Milk Allergy Q&A with Prof Adam Fox

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Sarah [00:00:04] Welcome to tonight's webinar with the allergy team and Professor Adam Fox. Tonight, we're going to do a special all about living with a milk allergy. And we have hundreds of people coming and hundreds of questions to get through. So it's an exciting evening. As ever, Professor Adam fox can't answer any specific questions to your child for that. You need to see your allergy clinician or your doctor, but what Adam can do. is give us a wealth of information and knowledge to make us all so much more informed. Adam, if you haven't met him before, is a brilliant doctor who has a wonderful way of explaining quite complex things in a most brilliantly understandable way. He has, he's chair of the National Allergy Strategy Group. He was the president of the British Society of Allerging and Clinical Immunology. He has worked a lot at Guy's and St. Thomas's and he is just all round brilliant. So Adam, thank you so much for joining us tonight. we are going to do our best to get through as many questions as possible and I apologise if we slightly paraphrase some to join them with other questions but we will do our absolute finest. I have also before coming on this call already managed to persuade Adam to do another a follow-up round two milk Q&A because there's that many questions and that will be for our members and also tonight we are launching our special thriving with a milk allergy, which we will tell you about at the end. But for now, thank you for joining us and most of all, thank you, Adam. So I'm going to start with some general questions. Lindsay says, is a dairy allergy different to a cow's milk protein allergy?

Prof Adam Fox [00:01:55] Okay, so I always know when I do this session, I always get this look from Sarah saying that I have to keep it shorter than I was planning to, so I'll try to. It just keeps getting lots of different names and it often causes confusion. So I get people coming to my clinic telling me about their milk intolerances and lactose allergies, and often they're talking about quite different things. But... Essentially, I'm always bothering the people I work with to not use the term dairy. Really don't like it because it means different things to different people, which is awful when you're trying to be really precise with your terminology. So I never use the term dairy because some people think it's milk, some people thing it's milk and eggs, some think it is something else. So a milk allergy is distinct from lactose intolerance, which is an issue with digesting sugar, which you rarely see in small children, other than briefly after periods of tummy upsets. But milk allergy broadly can mean two things, the two different types. So there's the immediate type milk allergies, where when you have milk, you immediately come out in hives. It involves allergic antibodies that can potentially cause really nasty reactions. And the other type of milk allergy, delayed type milk allergy that used to be called cow's milk intolerance, which is what causes a lot of confusion, but we would now refer to as a non-IGE mediated or a delayed type milk allergy. And that's where an infant having regular milk in their diets might get chronic symptoms of things like reflux or colic or diarrhoea. or flares of eczema, which is because of the milk in their diet, but they won't get the obvious immediate symptoms you get with an IgE-mediated.

Sarah [00:03:30] Okay, so Anastasia wants to know why cow's milk protein allergy occurrence and diagnosis seems to be going through the roof. Firstly, is that the case? And secondly, if so, why?

Prof Adam Fox [00:03:41] So I don't think there is any good evidence to say that there is more cow's milk allergy around now than it was 10 or 20 years ago. What there is good evidence of is that there are more children presenting in emergency departments with severe allergic reactions, which intuitively would think mean there must be more children with food allergy. and there's some evidence suggesting that it might be, but then it could well be because there's more allergies to things like nuts and sesame and legumes that we didn't see so much a few years ago. But when you look specifically at the evidence for cow's milk allergy, there's not good evidence that we're seeing more of it. We are hearing more about it because I think there's a much better prevalence, sorry, much better sort of understanding and awareness about it, but not always in a good way. And there's maybe slightly sort of dark forces at play here because they're all some commercial organisations that may benefit a little bit, so for example the manufacturers of the special broken down infant formulas, who potentially have got a little bit of gain by promoting the idea that every child that's got a little bit of eczema reflux, colic, loose stools, any of those different things, it might be a milk allergy, when of course it's actually unlikely to be. And the obvious question is well how much milk allergy we think there is around. it's probably around half of 1% to 1%. So about, you know, one in 100 to maybe one in 200 kids that have a genuine milk allergy. If you ask groups of parents how many of them think their child has got a milk allergy, sometime, some point during infancy, you're going to get, you know, something like one in 10. So it's dramatically over perceived. And some of that is because of social media and some of these other influences that make us think that every time something's going on, maybe it's because an underlying milk allergy but actually it's pretty uncommon.

Sarah [00:05:20] Oh, interesting. So we've got a few questions from parents about why their children can tolerate some foods with milk, but not others. So Cam and Catherine both have questions about this. Cam, whose eight year old has got a milk allergy and has had it since birth. He had a reaction after accidentally consuming some chocolate, but he's able to digest butter with things like bread, naan bread, etc. He's also have brownies that contain milk, and she's confused why he can eat some and not others

Prof Adam Fox [00:05:48] Yeah, so it's a really, really good question. If you go back 15, 20 years, we used to have these really blanket views that, you know, you just had to avoid milk completely, but our patients were coming in all the time and telling us about things that were happening that we were sort of saying, well, maybe it was just you were lucky on that occasion where it didn't really have as much milk in, but it then became pretty clear. And this is about 15 years ago, there were some really important studies done in New York where with immediate type milk allergies, they essentially established that 80% of those kids could tolerate milk when it was baked. So it comes down to which milk proteins you're allergic to. And it's not a simple sort of that there's two different types, like it is with egg, where there's two types of egg allergy. With milk, there's a whole range of different proteins within milk that you can be allergic to, and different combinations will give you different sort of things that you're OK with. Butter's a good example. It's predominantly milk fat. And remember, it's the protein that you are allergic to So actually, a lot of people with a milk allergy can tolerate butter. but with baked milk it's about 80% of kids with immediate allergy will be okay with baked milk whereas 20% will react to milk in all forms and then there's everything in between on the spectrum and as you start to outgrow it because most kids do outgrow their milk allergy you'll find there'll be times where their tolerance is getting a little bit better and then of course different things will happen on different days if you're under the weather you're going to be more sensitive so you might react to something that on a different day you wouldn't Whereas, For example, if you've done a lot of exercise, if your child's out of breath, they might be more sensitive. So again, they might react to something that they otherwise wouldn't on a day that they were otherwise not subject to those factors. So essentially, pretty much everybody with a male calorie is on a spectrum. And... There's a degree of tolerance that for some kids is next to nothing, for others is actually really high. I've got kids who can eat yoghourts but have plain milk there yet. Something you need to discuss with your doctor because there's sometimes, it's a little bit easy just to put people in boxes and say we'll just avoid everything. When actually being able to get something in the diet both makes life easier and potentially could drive tolerance developing faster, getting you out, growing faster. So for me, it's always a bit of a way of how can we find out what's the most we can get away with so that we can. liberate that data a little bit and speed up how quickly kids outgrow it. It needs a bespoke approach.

