MILK ALLERGY

What is allergy to cow's milk

The CMA is a reality, but also a fashion. While many years ago, the diagnosis of allergy to cow's milk allergy with interest that the pediatrician was making were mostly positive, in the sense that he touched this place before clinical diagnosis usually protracted, not properly framed, the Nowadays, vice versa, it is necessary that more frequently to him touches disprove the origin of allergic disorders such as interpreted and treated with diet unnecessary and often inconvenient. Nowadays the diagnosis of milk allergy is placed too easily and certainly is not always supported by facts oggettivi.Una basic premise is to clarify, for the uninitiated, that cow's milk is defined as milk cow and all the dairy products derived from it: so is cow's milk infant formula normally used in the feeding of the infant, the pasteurized milk of central milks sterilized or longer storage, the condensed milk, cow's milk contains proteins also lactose-free milk sometimes incongruously data intolerant or allergic children, milks antireflux the latticelli acids etc.. Cow's milk proteins are also found in many common food products, cheese, yogurt, biscuits as well as sausages, ham, chocolate, etc..
The allergy to cow's milk allergy is a protein contained in it which are mainly casein , alpha-lactalbumin and beta-lactoglobulin. A far cry from cow's milk protein allergy is intolerance to lactose, which is milk sugar, is that it is on the surface of the intestine due to the lack of the necessary enzymes for its digestion.
The cow's milk allergy , cow's milk, is the most common food allergy of childhood, but it is not as frequently affects more than 2-5% of children. And it is important to emphasize, especially a disease of the young child, under two years of life but primarily in the first year of life. In half of cases, the cow's milk allergy will disappear within a year, 80% of cases within three years.
diseases that can cause allergy or which may be associated are many. The most common manifestation of cow's milk allergy is atopic dermatitis, as in it does not always food allergy is a major factor. But milk allergy can also give vomiting or gastroesophageal reflux disease, chronic diarrhea, the isolated deficiency of growth, ("malabsorption"), infant colic, constipation, allergic colitis, persistent cough, the 'asthma, persistent colds, urticaria, anaphylaxis in common parlance called anaphylactic shock, and other less common morbid pictures.

 

