Most High-Risk Kids with Milk Allergy Tolerate Baked Milk After Oral Food Challenge

In a recent study, two-thirds of children with high-risk cow’s milk allergies were tolerant to baked milk after undergoing a baked milk oral food challenge.1

Investigators hypothesized that consuming baked milk could strengthen tolerance in children allergic to cow’s milk. After all, an oral food challenge for baked milk is recommended for high-risk patients since the benefits outweigh the risks of a prolonged exclusion diet.

According to Food Allergy Research & Education (FARE), approximately 70% of children with cow milk allergy tolerate baked cow milk.2 Young children who are allergic to fresh milk, but not baked milk, may be more likely to outgrow their milk allergy at an earlier age than children who react to baked milk. Children who pass the baked milk oral food challenge can add foods like breads or crackers, cow’s milk listed as the third ingredient, processed goods that say “may contain milk”, and recipes that have 1 cup of flour for every 1 cup of milk into their diet.3

“When a person with a milk allergy is exposed to milk, proteins in the milk bind to specific IgE antibodies made by the person’s immune system,” FARE states on their website.2 “This triggers the person’s immune defenses, leading to reaction symptoms that can be mild or very severe.”

A team, led by Olga Domínguez, from the pediatric allergy and clinical immunology department at the Hospital Sant Joan de Déu, in Barcelona, Spain, sought to identify the predictive biomarkers for baked milk oral food challenge outcomes in a high-risk cohort.1 The team also compared the oral food challenge thresholds for baked and pasteurized cow’s milk protein.

Domínguez and colleagues conducted a prospective study of children aged ≥ 12 months to < 6 years with a history of cow’s milk allergy. An allergy diagnosis consisted of prick testing, specific IgE for cow’s milk and components, specific IgE for G4, and the basophil activation test. Participants underwent a baked milk oral food challenge for a cumulative dose of 1 gram of cow’s milk protein. Children with a baked milk tolerance underwent a cow’s milk oral food challenge to confirm a cow’s milk allergy.

The study included 50 patients, with 66% who had a history of anaphylaxis. During the baked milk oral food challenge, 36% reacted, and 39% had anaphylaxis. The median reactivity threshold in the sample was 138 mg of cow’s milk protein.

The study identified several risk factors for a baked milk allergy, including an anaphylaxis history, being > 3 years old, increased CM-sIgE and casein-sIgE, and a positive basophil activation test result. The cut-offs were >5 mm for skin prick testing with casein, ≥8.5 kUA/L for CM-sIgE, and ≥5.7 kUA/L for casein-sIgE.

“These made it possible to distinguish [baked milk]-allergic patients from [cow’s milk allergic] patients who tolerated [baked milk],” investigators wrote.

Patients who tolerated baked milk had a cow’s milk oral food challenge threshold of 270 mg, with 43.8% reacting to < 100 mg and 40% experiencing anaphylaxis.

Investigators concluded by noting that baked milk oral food challenges are not risk-free, as seen with more than a third of participants having reactions. However, the early introduction of baked milk products in oral food challenges led to two-thirds of children at high risk of a cow’s milk allergy to be baked milk tolerant.

After oral food therapy, patients’ reactivity threshold to pasteurized milk was less than half of the tolerated dose of baked milk (1000 mg).

References

1. Domínguez O, Riggioni C, Poyatos E, et al. Biomarkers of Tolerance to Baked Milk in Cow's Milk-Allergic Children at High Risk of Anaphylaxis. J Investig Allergol Clin Immunol. Published online May 5, 2025. doi:10.18176/jiaci.1074

2. Milk Allergy. Food Allergy Research & Education. https://www.foodallergy.org/living-food-allergy/food-allergy-essentials/common-allergens/milk. Accessed May 13, 2025.

3. How to Add Baked Milk into Your Child’s Diet After a Baked Milk Challenge. Massachusetts General Hospital. https://www.massgeneral.org/children/food-allergies/how-to-add-baked-milk-into-your-childs-diet-after-a-baked-milk-challenge. Accessed May 13, 2025.