Sarah [00:07:59] Yeah, absolutely. So we've got a question from Rebecca. She's got a six month old. If the baby's had a certain reaction to a food, i.e. hives or eczema, is that the reaction they'll always have? Or could it get more severe with subsequent exposure or reactions?

Prof Adam Fox [00:08:17] Yeah, so the short answer is it's not always going to be the same. I get some families that will come in and say my child's got a milk, egg and a peanut allergy. With peanut they get hives, with egg they vomit and with milk something else happens. With the idea being that that's what's going to happen each time and that's just not the case at all. The nature of a reaction is going to depend on the very specific set of circumstances. So how much of the food is eaten, the form that it's in. certain forms do predispose you to certain symptoms, so for example baked milk or baked egg makes you more likely to vomit a little bit later because of course it takes a little while longer to be digested, but if you've had one type of reaction you might get a very different on another occasion. And to be honest this is why food allergy is hard because if you knew that your child was only ever going to get high you wouldn't have to worry so much. It's the fact that we don't know which child unpredictably, who previously only had just hives, is then going to have a more severe reaction and unfortunately allergic reactions are inherently unpredictable. I think in 10-15 years we'll have a much better handle on this. It's pretty clear there are groups of children where the risk of severe reactions is lower. For example, with milk allergy, the kids that are okay with baked milk, they are less likely to have bad reactions, but it doesn't preclude it completely. And so consequently everybody still has to keep their eye on the ball all the time.

Sarah [00:09:35] said in there that that's why food allergy is hard and I'm just thinking about there's 170 odd people on this call and they're here because it is hard so thank you again for kind of giving up your time. Lydia's got a question about how you diagnose a milk allergy. You mentioned earlier that lots of people think they might have a milk allergies or their child might have milk allergy but actually they don't and you mentioned about how lots of those symptoms that you can put down to milk allergy can also be other kind of baby symptoms. So firstly, how would you diagnose it? And secondly, Lydia and Mira and Sally want to know more specific questions. For example, can weight loss be a sign of it? And Sally wants to know, could her baby be rubbing her face a lot because of CNPA discomfort?

Prof Adam Fox [00:10:28] Okay, so this is actually a really really big question because there's lots of different contexts for this and of course there's different types of milk allergy. So the first context to think about is the infant who's exclusively breastfed and that's where it gets particularly tricky because whether it's an immediate or a delayed allergy it can actually look broadly the same. You can just have a child who's got chronic symptoms whether that's because they've got the sort of allergy that were you to give the baby directly milk, it would cause hives or would actually just cause more delayed symptoms, you don't know, but what it would typically look like will be symptoms like persistent eczema, loose stools, reflux. Faltering growth isn't a particularly typical one and I know parents get really frustrated when when the GPs will say, but your child's growing okay, so they can't have a male collagen, you're right, it is nonsense. The overwhelming majority of kids who have got male calories won't be losing weight. But the thing is, is that if you, there was a lovely study a few years ago done at St. Thomas's that involved thousands of children being closely observed, not if it wasn't around about male calories, it's rather allergy stuff. but all of their symptoms were carefully monitored, they had lots of allergy testing, they were clearly defined as the way they had milk allergy. Turned out that most children at some point during their first year of life will exhibit the signs that people typically associate with milk allergy, but only about half of 1% of them actually had a milk allergy so clearly if you just say, my child's got chronic eczema or reflux or colic or loose stools, you're gonna get it wrong most of the time. so The typical clues that I would look for are multiple symptoms. So the eczemay baby who also has reflux, colic and loose stools, that makes it more likely than just a child with eczema. A child who already comes from a very atopic family and allergic family, it's more likely there's going to be allergy there. A child where they are treatment resistant. So for me the first line for treating eczema is never change your formula even though I know that people often get told that. It's always do what we know works with eczema, moisturisers, anti-inflammatory creams and for me a big sign that maybe we need to think a little bit harder about allergy is that that didn't do the job. treatment resistance. Same in reflux and other things, really really important side. But another huge clue is what happens when you change the amount of milk in that infant's diet. So if you've transitioned that child from breast milk to formula, key question, what happened to those symptoms, because if those symptoms got... no worse when you went from breastfeeding when only a tiny bit of the milk that's in mum's diet gets through to when you gave them a huge amount of milk because you were giving them formula directly. That's not a good story for a milk allergy. Whereas it's much more likely if you notice that actually they didn't really have much of the symptoms before but once you introduced formula and the more you introduced the worse the symptoms got, those things are big clues. So it's those sorts of clues you need to keep an eye out for. That's predominantly for the delayed type milk allergy. Of course, with the immediate milk allergy, the story's pretty straightforward for most people. They gave the first bottle of infant formula or milk as a complementary food for the first time at six months, and their child came out in an immediate and obvious reaction. Remember with immediate allergies, you can do a skin prick test or a blood test and you can confirm it's much easier to nail down that it's definitely milk allergy. Whereas with delayed allergies, the only thing you've got out of your sleeve really that's completely reliable is excluding it from the diet till the symptoms get better, reintroducing it a few weeks later till the systems get worse.

Sarah [00:14:00] And if you had a child presenting with that, would you advise the parent to exclude the milk or would you wait, would you suggest they waited for medical advice?

Prof Adam Fox [00:14:10] So typically, yes, because if you just give blanket advice of saying cut things out, that there are unintended consequences. So cutting milk out of your diet makes breastfeeding harder, which means you're more likely to stop. So always really reticent, because as a paediatrician, always doing our best to try and maintain people breastfeeding as much as possible. So I think if you've, you know, for example, if you introduced the first bottle of formula and you noticed an obvious reaction or a suspected reaction, I'd sort of ideally say, well, look, try and stick with breastfeeding, get some advice, and hopefully that advice will then be able to get you closer to the truth.

Sarah [00:14:41] And while we're talking about diagnosis and testing, Fiona asks what if there's a discrepancy between blood tests and skin prick tests, i.e. a low IgE to blood tests but consistently high 10 millimetre plus to skin prick test.

Prof Adam Fox [00:14:56] Yeah, so it doesn't happen as often as you think. So broadly, with a good history and doing the testing, you usually get your answer, but you do sometimes get what we call discordant results where one says, no, you're not allergic in the answers. Yes, you are. That's what food challenges are for. And that can be really frustrating. I know in NHS clinics where there's limited capacity for that sort of thing, they have a little bit of sort of inevitability. They get an error on the side of pessimism and say, well, look, this test says you probably are allergic, so we better avoid it. But the ideal would be is that if the tests just don't stack up there's inconsistency between the tests and the history in the test, then ideally bring that child into a safe place, give them milk and get your answer. It's a safe test, a food challenge, as long as it's done in the right place with the right people.

