The Milk Ladder - has my baby grown out of Cow's Milk Protein Allergy?

An assessment of your child’s allergy, medical history and/or results indicate that it is time to see if they have outgrown their food allergy. This can be done by adding milk into the diet gradually at home.

Milk is introduced into the diet by following a ‘milk ladder’ where each food contains increasing levels of milk protein. It is important to start with well-cooked/processed milk first before progressing to ‘raw’ dairy products. This ‘milk ladder’ is based on scientific research. Some of the foods may seem unusual to include in an infant’s diet, but it is because the type and amount of protein is suitable for the reintroduction process.

Remember, these foods are part of a mixed diet and are not expected to be a significant part of the child’s diet. The Milk Ladder should only be used in children with Mild to Moderate Non-IgE cow’s milk protein allergy under the supervision of a healthcare professional.

• Do NOT start this challenge if your child has had a positive blood or skin test (Specific IgE or Skin Prick Test) to cow’s milk.
• Do NOT start this challenge if your child is unwell, e.g.
• Has a cold or any other lung infections or breathing problems
• Any tummy/bowel problems e.g. tummy ache or loose nappies
• Any ‘teething’ signs that are upsetting your childAtopic dermatitis (eczema) has flared up
• Do NOT start this challenge if your child is having any medication which may upset their tummy, e.g. antibiotics.
• Do NOT start this challenge if your child is taking antihistamin (e.g. Piriton, Zirtek...)
• Do NOT try any other new foods during this challenge.

Throughout the challenge, it is useful to keep a record of the foods tried/the amounts eaten and any reaction (including how long after the food was eaten did the reaction occur).

Before starting the Milk Ladder

Make sure you have a suitable antihistamine at hand (ask your pharmacist) Start the challenge by testing some cow’s milk on your child’s skin (on the cheek or where eczema may flare up). Wait a couple of hours, if no reaction (e.g. rash/itchy skin) progress to the Milk Ladder. Each of the foods listed contain progressively more milk protein in them. Try each food for a few days (up to a week) before moving onto the next food.

The Milk Ladder (available here on the web)

This Milk Ladder is designed to be used with homemade recipes to ensure that each step has the appropriate milk intake. You can ask your health professional for the recipes if you wish. If you prefer to use store-bought alternatives seek further advice from your healthcare professional if necessary.

1. One malted milk biscuit, build up to three. If using store-bought biscuits rather than homemade look for a biscuit that contains milk powder rather than whey powder.

2. Half a muffin and build up to one muffin.

3. Half a pancake and build up to one. If using store-bought pancakes, they should contain milk protein rather than whey powder. (Pancakes contain less milk than muffins but are cooked for a shorter time).

4. Half an ounce (15g) of hard cheese such as cheddar or parmesan. Once tolerated introduce 15g baked cheese e.g. on a pizza or lasagne

5. Try 125mls (4.5oz) yogurt. Once your child tolerates yogurt you can include butter, chocolate buttons and cream cheese.

6. Pasteurised milk (or suitable infant formula). Introduce 100mls pasteurised cow’s milk or infant formula (powder) and mix with current milk replacement. If this is tolerated switch all current milk replacements to pasteurised milk or suitable infant formula. UHT and sterilised milk will be tolerated as well.

Some children may be able to tolerate a certain amount of cow’s milk in their diet e.g. include milk in foods, have ordinary butter/margarine and cheese but are unable to tolerate drinks of milk. If they have more than the amount that they are able to tolerate then they may develop symptoms (up to 48 hours later). If this is the case it is sensible to include dairy products and cow’s milk up to the certain amounts they can tolerate while remaining symptom free.

If at any time your child has a reaction then you should STOP THE TEST but re-try in 6 months.

Symptoms of a reaction are usually similar to the reaction your child first presented with. These include:

• Tingling, itching in mouth
• Developing rash
• Dry/red patches of skin appearing
• Nausea/vomiting
• Abdominal pain
• Diarrhoea / constipation
• Wheezing (give inhaler if available)

If any of these occur at any stage in the reintroduction, give your child some antihistamine and monitor their condition. You and/or your child may feel quite nervous about trying this milk challenge, this is quite normal but you can help them by allowing adequate time and doing the challenge at home under your supervision in a calm environment.