Cow's milk protein is the main food that triggers eosinophilic oesophagitis (EoE) in patients of all ages, and once it is identified as such, milk and all milk-containing products should be avoided in the diet. A recent study published in Alimentary Pharmacology & Therapeutics by Gonzalez-Cervera J et al, evaluates tolerance to sterilized cow’s milk, which is boiled instead of UHT processed, in patients with EoE already known to be triggered by cow’s milk, in terms of maintenance of disease in remission.

Milk is composed of several proteins with allergenic potential. Most allergic reactions to milk are mediated by immunoglobulin E (IgE). However, some patients might present a late, non-IgE-mediated milk allergy that manifests primarily with gastrointestinal involvement, including EoE. Previous evidence showed that baked milk (this is, cooked products that contain milk, such as muffins and cookies) are well tolerated by up to 75% of children with IgE-mediated milk allergy, increasing with long-term use. A retrospective case series also showed that a proportion of patients with EoE triggered by milk could also tolerate baked products containing milk with no recurrence of oesophageal eosinophilic inflammation. However, none of the EoE patients included sterilized milk in their diets, which is boiled for at least 20 minutes instead of UHT processing. This leads to denaturation of some proteins due to the effect of heat, which thus lose their antigenic capacity. As sterilized milk is commercially available, it could provide a potential solution for patients who must avoid fluid milk.

In this investigation, 18 adolescents and adult patients with EoE who had milk identified as an offending food after an empirical food elimination diet-based approach and who were in remission on a milk-free diet were prospectively recruited. They were given 200 mL of sterilized cow’s milk twice daily for 8 weeks. Endoscopic assessment, intraepithelial peak eosinophil counts, oesophageal-related symptoms, health-related quality of life (HRQoL), blood eosinophils, eosinophil cationic protein (ECP), skin prick test and serum total and specific IgE to major milk proteins were assessed before and after sterilized milk intake.

Overall, 12 patients (66.7%) maintained EoE in remission (<15 eos/hpf in endoscopic biopsies and no oesophageal symptoms) while EoE recurred in the remaining 6 (33.4%). Among sterilized tolerant patients, endoscopic changes did not varied from baseline, but inflammatory features (oedema, furrows and exudates) reappeared in non-tolerant patients. HRQoL scored well at baseline and was maintained among sterilized milk-tolerant patients, but deteriorated in reactive ones. No significant changes were observed in blood eosinophil count, and other blood protein markers. However, cow's milk-specific IgE slightly increased in non-tolerant patients. Nutrients intake were measured at baseline and along the study period with the aid of validated nutrition diaries. Compared to baseline, the weekly intake of saturated fatty acids, medium change triglycerides and calcium significantly increased at the end of the study period.

Furthermore, tolerance to sterilized milk was maintained long-term for 1 year among the patients who continued consuming it regularly, and also incorporated to their diets baked milk-containing products.

In conclusion, this study provides evidence that two thirds of patients with EoE triggered by milk proteins are able to tolerate sterilized milk, without presenting signs of disease recurrence in the short or the long term. In addition, once verified, patients tolerant to sterilized milk patients could also tolerate products containing baked milk. These result may help many patients to improve their diets by allowing them to consume a greater variety of foods, maintaining adequate control of EoE in the long term.

Author of this summary
Alfredo J Lucendo. Department of Gastroenterology. Hospital General de Tomelloso. Tomelloso, Ciudad Real. Spain.

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Gonzalez-Cervera J et al. Aliment Pharmacol Ther. 2022 Aug 2. doi: 10.1111/apt.17171.