Sarah [00:15:38] Okay, and so Carly's got a question. Can kids with an IgE, immediate allergy to fresh milk, present with non IgE reactions to baked? For example, her son has on-off blood in his stool. The paediatrician says it's not an allergy, but it flares up on weeks where he has more baked milk in his diet.

Prof Adam Fox [00:15:56] Yeah, I mean, you can sometimes get what we often refer to as a mixed picture. So this idea that it's a binary, you either have an immediate typology or a delayed typology. And there was that the first person that described all of this going up, showing my age now, if you're going back to sort of 1980s, there was a guy called David Hill in Australia. And he actually used to produce these beautiful graphs of all of the children that he had. with um with milk allergy and plotting the time it took for their symptoms to show themselves what their symptoms were and he showed pretty nicely that there was this continuum that there were kids in the middle who had features of immediate allergy like a raised positive test but their symptoms are quite delayed or other people that had negative tests but their symptoms were quite fast and more classic of immediate allergies so you can get that it is uncommon and I think we just need to be a little bit open-minded but in both directions because actually sometimes there's a little bit of over-perceiving of symptoms being related to milk. I think once you've got a kid with a food allergy it's tempting that whatever happens to your child you're thinking oh they must have accidentally had milk or somehow that food that I gave them had a little but of milk in it. You can get kids who get a little bit of blood in their stool and it's nothing to do with that. It can be because of infection, can be for other reasons. So it's just important to keep open-minded but what gives the game away will be consistency. If you find reproducibly that every time you're trying that, that it's leading to those symptoms, then it's more likely that that is the cause.

Sarah [00:17:17] So keep a food diary.

Prof Adam Fox [00:17:19] Yeah, keep an open mind and keep a food diary, yeah.

Sarah [00:17:22] So we've got a question on breastfeeding, which you briefly touched on. This is from Emma and Abby. They both have questions about how long it takes for allergens to pass through the breast milk. Emma says, I'm breastfeeding my four-month-old, who I suspect has some kind of allergy. I'm trying to keep a food-slash-symptom diary. Typically, how long does it take for an allergen like dairy to pass though a baby and cause a flare-up? And Abby's-

Prof Adam Fox [00:17:47] Yeah, so this is a really tricky one, and this is one of the areas where keeping a food diary is actually not that helpful and can actually just cause a lot of confusion. Because if you try to relate your diet to your infant symptoms, it's really difficult and tricky to pin down, because there are so many other things that will potentially cause symptoms. And so the potential for sort of misconnecting things and making spurious connections is really big. The truth is, the only way you can really reliably do it is cutting the food out completely from your diet. Do the symptoms get better? Reintroduce it? Do they all get worse? And when you do that sort of thing, you'll realise that actually, the changes happen pretty quickly. So I would say that most children who have got a genuine milk allergy, mum's breastfeeding, has got milk at her own diet. I get an email by sort of day two to say, I've got a different baby. You know, things are clearly better. And likewise, when we do the reintroductions, I usually recommend doing the introduction in the morning and usually by that evening, that child is demonstrating that there's a problem. As soon as I've cut the milk out of, you know, mum's cut milk out the diet on my advice. And I get any email a week later saying, I think things have got better. I'm sort of thinking, not very convinced because, you know, that's, you know, this is something that just could have been getting better naturally. It's usually much clearer. And again, if you're not sure, if it's just not a clear picture, the reproducibility, the consistency will give the game away. Reintroduce it. If you're just not sure cut it out again, do things change, reintroduce again, do things get worse again?

Sarah [00:19:18] Because you wouldn't normally recommend that a breastfeeding mother just gives up milk on the off chance. But if it's a really short week, it's not much harm in trying it for sort of 48 hours.

Prof Adam Fox [00:19:27] Yeah, the thing is that's just not what happens in reality. And the truth is that often, even when things don't get any better, unsupervised parents will often just cut it out and then just not reintroduce it. And then because things aren't better, they'll cut another food out, and then another food. And by the time they're in my clinic, I'm seeing mums who are almost starving themselves on these really narrow diets with kids who have just got reflux and just need some anti-reflux medication, or just needed proper eczema treatments. So that's why we're little bit guarded about this sort of blanket advice, just give it a go and see what happens because every child is different and there's a thousand different scenarios that can come up.

Sarah [00:20:05] It's hard though, right, because it's really difficult.

Prof Adam Fox [00:20:07] It's really hard. As a doctor who's been seen for 20 years, I can tell you it's really hard. So asking people to deal with it on their own when there's all these different types and all these multitude different presentations some of which are meaningless some which are really meaningful and separate it all about and then often sadly you're adding in an inexperienced clinician who actually is not guiding you in the right direction of course it's really hard and yeah I mean look for years I've been you know sort of trying to sort of you know support people developing guidelines and things but you know the guidelines have got you It's a really tough area.

Sarah [00:20:46] So if you're a mum listening right now, suspecting this, and you know it's gonna take you several weeks to get in to see someone, what would you do?

Prof Adam Fox [00:20:56] Goodness, that's a really hard question. And I mean, I think if you sort of, you know, reflect on this and think, look, this is above and beyond just a little bit of one thing, it's multiple symptoms. They're severe, they're persistent, they're treatment resistant. You know, all of these clues, then yeah, it's not unreasonable to say, well, I'm gonna briefly do an exclusion. You know even if it's just for a week or two, that's reasonable. But if it doesn't get better, I'm going to reintroduce it. That's not an unreasonable thing to do.

Sarah [00:21:26] Be more pushed for a doctor to see a doctor.

Prof Adam Fox [00:21:28] While you're trying to, yeah, and the thing that I would sort of nudge you firmly towards is, is in 2011 with NICE, the National Institute of Clinical Excellence, myself and colleagues were asked to develop a guideline, which I think is, you know, the basics here haven't changed over the last 15 years, the presentations, the prevalence, the, you know, systems, etc. And I think it stands up pretty well. and it's a really good document that also guides you to sort of nudging your GP towards the sort of questions they should be asking you and who they should referring and what advice they should be giving and I think that's that you know it's this pretty solid guidance in there.

Sarah [00:22:03] Can you pop me the link for that later? Yeah.

Prof Adam Fox [00:22:05] Yeah of course if you just type in nice clinical guideline food allergy or cg116 it's clinical guideline 116 it comes up straight away and there's a parents guide that goes with it.

Sarah [00:22:16] OK, that's brilliant. So this is really similar. Mira, an A&E doctor diagnosed CMPA in her seven-week-old and suggested that she cuts all dairy and soya out in her diet. She wants to know how strictly this elimination needs to be. And would you recommend Mira takes a calcium supplement? I expect that's getting on the borderline of where you can't answer it. But do you have any advice for her?

