Introducing baked milk to milk-allergic patients: what happens next?

Published online: February 2, 2018

Cow’s milk allergy is the most common food allergy in infants and young children. Successful introduction of baked milk to milk allergic patients is associated with accelerated resolution of milk allergy. It is now common clinical practice to challenge patients with milk allergy first to baked milk, and then add baked milk into the diet in increasing quantities. However, very little is known about what happens over time when baked milk is introduced outside of the research setting.

In this study published in The Journal of Allergy and Clinical Immunology: In Practice, Dunlop et al reviewed the experiences of 206 milk-allergic patients who were challenged to baked milk in an academic pediatric allergy clinic, and then followed for a minimum of 2 years. They looked for characteristics that predicted advancement of milk intake, including patient age, challenge characteristics, level of milk specific-IgE, and presence of other allergic diseases. At follow-up, they assessed the forms of baked milk that were being ingested and collected data on adverse reactions.

Of the 206 patients challenged, 187 were sent home with personalized instructions to incorporate baked milk into their diets. After a minimum of 2 years of follow up, 43% of the patients had progressed to direct milk, 20% to less-cooked forms of milk, 10% remained ingesting baked milk, and 28% were strictly avoiding milk. Higher milk-IgE levels were associated with decreased odds of passing a baked milk challenge and also decreased odds of advancing to less-cooked forms of milk at time of follow up. Predictors of progressing to less-cooked forms of milk were passing the challenge and younger age. Presence of asthma, eczema, other food allergy, or allergic rhinitis was not associated with success or failure of advancing to less-cooked forms of milk. With regard to adverse reactions, of the 187 patients instructed to begin some level of baked milk introduction, there were 78 reported milk reactions involving 66 patients (35%) during follow up. Of these, the majority (59 events, 77%) were classified as mild, 11 (14%) were classified as severe, and 6 (7.7%) were eosinophilic esophagitis.

The majority of patients who underwent a baked milk challenge, including those who failed their challenge, were able to successfully progress to consume direct or less-cooked forms of milk at time of follow-up. However, 28% were strictly avoiding milk and adverse reactions were common, and even a successful baked milk challenge did not guarantee future tolerance of baked milk or the absence of later reactions, even to previously tolerated doses.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.