Dr. Douglas Mack has become an evangelist for clear communication about risks when treating food allergies in children. The Canadian allergist was an early adopter of oral immunotherapy, and co-owns a busy OIT practice near Toronto.
He has seen thousands of successful OIT graduates at his Halton Pediatric Allergy clinic. And he knows well that food allergy therapies can be life-changing. Yet, Mack is unfailingly candid about differing therapy risk levels and the need to ensure parents are fully informed before agreeing to treat a child.
He finds risks particularly important to consider with milk and egg “ladders,” and especially when a patient has asthma.
Recently Mack and two U.S. colleagues published a guidance article for allergists on how best to safely treat patients with therapies such as food ladders and OIT. “We need to do this in a way that is safe, recognizing the potential for risk,” Mack says.
Milk and egg ladders are the less-studied cousin of oral immunotherapy. Like OIT, they involve a patient eating small amounts of an allergen and gradually progressing to larger amounts. But on the ladders, patients start with small amounts of thoroughly baked foods like muffin crumbs or pieces. If those are tolerated over time, the idea is to progress to less cooked food. For instance, cheese melted into a pizza with milk allergy.
Mack says ladders have not been subjected to nearly as much scientific rigor as therapies like OIT. Therefore, he and his colleagues are concerned about when this therapy is used, and a lack of awareness about risks.
Their article notes that some patients who tolerate easily the introduction of baked milk or egg may be in the process of outgrowing their allergies. But the authors caution there are higher-risk patients with persistent milk or egg allergies who may not be candidates for “ladder” therapy.
Extra Caution with Milk and Egg Allergy
Underscoring that concern, the paper, published in the Journal of Allergy and Clinical Immunology: In Practice, raises two fatal and a few near-fatal reactions to milk or egg products in patients with asthma. The authors emphasize that “milk, including baked milk, should be appreciated as a potential trigger of a severe reaction.”
Fatalities are not common but, importantly, the two they raise relate to baked milk. One involved a 3-year-old Alabama boy named Alastair. In July 2017, the child was taking part in a food challenge to see whether he could tolerate food containing baked milk. The boy, who also had asthma, died following an anaphylactic reaction.
The May 2021 anaphylaxis death of Brooklyn Secor also involved a baked milk product. The Canadian 9-year-old, who was allergic to dairy and had asthma, had been following a milk ladder protocol for six months. But the girl did have an asthma flare-up the night before she died. Then the next day after eating her dose of muffin crumbs, Brooklyn suffered a severe anaphylactic reaction that took her life.
In the right patient, Mack is a proponent of milk and egg ladders. They can expand diets and improve the lives of children. But he stresses the need for physician guidance with any food introduction to allergic patients.
“When we consider any type of dietary advancement therapies, these should be done under the guidance of a medical professional,” he says.
Fatal reactions are rare, but they do highlight the risks in approaches such as ladders, Mack says. That is why oversight from a physician, providing information about risks, how to safely navigate the daily allergen consumption, and engaging in regular check-ins “is absolutely paramount,” he says.
To help inform families, Allergic Living asked Dr. Mack for further insights.
What should families and doctors consider with food ladders?
If you think your allergic child might be a candidate for a milk or egg ladder to expand the diet, the first step is to get informed. Discuss, at length, the various factors involved in desensitization with your allergist.
With a therapy like baked milk and egg ladders, Mack says allergists need to have an “extensive discussion to prepare the family for the ups and downs.”
Factors to weigh include:
1. Overall risk level. Mack says it is necessary to distinguish between two groups of patients – low risk and high risk – when considering baked milk or egg introduction.
Low-risk traits: young child, non-asthmatic, and declining IgE levels on blood or skin-prick tests. For low-risk patients, Mack meets with families to outline the process. If a ladder is the chosen therapy, the patient often starts with a baked food challenge in his office.
High-risk traits: older child, high or increasing IgE levels on blood or skin-prick tests, asthma (especially uncontrolled), previous reaction to baked products, and previous severe reactions. Instead of ladders, Mack generally recommends avoidance or possibly OIT for his patients who fall into the high-risk category.
“These ladders are helpful for our patients who are low risk. In patients who are high risk, that is where I get concerned,” he says.
2. Asthma. There is a well-recognized link between asthma and severe reactions. Mack notes that uncontrolled asthma puts patients in danger, especially since treatment will be pushing the immune system. If the patient has uncontrolled asthma, and is having asthma symptoms, it would be wise to hold off. “I have a lot more caution with asthma,” he says.
3. Variability in dosing. Extensive heating through baking modifies a food’s milk or egg protein, so that it is less allergenic. However, the amount of protein a patient is exposed to in a baked product can vary depending on the food. For example, in cookies or muffins the protein is extensively broken down. But a pancake, which is not cooked as thoroughly, contains more milk protein. It is also important to consider that recipes have varying amounts of milk or egg, or different baking times, or inconsistent temperatures. Inconsistencies in protein levels can even arise within one product, such as when the center of a muffin is less baked than the outside.
What should parents watch for with ladder therapy?
Once a patient begins a milk or egg ladder, the family’s level of responsibility increases. In addition to preparing the baked product, they must assess their child’s health each day. The allergists’ article says the parents need to determine whether it is safe to provide the daily dose, while assessing any possible reaction signs.
Mack tells Allergic Living that parents should be on the lookout for the following during ladder therapy:
- Any type of reaction.
- Significant distaste for the food or other pushback.
- Development of asthma symptoms.
He stresses communicating with the doctor about any of those situations; they might indicate a need to alter the approach. For instance, delaying progression on the amount of baked good consumed.
Are patients who tolerate baked milk or egg still allergic?
Yes. When a patient passes a baked egg or milk challenge, they are still allergic to egg or milk in raw or less-cooked form, Mack says. This is different from patients who pass an oral challenge to other allergens, such as peanut or tree nut. Those allergies would be considered outgrown. The key difference is that the “outgrown” patients were not consuming only heated forms that altered the allergenic protein.
“Tolerance with baked products is a much more tenuous proposition, and once tolerant may not necessarily mean always tolerant,” the paper states. This relates to the inconsistencies involved with ladders, such as baking time and amount of allergen.
There is a perception that the patients who are eating baked products are outgrowing their allergies to milk and egg quicker. But Mack says there is not enough evidence to support that claim. More research is needed to show whether completing a milk or egg ladder can help kids outgrow those allergies, he says.
Final takeaways with milk and egg ladders?
Mack would like to see research focusing on the standardization of protocols for milk and egg ladders. In the meantime, families who navigate these therapies should do so under the guidance of a trained allergist, understanding the risks and the vital need for communication.
“As allergists, we must recognize the unique challenges these procedures bring, and strive for the safest possible implementation,” the paper states.
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