Baked, cooked, and unheated milk foods in the management of cow’s milk allergy

Background:

Cow’s milk allergy is a common food allergy in early childhood and is managed with strict avoidance, however alternative management approaches are increasingly employed in clinical practice. Methods of food processing including baking, cooking, frying or fermentation, in addition to the amount of allergen and the presence or absence of a grain matrix may all affect tolerance to milk proteins. Baked milk oral food challenges are common in children with IgE-mediated food allergy as tolerance may lead to a more liberalized diet. A “milk ladder,” incorporates a stepwise progression from highly processed and small amounts to less processed and larger amounts of milk proteins.

Methods:

We conducted a narrative review to explore the use of alternatives to strict avoidance of milk using baked milk and milk ladders in both IgE- and non-IgE- mediated cow’s milk allergy.

Results:

The majority of children with IgE-mediated cow’s milk allergy tolerate baked milk ingredients. Milk ladders are employed to liberalize the diet and establish tolerance in mild to moderate non-IgE-mediated CMA. Possible benefits to less strict avoidance include 1) hastening of resolution of a food allergy, 2) increased diet diversity, 3) less healthcare utilization, 4) decreased cost, 5) decreased patient burden and 6) decreased nutrition risk.

Conclusion:

The management of cow’s milk allergy has evolved from strict avoidance to the use of tolerated milk ingredients beginning with an oral food challenge to baked milk (for IgE-mediated food allergy) or home introduction of milk using a milk ladder (for non-IgE-mediated food allergy). The use of ladders for IgE-mediated food allergy and the use of baked milk in non‐IgE-mediated food allergy require further assessment.