Prof Adam Fox [00:22:39] Yeah I mean it's important the mums have got a source of calcium so if they're not having the normal calcium they get through milk then they need to be replacing it with something else or getting advice about you know the amount of calcium they should be having in their diet and of course that will you know be individually a little bit different. So I often find myself reminding the mumps they're not the one with the allergy. So they don't need to avoid may-contains, I think that's, you know, and I'll be honest, when somebody says my child is so desperately sensitive that even if I have a may- contain, we see symptoms, I'm starting to think, you know, is there a bit of self-fulfilling prophecy here? Is it that the child has the symptom and then everybody says, well, there must have been an accidental bit of milk in what I ate, that may contain must have had milk in it. Whereas actually, for me, it's a sign that we need to just think about is there another explanation? Not saying it's not possible, but it just raises that flag. So I would say that the majority of parents of breastfeeding mums don't need to exclude milk from their own diets, because most babies aren't that sensitive. But for the ones that are, you're just gonna have to tailor it to your individual child. And that means that you can keep a little bit of an open mind. You're never gonna cause any harm. um by having a small amount of milk um in your own diet but it might tell you whether there are symptoms or not so you can always you know almost do your own sort of mini version of the milk ladder if you've gone for a completely exclusive diet then try a little bit i'm not a big fan of cutting out milk and soy reactively immediately because actually the co-reactivity with soy is not as much i think as people think. If the baby's really unwell and the priority is you've just got to get this kid better as quickly as possible, then yes, you might avoid those two things together. But if it's not that sort of situation, I'd usually say, well, cut the milk out, see what happens. If it's not quite doing the job or it partly does the job, then yeah, cutting out soy as well might also be an option. But what I see a huge amount of is babies that have had milk and And a year down the line, that child is still avoiding soy, even though it was a completely innocent bystander right from the get-go. And it's particularly frustrating because soy is so helpful as a milk substitute in people with a milk allergy. So there's that risk of throwing the proverbial baby out with the bath water. So if you can do it one at a time, it's better.

Sarah [00:24:56] Also, soy is a nightmare to cut out. It's in everything.

Prof Adam Fox [00:25:00] It is in everything, yeah.

Sarah [00:25:01] Um, so we've got lots of questions about reintroducing milk when breastfeeding. Ellie, Lindsay and Raj want to know when to do this. They're worrying, worried about waiting too long and making things worse. So Ashley says when reintroduce dairy into the breastfeeding diet, should it be done gradually similar to the milk ladder, which you've just said, and if there's a noticeable reaction, does there need to be an amount of time to wait before trying again?

Prof Adam Fox [00:25:26] Okay, so it comes down to sort of the context of you trying to, why you're doing it. So if you're doing it because it wasn't, it's a diagnostic test, you think your baby might have a milk allergy, so you're going to exclude it to see whether they get better, and then you're going to reintroduce it to if they get worse. Definitely, you don't want to be doing one of these milk ladders that take ages, because you're not going to get a clear answer, you're gonna get a child that will seem to be okay for the first couple of steps, then we'll get a cold. then get loose stools and you've no idea whether it's to do with the milk or whether it is to do with a viral infection. You need to do a little bit of a short sharp shock. Now delayed allergies by their nature are dose dependent and what that means is that the more you have the worse the symptoms will be. So you can still do a sort of you know essentially what I normally recommend is reintroduction over about three days. So that means you have a little bit of milk on day one, a normal amount of milk on day two and loads of milk on day three. So it's short enough that you shouldn't let other things complicate what's going on, i.e. other things happening to the baby. But you're not being cruel and just doing an absolute bucket of milk straight away in one go that will then cause horrible symptoms that child's then got to put up with for two days. But by doing it sort of a little more gradually, if the little bit tells you, don't do this, it's not going well, then you pull out before you've given them even more. However, if you've got a child who definitely had a milk allergy, but they've got to a year, it's a delayed type allergy and you're thinking of reintroducing milk back into the diet, to see what you can get away with, that's where the milk allergy fit, so the milk ladder would fit in.

Sarah [00:26:57] So Lindsay's baby has CMPA and she has cut out dairy and soya during breastfeeding. She'd like to know whether it's best to introduce her child to soya for the first time by reintroducing it to the maternal diet or giving it to the child directly during weaning.

Prof Adam Fox [00:27:12] Yeah, you're only going to really get your definitive answer by giving it directly to the baby. But if you are breastfeeding, it's not a bad idea to take advantage of that. So again, do a mini sort of version through your own breast milk. And if after three days of small, medium, large amounts, your baby's absolutely fine, that's your sign. Say, right, let's have a go with the baby as well. But of course, if you're not breastfeeding you're just going to have to go straight to the babies.

Sarah [00:27:35] Formula. Camille asks, her baby is currently exclusively breastfed but she needs to start a formula. Which formula do you recommend for a child with a milk allergy?

Prof Adam Fox [00:27:47] So you've got quite a few options here and it depends on the age. So the sort of options you've go are, the ideal is if you can keep breastfeeding, you know, great, if you're not able to, then we've got these hypoallergenic formulas, so the special broken down ones and they're divided into the sort of almost completely broken down one that are suitable for most kids apart from ones who are really sensitive. The ones that are what we call amino acid formulas, they're completely broken down. So they've got no milk in at all. So they'll be great even for the most sensitive child, but they're quite a bit more expensive. So there's a lot of resistance from GPs, et cetera, to use them unless they absolutely have to. You've also got soy milk, which will be fine for most kids, particularly with immediate type allergy. And you've got these new kids on the block, the rice hydrosilates. So these are broken down formulas that aren't based on milk proteins. They're completely milk free. but they're based on rice protein. And they are safe. They've gone through all the governance and regulatory stuff that they needed to to now be acceptable here. So again, individual decision will depend on timing. There's no point trying to get an eight month old to drink near Cape, one of these sort of really smelly, nasty, broken down format. You want to hide into nothing. They're just going to turn their nose up.

Sarah [00:29:01] I still remember that smell.

Prof Adam Fox [00:29:02] Yeah, it does, it lives with you. Whereas in the younger children, if they're sort of, you know, three or four months, soy isn't an option because the guidance around soy, because of concern about plant estrogens, is that you're not meant to use infant soy formula until they're six months of age. So in the young child, if the need to have a formula, we'll typically go for one of these high-paralogenic ones. And then depending on the clinical presentation, it will either be one of these extensively hydrolyzed ones. So pepti on the tramogen or alfari, there's a Or if it's a child who's had previous anaphylaxis or it's the child who has tried those almost broken down ones and didn't get on with it, they still had symptoms, then you might go for the completely broken down ones like neocates or pure amino or alpha amino. So, whereas if it says sort of six month old with an immediate type allergy, I would typically go for an infant soy formula, much cheaper, less medicalised by over the counter, although the supply has been a bit of a disaster and very unreliable recently.