When thinking allergy and when to exclude

In some cases the ratio between the intake of milk and the appearance of symptoms is quite evident. For example, a typical case of allergic reaction to milk is clear that the assumption by small hives infant, until then fed breast elusively, the first bottle of formula or milk first flour. In this case, the temporal relationship is obvious and immediate reaction after ingestion of the food is unmistakable. But not always the case: sometimes the relationship is less clear and not as easily identifiable. An essential criterion when considering allergic origin of certain symptoms is the age of the child. We have already said that the milk allergy should be considered a disease of the young child, especially the first year of life. So on the one hand the acute urticaria of the small child in the first year of life, especially food allergy and particularly from milk allergy, urticaria in subsequent years is not nearly as allergic to any food and milk in particular . Similarly atopic dermatitis in the very young child is very often from food allergy, in particular milk and egg. The same can not be said for atopic dermatitis of the older child: in it the allergy to food, apart from particular cases, is not a critical factor and, indeed, if it previously has been usually present after the first-second year of life has disappeared.
To continue with another frequent situation of daily practice one can say that even for the symptom chronic diarrhea an important factor is age. For it, in fact, it is fair to suspect milk allergy if the child is small, especially if you did not pass the first year of life. More difficult than the chronic diarrhea is due to the milk if it occurs at a later date so that it can be said that, with rare exceptions, chronic diarrhea from milk intolerance is practically nonexistent after the first 24 months of life. Same concept can be expressed for some children have stunted growth: growth deficiency in malabsorption of milk intolerance may be important in young children, it is more important in the older child, more than two years, except for very specific exceptions.
By this, the first parade you can easily deduce how frequent are situations where the suspected allergy to milk is misplaced and unjustified consequential diets. Just think of the older child's atopic dermatitis treated with diet, diarrhea or chronic deficits isolated accretion of the child three or four years covered by allergy to milk just because a positive RAST came!
Other criteria which might induce a suspicion milk allergy is the temporal relationship between the onset of symptoms and the introduction of the food in the diet of the child (eg diarrhea appeared some time after the introduction of infant formula) and all those other criteria that are generally used in diagnostic allergy, namely the family and personal history of the child, the coexistence of other symptoms, etc.. It 'important, because it represents a risk factor for allergic disease, whether in the family there are cases of allergy, food or respiration. But even in this case are necessary details. For family history of allergies do not have to understand the presence of cousins, uncles, grandparents, with vague diagnosis of allergy more or less established. Familiarity should be very narrow, limited to parents and siblings of the child. In fact, since now the high frequency of allergic diseases (according to some statistics as much as 40% of the general population has some allergy) is virtually certain to find the child's extended family in other cases of allergy and therefore this criterion would lose value. Not only that, the allergy of immediate family must be documented and verified with meaningful tests. Does not matter, for this purpose, diagnosis supported by scientifically test without any validity as the cytotoxic test, the kinesologia applied, the test of muscle power etc..
In the personal history of the child may be important earlier or intense colic symptoms trivial gastroesophageal reflux, as well as important to frame a symptom as food allergy may be the coexistence of symptoms against different devices. In a child with atopic dermatitis, very small, asthma could be an allergy to milk, chronic diarrhea can be more easily allergy if over age dl child is assessed the presence of pruritic dermatitis, the particular characteristics of the skin and so on.
addition to these criteria must consider the compatibility with allergy symptoms presented: not everything that appears "strange" and not easily be framed is due to food allergy, and in particular to milk. For example, not all rashes are due to the infant's "allergy" as there is a deep-rooted tendency, when faced with a child with "spots" or "bubbles", to ask first of all what the child has eaten or What ate the breastfeeding mother. It 'a wrong mental attitude common to many parents but also to many doctors. The only two skin diseases that may, but is not always so!, Have an allergic origin are urticaria and atopic dermatitis. For all other allergy rashes unless you think the less you make mistakes. Urticaria is a disease characterized by successive throw of the detected items and intensely itchy: are elements that quickly disappear to reappear in different locations. The other hand dermatitis is characterized by lesions that tend to persist in time, too itchy. So a first discriminating factor is itching: diseases of the skin allergy damage usually itching and scratching. Not only that, being atopic dermatitis practically the only potentially allergic disease with persistent lesions, and it is highly unlikely that it will appear in the first two months of life, it follows that anything to do with the milk allergy have all those rashes that appear in the very young child, the first two months of life. However, it is frequent that small neonates and infants in the first two months of life are considered allergic and treated and labeled as such for the future for trivial injuries such as acne babies, acne-like rash youth appears to decline in the first month of life to disappear spontaneously after a fortnight, or seborrheic dermatitis, the so-called cradle cap, which is not itchy and appears, in fact, earlier.
addition to the positive criteria that allow you to suspect the presence of an allergy, there are criteria that allow the exclusion drastically. Part of it has already been discussed (age, type of symptoms, etc.). Earlier but I want to point out two situations in which it can be excluded that the child is allergic to milk as it has been diagnosed and is treated as such by special milk. The first is the frequent use of improper milk. We often observe in practice every day children diagnosed as allergic often only for the blood test results. The tests, as we shall explain later, are definitely not an absolute value and must be critically evaluated and should not, on the basis of modest positivity, in the absence of a clinical picture compatible, for them diagnose an allergy. However often these children, improperly labeled in this way, are just as improperly treated milks were erroneously believed milk foods for allergic children. The most striking case is that of the goat's milk. But similar argument can be made ??for milk with reduced lactose content (Zymil, Accadì, HN25, etc..). Goat's milk is structurally very similar to cow's milk for the baby that was actually allergic to, and not wrongly held that, to cow's milk was important to his assumption of the symptoms and continue to submit those problems for which the child has changed power. Goat's milk, in other words, is not the food to be prescribed to children with true allergy to milk and if a child is supposed allergic to cow's milk has no problems with goat's milk simply means that it is not allergic to As can be more or less positive test on the blood. Even more absurd is the use in cases of suspected allergy to milk of reduced or no lactose. In these milks, as mentioned, the factors that determine the milk allergy, that is, the proteins are present in an integral manner; what is absent or present in reduced measurement is lactose, ie milk sugar, which is responsible for all another type of event. Fortunately, the doctors who prescribe these milks in children "allergic" are the same as usually "give" the diagnosis of allergy who is not allergic and therefore the intake of these foods, in most cases, does not mean the damage would if they were real people with allergies.

