Home-based cow's milk reintroduction using a milk ladder in children less than 3 years old with IgE-mediated cow's milk allergy

Abstract

Background: The development of tolerance to cow's milk in allergic children is best determined by supervised baked milk exposure. Widely recommended hospital-based challenges can potentially delay contact because of resource limitations. Objective: We sought to determine the efficacy and safety of our low-dose home-based reintroduction programme. Methods: In our allergy service, children with IgE-mediated cow's milk allergy who met set criteria (presenting with skin and/or gastrointestinal symptoms only and skin prick test < 8 mm) are considered for home-based milk reintroduction (HMR). Early contact is low-dose ingestion of a commercial baked milk biscuit with slow gradual further exposure followed by increasing milk contact using a milk ladder. We retrospectively reviewed 4-6 monthly attendance records assessing allergic symptoms, evolving milk tolerance, and compliance. Tolerance was determined using a 7 scale scoring system based on the milk ladder. Results: The clinic attendance and dietetic contact records of 86 children (49 girls) who underwent HMR were reviewed. HMR was started at a median of 13 months with 49% 8-12 months, 40% 13-18 months and 11% 19-33 months. Allergic symptoms were reported in 81 (43%) of 189 dietetic reviews, 65 (80%) of which were from the milk ladder; no patient experienced anaphylaxis requiring treatment with intramuscular adrenaline. After four reviews, only eight patients were not tolerating almost all dairy products, and there was a high rate of completion with only a further seven patients lost to the programme. Conclusion and Clinical Relevance: Cow's milk can be successfully and safely reintroduced in a cautious low-dose exclusively home-based programme in the appropriate clinical and family setting.