearChildren with a history of allergic reaction to baked egg were excluded from the control group39Median 16 months (IQR: 14\u201419 months)\u2013 Significantly younger age of allergen resolution in the treatment group than the control group (median age 24 months vs. 78 months, p < 0.001)\u2013 82% of children in the treatment group were able to tolerate lightly cooked eggs, versus 54% in the control group (p = 0.001)23%One patient developed anaphylaxis (rash and vomiting) and EpiPen was given. The protocol was stopped and the child continued with egg avoidanceNot mentionedThomas et al.\/2021 [7]Retrospective study\/Egg Ladder\u2013 Single food allergy\u2013 History convincing of IgE-mediated egg allergy\u2013 Mild or no eczema\u2013 No or well-controlled asthmaWritten action plan for food allergy management andeducation providedHistory of anaphylaxis to any food containing egg or a non-IgE-mediated egg allergy47Mean age 40 months (IQR: 12\u201360 months)43% were able to complete the egg ladder over an average of 15.5 months59.60%Two patients had severe reaction (by parent report). One was treated with adrenalineNot mentionedPage 4 of 5Chua\u00a0et\u00a0al. Allergy, Asthma & Clinical Immunology           (2022) 18:51 understanding of the procedures and to ensure new unexpected risk factors (e.g. loss of asthma control) have arisen. We propose a Food Ladder Safety Checklist to assist with patient selection using \u201c4 A\u2019s\u201d based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence (Additional file\u00a0 1). Allergists may decline or delay offering food ladders while optimizing any modifiable factors, such as asthma, or opt for an alternative dietary advancement therapy such as oral immunotherapy (OIT).A shared decision\u2011making process to\u00a0making the\u00a0most suitable choiceShared decision-making (SDM) refers to the process by which patients play an active role in managing their health [25] It is also a bidirectional conversation that incorporates pros and cons of approaches and integrates patient preferences into decision making. This is different from informed consent, in which patients only agree or disagree with a treatment option. SDM involves three steps: (i) creating choice awareness but providing an unbiased list of options, (ii) discussing options based on clinical relevance and current medical evidence, and (iii) discussing patient preferences, i.e., \u201cwhat matters most\u201d to the patient. It is essential to clarify goals and expectations of treatment, experience with previous management strategies, and possible fears. In the context of food allergy, it is important that the allergist provides different options to patients and families [25]. For example, if a patient has multiple food allergies, an option of milk or egg OIT instead of ladders could be incorporated as part of a multiple food OIT protocol, which has also been shown to be safe and effective [26] Ultimately, for patients with identified contraindications such as uncontrolled asthma, or where dose adherence would be unlikely, strict avoidance while carrying an epinephrine autoinjector and future reassessment for spontaneous resolution might be a better option [27].ConclusionMilk and egg ladders are safe and effective dietary advancement therapies, in patients who have a high likelihood of outgrowing their milk and egg allergies. Nevertheless, any form of dietary advancement therapy carries a risk of allergic reaction, including anaphylaxis, as these patients are still allergic to milk and egg at baseline. Careful attention needs to be paid to proper patient selection and managing allergic comorbidities such as asthma, prior to initiating a milk or egg ladder, and a food ladder safety checklist can assist with patient selection. Despite recent media reports, the risk of death with milk\/egg ladders or food immunotherapy in carefully selected patients is extremely remote, and does not exceed the risk of death from avoidance or other forms of allergen immunotherapy such as subcutaneous immunotherapy with aeroallergens [2].AbbreviationsIgE: Immunoglobulin E; IQR: Interquartile range; OFC: Oral food challenge; OIT: Oral immunotherapy; SDM: Shared decision-making; SPT: Skin prick testing.Supplementary InformationThe online version contains supplementary material available at https:\/\/ doi. org\/ 10. 1186\/ s13223- 022- 00696-w.Additional file\u00a01. The food ladder safety checklist.AcknowledgementsNone.Author contributionsGTC and ESC drafted the manuscript. JY, SCB, AC, TVL, contributed substantially to the conception of the study. LS, BW, EA, RM critically revised the manuscript. TW supervised and led the study. All authors read and approved the final manuscript and agreed both to be personally accountable for the author\u2019s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All authors read and approved the final manuscript.FundingThis study was supported by the University of Hong Kong Seed Fund for Basic Research for New Staff (Project code: 202009185024).Availability of data and materialsNot applicable.DeclarationsEthics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsGTC is the council member of the Hong Kong Institute of Allergy and the Hong Kong Allergy Association. LS and BW have no conflicts of interest to declare. ESC has received research support from DBV Technologies; has been a member of advisory boards for Pfizer, Pediapharm, Leo Pharma, Kaleo, DBV, AllerGenis, Sanofi Genzyme, Bausch Health, Avir Pharma, ALK; is a member of the healthcare advisory board for Food Allergy Canada; and was co-lead of the CSACI oral immunotherapy guidelines. JY received