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\begin{document}

\title{Single low-dose exposure to cow's milk at diagnosis accelerates cow's
milk allergic infants' progress on a milk ladder programme}



\author[1]{Yvonne d’Art M}%
\author[2]{Lisa Forristal}%
\author[3]{Aideen Byrne}%
\author[3]{John Fitzsimons}%
\author[4]{Ronald Van Ree}%
\author[2]{Audrey DunnGalvin}%
\author[1]{Jonathan O’B Hourihane}%
\affil[1]{University College Cork School of Medicine}%
\affil[2]{University College Cork School of Applied Psychology}%
\affil[3]{Childrens Health Ireland Dublin Ireland}%
\affil[4]{Amsterdam UMC Locatie AMC}%


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  \date{June 03, 2024}


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\begin{abstract}
\textbf{Background} Cow's milk protein allergy (CMPA) is one of the most
common food allergies in infancy. Most infants with CMPA tolerate baked
milk from diagnosis and gradually acquire increased tolerance.
Nevertheless, parents often display significant anxiety about this
condition and a corresponding reluctance to progress with home
introduction of dairy due to concerns about possible allergic reactions.
\textbf{Objective:} To evaluate the impact on gradual home introduction
of foods containing cows milk after a supervised, single low dose
exposure to whole milk at time of diagnosis. \textbf{Methods} Infants
less than 12 months old, referred with suspected IgE-mediated cow's milk
allergy were recruited to an open-label randomised, controlled trial of
intervention - a single dose of fresh cow's milk, using the validated
dose of milk that would elicit reactions in 5\% of CMPA subjects - the
ED \textsubscript{05} -- vs routine care. Both groups implemented graded
exposure to CM (using the 12 step MAP Milk Tolerance Induction Ladder),
at Home. Parents completed food allergy quality of life and State and
Trait Anxiety Inventories (STAI). Main outcome measures were milk ladder
position at 6 months and 12 months post randomisation. \textbf{Results:}
Sixty patients were recruited, 57 (95\%) were followed to 6 months. By 6
months 27/37 (73\%) intervention subjects had reached step 6 or above on
the milk ladder compared to 10/20 (50\%) control subjects (p=0.048). By
6 months 11/37 (30\%) intervention subjects had reached step 12 (ie
drinking unheated cow's milk) compared to 2/20 (10\%) of the controls
(p=0.049). Twelve months post randomisation 31/36(86\%) of the
intervention group and 15/19(79\%) of the control group were on step 6
or above. However, 24/37 (65\%) of the intervention group were at step
12 compared to 7/20 (35\%) of the control group (p=0.03). Maternal STAIs
were significantly associated with their infants' progress on the milk
ladder and with changes in skin prick test and spIgE levels at 6 and 12
months. \textbf{Conclusion} This study demonstrates the safety and
effectiveness of introduction of baked milk implemented immediately
after diagnosis of cows milk allergy in a very young cohort. A
supervised single dose of milk at the ED \textsubscript{05}
significantly accelerates this further, probably by giving parents the
confidence to proceed. Maternal anxiety generally reflects infants'
progress towards completion of the milk ladder, but pre-existing high
levels of maternal anxiety are associated with poorer progress.%
\end{abstract}%



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