RationaleWe recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT.Methods30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations.Results8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group.ConclusionProlonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms. RationaleWe recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT. We recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT. Methods30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations. 30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations. Results8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group. 8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group. ConclusionProlonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms. Prolonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms.

RATIONALE: To examine the success and predictors of baked egg introduction in patients with egg allergy. METHODS: Egg allergy was defined as a positive egg challenge (OFC), symptoms with exposure and/or positive egg-specific IgE. Patients who were advised to introduce baked egg based on clinical parameters were identified through chart review. Phone follow-ups were conducted to determine if introduction was successful. RESULTS: 44 egg allergic patients, ages 2.2-16.5y, were included. 7 patients (15.9%) reacted to baked egg and returned to strict egg avoidance. Of those, 6 had a history of egg anaphylaxis and 3 had failed a previous egg OFC (1 severe, 1 moderate, and 1 mild reaction). 25 (56.8%) tolerated and continued baked egg. Of those, 5 had history of anaphylaxis, 12 had failed an OFC (2 severe, 7 moderate, 3 mild reactions). 12 (27.3%) tolerated baked egg and progressed to full egg. 1 had history of anaphylaxis, and 6 had failed an OFC (4 moderate, 2 mild reactions). In comparing the 3 groups, the mean egg-specific IgE was significantly higher (p = 0.04) in those who failed baked egg introduction {4.1 kU/l (range 0.43-7.2)} compared to those who tolerated introduction {2.1 (<0.35-10.1)} and those progressing to full egg {2.9 (0.48- 7.8)}. There were no differences in age (means: 8.0, 7.0, and 7.8 yrs), egg-related anaphylaxis history, or OFC reaction severity. CONCLUSIONS: Baked egg introduction was overall well tolerated in this selected group of allergic children. Egg-specific IgE was predictive of successful baked egg introduction, while age, anaphylaxis history and OFC reaction severity were not.

RATIONALE: To examine the success and predictors of baked milk introduction in patients with milk allergy. METHODS: Milk allergy was defined as failing a milk oral challenge (OFC) and/or a positive milk-specific IgE plus history of symptoms with milk exposure. Milk allergic patients who were advised to introduce baked milk based on clinical parameters were identified through chart review. Phone follow ups were conducted to determine the outcome of the introduction. RESULTS: 45 milk allergic patients ages 1.9 to 20 years were included. 6 patients (13.3%) reacted to baked milk and returned to strict milk avoidance. Of those, 1 had a history of milk anaphylaxis and 3 had previously failed a milk OFC, 1 with moderate and 2 with mild reactions. 28 (62.2%) tolerated introduction of baked milk. Of those, 4 had a history of anaphylaxis; 19 had previously failed an OFC (1 severe, 11 moderate, 6 mild reactions).11 (24.5%) tolerated baked milk and progressed to full milk at home. 2 had a history of anaphylaxis and 7 had previously failed an OFC (4 moderate, 3 mild). In comparing the 3 groups, there were no differences in milk-related anaphylaxis history, OFC reaction severity, mean age {9.2 yrs (range 1.9-14.7), 7.4 yrs (1.8-20.5) and 7.9 yrs (2.0-14.5), respectively}, or mean milk-IgE {1.7kU/L (range 0.36- 3.6), 4.3 (<0.35-41.8) and 1.0 (<0.35-3.4)} at the time of baked milk introduction. CONCLUSIONS: Home introduction of baked milk was overall successful in this selected group of milk allergic children, regardless of milk-related reaction severity history, age, or milk-specific IgE.

BACKGROUND:Cow's milk allergy (CMA) is the most common food allergy in infants and young children, affecting 2% to 3% of the general population. Most studies have shown the prognosis of developing tolerance to cow's milk to be good, with most outgrowing their allergy by age 3 years.OBJECTIVE:To define the natural course of CMA and identify the factors that best predict outcome in a large referral population of children with CMA.METHODS:Clinical history, test results, and final outcome were collected on 807 patients with IgE-mediated CMA. Patients were considered tolerant after they passed a challenge or experienced no reactions in the past 12 months and had a cow's milk IgE (cm-IgE) level <3 kU/L.RESULTS:Rates of resolution were 19% by age 4 years, 42% by age 8 years, 64% by age 12 years, and 79% by 16 years. Patients with persistent allergy had higher cm-IgE levels at all ages to age 16 years. The highest cm-IgE for each patient, defined as peak cm-IgE, was found to be highly predictive of outcome (P < .001). Coexisting asthma (P < .001) and allergic rhinitis (P < .001) were also significant predictors of outcome.CONCLUSION:The prognosis for CMA in this population is worse than previously reported. However, some patients developed tolerance during adolescence, indicating that follow-up and re-evaluation of CMA patients is important in their care. cm-IgE level is highly predictive of outcome.CLINICAL IMPLICATIONS:The increasing potential for persistence of CMA, along with cm-IgE level's effect on prognosis, should be considered when counseling families regarding expected clinical course.