Predictors of Milk Tolerance Following Baked Milk Challenge

Rationale: Introduction of baked milk (BM) is a mainstay in the management of cow’s milk allergy. We sought to characterize predictors of BM tolerance and progression to baked cheese and direct milk among patients undergoing BM oral food challenges (OFC).

Methods: 126 patients challenged to BM from 2009-2011 were reviewed. OFC success was defined as consumption of ¼ cup BM. Logistic regression was performed utilizing milk-IgE level (log-transformed), age, gender, duration of follow-up, and OFC outcome to determine predictors of subsequent milk intake. 

Results:

99 patients (4 months-18 years) old were included. Median duration of follow-up was 51 months (range 1.9-85 months). 65% passed the BM OFC. Among those failing, 91% were permitted to introduce specified quantities of BM. Of those passing, 75% progressed to unlimited BM or more, 61% advanced to  baked cheese or more, and 38% advanced to direct milk, compared to 48%, 40%, and 26% of those failing the BM challenge (p=0.004,0.046, and 0.234, respectively). 

Milk-IgE was significantly associated with OFC outcome (OR 0.19, p=0.001) and progression to unlimited BM (OR 0.35, p=0.046) or baked cheese (OR 0.38, p=0.05) but not direct milk (OR 0.96, p=0.16). Patients with milk-IgE >10kU/l were less likely to tolerate unlimited BM (10% vs. 54%, p=0.015), baked cheese (8% vs. 45%, p=0.04), or direct milk (4% vs. 29% p=0.06). Gender, duration of follow-up, and age were not significant predictors. 

Conclusions: OFC outcome and milk-IgE were the most important predictors of persistent tolerance to BM or more concentrated forms of milk.