Overcoming anaphylactic severe cow’s milk allergy with slow and low-dose oral immunotherapy: A 10-year path to tolerance

Cow's milk allergy (CMA) is a common pediatric food allergy that can cause significant nutritional and quality-of-life challenges. Severe cases, characterized by high milk-specific IgE levels and a history of anaphylaxis, rarely develop natural tolerance. Oral immunotherapy (OIT) is generally avoided in such high-risk patients due to the risk of serious allergic reactions, leaving strict avoidance as the standard treatment. However, prolonged avoidance may delay tolerance acquisition and increase psychosocial burden. We report a female patient with severe CMA and multiple food allergies who underwent a carefully tailored, ultra-low-dose OIT over 10 years. At treatment initiation, her milk-specific IgE was >100 kUA/L, and an oral challenge with 1.1 mL of milk induced anaphylaxis. The OIT protocol started with a dose well below her reaction threshold and increased gradually, resulting in no serious adverse events. Over time, she achieved tolerance to 200 mL of pure milk and resumed unrestricted consumption of milk and other previously avoided foods such as egg and wheat. This is the first report of successful long-term ultra-low-dose OIT in a highly sensitized child with severe CMA, showing that slow, cautious escalation can safely induce unrestricted intake even in patients previously deemed unsuitable for OIT. Given the limitations of biologics and emergency care availability worldwide, this low-risk, home-based protocol using locally available foods offers a feasible and affordable approach for managing severe food allergies globally. Such individualized, sustained OIT may improve long-term outcomes and quality of life for children with severe food allergies.