speaking honoraria from UBC CPD, Sanofi, AstraZeneca, Pfizer, Stallergenes Greer, Novartis, Pediapharm, Medexus Pharma. She has served on advisory\/consultancy committees for Sanofi, Pfizer, HealthLinkBc, Stallergenes Greer, and LEO Pharma. SBC has been a member of advisory boards for Bausch Health, and Pfizer, and was a committee member of the CSACI oral immunotherapy guidelines. TV has served on advisory boards and received honoraria from Aralez\/Miravo, Bausch Health, and Pfizer. EA is a collaborator with the Institute for Health Metrics and Evaluation. She is an employee of Public Health Agency of Canada (PHAC), but the views expressed are her own and not that of PHAC. RM is an advisory board member for ALK, Sanofi, Pfizer and has received speaker honoraria from Novartis, Pediapharm, CSL Behring and Astrazeneca. TW has been a member of advisory boards for Sanofi, Cerave, Leo Pharma and Miravo and has received speaker honoraria from Pfizer and Stallergenes Greer.Page 5 of 5Chua\u00a0et\u00a0al. Allergy, Asthma & Clinical Immunology           (2022) 18:51  \u2022 fast, convenient online submission \u2022  thorough peer review by experienced researchers in your field\u2022  rapid publication on acceptance\u2022  support for research data, including large and complex data types\u2022  gold Open Access which fosters wider collaboration and increased citations  maximum visibility for your research: over 100M website views per year \u2022  At BMC, research is always in progress.Learn more biomedcentral.com\/submissionsReady to submit your research ?  Choose BMC and benefit from: Author details1 Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 1\/F, New Clinical Building, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong,, SAR, China. 2 Department of Paediatrics and Adolescent Medicine, The Hong Kong Children\u2019s Hospital, Hong Kong, SAR, China. 3 Department of Paediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. 4 Division of Allergy and Immunology, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada. 5 British Columbia Children\u2019s Hospital Research Institute, Vancouver, BC, Canada. 6 Community Allergy Clinic, Victoria, BC, Canada. 7 Food, Nutrition, and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, BC, Canada. 8 Department of Pediatrics, Pediatric Allergy & Asthma, University of Alberta, Edmonton, AB, Canada. 9 Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada. Received: 18 March 2022   Accepted: 30 May 2022References 1. Mondello W. Girl with milk allergy dies of severe reaction related to desensitization 2021. https:\/\/ www. aller gicli ving. com\/ 2021\/ 12\/ 20\/ girl- with- milk- aller gy- dies- of- severe- react ion- relat ed- to- desen sitiz ation\/. 2. CSACI\/BSACI Statement on OIT 2022. https:\/\/ www. csaci. ca\/ wp- conte nt\/ uploa ds\/ 2022\/ 01\/ CSACI-_- BSACI- State ment- on- OIT. pdf. 3. Leech SC, Ewan PW, Skypala IJ, Brathwaite N, Erlewyn-Lajeunesse M, Heath S, et al. BSACI 2021 guideline for the management of egg allergy. Clin Exp Allergy. 2021;51(10):1262\u201378. 4. Venter C, Brown T, Shah N, Walsh J, Fox AT. Diagnosis and management of non-IgE-mediated cow\u2019s milk allergy in infancy\u2014a UK primary care practical guide. Clin Transl Allergy. 2013;3(1):23. 5. Lambert R, Grimshaw KEC, Ellis B, Jaitly J, Roberts G. Evidence that eating baked egg or milk influences egg or milk allergy resolution: a systematic review. 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Grass pollen allergy as an anaphylaxis cofactor during peanut oral immunotherapy. Ann Allergy Asthma Immunol. 2021;127(2):263\u20134. 25. Graham F, Mack DP, B\u00e9gin P. Practical challenges in oral immunotherapy resolved through patient-centered care. Allergy Asthma Clin Immunol. 2021;17(1):31. 26. Eapen AA, Lavery WJ, Siddiqui JS, Lierl MB. Oral immunotherapy for multiple foods in a pediatric allergy clinic setting. Ann Allergy Asthma Immunol. 2019;123(6):573-81.e3. 27. Foong R-X, Santos AF. Biomarkers of diagnosis and resolution of food allergy. Pediatr Allergy Immunol. 2021;32(2):223\u201333.Publisher\u2019s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/isShownAt":[{"value":"10.14288\/1.0420748","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/language":[{"value":"eng","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#peerReviewStatus":[{"value":"Reviewed","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/provider":[{"value":"Vancouver : University of British Columbia Library","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/publisher":[{"value":"BioMed Central","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#publisherDOI":[{"value":"10.1186\/s13223-022-00696-w","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/rights":[{"value":"Attribution 4.0 International (CC BY 4.0)","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#rightsURI":[{"value":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#scholarLevel":[{"value":"Faculty","type":"literal","lang":"en"},{"value":"Researcher","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/subject":[{"value":"Food ladders","type":"literal","lang":"en"},{"value":"Milk allergy","type":"literal","lang":"en"},{"value":"Egg allergy","type":"literal","lang":"en"},{"value":"Safety","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/title":[{"value":"Patient selection for milk and egg ladders using a food ladder safety checklist","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/type":[{"value":"Text","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#identifierURI":[{"value":"http:\/\/hdl.handle.net\/2429\/82768","type":"literal","lang":"en"}]}}