A key criterion, finally, to exclude the diagnosis of milk allergy, even when it has been properly placed on clinical criteria and appropriate assessment of the test is that the skin on the blood, is the lack of positive response to his exclusion. If a child has been, rightly, suspected to be allergic to a certain disorder and for this reason has been put on a diet with food adequate and appropriate alternative to milk but you do not like enhancements of the same symptoms you should see that for that child, for which the suspicion was justified, in reality milk allergy is not important, as they can be test positive. In other words, you should not continue the diet if it obviously does not determine the improvements expected even if the analysis and skin tests were positive. In these cases the tests are not the expression of a true allergy but only a "sensitization, without negative manifestations related to milk.

What do allergy tests

The allergy testing, both cutaneous (skin prick test) than blood (PRIST, RAST, ImmunoCAP) are not, as stated, an absolute value and must be evaluated critically by physicians trained in materia.I blood tests are undoubtedly useful in particularly those for children in which the use of antihistamines, for the presence of extensive skin diseases, for the risk of dangerous events, one can not use skin tests, that in truth would always be preferred. However, the blood test led to a marcatissimo increase in incorrect diagnosis of allergy, especially food and contributed significantly to the explosion of children considered to be "allergic". The ability to make assessments allergy with a simple blood test allows many doctors who do not have specific skills to bypass completely the medical expert on the subject which means, unfortunately, very often, serious errors of diagnosis and treatment. The evaluation of allergy testing, especially when it comes to food, it requires very specific skills, experience and common sense.
because allergy testing is not an absolute value? it must be considered only an aid in the diagnosis and not the cornerstone on which to base the diagnosis itself and the subsequent treatment?
The simple answer to a complex problem is this:
1. because positive test does not mean allergy,
2. because not all allergies are the same.

A positive test does not mean allergy
A positive allergy test does not always say, quite simply, that the child has certain symptoms that because some are allergic. This applies in particular for food and in particular for blood tests. Even for those skin allergy positivity does not necessarily mean we are less often they give "false positives" that is positive in non-allergic.
A positive test simply expresses the condition of "awareness", ie the child as a result of previous contact with the 'food product has a particular type of antibody, called IgE, which are the fundamental element for realizing, in further contact, the allergic reaction itself. But the presence of these IgE precondition that the allergic reaction occurs, then this does not mean that to happen. The sensitization, that is, the presence of antibodies specific type of IgE directed against the proteins of milk, although representing an essential requirement for a certain type of allergic reaction is not necessarily correlated with it.
However the tests are in fact the measurement of sensitization and not of allergy. With the blood test will measure specific IgE against milk mind precisely on the blood, the skin test specific IgE present in the skin, placed on special cells called mast cells.
Sensitization therefore does not mean allergy and this is especially true for the low positivity, 0.35 to 3.5 of the RAST (the I and the Class II-positive) and + + + or the prick. The statistical probability of a positive test for milk match the actual symptoms resulted from its assumption (the so-called positive predictive value) is on average less than 50%. Therefore beware: in less than half of children who have a positive test for milk milk really hurts! Other, but positive blood tests or tests on the skin do not have problems with hiring and tolerate it without any problems. Some people have tried to study statistically what are the levels at which the probability is very high that the positive test expresses a true allergy: RAST for when the value is about 15 kU / l or above you may think that the milk is really offending and that its intake almost certainly can cause symptoms, for Prick is considered predictive of reaction almost certain assumption a diameter of the wheal (swelling on the skin induced by the introduction of the milk itself, as "extract" or as commercial milk fresh, using Pointed with special needles) greater than or equal to 8 mm. For these high levels of positive tests are certainly significant and express, with almost absolute certainty, a condition of true allergy. Below these levels, except for special cases such as the person who has had an anaphylactic reaction after ingestion of milk or, for example, the child who presented urticaria on the first bottle of formula, a positive test should always be confirmed on practical grounds. In other words, the diagnostic suspicion that emerges from the medical history of the child and its symptoms, and that is strengthened by positive tests must be confirmed by the disappearance of the symptoms when the milk is suspended from baby feeding assay (elimination) and reappear to rebuttal, that later when after a period of 1 or 2 months of well-being, the milk, in a medical environment and not at home and under the supervision of experienced personnel is readministered (challenge test or challenge).
then the real test for the diagnosis of allergy to milk and other foods, is therefore empirical, practical, tests on the blood of the much abused, often in a totally illogical and required to test food absolutely irrelevant in relation to the clinical history of the child, not the absolute truth, in fact, quite the opposite.
E 'history of everyday life, on the contrary, see babies kept on a diet, even for a very long time, because they have a positive RAST despite the abstention from milk does not cause any significant improvement of OCD. In these cases it is often a kind of psychological terrorism that imposes this restriction: "The child has the positive analysis, and is allergic to milk and although it does not improve taking who knows what could happen in the future if you take even the shock anaphylactic "Far from it, the child who test positive, that is, sensitized, which normally takes the milk without problems or not improved when cow's milk is removed no risk if you keep taking it, in the first case, or if begins to take in the second: the intake of milk in these children, sensitized but tolerant of all no risk but rather to the gradual desensitization.