Sarah [00:29:59] And did you do that? But should you do this for your GP and get a prescription? Yeah.

Prof Adam Fox [00:30:02] Yeah, yeah, yeah. Absolutely. So, well, you'll definitely remember to do it when you have to pay because you can get these things over the counter, but the prescription ones are that you get through prescriptions, the extensively hydrolyzed amino acids ones, they are really expensive. So yeah, we definitely really should be having this.

Sarah [00:30:22] and presumably helpful to get some guidance as well if you haven't had one.

Prof Adam Fox [00:30:25] Well, yeah, absolutely, because they will have each commissioning group will have its own guidance that's very sensible and evidence-based. It's not just because they're trying to save money and get you onto the cheaper formula first. There will have been medical input into it that would have said, look, if you can get away with one that isn't completely broken down, then why wouldn't It's just not necessary to be on a completely broken down one.

Sarah [00:30:47] And if you use the one that's not completely broken down, does that also give you a stronger chance of your baby recovering its allergy sooner because it's got no...

Prof Adam Fox [00:30:55] No, not really. I've not seen that. They'd love to imply that it does. I have not seen convincing evidence. Of course, you know, there's always a risk of comparing apples with oranges here anyway, because the kids that can't tolerate those formulas tend to have more severe allergy. So if you just compare kids who were on the amino acids to the kids who are on the extensively hydrolyzed, of course, the ones on extensively hydrolysed will appear to grow out of it sooner. But that's because they probably had a milder form of allergy. If the doctors were doing their job properly, they were probably a milder form of malcalogy in the first place. But, you know, my personal view is that I think soy formulas are rather underused. The issues around milk and soy cross-reacting with each other is really delayed allergy, not immediate allergy. So if you've got a child with immediate allergy, especially if they're sort of getting up to six months of age, soy is a really, really good alternative because, as I said, it sort of de-medicalizes them because you can buy over the counter. It tastes much better. It's completely milk-free. You know, you get all of those benefits without the nasty smell.

Sarah [00:31:59] So Mira's seven-week-old has been diagnosed with a milk allergy. Would it be sensible to delay immunizations whilst the baby's intestine recovers from the blood in the nappy? We'll come back to infants in a minute, I just wanted to ask you some questions about some older children. Katie is asking, does IgE-mediated cow's milk allergy present differently at different ages? For example, is it impacted by puberty, adolescence or other life stages or hormones?

Prof Adam Fox [00:32:27] Not really. I mean, the first thing is it will be very, very unusual, of course, nothing, you never say never, be very unusual to have an immediate type allergy to milk for the first time when you're older, you know, either it was always there and you've never had it, but to sort of get it from previously being okay, yes, there are cases you see, you know, after nasty diseases and liver transplants, sometimes these things happen, but that would be very unusual. So usually what you do find is that the kids get older, their immune systems are more mature, they've got a little bit more oomph. and you will see a greater proportion of significant reactions potentially with a little bit of a respiratory component or essentially anaphylaxis amongst the older kids that react and those are less common in the younger kids.

Sarah [00:33:11] Sarah, her child is seven, has a milk and various nut allergies and has been told not to come back to allergy clinic for two to three years. Is this because the healthcare professionals think there will be no change in this time or is this due to limited NHS funding? Could it be beneficial to go privately for an additional patch test, blood test during that time and potentially a food challenge?

Prof Adam Fox [00:33:31] Yeah, it can be a little bit of both and it's the sort of thing that's worth having, you know, asking the doctor when they're saying that. I mean there are some services that are struggling and so consequently they're maybe not seeing patients as often as they would otherwise like to, but there are certainly plenty of scenarios when you've got an older child who's got long-standing allergies that just haven't gone anywhere and if they're not able to offer you desensitisation or other treatments in that clinic then actually chances are they'll just be telling you the same thing. next year and the year after and giving you a little bit of space is more you know firstly it's you know it saves you from going to see them and just be told the same thing. Look, in the old days, you know, when resource was sort of a little bit less of an issue, we did like to keep hold of those kids and see them once a year, if for no other reason, not so much because we thought their allergy tests were going to look profoundly different, but if nothing else, to go through their EpiPens with them, to chat to them about avoidance and to pick up the other comorbid issues, you know, the asthma, the hay fever, etc. It felt like better practise to see these, you know see these kids every year, but unfortunately that's challenging for a lot of services.

Sarah [00:34:32] With someone though with a milk allergy, where they've still got a chance of growing out of it at seven, I can see that you would want to potentially try and get your child tested. Is once every couple of years okay or should it be more often than that?

Prof Adam Fox [00:34:46] Well, you can you can go every year and find that it didn't make any difference. So it

Sarah [00:34:52] You don't want to miss a window.

Prof Adam Fox [00:34:53] No you don't, but there's not really a window because don't forget if they're growing out of it they're still going to have grown out of the following year. You don't have a window that closes if you don t jump in there in the middle of it. So you know often I'll see kids and I'll say oh look the numbers are looking a little bit lower than they were last year, maybe let's just see you again in a year. I mean if the trend continues down maybe we take that a little more seriously when it's you know looking more like it's a meaningful change. But I think it's really important message there that you know things can change even later The conventional wisdom was that if you got to secondary school, you were 12 and you're still allergic to milk, then there's just no point following you up because you're definitely not going to outgrow. And that is just not true. And there's really nice data from the US from some years ago now looking at about a thousand kids in this big study, which looked at sort of the severe end of milk allergy and showed that even amongst the teaching hospital population, half of the 12 year olds had outgrown their milk allergy by the time they got 16. that was a really positive message saying look things can change and we certainly see it in practise but bear in mind you know those those 12 year olds are already the small minority of people who haven't already outgrown it but even amongst that group things do change over time so you know never say never

Sarah [00:36:02] I'm clinging onto that hope. Helen is feeling rather cut adrift by her allergy clinic. Her 16-year-old daughter with a milk allergy was discharged from her allergy team last year. They said that she would be too old for any trials or new developments unless they're released in the next year. How does she keep abreast of new developments and get involved with trials? She's had anaphylaxis and has a huge anxiety around food.

