The Milk Ladder (For Non-IgE/delayed milk allergy)
Staged reintroduction of dairy back into the diet for children with mild to moderate non-IgE (Immunoglobulin E) cow’s milk protein allergy.
Most children with a milk allergy will outgrow it as they get older. The following plan explains how to introduce milk daily in a slow and safe way.
What is the milk ladder?
It is a plan to re-introduce milk products gradually in stages, starting with foods that contain only a small amount of well-cooked milk and progressing towards un-cooked dairy products and fresh milk.
Who should attempt the milk ladder?
This milk ladder is for infants and children with a mild to moderate cow’s milk allergy
known as a ‘non-IgE mediated’ (delayed) milk allergy. It is not suitable for children with a milk allergy that results in severe or immediate type allergic reactions known as an ‘IgE mediated’ milk allergy.
When should this milk ladder be attempted?
The milk ladder can normally start once your child has been on a milk free diet for at least 6 months and is over 9-12 months of age.
You should only attempt the milk ladder or move up to the next step when your child is well (ensure eczema, tummy and bowel symptoms are settled).
How should the milk ladder be attempted?
- Give a small amount of the food from the step you are working on (see below)
in the morning away from nap time so you can look out for any symptoms. - Gradually increase the amount that you give daily until a full portion is tolerated.
- Keep these foods in the diet when moving onto the next step.
- Each step should take at least 2-4 weeks.
What if my child reacts?
If your child does not tolerate the food from a particular step, go back to the most recent tolerated step. Retry the next step in 2-3 months’ time.
Symptoms to lookout for include: Worsening eczema, tummy pain, reflux, increased wind, nausea, constipation or loose stools.
Sometimes it is difficult to work out if delayed-type symptoms are due to a food your child has eaten or another reason such as a tummy bug, being stressed or anxious. Symptoms caused by milk-based products should be re-producible.
If any IgE mediated symptoms occur, immediate hives, rash, swelling or difficulty breathing, please stop giving the suspected food and seek medical attention and contact your health care professional.
Start each step with a small amount and gradually increase as tolerated. Only move onto the next step when a full portion is tolerated.
An example on how to increase the quantity follows the table below:
| Step 1 | Manufactured foods containing cow’s milk in the processed form. Choose foods that contain milk powder.
• Malted milk, Shorties, Garibaldi, Rusks containing milk powder • See recipe attached for free from alternatives (including gluten/soya/egg free) |
| Step 2 | Other BAKED products containing larger amounts of cow’s milk.
• Plain fairy cake, sponge cake or muffins (avoid chocolate chips) • Plain scones, croissants, brioche (plain) • Milk loaf / roll • Flapjacks • See recipe attached for free from alternatives (including gluten/soya/egg free) |
| Step 3 | COOKED foods containing small amounts of cow’s milk.
• Pancakes/waffles – (shop bought then homemade) • Yorkshire pudding – (shop bought then homemade) • Naan bread • Cheese flavoured crisps and crackers (e.g Mini Cheddars, Wotsits, Quavers, cheese breadsticks) • See recipe attached for free from alternatives (including gluten/soya/egg free) |
| Step 4 | COOKED foods containing larger amounts of cow’s milk, cheese or yogurt.
• Sauces and soups made with heated milk or cheese • Fish pie, shepherd’s pie and lasagne • Curry made with yogurt or milk • Pizza or cheese on toast • Thepla (flatbread) made with yoghurt • Milk puddings: custard, rice and semolina puddings • Chocolate & chocolate coated items e.g. chocolate buttons or chocolate coated biscuits
|
| Step 5 | UNCOOKED Yogurt and cheese.
• Fermented desserts such as yoghurt, fromage frais, Shrikand • Hard cheese then soft cheese e.g. cheddar, paneer, cream cheese |
| Step 6 | UNCOOKED Fresh milk products.
• Fresh cow’s milk, dairy cream, ice-cream |
How to increase the quantity at each step
- Start each step with a small amount and gradually increase until a full portion is tolerated (a full portion will depend on your child’s age and appetite).
- Once a full portion is tolerated for one week, you can then move onto the next step.
Example of attempting the milk ladder using biscuit of choice from
Step 1 (progression in the first week can be slower if desired)
- Day 1: Give ¼ of a biscuit from step 1 and observe for symptoms
- Day 2: Observe for symptoms
- Day 3: Give ½ of a biscuit from step 1 and observe for symptoms
- Day 4: Give 1 biscuit from step 1 and observe for symptoms
- Day 5: Give 2 biscuits if appropriate for age/appetite and observe for symptoms
- Days 6-14: Continue giving tolerated amount daily for at least 1 week before moving onto step 2
If symptoms occur, then stop giving the biscuit and re-attempt in 2-3 months.
Alternative Recipes (including gluten/soya/egg free)
Step 1: Biscuit recipe (sweet/plain)
The following recipe makes 20 small finger size biscuits. Use fruit and vanilla essence to make a sweet biscuit or dairy free cheese to make a savoury biscuit.
| Ingredients | Recipe |
| · 125g flour (wheat or wheat free)
· 1g xanthan gum (if using wheat free flour) · 50g cold dairy free margarine · 60 – 80g mashed / grated fruit e.g. banana, apple, pear * · ½ teaspoon vanilla essence* · 2g skimmed milk powder
*To make a cheese biscuit replace the fruit and vanilla essence with 40g grated dairy free cheese |
1. Preheat the oven to 180oC / 350o F /Gas 4
2. Mix the flour, xanthan gum and milk powder together in a bowl 3. Rub in the dairy free margarine 4. Mix in the fruit and vanilla essence or dairy free cheese 5. Place the dough into the fridge for 30minutes if you have time which makes it easier to handle 6. Roll out the dough and cut into 20 finger sized biscuits 7. Bake in the oven for 10 – 15 minutes
|
Step 2: Muffin recipe (sweet/plain)
The following recipe makes 10 muffins. Use fruit and vanilla essence to make a sweet muffin or dairy free cheese to make a savoury muffin.
| Ingredients | Recipe |
*To make a cheese muffin replace the sugar, fruit and vanilla essence with 60g grated dairy free cheese |
1. Preheat the oven to 180 – 200oC / 350 – 400o F /Gas 4 – 6
2. Mix the flour, xanthan gum (if using), baking powder, sugar (if using) and salt together in a bowl 3. Whisk the oil and milk in a separate bowl and then add this to the flour mix – Stir well 4. Mix in the fruit and vanilla essence or dairy free cheese 5. Divide the mixture equally between 10 muffin cases 6. Bake in the oven for 15 – 20 minutes |
Alternative Recipes (including gluten/soya/egg free)
Step 3: Pancake Recipe
The following recipe makes 6 pancakes.
| Ingredients | Recipe |
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Contact
Department of Nutrition and Dietetics – Paediatric Dietetic team
Tel: 01296 831 990 (select option 1)
Email: bht.cmpa@nhs.net