D3.284 - Milk Aversion After Successful Desensitization in a Milk-Allergic Child

Food aversion represents an important yet often overlooked aspect of feeding difficulties in children and adolescents with food allergy. It is characterized by persistent avoidance of specific foods despite confirmed immunological tolerance. Learned aversion may arise following early adverse reactions, prolonged elimination diets, and heightened parental anxiety. Importantly, food aversion can persist into adolescence and adulthood, even after successful oral immunotherapy (OIT), limiting real-life dietary expansion.

We report a 16-year-old male (written informed consent was obtain from his parents) with multiple IgE -mediated food allergies (milk, peanut, tree nuts, soy, sesame). An anaphylactic reaction to milk occurred in infancy, followed by lifelong strict avoidance of milk and dairy products. Diagnostic work-up demonstrated multiple food sensitizations. Egg allergy was excluded by open food challenge at 3 years of age, while peanut allergy was confirmed following vomiting during challenge.

Due to persistent milk allergy, milk OIT was initiated at 13 years of age. A double-blind placebo-controlled food challenge (DBPCFC) identified the maximum tolerated dose, with mild objective symptoms (tongue tingling and upper lip angioedema). OIT was started using baked milk (2.7 ml; 90 mg milk protein) incorporated in a muffin. Over nearly two years, OIT was well tolerated without adverse reactions. Post-treatment DBPCFC confirmed successful desensitization.

Despite immunological tolerance, the patient refused consumption of milk in its natural form, reporting intense aversion to its smell, taste, and texture, accompanied by nausea. Introduction of other dairy products such as cheese and yogurt was also unsuccessful. Desensitization was successfully maintained through regular ingestion of milk-containing foods with masked sensory characteristics.

This case highlights that food aversion may persist or emerge even after successful OIT and confirmed tolerance. Addressing sensory-based avoidance is essential for meaningful dietary inclusion. Tailoring allergen introduction to individual sensory preferences represents a practical strategy to support long-term desensitization and improve quality of life.