Prof Adam Fox [00:36:26] Yeah, well, look, I mean, you know, the fact that you've got the Natasha trial going on, which is doing milk desensitisation, even kids up until they're already 20s, is, you know, clear evidence that, you know, that the research community has definitely not given up on these kids. There's a lot of interest in milk desenitisation as there is in other forms of desensilisation. And that's wholly appropriate. You know, currently within paediatric services, we do that up to 18. But if you're in the US where they're a little bit less sort of fixated between adults and kids because they train as allergists that see everyone. It's sort of a bit of a Uk thing, an Australian thing, that we have paediatric allergists that go up to this age and then adult allergist. And the other allergists generally, for obvious reasons, have been less interested in food allergy and more interested in respiratory allergy. So it can feel very much sort of isolating that once you've left paediatric services, nobody's really interested. But the fact that in the US, there are clinics that offer desensitisation for adults, you know, is clearly a sign which way the wind's blowing is that is going to be a thing in the future. There's already sort of, you know other treatments available for even adults with milk allergy. So biologics, so these injectable medications that make you much less sensitive. So there's a lot going on in this space. I think probably in terms of keeping in touch. probably the right portal is through organisations like yourself, yourselves, the allergy charities, Anaphylaxis UK, Allergy UK. You know, these are the organisations that the studies will go to when they're looking for patients. And they also, you know, they know the research community, so they're able to sort of tell you what's going on.

Sarah [00:37:57] So you've kind of answered Clarissa's question whose son is 11 and she wants to know about his chances of growing out of it. We've had lots of other questions along those lines, but also parents are wanting to know if there's anything they can do to increase the chances so that their children might grow out of their allergy.

Prof Adam Fox [00:38:15] Yeah, I mean, I think the trick that's often missed, and certainly among some of the older patients that I see, they've often not had that conversation with their doctor about the possibility of baked milk. So the fact that there is a chance that there's a degree of tolerance, and my preference is to try and build on that wherever we can. So even if I find I'm bringing kids in, either the older kids who have never been offered this, a chance to come in and eat one of these cupcakes or fairy cakes with a little bit of baked milking. And if they if they do react, if they have a mild reaction after they finish their second cupcake, we might be sending them home on quarter of a cupcake every day and say, well, at least keep a little bit in because that might drive a degree of tolerance. But to be honest, it's those kids where it would be great to be able to have the conversation. I realise this isn't available everywhere about desensitisation because, you know, there are very real options at St Thomas's where, you know, we've got a programme where we're able to offer this. where you're able to say, look, you know, this isn't going anywhere in a hurry. Is there an opportunity to give small but increasing doses under a degree of medical supervision to allow you to actually increase the amount of milk that you can tolerate and keep you safer as a consequence and potentially drive you more quickly towards outgrowing it.

Sarah [00:39:25] Yeah, and it's not just St Thomas's who are doing this, is it? No, no, no.

Prof Adam Fox [00:39:27] No, no, no. Absolutely a lot of the big teachers lost it.

Sarah [00:39:29] In Bristol. Yeah, yeah, yeah.

Prof Adam Fox [00:39:30] Yeah, yeah, yeah. Yeah, it's yeah, I know some Thomas's.

Sarah [00:39:37] I don't know you don't have to be in central London. That's right

Prof Adam Fox [00:39:40] That's right, yeah, and please don't all ask the Cummings and Thompsons. Yeah, no, no. It's really important that you pick this up at your conference. What access is there and if there's not a programme there, are they plugged into research? The Natasha research study is a number of big allergy centres across the UK and I'm not sure where they are in terms of recruitment at the moment, but they took on a lot of people of the milk and peanut OIT.

Sarah [00:40:02] one of our family members is doing it in the farthest reaches of Northern Scotland. So it is really, it is

Prof Adam Fox [00:40:08] Yes, in Aberdeen, I think. Yeah, yeah, yeah. That's right. Yeah. I know they always send her.

Sarah [00:40:13] So it's definitely worth looking into. So staying with what parents can do to help their children. Anastasia, Mira, Kate and Lydia want to know the likelihood of siblings developing milk allergy if their first child is allergic and if there's anything they can do to prevent it. Vaginal birth, diet while pregnant, breastfeeding versus formula. You've already said breastfeeding is key. Is there anything else these parents can?

Prof Adam Fox [00:40:39] Yeah, it's tricky. There's not a sort of big silver bullet that really makes a big difference. I do have a number of sibling pairs where we see, you know, milk allergy in the younger child, particularly delayed type milk allergy. It's not as sort of directly inheritable things. That's certainly not a done deal. There was a huge amount of work done many years ago, there was an enormous German study looking at what you should do if you can't exclusively breastfeed. What should you do instead? And the conclusion of that study is that if you're sort of, you know, up to four months of age and you're not able to continue exclusively breastfeeding, the suggestion was is that you went onto an exclusively hydrolyzed formula rather than just going onto a regular formula. But. it's sort of generally considered a little bit contentious, it wasn't a big effect, there were conflicting results from other studies. So broadly that's typically what I'd recommend. I think if there's one thing, and this is enormously frustrating because I hear this story so many times, will be the parents who sort of walk into my clinic room, they sit down and they've got their sort of seven month old infants and they say, well I've exclusively breastfed apart from on day one and two we had a couple of top-up formula feeds. And I know what they're going to say. And the next line is, and when there were five months, we decided to start top ups and we gave them a bottle of formula and they had an immediate reaction to it. And the research does support this, that that sort of early exposure, but briefly, just sort of two or three single doses. seems to be a real risk factor. I think particularly so when it's alongside other things like caesarean sections. But I always say, if you need a caesarian, you need your caesary and you can't not do it because you're worried about a notional risk of something else. What I've found is that when you try and engage midwifery teams around sort of this practise of using top-up formulas, late at night for these babies, the general response is, well, we don't do that. So it's quite hard to sort of push that change in practise, saying, well, look, if you're going to do it, can you maybe do it with these extensively hydrolyzed formulas? And so I guess if you are after a little bit of advice, and I'm not gonna sort of make great claims about the level of evidence behind this, but if you think there's a chance your baby's gonna end up with a few top-up feeds, you could always take a tin off extensively hydrolyze formula. But the idea is to avoid that if you can. If you can't, you can's. But... that does seem to be a risk factor, that sort of exclusively breastfed baby that just has those one or two top up feeds very early on.

Sarah [00:43:06] Well, that was definitely the story of my son.

Prof Adam Fox [00:43:09] Oh, was it? Okay, I didn't know that. Okay.

Sarah [00:43:12] No, it's exactly that. So, we need to cover weaning and milk ladders. So we need to speed up. We've been doing really well. We got 15 more minutes though and loads more questions. So, waning. Claire wants to know when you should start weaning your child if they have suspected milk and soy allergies. They haven't seen a dietician yet. She's just over six months old. She is keen to start solids. When can we introduce other allergens? Are there any precautions or advice we should follow and if so when and should we have introduced allergens at four months and she's concerned they've missed the opportunity.

