Mauro Calvani, MD, Iride Dello Iacono, MD, Valentina Giorgio, MD, Stefano Miceli Sopo, Valentina Panetta, MD and Salvatore Tripodi, MD.
Background: The diagnostic gold standard for food allergy is an oral food challenge (OFC) with the suspected food. Usually, an OFC is stopped at the onset of mild objective symptoms for fear of severe reactions. However, there is no consensus on this issue.
Objective: To investigate the effectiveness and side effects of a new model of oral milk challenge in order to increase the diagnostic accuracy of cow¡¯s milk protein allergy and reduce the number of many useless elimination diets. This model is characterized by a conservative diagnostic protocol and ¡°step-up cow’s milk administered dosing.¡± The secondary aim was to investigate possible factors influencing severe reactions.
Methods: Sixty-six children (median age 1 year, range 1¨C18) with suspected immunoglobulin E (IgE)-mediated cow’s milk allergy performed a conservative oral food challenge (OFC), i.e., the OFC was continued even in the presence of subjective, even repeated, or mild local or multiple organ objective symptoms. If the first objective reaction occurred when the quantity of milk was > 10 ml, the investigator would decide whether to continue the OFC or prescribe a gradual increase in milk feeding at home.
Results: Symptoms developed during the OFC in 42.4% of the children. Local, generalized and severe generalized reactions developed in 11 (16.7%), 11 (16.7%) and 6 (9.1%) children, respectively. Only 14/28 (50%) who developed objective symptoms during the OFC were considered to be affected by cow’s milk allergy. In the remaining 14 both subjective and objective symptoms developed and the OFC was continued without the emergence of additional symptoms. Epinephrine was administered to 6 of the 28 children (21.4%) who developed objective symptoms. All but one had subjective symptoms following the early doses of milk, whereas all children who later tolerated milk had their first subjective or mild symptoms following doses ¡Ý 10 ml.
Conclusions: This new model of oral milk challenge criteria led to frequent severe allergic reactions hence its use in daily practice seems inadvisable. However, our study provides evidence that a severe allergic reaction does not invariably occur if the offending food continues to be administered after the onset of symptoms. If mild symptoms appear at doses higher than 10 ml, continued milk administration, on the same day or in subsequent days, seems to facilitate the development of tolerance and may reduce the number of useless elimination diets.
Michael B. Levy, MD, Michael R. Goldberg, MD, PhD, Liat Nachshon, MD, Elvan Tabachnik, MD and Yitzhak Katz, MD
Background: Most reports in the medical literature on food allergy mortality are related to peanuts and tree nuts. There is limited knowledge regarding these reactions and often only a partial medical history is described.
Objective: To record and characterize all known cases of mortality due to food allergy in Israel occurring during the period 2004–2011.
Methods: All cases of food allergy-related mortality that were known to medical personnel or were published in the Israeli national communications media were investigated. We interviewed the parents and, when feasible, physicians who treated the final event.
Results: Four cases of food-related mortality were identified: three cases were due to cow’s milk and one to hazelnut. All were exposed to a hidden/non-obvious allergen. All four had a history of asthma but were not on controller medications, and all had experienced previous non-life threatening accidental reactions. Three of the four patients had not been evaluated by an allergist, nor were they prescribed injectable epinephrine. The one patient who had been prescribed injectable epinephrine did not use it during her fatal anaphylactic attack.
Conclusions: Fatal reactions to cow’s milk and hazelnut but not to peanut are the only reported food mortality cases in Israel. Although these patients had previous reactions following accidental exposures, none had experienced a life-threatening reaction. Patients at risk are not adequately evaluated by allergists, nor are they prescribed and instructed on the proper use of injectable epinephrine. Cow’s milk should be considered a potentially fatal allergen.
Silvia Sanchez-Garcia, MD, Pablo Rodriguez del Rio, MD, Carmelo Escudero, MD, Cristina Garcia-Fernandez, MD, Antonio Ramirez, MD and M.D. Ibanez, MD, PhD
Background: In the last two decades milk oral immunotherapy has gained interest as an effective treatment option for milk-allergic patients.
Objectives: To report on the efficacy of a milk oral immunotherapy.
Methods: Children with immunoglobulin E-mediated cow’s milk allergy were included in the protocol. The treatment consisted of an induction phase in which milk doses were increased weekly in the hospital, while the tolerated dose was continued daily at home. The goal was to achieve a minimum milk intake of 200 ml a day. During the maintenance phase, patients ingested at least 200 ml of milk in a single dose every day.
Results: The protocol was applied to 105 milk-allergic children diagnosed by specific IgE to milk and controlled oral food challenge. The mean duration of the induction phase was 19 weeks. Of the 105 subjects, 86 (81.9%) successfully complied with the protocol and 19 (19.1%) failed. Causes of failure were moderate/severe reactions in 12 patients (12.44%) and personal reasons in 7 (6.66%). A total of 182 adverse reactions occurred during the induction phase, most of them mild. Baseline specific IgE to milk and casein were significantly lower (P < 0.05) in the successfully treated group compared to the group in which the treatment failed.
Conclusions: Milk oral immunotherapy is a safe and effective treatment for milk-allergic children, although adverse reactions may occur. Baseline milk and casein-specific IgE may be useful to predict a good response to milk oral immunotherapy.
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[1] IgE = immunoglobulin E