April 4, 2011 (San Francisco, California) — Being able to tolerate heated or baked milk products — such as in pizza and muffins — is a favorable prognostic indicator in children with a history of milk allergy, and regular intake of such baked products during an extended period may help resolve allergic symptoms, according to researchers here at the American Academy of Allergy, Asthma and Immunology (AAAAI) 2011 Annual Meeting.
"After 3 years of follow-up, we've found that children who are able to tolerate baked milk products are much more likely to develop complete tolerance to milk products," said Hugh Sampson, MD, professor of pediatrics and dean for translational biomedical sciences at the Mount Sinai School of Medicine in New York City.
In a study of 94 children, 60% of 70 patients who were initially tolerant of heated milk products became tolerant of all forms of milk, and 26% were able to regularly tolerate some form of heated milk or cheese, Dr. Sampson said.
During the study, in which children were followed-up for a median of 31 months, patients who demonstrated tolerance to heated milk in the form of muffins or waffles underwent sequential challenges to foods such as pizza, macaroni and cheese, and unheated milk. Immunologic parameters such as skin prick tests and milk-specific immunoglobulin E levels were measured regularly. Only 9 of these children (13%) later chose to avoid all forms of milk, he said.
"If children could initially tolerate the baked form of milk, they were 16 times more likely to develop complete tolerance than an age-matched control group," Dr. Sampson added. In these children, the median time to unheated milk tolerance was 21 months, he said.
However, children who were initially reactive to heated or baked milk products fared more poorly: Only 8% could eventually tolerate unheated milk, and 13% were able to tolerate only heated milk products or cheese. The rest had to avoid milk products completely.
Although children in the group who were initially tolerant to baked milk products were regularly eating these products, only 2 developed serious symptoms — 1 was diagnosed with ulcerative colitis, and another with eosinophilic esophagitis. In the group of children who were initially reactive to baked milk products, 1 developed eosinophilic esophagitis.
Among the 75 children who regularly incorporated heated milk products into their diets, milk skin prick test wheal sizes decreased substantially (from a mean of 8 mm to 6.7 mm; P = .0001), although milk-specific immunoglobulin E levels did not change significantly.
Interventions to desensitize children to food allergens by gradually exposing them to the foods that cause symptoms have become a hot topic for research among allergists, commented Wesley Burks, MD, professor of pediatrics and chief of the Division of Pediatric Allergy and Immunology at Duke University Medical Center, Durham, North Carolina. Although such research is still in its infancy, it has contributed some real insights into the kind of treatments that might be helpful in resolving patients' food allergies, he added.
These food allergy interventions consist of baked forms of the food, oral immunotherapy (or gradually increasing doses of the foods), and sublingual tablets containing tiny doses of the allergen. A variety of abstracts on such approaches were presented at the AAAAI meeting. "These studies have very small numbers, and we're still trying to figure out the right doses and the right way to accomplish desensitization," Dr. Burks said. "These studies are very exciting and encouraging, but at the same time, they're complicated and time consuming. In many ways, they can be seen as preliminary," he added.
Yet data are beginning to accumulate on the desensitization approach to a range of food allergies, including allergies to peanuts, milk, and eggs. Using baked forms of a food allergen as a way to desensitize patients has proven promising for egg allergies as well, Dr. Sampson said. "Regularly putting baked forms of a food into an allergic person's diet may be a useful way to bring about tolerance," he said.
In addition, Dr. Burks' work indicates that both sublingual and oral immunotherapies may be helpful in overcoming food allergies, although there are clear differences between the approaches.
In a study of 30 children with milk allergies, the efficacy and safety of sublingual immunotherapy (SLIT; with a maintenance dose of 7 mg a day) and oral immunotherapy (1000 - 2000 mg/day) were compared for the first time in a study presented here at the AAAAI meeting.
After 3 months of maintenance, the median oral food challenge threshold was 940 mg in the SLIT group vs 6140 to 8140 mg in the oral immunotherapy group (P = .001).
Results indicated that of 6 children in the SLIT group who completed a final oral food challenge, only 1 could tolerate a full challenge dose. However, symptoms from immunotherapy were more severe in the oral immunotherapy group than in the SLIT group. Antihistamines were used for 1% of children who received SLIT and 18% of those who received oral immunotherapy. Epinephrine was used twice during SLIT, and 4 times during oral immunotherapy.
"At the doses used, oral immunotherapy was more efficacious than SLIT in desensitizing to milk, but was associated with more frequent adverse events," the authors wrote in their conclusion.
Dr. Burks and Dr. Sampson have disclosed no relevant financial relationships.
American Academy of Allergy, Asthma & Immunology (AAAAI) 2011 Annual Meeting; Abstract 91, Abstract 266. Presented March 19, 2011.
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