Prof Adam Fox [00:43:49] I would say just get on with it. I don't think there's, milk allergy isn't particularly a reason to wean early, it's more sort of eczema and egg allergy that are those big signs that there's a good chance, you know, there's a high chance of developing allergy to sesame, peanut, tree nuts. where early introduction may reduce that risk. So I would say really, it's sort of, you know, from six months introducing those other allergenic foods, don't delay the introduction of the other allergens and don't delayed because you think you might get a test a couple of months further down the line because the law of unintended consequences, you wait, but as a consequence, you increase the risk of getting the allergy by waiting. You'd have been better off just getting on and doing it at the time. So I will say that, you now, unless you have very, very immediate access to those sorts of tests, you're better off getting on with weaning.

Sarah [00:44:34] to Laura also on weaning. She's weaning her second baby and her firstborn has an egg allergy. Would you suggest, this is a great question, testing allergens in a hospital car park just in case of any reactions?

Prof Adam Fox [00:44:48] It's a really tricky one, this, and I'm not an advocate of this because I think that firstly, you know, you need to be clear that the first allergic reactions that infants have, their immune systems are very immature, they're almost, with rare exception and not particularly severe, those first ever exposures, so. um it just it for me it sort of feeds a little bit of a mentality that my child's you know allergic to everything until i've proven that they're not and you know even the multiply food allergic kids that we see the the majority of foods are absolutely fine so you know for me i think it's very reasonable to do this stuff at home yes of course if you feel more comfortable having periods on available that's absolutely fine as well but um if you if you ask me you know if it's the difference between getting on and introducing stuff or not then yeah go to the park if that's what you have to do. But I don't think it's necessary.

Sarah [00:45:38] Um, thank you, um, and as part of our

Prof Adam Fox [00:45:41] But that maybe the caveat to that is that, you know, it just sadly reflects. the failings of our systems that parents feel that they have to do that and it's incredibly frustrating because you know if if if people were just properly supported if the midwives really you know that that the health visitors and midwives the gps the community practitioners really knew their stuff on the allergy this this just wouldn't be necessary and you know within specialist practise and i know this happens in a number of places we we have virtual clinics and in-person clinics where people can do these first introductions in a really safe environment and I know some really good GPs who offer that to parents, you know, that would be marvellous. but back in the real world sadly sometimes you just feel completely out there on your own and and you feel like the only thing you can do is park outside A&E.

Sarah [00:46:26] Totally, especially if you've had an older sibling where they've had serious interactions and stuff and you can totally relate to that anxiety that you feel with these introductions and stuff. Thanum and Katie are among those wanting to know if there is research or evidence to suggest that improving the gut microbiome by prebiotics or probiotics can help with an IgE-mediated cow's milk allergy.

Prof Adam Fox [00:46:54] Well, it's a great question. And it's one that I think we sort of do have an answer to because some years ago, and this is again, 10 or 12 years ago. I was one of the researchers involved in a global study. We did this across the US, Europe, Asia, where we recruited hundreds of children with milk allergy who had already introduced formula for feeding. And they were randomly selected to either get a hypoallergenic formula that was just a hypaallergenics formula. And that was it. versus one that had pre and probiotics in. So all the things that should sort of, you know, really promoted a healthy gut microbiome. And we were able to demonstrate that the milk did have an influence on their microbiome, you could show improved levels of Lactobacilli and Bifidobacteria, the sort of gut bugs that you want to have. But did it make any difference to the key outcomes, which were, do you outgrow your milk allergy any faster? Are you less likely to get other allergic issues? didn't make a difference, and that was a large, randomised controlled study paid for by the people who had the biggest vested interest in showing a positive result. Now, for me, that told me two things. Firstly, it restored my faith in commercial research because these guys had so much money riding on finding a positive result, but the research was done very robustly and didn't show a positive result, and all credit to them, it was published and shown for what it was. But it also strongly suggested that actually on a superficial level, the gut microbiome manipulation didn't make any difference to those things. Now that said, you know, there's a million different ways you can influence your gut microbiomes. And it might have been that it was the wrong bugs that were in there, or there weren't enough of them, or it was given too late or too early or in the wrong combination. We're in such an infancy of our understanding about how you can the gut micro biome that just saying, well, it doesn't work blankly because that study didn't, isn't really enough. I think there's still a long way to go with that. Thanks for watching! but superficially in the way that you know we would love it to have worked, it just didn't.

Sarah [00:48:58] That's so disappointing to hear. You just kind of hope that by feeding your children a probiotic, you can magically get rid of the milk allergy. Now, we have had tonnes of questions about the milk ladder. So I'm going to ask you to cover quite a few of them together. But first off, can you start by explaining what the milk ladder is and whether it's for both immediate and delayed milk allergies?

Prof Adam Fox [00:49:19] Yeah, so this is really confusing and it's not just confusing for patients, there's a lot of confusion because there is no consistency here. So the origins of the milk ladder were initially for children with delayed milk allergy who were not at risk of nasty reactions at home that when they came when they got to about a year when we know a proportion of them started to outgrow it to allow them to have less restricted diets. So rather than rigorously avoiding milk in all forms, when actually they were okay with milk as long as it wasn't plain milk or yoghurt, they would go up these sort of steps gradually and find at what level they would start to have loose poos or reflux or flares of their eczema so that they could then stick at a level just below that, have a less restricted diet, and then a few months later have another go at moving up it. And because these kids gradually outgrow it, you know, usually quite early, that was really, really helpful. And I always have to remind people that this is not therapeutic. They're not outgrowing their milk allergy because they're on it. There's no benefit therapeutically from them being at a level that gives them symptoms. It's purely so that you're not avoiding it more than you need to. However, over time, what happened is that, and this was an enormous frustration to myself and colleagues as we published the sort of the first milk ladder, the map milk ladder in 2013, something like that. And we suddenly found that people were using it on kids with immediate allergy, which really worried us because these were kids who might be okay, just gradually increase it, but it was essentially being used as a desensitisation tool, but in kids who might, from the middle of nowhere, suddenly have a really nasty reaction. And I can certainly think of a multitude of occasions where I met families who were told to go on a milk ladder for their immediate type allergy and had a really nasty anaphylaxis episodes because they were just at home introducing stuff. However, There is a utility for immediate type allergy because for some children with milder forms of milk allergy, particularly younger children, and this is certainly within my own practise, will use home milk ladders. But they have to be carefully selected kids. And it needs a really careful risk assessment with an experienced clinician to be able to say, yes, you've got an immediate milk allergy but there's all these different reasons why actually I'm comfortable enough that you could get on and do this at home and it would be reasonably and sensibly safe. And in my judgement, you're a sensible enough family that you're gonna know when it's not going right and you're going to flag that up to me. So I don't want to sort of write this off and in fact. What's been going on in the US is that a number of people started to look at this a little bit more critically, and they're starting to do some studies to start exploring, you know, how do you find the right kids that you can do this? Because it's great if you can keep all of these kids out of hospitals, that they don't have to avoid milk for ages and wait until there's more testing and have supervised in-hospital X challenge that means they're gonna have to wait years. And as a result, be avoiding milk way longer than they need to. So essentially it's really intended for delayed allergy but there is a utility in immediate allergy but with careful risk assessment with somebody that knows what they're doing, not as sometimes as often happening that because people just cannot get an appointment they're just downloading a milk ladder off the off the web and having a go at doing it at home that's that's not that's I do.

