Home-based Cow’s Milk Reintroduction Using a Milk Ladder in Children <3 Years Old With IgE-Mediated Cow’s Milk Allergy

Although the majority of children with IgE-mediated cow’s milk allergy outgrow their allergy, it has been shown that tolerance to extensively heated milk (baked milk) often develops earlier than to fresh milk, and early regular dietary incorporation of baked milk is associated with accelerated resolution of milk allergy. Since 2012, the authors have managed selected young children with IgE-mediated cow milk allergy with a home-based milk reintroduction (HMR) followed by at-home exposure to increasing amounts of cow’s milk with a locally devised milk ladder.

Children younger than 3 years of age with diagnosis of IgE-mediated cow milk allergy (presenting with skin and/or gastrointestinal symptoms only and skin prick test <8 mm) were considered for home-based milk reintroduction (HMR). Children considered unsuitable for HMR included history of allergic reaction to trace baked milk ingestion; allergic reaction including respiratory or cardiovascular symptoms; recurrent wheezing (suspected asthma); skin prick test >8 mm; and/or parents/caregivers unable to understand or unwilling to follow home reintroduction program.

All infants approaching 12 months of age were considered candidates for home milk reintroduction (HMR) and further milk ladder escalation at home. Parents/caregivers agreed to follow the written instructions on HMR and milk ladder escalation. Initial dosing was a crumb of a commercial malted milk biscuit (∼0.35 mg milk protein) with gradually increasing dose over the following 5 weeks. Once the first stage was completed, parents/caregivers were instructed on how to proceed using the authors devised milk ladder, firstly with baked goods containing milk and then progressing to heated/fermented milk and then fresh milk products. Parents/caregivers were instructed to give trace amounts initially and then to increase amounts as tolerated. Each stage lasted about 4–6 months with flexibility depending upon child’s symptoms and family lifestyle. Parents/caregivers were instructed to reduce the dose or revert back to the previous stage if child developed allergic symptoms. The authors retrospectively reviewed 4–6 monthly attendance records of all children who reintroduced baked milk at home over a 6-year period from 2012 to 2017, assessing allergy symptoms, evolving milk tolerance, and compliance. Tolerance was determined using a 7scale scoring system based on the milk ladder ranging from no tolerance to normal diet.

Eighty-six children underwent HMR. Median age at initial assessment at first allergy clinic visit was 8 months of age, and median age at which baked-milk reintroduction was started was 13 months of age. Mild to moderate allergic symptoms were reported in 43% of the children, which mirrored the child’s presenting symptoms at diagnosis; 80% of these reactions occurred while the child was increasing milk exposure through the milk ladder. When this occurred, parents were instructed to reduce the dose and then later were able to continue with the program. No patients experienced anaphylaxis requiring treatment with epinephrine. After 4 review cycles, only eight patients were not tolerating almost all dairy products. The majority of patients/parents were compliant with the program, with only 7 patients lost to follow-up.

The authors showed that home milk reintroduction for younger children with prognostic indicators suggesting less reactivity to milk can achieve full dairy tolerance by starting with very low doses of baked milk followed by gradually increasing exposure to cow’s milk using a milk ladder.

Performing baked-milk oral challenges for every child who has IgE-mediated cow milk allergy is often not feasible or realistic due to scheduling constraints, too few allergists performing oral challenges, and/or family concerns. This retrospective study suggest and approach that may be practical for clinicians on when and how to advise select families with young children who are cow milk allergic about home milk reintroduction followed by at-home exposure to increasing amounts of cow’s milk using a milk ladder. Now if only Pepperidge Farm would let us know how many grams of protein are in Goldfish crackers, we would be set.