Cow’s Milk Reintroduction (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.

Points to remember

• Do NOT attempt this milk reintroduction if your child has previously had breathing problems or faintness / floppiness after having milk or other dairy products.
• The milk ladder can be used in children who have previously suffered from hives or skin swellings. However, because of the risk of allergic reactions, in this case, it should only be with guidance from a children’s allergy health professional.
• It is very important that you follow the plan advised by the allergy doctor, dietitian or nurse. DO NOT move the next stage without agreement.
• If you have any concerns or questions, please contact the allergy team or dietitian.
• Your child will usually start with milk which has been baked in the oven, such as malted-milk biscuit (Most digestive biscuits no longer contain any milk), and then slowly builds up to eating more of this food, before going on to less well-cooked dairy products (milk ladder). If you are introducing foods which require cooking/ baking, please cook following the manufacturer’s guidelines or recipe. Do not give under-cooked food.
• Start at the step you have been advised to by your doctor or dietitian. If your child is avoiding other food groups for example wheat or egg, please seek advice from your dietitian on alternative food items for the milk ladder
• Ensure your child is well and does not have a cold or temperature. If your child has had a flare up of their eczema, asthma, hay fever, or has taken antihistamines in the last five days do not undertake the challenge.

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

Table 2 – MILK LADDER How much food

For products with a large quantity e.g. pizza, lasagne you can introduce more slowly by doubling the portion each day until a full standard portion for your child’s age and appetite is reached.