Effectiveness and Safety of Milk Ladders in Children with IgE-Mediated Cow's Milk Protein Allergy

NCT ID: NCT06664918

Last Updated: 2025-03-18

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 92 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2024-12-03
• Study Completion Date: 2029-03-31

Brief Summary

Cow's milk protein allergy (CMPA) is one of the most common food allergies in early childhood. The first-line treatment of CMPA is the elimination of cow's milk proteins (CMPs) from the child's or maternal diet.

Available data from the literature indicate that most children with CMPA acquire tolerance to CMPs with age. An assessment of tolerance acquisition to CMPs is commonly performed using milk ladder. However, scientific evidence regarding the effectiveness and safety of the milk ladder in children with CMPA is limited. Currently, there is no standardised milk ladder protocol, and different versions of the ladder and recommend by scientific societies in various countries.

This study aims to assess the effectiveness and safety of the 4-step milk ladder (4-ML) compared to the 6-step milk ladder (6-ML) in children with IgE-mediated CMPA. This is an open-label, randomised superiority trial with two parallel arms and a 1:1 allocation ratio.

Detailed Description

Introducing baked milk into the diet of children with cow's milk protein allergy (CMPA) has been shown to potentially accelerate the development of tolerance to raw milk. However, there is no standardised milk ladder protocol, and different scientific societies across countries recommend varying versions.

This study aims to assess the effectiveness and safety of the 4-step milk ladder (4-ML) compared to the 6-step milk ladder (6-ML) in children with IgE-mediated CMPA.

We will perform an open-label randomised trial with two parallel arms in two departments of the same academic hospital. A total of 92 children with IgE-mediated CMPA will be allocated to introduce cow's milk into their diet according to either 4-ML or 6-ML with a 4-week break period between subsequent steps. Oral food challenge (OFCs) with tested products at each subsequent step of the milk ladder will be conducted in hospital settings. The primary outcome will be the percentage of children with tolerance to non-heated cow's milk proteins defined as no allergic reaction to non-heated cow's milk (120-240 ml depending on the age of the patient) during the last OFC; measured at the end of the 12-week observation period for the 4-ML and 20-week observation period for the 6-ML. Secondary outcomes will include the percentage of children with a negative OFC to each milk ladder step; the percentage of children with anaphylaxis (both those who were treated and who were not treated with adrenaline); the percentage of children with exacerbation of atopic dermatitis; growth; compliance; and quality of life of the caregivers and parents' anxiety about adverse events during their child's OFC.

The statistical analyses will be conducted with StatsDirect. The Mann-Whitney U test will be used to compare the means of continuous variables if non-normal distribution will be assessed. Proportions will be compared with the Fisher exact test. The difference in study groups was considered significant when the P value will be <05. The results of this study will be analyzed on the basis of intention to treat.

Conditions

Cow Milk Allergy; Food Allergy

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

4-step milk ladder

Group Type: EXPERIMENTAL

oral food challenge (OFC)

Intervention Type: OTHER

oral food challenges with subsequent steps of 4-step milk ladder (muffin, pancake,baked hard cheese, yoghurt/pasteurised cow milk or modified cow milk)

6-step milk ladder

Group Type: ACTIVE_COMPARATOR

oral food challenge (OFC)

Intervention Type: OTHER

oral food challenges with subsequent steps of 6-step milk ladder (cookie, muffin, pancake,baked hard cheese, yoghurt, pasteurised cow milk or modified cow milk)

Interventions

oral food challenge (OFC)

oral food challenges with subsequent steps of 4-step milk ladder (muffin, pancake,baked hard cheese, yoghurt/pasteurised cow milk or modified cow milk)

Intervention Type: OTHER

oral food challenge (OFC)

oral food challenges with subsequent steps of 6-step milk ladder (cookie, muffin, pancake,baked hard cheese, yoghurt, pasteurised cow milk or modified cow milk)

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• Age between 1 and 5 years.
• Diagnosis of IgE-mediated CMPA confirmed according to ESPGHAN guidelines, by a positive OFC with CMPs. In high-risk children (i.e., with a history of anaphylaxis), diagnosis based on positive skin prick testing and/or elevated specific IgE to CMPs is sufficient.
• On a therapeutic elimination diet for at least 6 months or up to 12 months of age.12
• Eligible regardless of the risk of systemic reaction (anaphylaxis) and asthma.
• Good overall health status.
• Parents without language barriers.
• Written informed consent signed by parents.
• Good cooperation with the child's guardians.

Exclusion Criteria

• Uncontrolled asthma, defined as the presence of shortness of breath, chest tightness, cough, and/or auscultatory changes despite treatment.
• Signs of exacerbation of a chronic disease.
• Signs of acute infectious disease (i.e., acute runny nose, cough, subfebrile fever, or fever).
• Signs of exacerbation of another allergic disease (i.e., conjunctivitis, allergic rhinitis, atopic dermatitis).
• Anaphylaxis due to CMPs in the last 6 months.
• Used antihistamines within 3-10 days before the challenge (depending on the characteristics of the drug and the reason for use).
• Acquired tolerance to baked CMPs or higher steps of the milk ladder.
• Use of immunosuppressive drugs or immunotherapy

• Minimum Eligible Age: 1 Year
• Maximum Eligible Age: 5 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Medical University of Warsaw

OTHER

Sponsor Role: lead

Responsible Party

Andrea Horvath-Stolarczyk

Associate Professor

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Andrea Horvath

Role: PRINCIPAL_INVESTIGATOR

Medical University od Warsaw

Hanna Szajewska

Role: PRINCIPAL_INVESTIGATOR

Medical University of Warsaw

Anna Nowak-Węgrzyn

Role: PRINCIPAL_INVESTIGATOR

Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland; New York Univeristy, Grossmann School of Medicine

Locations

Medical University od Warsaw, Department od Pediatrics

Warsaw, , Poland

Site Status: RECRUITING

Medical University od Warsaw

Warsaw, , Poland

Site Status: NOT_YET_RECRUITING

Countries

Poland

Central Contacts

Andrea Horvath, MD, PhD

Role: CONTACT

andrea.horvath@wum.edu.pl

048223179444

Daria Wiszniewska, MD

Role: CONTACT

daria.wiszniewska@uckwum.pl

048223179535

Facility Contacts

Daria Wiszniewska

Role: primary

daria.wiszniewska@gmail.com

783307607

Andrea Horvath, MD PhD

Role: primary

andrea.horvath@wum.edu.pl

22 317 9444

References

Wiszniewska D, Horvath A, Strozyk A, Nowak-Wegrzyn A, Grzela K, Szajewska H. Effectiveness and safety of the four-step versus six-step milk ladder in children with IgE-mediated cow's milk protein allergy: protocol for an open-label randomised controlled trial. BMJ Open. 2025 Apr 14;15(4):e098314. doi: 10.1136/bmjopen-2024-098314.

Reference Type: DERIVED

PMID: 40228856 (View on PubMed)

Other Identifiers

ML2024

Identifier Type: -

Identifier Source: org_study_id