Not all allergies are the same

allergy to milk, but this applies to all food allergies, may be due to different biological mechanisms. The main mechanisms that are the basis of allergy to cow's milk are:
- a mechanism that involves the origin of the adverse reaction to the recruitment of milk a particular type of antibody, called IgE (IgE-mediated allergy or Type I °);
- a mechanism that involves special blood cells called T lymphocytes (cell-mediated allergies or type IV). Are those commonly referred to as intolerances.
'm related to the first type of mechanism (IgE mediated) some forms of allergy such as urticaria and anaphylaxis. IgE-mediated allergy to milk are those with immediate reactions to the recruitment of milk (the reaction appears within an hour of food, usually within 15-20 minutes), sometimes potentially hazardous for life.
I vice versa cell-mediated (intolerance) reactions slow delayed, chronic diseases, especially diseases of the digestive tract such as poor growth and chronic diarrhea.
In some diseases, finally, as in atopic dermatitis, may be involved both the mechanisms, with a different weight depending on the case.
However tests usually performed, both with the collection of blood that on the skin, are based on the research of IgE, as previously seen, and are then tests exclusive of sun allergies of I ° kind. There can not be so rash from cow disease typically and exclusively type I °, that is due to IgE, a negative test, if the test is negative means that there is no allergy to milk, but the cause is a ' other. On the other hand we can not wait for the test to be positive in the majority, for example, diseases that are mainly gastrointestinal allergy intolerance, cell-mediated. By definition in a child with chronic diarrhea or with poor growth tests will in most cases negative and therefore it is useless to run it. Indeed run can be misleading because the assessment of the person experienced the negativity could lead to exclude liability milk also quand'esso is really responsible. In these cases, the test does not exclude allergy or intolerance if you prefer.
For those that were once defined intolerance, ie non-IgE mediated allergies, for these reasons, even more so the real test to make diagnosis is the practical test, the test of elimination of milk for 1-2 months and his new administration after the elimination has achieved a significant improvement in symptoms (exclusion diet and challenge tests).

