Home Introduction of Cow's Milk - Milk Ladder

This guide is NOT suitable for children with severe or immediate allergic reactions to cow’s milk proteins. Please contact your health professional for further advice if you are unsure.

What is the milk ladder?

• It is a step-by- step process to reintroduce cow’s milk into your child’s diet when they have been diagnosed with a cow’s milk allergy. It starts with baked milk products, which are less likely to trigger an allergic response and gradually works towards introducing pasteurised uncooked milk.

When should I start the milk ladder?

• If your child has a mild to moderate Non-IgE Cow’s Milk Allergy and has been given advice by their health care professional that they can commence a home re-introduction of cow’s milk using the milk ladder.
• This may be around the time your child is 12 months old and has excluded cow’s milk for at least 6 months.

What should I do before starting the milk ladder?

• Make sure your child is feeling well. If they have a cough, cold, fever or tummy bug wait until the symptoms are better before starting the milk ladder.
• If they have eczema or ongoing unrelated tummy symptoms wait for a time that they are settled/well controlled.
• Your child should not be on any antihistamine medication before or during the challenge days. This is because they can delay or hide reactions. If you need to stop the milk challenge due to an adverse reaction, you may need to give an antihistamine then.
• If your child has changed any medication recently we would recommend waiting until your child is established on this medication prior to starting the milk ladder.
• If your child has more than one food allergy/intolerance do not introduce any of these foods at the same time as doing the milk ladder.

When is a good time of day to start the milk ladder?

• Start the challenge earlier in the day to allow you time to observe your child for any allergic symptoms related to cow’s milk.
• Choose a time when you are not busy or need to go out.
• Give the full portion for that day all at once rather than spreading it out where possible.

My child has become ill with a bug once the milk ladder has started, what do I do?

• Stop the milk ladder at the stage you are on.
• You can continue to offer any foods they have previously tolerated from earlier stages.
• Wait until your child’s symptoms have resolved before restarting the milk ladder.

My child will not eat the food or the portion size suggested in the milk ladder, what should I do?

• Some children may be worried about trying new foods especially if they have had previous bad experiences. Do not force your child to eat but retry the food at a later date.
• At some stages of the milk ladder you may find the portion size suggested is more or less than your child would normally eat of that particular food. The portion sizes are a guide and it is fine to offer them their usual portion if this is more appropriate. The main aim is to gradually build up to their normal portion size and offer this daily for at least 5 days to check their tolerance to it.

What do I do if my child reacts to a step on the milk ladder?

• Stop the milk ladder at the stage you are on and treat the reaction if appropriate, as some reactions require time rather than treatment.
• Contact your local doctor or emergency department if you are concerned your child seems unwell.
• If your child was managing a previous step on the milk ladder with no symptoms, continue to include those foods regularly in your child’s diet to help maintain their tolerance.
• You can then retry the milk ladder again in 4-6 month’s time.
• If your child develops severe symptoms please seek advice from a health professional and do not repeat the milk ladder at home.

How do I make sure my child is having enough calcium?

• Breastmilk or cows milks substitutes should continue to be the main milk source for infants.
• Whilst on a cow’s milk free diet ensure you are offering regular cow’s milk free alternatives such as cheese, yoghurts and supermarket dairy free milks in foods. Check they are fortified with calcium.