A retrospective study comparing management strategies for IgE-mediated cow's milk protein allergy found dietary advancement therapy using a milk ladder resulted in significantly higher rates of successful milk reintroduction compared with complete milk avoidance. The study, published in Pediatric Allergy and Immunology, analyzed data from 371 pediatric patients treated between 2011 and 2020 at allergy centers in Ireland and Spain.
Key findings:
- 86.6% of patients using the milk ladder successfully reintroduced milk, compared to 61.0% in the avoidance group (P<.001).
- Milk ladder patients were 3.67 times more likely to succeed than those practicing avoidance (P<.001).
- Anaphylaxis occurred in 3 milk ladder patients (1.8%) vs 34 avoidance patients (17.0%) during treatment (P<.001).
- Median treatment duration was 12.5 months for milk ladder vs 21 months for avoidance (P<.001).
Researchers conducted a retrospective chart review of 171 patients managed with the milk ladder in Cork, Ireland, and 200 patients managed with milk avoidance in Mostoles, Spain. Inclusion criteria were a clinical diagnosis of IgE-mediated cow's milk protein allergy (CMPA) with skin prick test ≥3 mm or specific IgE >0.35 kU/L for cow’s milk. The primary outcome was a successful reintroduction of >150 mL of fresh pasteurized cow's milk daily without symptoms.
The milk ladder protocol involved home-based introduction of progressively less baked/heated milk products. Avoidance patients strictly eliminated all milk products until natural tolerance developed, confirmed by oral food challenge (OFC).
Baseline characteristics differed between groups. In the milk ladder group, 57.9% were male, 1.8% were premature, and 63.2% had vaginal delivery. For the avoidance group, these figures were 63%, 2%, and 81.5%, respectively. Breastfeeding rates before diagnosis were 39.8% in the milk ladder group and 90.5% in the avoidance group, with median durations of 8 and 5 months, respectively.
Atopic conditions were prevalent in both groups. In the milk ladder cohort, 81.9% had atopic dermatitis, 23.4% had viral-induced wheeze, and 11.7% had allergic rhinitis. The avoidance group reported rates of 61%, 47.5%, and 19.5% for these conditions, respectively.
Other food allergies were common, with 69% of milk ladder patients and 39.5% of avoidance patients having at least one additional food allergy. Egg allergy was present in 61.4% of milk ladder patients and 31.5% of avoidance patients, while peanut allergy affected 23.4% and 6.5%, respectively.
Immunological values showed some differences between groups. Mean skin prick test results were 4.59 mm in the milk ladder group and 2.9 mm in the avoidance group (P<.001). Mean IgE whole milk values were 18.64 kIU/mL and 12.6 kIU/mL, respectively (P=.514).
Multivariate analysis showed the milk ladder was independently associated with treatment success (OR 3.67, 95% CI 2.071-6.499, P<.001). Asthma/viral-induced wheeze (OR 0.394, P<.001), allergic rhinitis (OR 0.419, P=.01), and other nut allergies (OR 0.286, P=.012) were negatively associated with success.
In the milk ladder group, higher whole milk-specific IgE predicted treatment failure (37.22 vs 15.84 kIU/mL, P<.01). For avoidance patients, higher skin prick test results were associated with failure (3.64 vs 2.43 mm, P<.01).
Success rates were influenced by comorbid conditions, particularly in the avoidance group. Patients without other food allergies had higher success rates, especially in the avoidance cohort. In this group, success rates were lower for patients with asthma/viral-induced wheeze (59.2% vs 82.5%, P<.01) and allergic rhinitis (52.2% vs 75.9%, P=.02). These associations were not observed in the milk ladder group.
Accidental milk exposures occurred in 18.7% of milk ladder patients (32 patients, 30.72 cases per year) vs 53.0% of avoidance patients (106 patients, 60.5 cases per year) (P<.001). Anaphylaxis rates were significantly lower in the milk ladder group (1.8% vs 17.0%, P<.001). Notably, no anaphylaxis cases were caused by progression through the milk ladder; all 3 cases in this group were due to accidental exposure to less extensively heated milk products.
The median treatment duration was shorter for milk ladder patients (12.5 vs 21 months, P<.001), with fewer clinic appointments required (median 2 vs 5, P<.001).
As a retrospective study, unmeasured confounding factors may have influenced outcomes. The cohorts had demographic differences, including age at diagnosis (median 12 vs. 5 months).
The authors declared having no competing interests.