Cow’s milk reintroduction should only to be performed after obtaining advice from your doctor or dietitian.

The North West Paediatric Allergy Network accept no responsibility for adverse allergic reactions that occur during reintroduction of milk products.

Before starting reintroduction of dairy products using this milk ladder

Most children with milk allergy will outgrow the problem. It has been shown that many children who react to fresh milk, cheese and yoghurt may tolerate milk in a cooked or baked form. Cooking or baking milk, especially when mixed with flour and other foods makes the milk less likely to cause allergic reactions.

Your doctor has asked you to introduce cooked and processed milk into your child’s diet. This may help to make your child’s diet less restrictive, more interesting and enjoyable. It may also help your child to improve their tolerance to cow’s milk and dairy products.

Key things to note

Points to remember

  • DO NOT attempt reintroduction of dairy products at home if your child has previous suffered from breathing problems or floppiness after eating milk or other dairy products
  • this milk ladder can be used for children who have previously suffered from delayed skin or gastrointestinal reactions, as well as in children who have had hives or skin swellings
  • ensure your child is well when introducing dairy. If your child has been wheezy recently or has taken antihistamines in the last 5 days wait until they are better. DO NOT increase food portions or introduce new foods when your child is unwell
  • start at the step you have been advised by your doctor or dietitian. Your child may already be tolerating some foods of the ladder, so you can then progress from there
  • if your child reacts to an increase in amount/frequency of milk protein please DO NOT stop completely, go back to the previously tolerated stage until further review by your health professional
  • wheat free/egg free options of the milk ladder are available and should be discussed with your dedicated health professional

Stop the challenge if any of the following develop

  • Red, raised, itchy rash
  • Swelling to where the food has been applied
  • Vomiting / tummy pain / loose stools
  • Difficulty / noisy breathing
  • Wheeze / persistent cough
  • Dizziness / feeling faint / floppiness

Give antihistamine if a rash or swelling develops. Symptoms should resolve within half an hour.

In the unlikely event of breathing problems or faintness, please take your child to the nearest Accident & Emergency Department. Do not re-challenge, but contact your allergy team for further advice.

Table 1 – MILK LADDER Which foods

1Biscuits containing milk
  • malted milk biscuit
  • shortcake
  • NOTE: Most digestive biscuits no longer contain milk
2Baked products
  • plain cakes or plain muffins
  • scones
  • milk loaf
  • croissants
  • brioche
3Baked products cooked for less time
  • scotch pancakes
  • cheese powder flavourings e.g. quavers, wot-sits
4Foods containing cheese or milk
  • cream or cheese - on toast, macaroni cheese, pizza, lasagne, pasta bake
  • chocolate
  • shepherd’s pie/mash with butter, milk in sauces
  • soups or meals/purees containing milk
  • rice pudding/custards
5Less processed milk
  • yoghurt
  • fromage frais
  • soft cheese
  • butter
  • 6Milk (can be mixed with milk alternatives to taste)
  • infant formula or fresh milk
  • Table 2 – MILK LADDER How much food

    Give the food at LEAST 3 times a week once tolerated. Increase each stage weekly if possible.

    StageAmount of food
    1Grain of rice size (400mg)
    2Pea size (1000mg / 1g)
    3Teaspoon size (5g)
    4Tablespoon size (15g)
    5¼ portion
    6½ standard portion
    7Full standard portion