Food, drug, insect sting allergy, and anaphylaxis
Dietary baked milk accelerates the resolution of cow’s milk allergy in children

https://doi.org/10.1016/j.jaci.2011.04.036Get rights and content

Background

The majority (approximately 75%) of children with cow’s milk allergy tolerate extensively heated (baked) milk products. Long-term effects of inclusion of dietary baked milk have not been reported.

Objective

We report on the outcomes of children who incorporated baked milk products into their diets.

Methods

Children evaluated for tolerance to baked milk (muffin) underwent sequential food challenges to baked cheese (pizza) followed by unheated milk. Immunologic parameters were measured at challenge visits. The comparison group was matched to active subjects (by using age, sex, and baseline milk-specific IgE levels) to evaluate the natural history of development of tolerance.

Results

Over a median of 37 months (range, 8-75 months), 88 children underwent challenges at varying intervals (range, 6-54 months). Among 65 subjects initially tolerant to baked milk, 39 (60%) now tolerate unheated milk, 18 (28%) tolerate baked milk/baked cheese, and 8 (12%) chose to avoid milk strictly. Among the baked milk–reactive subgroup (n = 23), 2 (9%) tolerate unheated milk, and 3 (13%) tolerate baked milk/baked cheese, whereas the majority (78%) avoid milk strictly. Subjects who were initially tolerant to baked milk were 28 times more likely to become unheated milk tolerant compared with baked milk–reactive subjects (P < .001). Subjects who incorporated dietary baked milk were 16 times more likely than the comparison group to become unheated milk tolerant (P < .001). Median casein IgG4 levels in the baked milk–tolerant group increased significantly (P < .001); median milk IgE values did not change significantly.

Conclusions

Tolerance of baked milk is a marker of transient IgE-mediated cow’s milk allergy, whereas reactivity to baked milk portends a more persistent phenotype. The addition of baked milk to the diet of children tolerating such foods appears to accelerate the development of unheated milk tolerance compared with strict avoidance.

Section snippets

Participants

Subjects were recruited from the Mount Sinai pediatric allergy clinics from June 2004 to October 2007. The study was approved by the Mount Sinai Institutional Review Board, and informed consent was obtained. Eligible subjects were aged 0.5 to 21 years, had positive skin prick test (SPT) responses or detectable serum milk-specific IgE, and had a history of an allergic reaction to milk within 6 months before study entry or milk-specific IgE levels or SPT responses greater than 95% of predicted

Unheated milk tolerance within the active group

Eighty-nine children (median age, 6.6 years; range, 2.1-17.3 years) were enrolled17; 1 subject was not followed beyond baseline. Over a median of 37 months (range, 8-75 months), 88 children were challenged to progressively less heated forms of milk at varying intervals (range, 6-54 months). Among 88 “active” children, 41 (47%) now tolerate unheated milk, 21 (24%) tolerate some form of baked milk/baked cheese in their diet, and 26 (30%) avoid all forms of milk (Table I, intent-to-treat).

Unheated milk tolerance within the active group stratified by initial baked milk challenge outcome

Among 88

Discussion

Cow’s milk is the most common food allergen among children. Currently, there is no cure for food allergy. The standard of care focuses on strict dietary avoidance,1 which is extremely difficult but has been the cornerstone of food allergy therapy for decades. The advice is practical because the amount of allergen necessary to induce an allergic reaction varies22 and the severity of reactions is unpredictable.23, 24 Additionally, there has been a theory that lack of exposure will result in

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    Supported by grant AI 44236 from the National Institute of Allergy and Infectious Diseases and in part by grant CTSA ULI RR 029887 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCRR or NIH.

    Disclosure of potential conflict of interest: J. S. Kim receives research support from the National Institutes of Health. S. H. Sicherer has consultant arrangements with the Food Allergy Initiative, is an advisor for the Food Allergy and Anaphylaxis Network, and receives research support from the National Institute of Allergy and Infectious Diseases and the Food Allergy Initiative. S. Noone has received speaker’s honoraria from the Food Allergy and Anaphylaxis Network, is a reviewer for Up-to-Date, and is a volunteer newsletter reviewer for the Food Allergy and Anaphylaxis Network. H. A. Sampson has consultant arrangements with Allertein Therapeutics, LLC, and the Food Allergy Initiative; receives research support from the Food Allergy Initiative and the National Institutes of Health/National Institute of Allergy and Infectious Diseases; is a consultant/scientific advisor for the Food Allergy Initiative; is a Medical Advisor for the Food Allergy and Anaphylaxis Network; is a Scientific Advisor for the University of Nebraska—FARRP; and is 45% owner of Herb Springs, LLC. The rest of the authors have declared that they have no conflict of interest.

    These authors contributed equally to this work.

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