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The long-term natural course of IgE-mediated cow's milk allergy

Published online October 30, 2024

The rate of spontaneous resolution of IgE-mediated cow's milk allergy (IgE-CMA) up to the age of 5 years is 53-57%, as demonstrated by prospective studies. However, data on resolution rates beyond this age is based on retrospective studies only and is more variable. In the era of oral immunotherapy (OIT), information regarding resolution rates of IgE-CMA to adulthood, and risk factors for persistence, are critical for patient selection.

Nachshon et al. have previously described the resolution of IgE-CMA up to age 5 years in 31 of 54 patients with IgE-CMA identified from a cohort of 13,019 newborns followed from birth. In the current prospective cohort study published in The Journal of Allergy and Clinical Immunology: In Practice, the authors examined continued resolution rates of IgE-CMA in the remaining 23 patients up to age 17 years. Risk factors for persistence, and for systemic reactions to milk after age 5 years, in all 54 patients followed from birth, are described. IgE-CMA persistence was determined based on either a recent objective allergic reaction to milk and a positive SPT, or sensitization ≥95% PPV to milk (milk-sIgE ≥15 kUA/L, and/or SPT ≥8 mm). Resolution was diagnosed based on either patients’ report of unlimited dairy consumption or a negative oral food challenge (OFC).

An additional 8 of the 23 patients followed (35%) had spontaneous resolution between age 5 and age 17 years, and 15 remained persistently allergic. Overall, 39 (72.2%) of the 54 patients with IgE-CMA followed from birth had spontaneous resolution by age 17 years. Nine patients who underwent milk OIT over the years were considered milk-allergic in the primary analysis. However, the clinical course of 3 of them suggested possible spontaneous resolution. Considering this, the spontaneous recovery rate reached 77.8%. All 54 newborns with initially confirmed IgE-CMA were receiving only breastfeeding following discharge from the nursery for a median duration of 120 days, and 34 of them received transient supplementation with cow milk formula (CMF) in the nursery. Risk factors for IgE-CMA persistence at age 17 years included SPT >6 mm at time of diagnosis (p=0.03), no CMF feeding in the nursery (p=0.008), and wheezing on diagnostic OFC/initial reaction to milk (p=0.04). Seven patients experienced objective systemic reactions after age 5 years. These patients had more wheezing (p=0.045) or anaphylaxis (p=0.02) on diagnostic OFC/initial reaction and more current asthma (p=0.007).

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

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