Milk ladder therapy successful in mediating cow’s milk allergy
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Key takeaways:
- Infants in the milk ladder group were almost four times more likely to be successful in reintroducing cow’s milk.
- Infants without other food allergies were more likely to be successful in reintroduction.
Dietary advancement therapy using a milk ladder shows that cow’s milk can be safely reintroduced to infants with a cow’s milk allergy, according to a study in Pediatric Allergy and Immunology.
“The conventional strategy to re-introduce milk in patients with CMPA (cow’s milk protein allergy) IgE mediated relies on a full avoidance of milk protein until performing an oral food challenge to introduce milk,” Juan Trujillo, MD, PhD, pediatric allergist at Cork University Hospital and senior lecturer in the department of pediatrics and child health at University College Cork, told Healio.
“This strategy needs several outpatient follow-ups and allergy tests like skin prick testing and specific IgE to decide the optimal timing to complete an OFC,” Trujillo continued. “This could take a prolonged time depending on several factors.”
He further explained that Ireland has been using the milk ladder, which is a step-by-step approach to reintroducing cow’s milk into the diet, for over a decade with demonstrated results; however, a comparison between the two strategies has not been performed.
Methods
This multicenter retrospective study consisted of two cohorts from two pediatric allergy centers between 2011 and 2020 that underwent different methods of IgE-mediated CMPA management. One cohort (n = 171; mean age, 12 months; 57.9% boys) participated in the milk ladder in Cork, Ireland, and the other (n = 200; mean age, 5 months; 63% boys) practiced complete avoidance in Mostoles, Spain.
The main outcomes of the study included the successful reintroduction of 150 mL of cow’s milk that had 4.5 g of milk protein at a daily rate without any resulting symptoms. Success was determined by completing the iMAP milk ladder in the milk ladder cohort and an OFC in the avoidance cohort.
To determine IgE-mediated CMPA, patients needed to have an immediate presence of cutaneous, gastrointestinal, respiratory, and/or systemic anaphylaxis symptoms to the allergen and an SPT of at least 3 mm or specific IgE levels for cow’s milk of more than 0.35 kU/L.
Results
SPTs were completed for 192 participants in the avoidance group (mean SPT, 2.9 mm; 95% CI, 0.2-5.6) and 169 in the milk ladder group (4.59 mm; 95% CI, 2.87-6.3) whereas IgE was tested in 11 avoidance participants (12.6 kIU/mL) and 137 milk ladder participants (18.64 kIU/mL).
Among all participants, 270 (72.8%) achieved successful reintroduction to milk. Within the milk ladder group, 148 participants (86.6%; 95% CI, 80.6%-90.9%) were successful compared with 122 participants (61%; 95% CI, 54.1%-67.5%) in the milk avoidance group.
Within the milk avoidance group, 106 participants experienced accidental milk exposure resulting in 34 of them having an anaphylactic reaction. In the milk ladder group, 32 patients were accidentally exposed to milk with three resulting in an anaphylactic reaction.
“Successful re-introduction of milk into patients’ diet in the milk ladder group was expected (86% in milk ladder vs. 61% in milk avoidance); however, 25% more than the avoidance group was more than we were thinking,” Trujillo said. “The biggest surprise for us was to find out such a big difference between the number of accidental exposures (18.7% in milk ladder vs. 53% in milk avoidance).”
Researchers also found a lower value of whole milk-specific IgE was associated with successful treatments in the milk ladder group (P < .01). When it came to analyze the association of other food allergies with treatment outcomes, researchers found that among the whole cohort, participants without other food allergies were likelier to succeed in milk reintroduction, specifically those without a nut or peanut allergy. There was a negative association between the presence of asthma/viral-induced wheeze (P < .001), allergic rhinitis (P = .01) and other nut allergies (P = .012) with the success of treatment. Overall, participants in the milk ladder group were 3.67 times more likely to succeed vs. participants in the milk avoidance group (P < .001).
Trujillo said that he and his team attempted to rationalize the potential causes for these findings.
“If patients are currently using an active milk ladder strategy, every accidental exposure to products below the step of the ladder that the patient has achieved will not result in a reaction,” he said. “Parents will not be aware there was an exposure to milk outside this management.”
He further explained that due to the increase in successful reintroduction in the milk ladder group, there is a possibility that the timeline of outgrowing allergy in these patients is shortened, giving the milk ladder group fewer reactions as they achieve the reintroduction faster.
“The role of dietetics advance therapy such as the milk ladder shows promising opportunities in favor of the patient,” Trujillo said. “There is a decrease in the number of follow-ups, less complementary tests and active involvement of caregivers into the introduction of diet.”
Trujillo noted several limitations in this study including the retrospective cohort and the characteristics of participants between the Irish and Spanish groups, adding that the study will raise more questions than answers that he and his colleagues hope to respond to in future research.
“We like to think that this is the beginning of more in-depth research about the use of other managements outside the classical avoidance for patients with food allergy,” he said.
Perspective
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Kathleen Garcia-Benson, RDN, CSSD, LD, NASM-CPT, NBC-HWC
Maintaining good nutrition is vital for everyone, especially children, as it sets the foundation for long-term health. Milk is often recommended because it is a nutrient-dense source of essential macronutrients (protein, fat and carbohydrates) and rich in micronutrients (vitamins and minerals), making it a relatively low-cost, simple option. For children with a milk allergy, it is crucial to work with a health professional to ensure they still receive the necessary nutrients.
Many clinicians have observed that children who can tolerate baked or processed forms of allergens often outgrow their allergies more successfully. This study’s results align with those observations. These findings are significant because of the potential to help many children receive the relatively low-cost, nutrient-dense nourishment that milk provides.
The significance also lies in that positive outcomes open the door for more research on this specific topic. These findings could also suggest a future shift in clinical practice, potentially leading to updated guidelines and more standardized care practices for managing cow’s milk protein allergy.
As the study suggests, some children with a milk allergy do outgrow it. This has been my experience as well, and if we can speed up this process, we can help increase nutrient intake by introducing milk earlier. In my practice, I have observed that children who successfully tolerate small amounts of baked or processed milk often show signs of outgrowing their allergies faster. This aligns with the study’s findings and reinforces the potential benefits of earlier milk reintroduction.
Because the 12-step approach is not yet formalized or recommended by a national pediatric association, in real-life application, I would suggest that health care providers discuss it with their patients to see if it might be a good idea for their situation. I would not recommend that caregivers try this on their own without safety measures in place.
It is important to note that the 12-step process involves gradually progressing from heated milk products to less heated ones, as the baking process alters the structure of milk allergens, thereby decreasing allergenicity. The children who experienced anaphylaxis did so after accidentally consuming a less heated milk product. Care and stringency are essential in following the steps properly.
It is also crucial to remember that every child’s situation is unique, so it is vital for health care providers to understand the child’s specific allergy profile. What works for one child may not be appropriate for another.
National and international allergy management guidelines may need to be updated to reflect the evidence supporting the milk ladder approach, encouraging wider adoption and standardization of the method. Proper education and support are essential for families using the milk ladder.
Health care professionals should take into consideration the children who experienced anaphylaxis, as this underscores the vital importance of educating guardians on appropriate steps and safety measures. While this is a promising and exciting finding, more studies are needed to confirm its significance, followed by procedures to confirm its application and education outside of study environments.
Health care professionals should consider implementing close monitoring protocols during the reintroduction process to address any adverse reactions quickly, ensuring the safety and well-being of the child throughout treatment. It is also important to note that not all patients will respond the same way, depending on factors such as co-existing allergic conditions and the severity of the allergy.
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