The Cow's Milk Ladder

What is the milk ladder?

The milk ladder is a step-by-step approach to reintroducing cow’s milk into the diet for those diagnosed with cow’s milk allergy (CMA). It is intended for infants with non-IgE mediated (delayed) CMA. More recently it has been used in IgE mediated (immediate) CMA, only after appropriate review, and on the recommendation of an allergy team, to ensure it is safe to re-introduce cow’s milk using the milk ladder at home.

Never use the milk ladder at home for a child with IgE-mediated cow’s milk allergy on your own, without the advice and recommendation of a specialist allergy team.

If your child has been diagnosed with a condition called, Food Protein Induced Enterocolitis Syndrome (FPIES), the ladder should not be used and reintroduction in hospital is recommended.

The first step of the ladder starts with baked milk where the cow’s milk protein has been extensively heated and mixed with a carbohydrate, e.g.wheat flour (such as in a biscuit), for approximately 20-30 minutes in an oven. This changes the cow’s milk protein and is therefore less likely to cause an allergic reaction. The ladder then progresses through several stages to cooked milk, where the milk protein is cooked for less time, and then lastly to uncooked milk.

What ladder should I use?

There are many versions of the ladder including a four step, six step and 12 step ladder. This can make it confusing knowing which one to use. Generally, they all follow the same principles of starting with baked milk and building up to fresh milk. Your dietitian or allergy team will advise the best approach and the number of steps and types of foods which are appropriate for your child.

What to consider before starting?

Before starting, you need to ensure your child is well (no cough, cold or fever), there are no tummy symptoms, and their eczema is under control. Ensure that you offer the cow’s milk containing food earlier in the day, so you can observe your child for any allergic symptoms related to cow’s milk throughout the day.

When should I start the milk ladder?

This will depend on your child’s symptoms, age and when they were diagnosed. For non-IgE mediated CMA it is typical to start around 9-12 months of age. Most children will start at step one unless they have tolerated a food higher on the milk ladder by accident in which case they may go in slightly higher. If this is the case, your allergy team will advise where your child should start.

How much should I give?

On each step of the milk ladder there are suggested portion sizes which are used as a guide. In some cases, it may be advisable to start with smaller amounts such as ¼ or ½ portions depending on the child’s previous history and symptoms.

There are cases where even smaller amounts are advised such as a crumb. Your dietitian or allergy team may adapt the ladder depending on your child’s allergy history.

How long do I stay at each step?

This will vary from child to child. Some children progress on a step quickly (e.g. in a week), and others may stay at a step for several months. You can move to the next step when you are confident that your child is tolerating the recommended portion size (at least a few times to ensure it is tolerated before moving to the next step). Those children starting with smaller amounts (e.g. crumb or pea size) will take longer on the ladder due to the time to build up to a full portion.

What to do if you suspect a reaction?

If you suspect a reaction, always treat the reaction according to your child’s allergy action plan or the advice you were given by the allergy team. Then discuss the allergic reaction with your dietitian or allergy team to seek advice on the next step. If your child was tolerating a previous step prior to the reaction, with no symptoms, continue to offer the same cow’s milk containing foods from that lower step in your child’s diet while awaiting advice

What if my child is ill during the ladder?

Coughs, colds, and bugs are common in children which can make it harder to navigate the ladder. If your child is ill, simply pause at the step they are on and continue once their symptoms have resolved. You can continue to offer foods that have previously been tolerated on the milk ladder.

For more information about cow’s milk allergy please visit our CMA Roadmap which also features the milk ladder on milestone 7.

This leaflet has been produced with the support of Nutricia.

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