Long–term Follow–up After Baked Milk Introduction

Abstract

Introduction of baked milk (BM) to children with milk allergy is associated with accelerated resolution of milk allergy. This study was designed to characterize the clinical experience of one center with the introduction of BM and other forms of milk after challenge, including the relations of prechallenge and in-challenge characteristics with future successful milk introduction, as well as safety.The population included 206 children with milk allergy who had undergone a BM challenge in this center from 2009 to 2014 and who had at least 24 months of follow-up.Methods included retrospective chart review or telephone follow-up. Protocol includes an advancement in dose as tolerated over time if the starting dose is <2 g of BM. After consuming 2 g of BM 3 to 5 times per week for 2 to 3 months, patients are permitted to advance their milk ingestion to less-heated forms of milk (such as pancakes and waffles), then oven-baked cheese, then uncooked dairy products, as tolerated.Ninety-nine of 206 children passed the BM challenge; 107 reacted. Of the 107 who reacted at challenge, 58 required some form of treatment, and 24 required epinephrine. Eighty-eight of the 107 children who did not pass the challenge were instructed to consume some amount of BM. At the time of the last follow-up (median = 49 months), 40% had advanced to direct milk, 27% were eating some form of heated milk, and 33% were avoiding all forms of milk. Of those who had failed the challenge but were instructed to ingest some amount of BM, 29% had progressed to direct milk. Passing the BM challenge was associated with greater odds of advancing to less-heated forms of milk (odds ratio: 4.9; 95% confidence interval: 2.5–9.6). Most who had required treatment during the challenge were still practicing strict avoidance at last follow-up. Thirty-five percent of patients experienced milk reactions during the follow-up period; 77% were mild, but 14% were severe, and there were 7.7% who developed eosinophilic esophagitis.Introduction and advancement of BM in patients with milk allergy is associated with higher odds of advancing their level of milk ingestion but is not without risk. Patients need to be counseled about risk as well as ongoing availability of emergency medications.Incorporating BM into the diet of patients with milk allergy can be beneficial to allow increased food options. This study demonstrates the importance of performing a BM challenge in patients with milk allergy to determine if BM would be safe to include in the diet. Counseling about the possible risks of BM ingestion is important because reactions to previously tolerated doses and the development of eosinophilic esophagitis are possible.