The milk ladder: bringing milk back after cow's milk allergy

What the milk ladder is

Most babies with the delayed type of cow’s milk allergy grow out of it (Kent Community Health NHS Trust). The milk ladder is a way to find out when that has happened, and to bring milk back gently.

It’s a step-by-step plan, used at home, for bringing cow’s milk and dairy back into the diet. The idea behind it: the more milk protein is heated, and the longer it’s baked with flour, the less likely it is to cause a reaction (iMAP, Kent). So the ladder starts with a small amount of milk that has been well baked into food, like a biscuit, and moves up step by step to less-cooked dairy and finally to fresh milk.

The ladder comes from UK primary care guidance for cow’s milk allergy (MAP, now iMAP), written by doctors and dietitians who worked on the NICE food allergy guideline. If you’re new to the two types of milk allergy, start with cow’s milk allergy.

Who it’s for, and who it isn’t

The iMAP guideline says the home milk ladder should only be used in children with mild to moderate non-IgE (delayed) cow’s milk allergy, and not in other types such as IgE-mediated allergy or severe non-IgE allergy like FPIES.

It isn’t for your child, unless a specialist allergy team has said otherwise, if they:

• had a fast (IgE) reaction to milk, such as hives, swelling or vomiting within minutes to 2 hours
• have ever had anaphylaxis
• have FPIES: see FPIES
• have had a positive skin prick or blood test to milk: Kent’s leaflet says the ladder must not be used then

For children with the fast type, the Royal Berkshire NHS dietitians say the specialist allergy team will advise when and how milk goes back in. If you aren’t sure which type your child has, ask before you start.

Start only when your doctor or dietitian says so

Don’t start the milk ladder on your own. iMAP recommends support from a healthcare professional until the ladder is finished, ideally a dietitian, who will:

• confirm it’s the right plan for your child
• tell you when to start and which step to start on
• give you the recipes for the early steps
• tell you how much to give and how long to stay on each step

Timing. The iMAP plan keeps a milk-free diet, with a dietitian’s support, until about 9 to 12 months of age and for at least 6 months. The Royal Berkshire leaflet says the same: usually around 9 to 12 months, after at least 6 months milk-free. Kent’s leaflet says around 12 months of age, or at least 6 months after milk was removed, whichever is soonest. Your dietitian will pick the right time for your child.

Pick a good time. The NHS leaflets say to start when your child is well, with no cough, cold or fever, settled tummy and bowel symptoms, and eczema under control. Kent adds: not while actively teething, or within a few days of a vaccination.

How the steps work

The iMAP Milk Ladder has 6 steps. Your dietitian may change the number of steps or the foods to suit your child.

1. Biscuit (cookie): milk very well baked into a homemade biscuit
2. Muffin
3. Pancake
4. Hard cheese, such as cheddar, then cheese baked on food such as pizza
5. Yogurt
6. Pasteurized milk or a suitable infant formula

Steps 1 to 5 use milk baked or cooked into food. At step 6, if your child is under 12 months, the step uses a suitable infant formula, as your dietitian advises, not cow’s milk as a drink: fresh cow’s milk is a main drink only from 12 months (NHS, AAP). Until your dietitian says otherwise, your baby’s usual breast milk or prescribed formula stays their main drink.

Some general points from iMAP and the NHS trust leaflets:

• Use the recipes you’re given. The early steps use homemade recipes so each step has the right amount of milk. Ask before swapping in shop-bought foods. The recipes have egg-free and wheat-free versions, and iMAP updated them to follow WHO advice on sugar and salt.
• Start small. Many children start with a quarter or half portion and build up over a few days to a full portion.
• Give the new food early in the day, so you can watch your child for the rest of the day.
• Stay on each step for at least 3 days before moving up (Royal Berkshire, Kent). Delayed symptoms can take 2 to 3 days to show.
• Keep going with what works. Once a step goes well, keep giving those foods regularly, along with foods from earlier steps.
• One change at a time. If your child is also on an egg or soy plan, don’t move up two ladders at once (Kent).
• Pause if your child is unwell, and carry on when they’re better (Royal Berkshire).