How is it treated milk allergy

In addition to the specific treatment of various diseases, asthma, urticaria, atopic dermatitis etc.., Which is discussed in the relevant sections, of course, the primary treatment is avoidance of milk and its derivatives. A part can be found extensive lists of forbidden foods and granted and patterns of diet for different ages of children and the various types of specialty milks suitable for children allergici.I milks basically used for the dietary treatment of allergy to cow's milk are milks soy hydrolysates pushed, the total hydrolyzate, the hydrolyzate of rice. They can also be used for home-prepared food made ??from cream of rice, oil, lamb meat (diet Rezza).
soy milk, derived precisely from soy protein contains all different from those contained in cow's milk and milk derived from it. Is therefore indicated in IgE-mediated allergy, urticaria, anaphylaxis and atopic dermatitis. The soy milks are not shown if they are present gastrointestinal problems (GERD, chronic diarrhea, malabsorption with growth deficit) because in these cases there is a high risk that the child may become allergic, over time, even soy milk and that symptoms can be re-starting. To overcome this drawback there is a type of milk in which soy is hydrolyzed, ie soy protein are reduced into small fragments in a manner such as to reduce almost completely the ability to cause allergy.
gastrointestinal In the forms are instead indication so-called hydrolysates driven. In them, similarly to what happens nell'idrolisato soy, milk proteins are split off, frammentizzate, to obtain fragments of sizes so minute as to reduce of 90-95% the ability to induce reactions in subjects allergic to whole proteins. All these milks, in any case, it may retain, in greater or lesser extent, a certain capacity to do so. Therefore their use in immediate forms, dangerous (IgE-mediated), must be guarded and must be preceded by the skin test with the same milk and from a first administration of the test, in case of positive skin test, under medical supervision. No utility instead have the partial hydrolysates, the so-called HA, in which the frammentizzazione of proteins is little thrust and therefore the ability to induce allergic reactions in the subject very high. These milks are not absolutely indicated in the subject for the real possibility of allergic reactions to serious. Very nuanced, almost impalpable, it is also their usefulness also use most common of them is, that the administration at birth in order to prevent the allergy subject predisposed to it, the baby with at least two close relatives clearly allergic. In conclusion, the so-called HA milks have no practical guidance.
hydrolysates The total elementary or milk, or mixtures of amino acids, are the only ones who have no power allergic, in the sense that they are always and in every case tolerated in the allergic child. This is due to the fact that in them the proteins are completely and integrally frammentizzate and reduced up to their individual building blocks, ie the amino acids. In such milks are therefore present only amino acids, not able to give allergy, and are entirely absent even those small fragments of proteins that instead make sure not one hundred per cent so-called hydrolysates pushed. Their major limitation is the very high price and the taste is not very pleasant. Their indication is important in allergies in children who can not tolerate even the other milks or special diet Rezza. Some people also use them to purely diagnostic purposes: that from the beginning the child suspected allergic because without the confounding factor represented by any allergy to soy or hydrolyzate pushed, with the total hydrolyzate if it can be shown that certain symptom is truly nature allergic. The improvement or less of the child fed with these milks instead of with milks based on cow's milk allows to determine incontrovertibly if the diarrhea, vomiting immediate, asthma, atopic dermatitis, or are less due to allergy milk. Once it is determined in this way the state of allergy you can search for the continuation of the diet, another type of milk tolerated alternative, cheaper and tastier.
absolutely should not be used in children with allergy to milk proteins, and this especially if it is of immediate-type allergies, IgE mediated, goat's milk, the milk without lactose but with normal protein content (HN25, Zymil, Accadì), milks AR, the latticelli acids. The goat milk as well as having a chemical composition structurally very similar to cow's milk which makes it entirely not curative and potentially dangerous, is poor from the nutritional point of view and capable, by itself, to induce allergy. The other milks typically contain milk protein, that is, the factors responsible of allergy. Use these milks simply means continue to give cow's milk to the baby.
Rezza's diet is a type of power certainly historical value and is still very popular in hospitals in the capital. It 'a food prepared at home with cream of rice, olive oil, lamb, football. Has a good flavor and is, in many cases, definitely useful. However since it is a mixture of different foods is for the allergic child and often tending to further allergies, excessive load of different proteins against which the child may allergizzare.
A new product available for the diet of the child is allergic milk consists from hydrolyzed rice, currently only available in Italy. At the moment, the results seem positive although studies of this milk are still quite scarce.
addition to the use of special milks, non-essential in the older child, over the year, particular attention the parents of the allergic child must put in 'use of foods that do not contain milk protein. A list of these foods is available in the separate paragraph.
A problem is that the milk occult, that is not declared on the label, as European legislation will, in short, that an indication on the label of any potentially allergenic food . Another problem may be that the contamination of milk with other foods: the simplest example is the use of the same by the ice cream scoop to prepare various ice cream. The cream of the allergic child can thus be contaminated by mixed use of this tool. Finally, do not forget that milk can be also contained in the drugs and the most striking example is that of Betotal, a drug widely used, which contains condensed milk. Milk also contain erythromycin and Josalide.
As mentioned above, in a separate paragraph, are the lists of foods allowed and not allowed and various practical schemes of diet for different age of the child are allergic.

