Assessing Milk and Egg Ladders for Pediatric IgE-Mediated Allergies

Announcer:
You’re listening to On the Frontlines of Food Allergies on ReachMD. On this episode, we’ll hear from Dr. Allison Hicks, who’s an Assistant Professor of Pediatric Allergy and Immunology at the University of Colorado. She’ll be discussing the use of milk ladders as a management strategy for cow's milk allergy. Here’s Dr. Hicks now.

Dr. Hicks:
The key benefits of using food ladders include a couple of things. We have increased diet diversity compared to strict avoidance or using a baked milk or egg procedure since we’re introducing a more varied amount of foods into a child’s diet. There is thought that using food ladders might increase the hastening of resolution of a food allergy, so taking less time for a child to tolerate milk or egg in all form. The data is very limited on this, and we’re using data extrapolated from baked milk or egg diets which is in need of more confirmation. But there’s thought that introducing baked milk or egg into the diet may speed the time to tolerance, so if you’re introducing even more food that has an even higher allergenic protein content, you might hasten that resolution more rapidly. And then, because the ladder is used at home, there’s decreased healthcare utilization and, with that, decreased healthcare costs and patient burden since the family is not having to come in for multiple oral food challenges. 

There are risks and issues with using food ladders for IgE-mediated allergy. Most of the current ladders were not created for IgE-mediated allergy and instead were made for food intolerance or sensitivity, so they may have big jumps or not consider how strict we need to be with IgE-mediated allergy. And they were not made for the multicultural US diet, so sometimes they’re hard for families to follow. Because this is a home process, there is risk of reaction at home, so we have to be really careful with the patients we choose and the families that we think are a good fit for food ladders. And we don’t have very good tools right now to perfectly pick which family and child would be a good candidate and what children might be at higher risk for adverse reactions.

And then the ladders really just need better standardization. Some of the currently available ladders don’t even offer recipes; they just give families more ideas like muffins and pancakes. That might be hard for families to follow, so we need clear recipes that are simple and multicultural, and then we also need clear instructions for how to actually progress through the ladder and when to hold a dose, i.e. if the child has a febrile illness.

Ideally, the ladders would also involve protein quantification, meaning quantifying the allergenic protein in each of the recipes in each step so that we know we’re actually progressing in a safe manner. And then they should always think about nutritional content and try to make these as nutritionally sound as possible, but balancing that with palatability because we are mostly offering these to infants and toddlers, so we need to be able to have them like the food and want to eat it.

Announcer:
That was Dr. Allison Hicks talking about managing IgE-mediated cow's milk allergy with milk ladders. To access this and other episodes in our series, visit On the Frontlines of Food Allergies on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!