Oral immunotherapy (OIT) for the treatment of cow's milk allergy (CMA) represents an emerging reality that expands the possibility of an active treatment with the goal of improving the quality of life for children and their families, claims a new review of studies.

Researchers at the University of Messina (Italy) found that OIT using cow's milk can result in a desensitization state eventually achieved by approximately 36%-92% of children treated with specific immunoglobulin E (IgE) immunotherapy; the rate of permanent tolerance is unknown, but longer duration of desensitization may result in permanent tolerance. Most studies have shown the prognosis for developing tolerance to cow's milk to be good, with the majority outgrowing their allergy by age 3 years; recent reports indicate, however, that children may need longer to outgrow their milk allergy, with some developing tolerance only in their teenage years.

The possibility of adverse events or reactions during OIT is quite frequent, and the severity of reactions are greatest on the initial days and least on the days following desensitization, when high doses of cow's milk intake are reached by patients. Severe systemic side effects have been reported with either rush schedules or weekly up-dosing regimens. Mild reactions such as abdominal pain, throat pruritus, gritty eyes, watery eyes, transient erythema and sneezing usually do not require stopping desensitization. However, when rhinitis, dyspnea, asthma, generalized urticaria, and hypotension occur as a single symptom or in combination, OIT should be postponed or stopped.

The researchers found, however, that these reactions could be well controlled by antihistamines, steroids, or epinephrine. Because desensitization places patients at risk for systemic reactions, it is not appropriate to implement OIT in clinical practice settings at this time. The researchers suggest, therefore, that OIT be performed for research purposes or as “avant-garde” and modern therapy for IgE-mediated food allergy in specialized pediatric centers. The review was published in the December 2011 issue of Current Opinion in Allergy and Clinical Immunology.

“Before this treatment can be used in clinical practice, additional studies are needed,” concluded lead author Giovanni Pajno, MD, and colleagues of the department of pediatrics. “Currently, many issues remain unanswered: severity and type of food allergy responsive to specific immunotherapy, degree of protection, 'shared schedules' of desensitization in research settings, and well established risk-to-benefit ratio.”

Food allergies represent a frontier in which the application of specific immunotherapy may prove more fruitful when added to current therapeutic options. OIT, epicutaneous immunotherapy (EPIT), and sublingual epicutaneous immunotherapy (SLIT) and have all been studied for the treatment of IgE-mediated CMA, although reports on OIT thus far have been more extensive. ON the other hand, a large number of children with CMA develop tolerance spontaneously, and therefore waiting at least to the age of three before starting OIT seems reasonable.

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