 

What is the fate of the child allergic to milk

As mentioned allergy to proteins in cow's milk is a disease of the very young child, the 1st and 2nd year of life. In 50% of cases the allergy disappears within a year, 80% of cases within three years. In general, the child acquires tolerance earlier if symptoms are gastrointestinal later if they affect other organ systems. On average, the intestinal forms non-IgE mediated, known allergies, heal around a year and a half of life. The disappearance of allergy, that is the acquisition by the child of milk tolerance is independent of the positivity of the test, in other words the child acquires tolerance to the milk in respect of which was allergic while still testing, both on the blood that on the skin, remain positive. You should not therefore manage the child with milk allergy only Setting yourself on RAST and prick, you should not expect that these tests become negative in order to test if the child has acquired tolerance: these tests, theoretically, may remain positive for life. The time at which the child probably has reacquired the tolerance you can guess the function of various factors, the first of which is the time. Except in cases where the milk has been responsible for serious phenomena of anaphylaxis usually tolerance is tested every 6-12 months, in a suitable environment and ready to intervene in case of reactions. If any random transgressions food, with accidental intake of milk and dairy products, have not given results in important reactions tolerance test in the hospital, usually in an outpatient setting, can also be executed immediately. Some help may also come from allergy testing, which, however, as mentioned should not be considered an absolute value. Various scholars have tried to determine at what levels of positive RAST and prick it is better to postpone the execution of the test of tolerance because, at these levels, the presence of a possible reaction to food is almost a certainty. Are indeed very high levels for both RAST that for Prick, but also they are not an absolute value, in the sense that even for the lowest values ??are not bypassable reactions at the time when the child is allergic readministered, for test, the milk. Can make hypothesize an occurred acquisition by the child of milk tolerance test strongly decrease over time and also in this case, both those on the blood that for those on the skin, there are statistical parameters which allow to evaluate how likely it is that the child has been milk tolerance according to the decrease of specific IgE (measured by RAST) or the diameter of wheals (obtained with the Prick) and the speed with which it was made.
Testing of milk tolerance is performed as mentioned in the hospital environment and placing all of those principals that are needed to respond in case of reaction to the food. Only in case of RAST and prick entirely negative, the test can be performed with sufficient security, even by parents at home, being excluded in these cases the possibility of immediate reaction, serious and dangerous.
The test of tolerance must be staffed by expert in the field, with caution, giving the milk in increasing amounts scadenzate in time to administer the full amount of milk that a baby could take in a single meal.
Some schools of pediatric allergy usually perform tolerance testing, with the administration practice of milk, those children highly allergic to them, according to the elements we have mentioned, it is expected almost certainly the reaction. This is partly because in some cases children with allergy testing show strong positive then the practical test, it had no negative reaction to his appointment, and because in this way it is possible to evaluate the type of reaction and its extent in those who demonstrate not tolerate it. The type of reaction can be varied and variously intense and as a function of it we can adjust for the action to be taken subsequently. In certain cases, you will have to inform parents about the action to be taken to avoid contact of the child with food, and how to deal with serious occurrences such as anaphylaxis, in other cases, with less severe reactions, you can try a gradual desensitization to milk.

Common Mistakes

- Use milks HA. HA milks should never be used in the treatment of a child's allergic to PLV for the real possibility of allergic reactions. No longer exists, in addition, the indication for use for the prevention of allergies in infants at high risk for familiarity - Use the goat's milk. Goat's milk has significant cross-reactivity with cow's milk. That is, the vast majority of children allergic to cow's milk also has allergic reactions taking goat's milk .. It also is nutritionally valuable little (lack of ac. Folic above) and has considerable potential to induce allergies to himself;
- Use lactose-free milk but containing PLV (HN25, Humana Disanal, Similac LF, O-Lac, Accadì, Zymil). The protracted diarrhea after enteritis from secondary intolerance to lactose does not exist. There are forms of congenital lactose intolerance and late forms of the older child. In this case, the dominant symptom is abdominal pain more than diarrhea.
- Use soy milk in diarrhea LV employee, the risk of secondary sensitization to soy is too large. Hydrolysates are better motivated.
- Consider diarrhea, and put on a diet for the mother this, evacuations sometimes explosive, liquid, sometimes frothy, sometimes greenish, often very frequent in the early weeks of life, the breastfed baby. The breastfed baby potentially suffering from diarrhea.
- Consider manifestation of intolerance to milk the stool green. The stools more or less intensely green are not pathological. The green color is due to the oxidation of bilirubin (which becomes biliverdin) contained in the faeces and the iron content of the milk formula.
- Put on a diet toddler sensitized but tolerant may expose you to much more severe reactions to subsequent exposure random . The child who takes sensitized milk (if tolerant) essentially makes a desensitization continues.