Primary, tertiary care clinics see similar success with iMAP milk ladder
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Key takeaways:
- Mean times to completion included 12.7 months for primary care and 15.5 months for tertiary care.
- Allergic symptom rates included 46.2% for primary care and 46.4% for tertiary care.
Primary care settings safely and effectively used the iMAP milk ladder to reintroduce cow’s milk into the diets of children with IgE-mediated cow’s milk protein allergy, according to a study published in Clinical and Translational Allergy.
Typically, tertiary care centers in Ireland use the iMAP milk ladder to manage IgE-mediated cow’s milk protein allergy (CMPA), Juan Trujillo, MD, MSc, senior lecturer in the department of pediatrics and child health at University College Cork, and colleagues wrote.
“We have been working for several years with general practitioners with a special interest in allergy who are trained by us to maintain the same management of cows’ milk and egg allergy,” Trujillo, who also is a consultant in pediatric allergy at Cork University Hospital, told Healio.
There are two problems with CMPA, Trujillo continued.
“The first one is the increase of accidental exposure as kids grow older to major allergens like milk. The other one is that the passive role of the specialist and caregivers in the classical management of IgE-mediated CMPA needs to change,” he said.
These problems could be better managed with advanced dietary therapy such as the milk ladder, Trujillo said.
Study design, results
The cohort comprised 13 patients (6 boys) in a primary care clinic and 69 patients (42 boys) from a tertiary care clinic treated for IgE-mediated CMPA with the iMAP milk ladder between 2015 and 2021.
Mean ages at diagnosis of CMPA included 8.5 months for the primary care group and 11.14 months for the tertiary care group.
Clinical staff taught parents how to use the adapted Milk Allergy in Primary Care guideline, which uses 12 steps to reintroduce foods with different amounts of milk protein into the diets of children with CMPA.
The researchers defined success as intake of more than 150 mL of cow’s milk or an equivalent intake of 4.5 g of milk protein daily at step 12. Treatments that did not introduce liquid cow’s milk after 36 months of follow-up were considered failures.
Eleven (85%) of the 13 patients in the primary care group and 57 (83%) of the 69 patients in the tertiary care group successfully completed the ladder. Mean times to completion included 12.7 months (95% CI, 6.1-19.3 months) for the primary care group and 15.5 months (95% CI, 12.2-18.8 months) for the tertiary care group.
Also, the primary care group achieved tolerance in 25 months (95% CI, 15.4-34.6 months) and the tertiary care group achieved tolerance in 30.4 months (95% CI, 24.87-35.98 months).
Mean appointment totals included 3.5 (95% CI, 1.3-5.6) for the primary care group and 2.3 (95% CI, 2-2.7) for the tertiary care group, but this difference did not affect success rates, according to the researchers.
Further, 46.2% of the primary care group and 46.4% of the tertiary care group experienced allergic symptoms. Most symptoms were cutaneous, including 83.3% of the primary care group and 46.4% of the tertiary care group, or gastrointestinal, including 33.3% of the primary care group and 40% of the tertiary care group.
The milk ladder did not lead to any cases of anaphylaxis, although three patients in the primary care group and eight patients in the tertiary care group experienced accidental exposures, with one case of anaphylaxis in each group.
“None of the patients that were diagnosed with anaphylaxis due to CMPA first exposure had problems in maintaining and progressing in the milk ladder,” Trujillo said.
Although mild allergic reactions are common as children progress on the ladder, the researchers wrote, parents are trained to manage these reactions so the children can continue their progress.
Conclusions, next steps
Based on these findings, the researchers concluded that primary care settings can employ the iMAP milk ladder to reintroduce cow’s milk protein into the diets of children with IgE-mediated CMPA as safely and as effectively as tertiary care settings.
In fact, Trujillo said that a well-established primary care center with a trained staff can take care of patients diagnosed with low-yield IgE-mediated CMPA by using the milk ladder.
“A tertiary specialized center is not needed,” Trujillo said.
But general practitioners (GPs) need more than guidelines if they want to begin using the iMAP ladder with their patients, Trujillo warned.
“What a GP needs is to be prepared in the allergy field with courses or, if possible, postgraduate programs like the ones that we have in the U.K. or Ireland that allow them to critically and properly engage with patients with allergic conditions and to know how to handle a patient that needs to use a milk ladder,” he said.
However, the researchers also recommended further prospective and randomized studies to support general practitioners as they use the iMAP milk ladder in their clinical practice.
“The research was part of a retrospective comparison of different strategies to treat IgE-mediated CMPA,” Trujillo said.
Trujillo and his colleagues have finished their analysis and expect to publish three more studies in relation to this project.
“The next step will be using what we know to make it a prospective observational study that will increase the statistical power of the project,” he said.
For more information:
Juan Trujillo, MD, MSc, can be reached at juan.trujillo@ucc.ie.