Saturday, February 9, 2013

Congrats! Your Child Passed a Baked Milk Challenge!

Clueless. Get it?
Now what?

I get a lot of questions about baked milk dosing: how much, how long to bake, what foods to start with, what order to give them. It's such a helpless feeling to have to say "I don't know" most of the time.

We are back to doing milk dosing, but things have been a bit haphazard in our house. We try to do the milk dosing right after school so there's time to deal with reactions if we have to. However, I have also recently started an on-site job and my son works most weekends, so it's been difficult to find the time.

About a week ago, I gave him his dose (individual rice puddings baked 50 minutes; approx. 1.5 oz. milk in each, or ~1.5 g protein), only to realize that I was signed up to drive car pool that day and had to leave! A frantic call to my husband, followed by him abandoning his work day to drive home, and at least we were covered. However, this is clearly going to get harder and harder for us to do, so I encourage all of you with younger children (and hopefully stay-at-home schedules) to not wait to pursue this until just before college.

Anyway, the point of this post is to summarize a really great article from AINotes about food challenges and baked milk dosing. Here are the recommendations from Mt. Sinai for challenges/food introductions:

  • During the food challenge, give a muffin containing 1.3 g of milk protein (nonfat dry milk powder; Nestle Carnation) baked at 350 F for 30 min.
  • If muffin tolerated, challenged same day (2 hours after muffin) with waffle (<0.625 inches thick to ensure thorough heating), containing 1.3 g of milk protein (nonfat dry milk powder; Nestle Carnation) cooked in a waffle maker at ~500 F for 3 min.
  • If muffin/waffle tolerated, challenged 6 months later to Amy’s cheese pizza (Amy’s Kitchen, Inc), containing 4.6 g of milk protein, baked at 425 F for 13 min or longer.
  • Muffin, waffle, and pizza were administered in 4 equal portions over 1 hour. Subjects were monitored throughout and for 2-4 hours after completion of the challenge.
If the challenge is successful, patients are instructed to ingest 1-3 servings of foods containing milk every day:
  • Store-bought baked products (cookies, breads, bagels) with egg/milk listed as the 3rd ingredient or further down the list of ingredients.
  • Home-baked products that have 1 egg (or 1 cup milk) per 1 cup of flour or 1-2 eggs (or 1 cup milk) per batch of a recipe (yield 6 servings). If you offer home baked products, feed 1 serving at a time with at least 2 hours between servings.
  • Avoid products that do not qualify as baked egg: french toast, scrambled eggs, custard, etc.
There is a special note at the end indicating that, at least in one study, up to 8% of kids who passed a peanut challenge can have a recurrence of the allergy. This may be true of milk and egg as well, especially when these proteins are given in different forms (cheese vs. milk, for example). 

In our case, we've found our son can tolerate virtually any type of baked milk without a problem, baked butter in most instances, and very little baked cheese. This probably makes sense, as the amount of milk protein in cheese is proportionally higher than in liquid milk (which is only about 3% protein). But, the takeaway message is that you do have to be prepared for reactions as you work through this process.

At the very beginning of this article (Table 10:2), there's a note about how often food challenges for milk should be done. I was extremely surprised to see that the recommendation is to test every 12 months, barring history of an anaphylactic episode in that calendar year. By that measure, my son should have been tested for baked milk every year, starting after about age 8 (his last anaphylactic reaction to milk that I remember was around first grade). 

It's a shame that we waited until his late teen years to pursue this. It may not have happened even then, if our allergist's practice had not added a new doctor who had participated in the oral tolerance trial research. I'm heartsick that my son has been so restricted all through his teen years when a simple food challenge might have opened up so many more doors. 

SAFETY NOTE: please remember that I am talking about introducing baked milk only AFTER a child has passed an oral food challenge supervised by an allergist. This is NOT a do-it-yourself project. 

That said, I more than encourage any of you with grade-school-age kids to pursue this and press your allergist hard for challenges. Show them the chart. Show them the protocol. There's a brave new world out there! 

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