Milk Ladder: Gradual Re-introduction of Milk Products for children with Milk Allergy

Many children with a cow's milk protein allergy (CMPA) will grow out of this between the age of 1-3 years. The milk ladder is a step-by-step approach to reintroducing cow's milk into the diet of babies with cow's milk protein allergy (CMPA). Milk is gradually introduced into the diet at home by parents by following a 'milk ladder' where each food contains increasing levels of cow’s milk protein. A milk ladder should always be used under supervision of a trained pediatric allergist.

Milk Ladder: Gradual Re-introduction of Milk Products for children with Milk Allergy

For which patients with cows milk protein allergy (CMPA) is a milk ladder recommended?

Mild ladder is recommended for babies/children with non IgE mediated cow’s milk allergy only (e.g. symptoms of “colic”, unsettledness, reflux, blood in stools, diarrhoea). Milk ladder should not be used for babies with IgE mediated cow’s milk protein allergy (e.g. symptoms such as acute urticaria, angioedema, wheezing, anaphylaxis). Using a milk ladder at home in children with Ige mediated cow's milk protein allergy can be dangerous and can lead to severe reactions such as anaphylaxis.

What are the steps of a milk ladder?

Children with cow's milk protein allergy (CMPA) initially develop tolerance to milk in a cooked or a baked form. Cooking or baking milk, especially when mixed with flour and other foods makes the milk less allergenic. The tolerance to fresh milk appears a bit later. Hence reintroduction of milk in a child’s diet is started with baked products and gradually moving towards less baked/cooked forms. Raw dairy products are reintroduced in the last step.  The steps involved in the Indian milk ladder are shown in the accompanying figure.

How do you use a milk ladder?

It is recommended to start at step 1 of the ladder and gradually go up. If the child is already eating and tolerating some foods containing milk, start on the closest step in the ladder (rather than at the bottom).

  • If the child tolerates a step:  leave this food in the diet, and move onto the next step. Try each step for a period of at least a week. Gradually increase the food portion, until the child takes a normal portion for his/her age. The time spent on each step will vary from one child to another.
  • If the child does not tolerate a step:  Go back to the previously tolerated step, and then rechallenge after 3 months.

Some important considerations while using the Milk Ladder?

It is recommended to start the milk ladder when the child is well. It is better to avoid it if the child has eczema, cough, wheezing etc.

In case your child is suffering from cow's milk protein allergy (CMPA) do get in touch with a pediatric allergist for a proper diagnosis and management. Understand how to use a milk ladder before you start to reintroduce milk products at home.

Leave a Reply

Your email address will not be published. Required fields are marked *