‘Early Introduction’ of Cow’s Milk for Children with IgE-Mediated Cow’s Milk Protein Allergy: A Review of Current and Emerging Approaches for CMPA Management

Abstract

IgE-mediated cow’s milk protein allergy (CMPA) is one of the most prevalent food allergies in early childhood. Though the cornerstone of management involves the strict avoidance of milk products while awaiting natural tolerance, research increasingly shows that the rates of resolution are slowing down. Therefore, there is a need to explore alternative pathways to promote tolerance to cow’s milk in pediatric populations. This review aims to combine and appraise the scientific literature regarding the three CMPA management methods: avoidance, the milk ladder, and oral immunotherapy (OIT) and their outcomes in terms of efficacy, safety, and immunological effects. Cow’s milk (CM) avoidance virtually protects against allergic reaction until natural tolerance occurs, with hypoallergenic substitutes available in the market, but accidental ingestion represents the main issue for this strategy. Introduction to baked milk using the milk ladder was designed, with most CMPA patients successfully completing the ladder. Similar to baked milk treatment, many OIT protocols also demonstrated decreased IgE and increased IgG4 levels post protocol, as well as a reduction in wheal size diameter. Though these strategies are shown to be safe and effective in CMPA, future clinical trials should compare the safety and effectiveness of these three management strategies.

Primary care as a setting for introducing milk using the milk ladder in children with IgE‐mediated cow's milk protein allergy

“…In a recent review, the milk ladder was shown to be a safe and effective method of gradual introduction to milk in children with IgE‐mediated CMPA. 4 Two recent studies demonstrated the effectiveness of the iMAP milk ladder in tertiary allergy centres in Ireland and the UK 2 , 5 ; however, the employment of the milk ladder in children with IgE‐mediated CMPA in non‐hospital clinical settings by general practitioners has not yet been evaluated. We reviewed the safety and effectiveness of the use of the milk ladder for children with IgE‐mediated CMPA in a PC setting.…”

“…In a recent review, the milk ladder was shown to be a safe and effective method of gradual introduction to milk in children with IgEmediated CMPA. 4 Two recent studies demonstrated the effectiveness of the iMAP milk ladder in tertiary allergy centres in Ireland and the UK 2,5 ; however, the employment of the milk ladder in children The main outcome was reaching step 12 on the iMAP milk ladder, the introduction of unrestricted liquid cow's milk, which was defined as the uneventful intake of more than 150 mL of cow's milk or the equivalent intake of 4.5 g of milk protein daily. Failure to complete the ladder was defined as the failure to introduce liquid cow's milk after 36 months of follow-up.…”

Molecular Mechanism and Clinical Effects of Probiotics in the Management of Cow’s Milk Protein Allergy

“…OIT consists in the daily administration of the maximum tolerated dosage of the offending allergen, previously established through an OFC. After 6–9 months of OIT, another OFC is performed to test the desensitization, while the achievement of tolerance is assessed through an OFC performed after a variable period of the allergen elimination [ 44 ]. OIT apparently involves B-reg and T regulatory cells (Treg), and it leads to a decrease of CMP-specific IgE levels and to an increased level of IgG4 [ 43 , 45 , 46 ].…”

Safety and effectiveness of a milk ladder for managing children with IgE‐mediated milk allergy

“…1 A recent review explored the introduction of baked milk as a treatment for IgE-mediated CMPA and demonstrated that the number of patients who became tolerant to unheated milk during the study periods was greater in the gradual milk introduction group (range 54%-88.1%, mean 62.5%) compared to those who underwent complete avoidance of milk (range 0%-66.7%, mean 21.42%). 2 The aim of this study is to assess the introduction of milk in IgEmediated CMPA using an adapted home introduction milk ladder strategy. All ranges of severity, including those individuals who had anaphylactic reactions, or were already tolerant to baked milk, irrespective of their SPT weal size and specific IgE level were included for analysis.…”