Serve each food in a form that’s safe for your child’s age, such as soft pieces or strips: see safe food sizes and shapes. Until your child reaches the top step, your dietitian will tell you which milk to use instead. Rice drinks aren’t suitable: see plant milks for toddlers.

If your child reacts

Delayed symptoms can include reflux or vomiting, tummy pain, diarrhea or constipation, or eczema getting worse (Royal Berkshire). Your child may not react the same way as when they were first diagnosed.

• Mild delayed symptoms: stop the food on that step and go back to the last step that went well (iMAP). Keep giving the foods from earlier steps, and tell your dietitian. They’ll tell you when to try again: the NHS leaflets suggest waiting anywhere from 1 to 6 months, depending on the reaction.
• A fast reaction, within minutes or a few hours, such as a few hives or mild puffiness around the eyes: stop the ladder and talk to your doctor or dietitian before going on (Royal Berkshire). If your child wheezes or has trouble breathing, or their lips, mouth, tongue or throat suddenly swell, treat it as anaphylaxis and follow the steps below.

Signs of anaphylaxis are trouble breathing, wheezing or a cough that won’t stop, swelling of the tongue or throat, lips or mouth that suddenly swell, a hoarse cry, turning pale or floppy, becoming very sleepy or unresponsive, or signs in more than one part of the body at once. If you see any of these and your child has an epinephrine (adrenaline) auto-injector, use it right away, then call for an ambulance. Call 911.Call 999.Call your local emergency number (such as 112 in Europe or 000 in Australia). If you don’t have an auto-injector, call straight away. If you’re alone with your child, use the auto-injector first if they have one, then call on speaker. Don’t leave your child to find a phone. Keep your child lying down, never standing or walking (on their side if they’re vomiting, head and shoulders a little raised if breathing is hard). See signs of anaphylaxis.

If your child vomits once or twice a few hours after a step and is alert and like themselves, call your pediatrician or GP. Call 911 or go to the emergency room if your child is vomiting again and again, or is pale, floppy, very sleepy or hard to wake.Call 999 or go to A&E if your child is vomiting again and again, or is pale, floppy, very sleepy or hard to wake.Call your local emergency number (such as 112 in Europe or 000 in Australia) or go to the emergency department if your child is vomiting again and again, or is pale, floppy, very sleepy or hard to wake. See FPIES.

Where US and UK advice differs

• Where milk ladders are used. Food ladders were first designed in the UK for delayed (non-IgE) allergy and are now widely used in Europe. Canadian allergists have published a 4-step milk ladder for preschool children who have had only mild fast (IgE) reactions, overseen by an allergist. It isn’t used after a life-threatening anaphylaxis or with poorly controlled asthma (Canadian food ladders, 2021).
• Baked milk in the US. Many US allergists use baked milk differently. A 2023 AAAAI work group report says that up to 70% to 80% of children with milk allergy can eat baked milk before regular milk, but because it’s hard to predict who will react, baked milk is generally introduced through an oral food challenge watched by the allergist. Home introduction may be offered to some carefully chosen low-risk children. Either way, your child’s allergist decides.
• Cow’s milk as a drink. Both the NHS and the AAP say cow’s milk shouldn’t be a main drink before 12 months. The NHS allows it in cooking from 6 months, and the ladder’s early steps use milk baked into food on your dietitian’s plan. If your child is under 12 months at the top step, ask which formula to use.
• Who supports you. In the UK, the delayed type is usually managed through your GP, with a dietitian ideally leading the ladder (iMAP). In the US, ask your pediatrician or allergist what plan fits your child, and whether a registered dietitian can help.

For starting solids without dairy, see cow’s milk allergy. For other allergens, see how to introduce allergens.