Q:

11/1/2012
I have a 15 month old patient with h/o colic, projectile vomiting, choking/gagging on foods whose mother after giving the child exclusively FROZEN breast milk has noticed complete resolution of the projectile vomiting, choking and gagging on foods in the last 3 weeks. Peds GI has seen the child and thought the pt had a sensitive gag reflex and reflux but mother states prevacid which used to help no longer helps and the only thing that makes a difference is her frozen breast milk. No biopsies have been done to r/o EoE and IgE testing via blood to milk, soy, egg, wheat etc have been negative. Question from mother: does freezing the breast milk change the protein structure of the milk so it is not as allergenic anymore? I have not seen literature about though although there seems to be lots of literature on extensively heated or baked milk products being tolerated in milk allergic children. Would love this to be sent to Dr. Sampson or his colleague Dr. Anna Nowak-Wegrzyn. Thank you!

A:

Thank you for your inquiry. I will forward your question to Dr Anna Nowak -Wegrzyn. As soon as we receive her response, I will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

Thank you for the additional information, which was:
The child is symptomatic with non frozen breast milk. The mother travels on business every week and she noticed a clear correlation between the child's choking and gagging and inability to tolerate solid foods when fed non frozen breast milk during the times she is not at home (confirmed by nanny and then confirmed by mom when she decided to give exclusively frozen breast milk for 3 weeks) and resolution of symptoms when given frozen breast milk. Of note child is able to tolerate yogurt without problems. Mother noticed baby had worsening problems with cheese. Does this have to do with the processing of the milk in yogurt and cheese?

We have now received a response from Dr. Nowak-Wegrzyn, which is copied for you below.

Thank you again for your inquiry, and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Anna Nowak-Wegrzyn:

Thank you for the additional information. This is an interesting and unusual case. I have not heard a similar complaint during my 15 years of taking care of children with food allergy, nor did Drs. Sampson and Sicherer.

I am assuming that this child is allergic to milk, is this correct? I wonder if you have the results of serum specific IgE for cow milk, casein, beta-lactoglobulin and alpha-lactalbumin? My response is based on the assumption that this child is allergic to milk.

High temperature has a profound effect on whey proteins in cow's milk such as beta-lactoglobulin and alpha-lactalbumin that generally loose their allergenicty with high temperature. Freezing usually conserves protein structure and function, however there might some alteration of a minor specific allergenic epitope that is relevant for an uncommon patient. This might explain why this child tolerated frozen breast milk but not fresh breast milk, assuming that the mother eats dairy products in her diet.

As far as yogurt is concerned, yogurt is produced from pasteurized (heated) milk and there is evidence thatbacteria in yogurt ferment beta-lactoglobulin and decrease it's allergenicity.

Cheese can be produced from pasteurized or raw milk, what kind of cheese did the child react to? If cheese is produced from pasteurized milk, I would expect that such cheese would be tolerated by this child, similar to yogurt. I just saw a recent paper that showed whey proteins are present in a fully maturated cheese Parmigiano-Reggiano which is produced from raw milk. So if this child is allergic to whey proteins, he might tolerate yogurt but not cheese made of raw milk. Of course, there is also a possibility that cheese contains some additives such as spices or coloring derived from seed annato that has been identified as an allergen in itself. But this would not be tied to breast milk issue.

Please let me know if you have any questions.

Kind regards,
Anna Nowak-Wegrzyn, MD
Asoociate Professor of Pediatrics
Jaffe Food Allergy Institute
 
PLoS One. 2012;7(7):e40945. Epub 2012 Jul 19.
Tolerability of a fully maturated cheese in cow''s milk allergic children: biochemical, immunochemical, and clinical aspects.
Alessandri C,Sforza S, Palazzo P, Lambertini F, Paolella S, Zennaro D, Rafaiani C, Ferrara R, Bernardi ML, Santoro M, Zuzzi S, Giangrieco I, Dossena A, Mari A.
Source
Center for Molecular Allergology, IDI-IRCCS, Rome, Italy.
Abstract
Background: From patients' reports and our preliminary observations, a fully maturated cheese (Parmigiano-Reggiano; PR) seems to be well tolerated by a subset of cow's milk (CM) allergic patients.
Objective and Methods: To biochemically and immunologically characterize PR samples at different maturation stage and to verify PR tolerability in CM allergic children. Seventy patients, with suspected CMallergy, were enrolled. IgE to CM, á-lactalbumin (ALA), â-lactoglobulin (BLG) and caseins (CAS) were tested using ImmunoCAP, ISAC103 and skin prick test. Patients underwent a double-blind, placebo-controlled food challenge with CM, and an open food challenge with 36 months-maturated PR. Extracts obtained from PR samples were biochemically analyzed in order to determine protein and peptide contents. Pepsin and trypsin-chymotrypsin-pepsin simulated digestions were applied to PR extracts. Each PR extract was investigated by IgE Single Point Highest Inhibition Achievable assay (SPHIAa). The efficiency analysis was carried out using CM and PR oral challenges as gold standards.
Results: The IgE binding to milk allergens was 100% inhibited by almost all PR preparations; the only difference was for CAS, mainly á(S1)-CAS. Sixteen patients sensitized to CM tolerated both CM and PR; 29 patients tolerated PR only; 21 patients, reacted to both CM and PR, whereas 4 patients reactive to CM refused to ingest PR. ROC analysis showed that the absence of IgE to BLG measured by ISAC could be a good marker of PR tolerance. The SPHIAa using digested PR preparations showed a marked effect on IgE binding to CAS and almost none on ALA and BLG.
Conclusions: 58% of patients clinically reactive to CM tolerated fully maturated PR. The preliminary digestion of CAS induced by PR maturation process, facilitating a further loss of allergenic reactivity during gut digestion, might explain the tolerance. This hypothesis seems to work when no IgE sensitization to ISAC BLG is detected.

AAAAI - American Academy of Allergy Asthma & Immunology