I have a 6 month-old patient who reacted to modified milk protein found in her oatmeal baby cereal (immediate hives and facial angioedema); of note, she continues to tolerate 4 ounces of Enfamil Gentlease TID without reaction (even since her reaction).

Skin test results to cow's milk was 3+ positive (other components of the cereal tested negative). I checked blood work to a few milk IgE components and found the following (kUa/L): cow's milk 9.35, alphalactalbumin negative, betalactoglobulin 11.10; and casein 2.95

My question centers upon the fact she continues to tolerate a partially hydrolyzed formula despite being clearly milk allergic. I know heated milk products, if tolerated, can help with tolerance promotion; however, I could not locate a study demonstrating a similar clinical benefit using partially hydrolyzed milk formula (i.e. only found studies looking at primary prevention).

So, in my patient, is it serendipitous that she continues to tolerate the Gentlease and perhaps, extrapolating from the baked milk experience(s), I recommend she continue it hoping it promotes tolerance? Or, shall I be conservative, and recommend she discontinue it in favor of soy or rice-based formula?

My intuition leans towards keeping this 'foothold' and having the patient continue the formula yet I am not sure what to do and I wonder if I missed an article somewhere. I greatly appreciate any thoughts you might have regarding this clinical scenario.


Thank you for your inquiry.

I am asking Dr. Anna Nowak-Wegrzyn, who is an internationally known expert in milk allergy, to respond to your inquiry. As soon as we hear from Dr. Nowak-Wegrzyn, we will forward her response to you.

Thank you again for your inquiry.

Phil Lieberman, M.D.

We received a response from Dr. Anna Nowak-Wegrzyn. Thank you again for your inquiry and we hope this response is helpful to you.

Phil Lieberman, M.D.

Response from Dr. Nowak-Wegrzyn:
This cereal contains regular skim milk protein as well as whey. Serum IgE results suggest that this child is most likely more allergic to whey [beta-lac] than to casein. Children with lower casein levels are more likely to tolerate baked milk and also probably whey products, as well, of course hydrolyzed whey formula that contains only traces of casein. Whey proteins are more susceptible to heating than caseins. After 20 minutes of heating [boiling], whey proteins lost the ability to bind IgE whereas caseins retained ability to bind IgE even after being boiled for over 60 minutes [our own data]. My recommendations for this child would be to:

1. Continue ingesting Enfamil Gentlease.

2. Perform a challenge in the office to document tolerance to milk in the baked products and if so, introduce those products into her diet since adding baked milk products appears to accelerate development of tolerance to regular milk. 1-4

3. I would repeat spt/serum IgE levels at 12 months to monitor for resolution of milk allergy.

Kind regards,
Anna Nowak-Wegrzyn, MD

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