D2.306 - From baked cookie to unheated milk: Desensitization in a high-risk cow’s milk protein allergy patient

The gradual introduction of baked milk–containing products, such as cookies, has been shown to accelerate the resolution of cow’s milk protein allergy (CMPA) in selected children who tolerate baked milk. This approach has proven more effective than strict avoidance and is associated with improved quality of life. However, evidence remains limited in patients with high casein-specific IgE levels (>20 kUA/L). We present the case of a patient with persistent CMPA and elevated casein-specific IgE who underwent desensitization using homemade milk-containing cookies, aiming to describe the clinical course and safety of a baked-matrix–based desensitization approach in a high-risk profile.

A 10-year-old boy with a diagnosis of IgE-mediated CMPA since infancy and a history of anaphylaxis following accidental ingestion was evaluated. His relevant past medical history included egg allergy, currently resolved after completion of an oral immunotherapy protocol. Immunoallergological assessment revealed the following values: total IgE 71.30 kU/L; cow’s milk–specific IgE 39.30 kUA/L; α-lactalbumin–specific IgE 13.60 kUA/L; β-lactoglobulin–specific IgE 8.57 kUA/L; casein-specific IgE 34.30 kUA/L; whey-specific IgE 30.00 kUA/L.Due to persistent sensitization, an oral desensitization protocol was initiated in a specialized unit, starting with homemade cookies containing approximately 15 mg of milk protein, with gradual dose escalation toward unheated milk.

The patient experienced mild cutaneous reactions during the initial phases, which were controlled with symptomatic treatment, without further episodes of anaphylaxis. Progressive dose escalation over a 10-month period led to full tolerance of 200 ml (6.6 g milk protein) of unheated milk without symptoms.

We report the case of a high-risk patient who successfully underwent sequential food immunotherapy using a standardized dry baked matrix, in this case a homemade cookie, achieving progressive desensitization up to tolerance of unheated milk proteins. The intervention was conducted in a specialized setting with close clinical monitoring, underscoring the potential applicability of baked-matrix–based protocols even in high-risk CMPA patients.