Sarah [00:52:24] OK, that's really helpful and helpful in clarifying it. Fiona, Ros and Camille and Cheryl are all asking if there is criteria for starting the milk cladder and at what age is best.

Prof Adam Fox [00:52:38] Earlier the better, that's an easy one. I mean, the way that I sort of now manage milk allergy in my own clinics is that if I'm able to get these kids when they're under a year, and so the idea is, you know, six months when milk's introduced as a complimentary food, they have an immediate reaction, they have clear diagnosis. I typically bring those kids in, and this is a protocol shamelessly ripped off from a colleague of mine from Dublin, who basically brought all of these kids in and did what's called a one-shot milk challenge, where you give them the amount of milk that will cause a reaction. in just 5% of milk allergic kids. So essentially you're triaging these kids to get the most sensitive and separating them out from the 95% of kids who are less sensitive. And those 95% with close supervision from a specialist dietician will do a home milk ladder. And the majority of those kids, because we're getting in very, very early when they've got a lot of what we call immunoplasticity, i.e. their immune system is way more open a suggestion than it is when they're older. most of those kids are drinking plain milk by the time they're 18 months, which is way better than you're going to get by waiting for longer before you do any sort of introduction. But it needs close supervision, it needs somebody to give you the recipes to tell you what, you know, all the ins and outs, when not to give the days, what to do when you get little reactions, you know it's not something just have a crack at doing yourself at home. So this is the sort of thing where you really need to pick up with your clinician when they've been diagnosed and saying look are there some angles here that we can, you, know make this all go away a lot faster by early intervention. And increasingly the whole of our specialty that the wind is blowing towards early intervention with all of this stuff.

Sarah [00:54:15] And is that for children with an IgE allergy? What about the delay?

Prof Adam Fox [00:54:19] Yeah exactly, with a delayed allergy there's no value in trying to do that. All you're going to do is get symptomatic children but it's a condition that typically gets better by a year or two so it's not unreasonable to wait it out for a few months and then start gradually introducing so they're only avoiding the amount that they have to.

Sarah [00:54:36] Okay, cool. Catherine and Laura are both incredibly nervous about doing the milk ladder in case their children have reactions. Laura said she'd feel happier if her child had an EpiPen, and Catherine's worried that she's taking it too slowly and therefore is doing more harm than good. This kind of anxiety with both like, it's just generally ladders and stuff like that. What recommendations would you give?

Prof Adam Fox [00:54:57] Yeah, I mean these ladders aren't right for everybody and if it's going to make life miserable and full of anxiety every day when you're doing it then you know you need to talk to the person that's recommended it because it may just not be the right thing for you. So you either need to have a really frank conversation about what the real risk is to make sure that you're not over perceiving it or you might be entirely appropriate and worrying about that and it was far too gung-ho for you to have been recommended that. So I think it's the sort of thing that you've just got to pick up with a person who is able to make a sensible risk assessment of your individual case.

Sarah [00:55:26] How do you recognise a reaction on the ladder and how do you know when to stop? Bridget's daughter gets a red skin with the odd small hive but milk doesn't seem to affect her digestive system. Should she persevere to the next step of the ladder or stop? And we've got a similar question about whether to push on with a two-year-old who's got to stage five of the ladder and now gets some blotchiness.

Prof Adam Fox [00:55:49] Yeah. So I think again, this is going to be really, really individual because if the previous reaction was a visit to intensive care and three rounds of adrenaline, then you need to be a lot more careful. And even even the suggestive mild reaction means you should definitely be backing off. But if it's a delayed type reaction, the allergy tests have always been negative. And the worst case scenario here is an unpleasant afternoon with the screaming ABDAPs, then it's not unreasonable to persevere or just gently step back and wait a few weeks and go back up again. So it's very, very much case specific.

Sarah [00:56:19] Okay, that's helpful. Anastasia and Bridget, if multiple allergies, which ladder is best to start first, especially interested in milk, egg and milk soy combinations?

Prof Adam Fox [00:56:29] Yeah, I mean, it comes down to what's more important to get into the diet. So, you know, based on the individual testing, there'll be a great chance of success in one rather than the other, but it might just make a much bigger difference to your day-to-day life, if they're okay with baked egg rather than baked milk. So, there's no right answer to this.

Sarah [00:56:46] Louisa is about to start the milk ladder with her five-year-old son who's got autism and she wonders what you recommend when he doesn't like trying new foods and textures.

Prof Adam Fox [00:56:55] Yeah, this is where the dieticians really come into their own, because for some kids, it's all very well saying this is what the milk ladder is, but some kids just aren't going to, are just not going to eat those foods. And so having somebody that's able to give you appropriate alternatives is super helpful. So, you know, we were in our clinic work really closely with dietician who will do all sorts of different, you know, different foods, different, different textures, different things. But, you know, there's plenty of options to get the same amount of milk in the same form.

Sarah [00:57:24] Adam, I think we are there. We have not, unfortunately, got all of the questions. We haven't done OIT, or may contain, but we will do those on our next Q&A.

Prof Adam Fox [00:57:34] Oromalizumab. Really important. There's a revolution in the US with biologics, these new medications.

Sarah [00:57:42] Oh, well, it's the outside OIT. Yeah. OK, so that's going to be definitely covered in our next session. For those of you who want to see OIT beforehand and learn more about it, we did an amazing Q&A with Adam, his dietician, Karen Wright, and also James Gardner, who's a nurse consultant, which did a deep dive into OIT, so if you want to learn more about that and you cannot wait until our next session with Adam which will be on the 25th of April. then please go and check that out. It's in our membership portal. Adam, before you go, we've had a lovely comment in the chat from a mum who says, this session has been super helpful and how brilliant you are. And she's incredibly grateful for your time and effort. And thank you so much from all of us for this. If you do have some feedback, if you could fill in the feedback form that we've got at the end of this session, that would be great. And finally, I want to let you know about that we're launching our thriving with a milk allergy. which is a complete guide to managing family life confidently with a milk allergy. It's got lots of input from Adam, from dieticians like Lucy Upton and Paula Hallam and Karen, like we mentioned. And we're gonna cover all sorts of things from how you live at home, do you have the allergens in your house to all sorts different things that we've got. And yes, so thank you so much, Adam, once again. And thank you everyone for coming. It's been a great session. Good night. Thanks for having me.