The Milk Ladder; What It Is and How to Use It

The original milk ladder was created to help young children with mild forms of non-IgE-mediated milk allergies to reintroduce milk-containing foods after an elimination diet. The milk ladder approach was then adopted to treat children with IgE-mediated milk allergy and histories of mild to moderate symptoms, and it’s now widely used by doctors around the world, including for children with more severe forms of IgE-mediated allergy.

The ladder starts with the most easily tolerated forms of milk-containing foods—those with low amounts of extensively-heated milk protein—and ends with fresh cow’s milk. Although mild reactions are relatively common when a child is introduced to a new food on the ladder, when the milk ladder is used by the right target audience and is followed correctly, the risk of severe reactions is minimal.

The potential rewards, however, are plentiful, even if a child does not reach the top of the ladder. Just being able to incorporate baked milk into a child’s diet not only improves their nutrition but typically reduces the severity of any allergic reactions they experience if they accidentally come into contact with milk. This improves both their and their parents’ quality of life by reducing the general anxiety levels in the household, making it easier for their parents to buy food and making it possible for them to enjoy a more varied and diverse diet. Eating baked milk on a regular basis may even help milk-allergic children to outgrow their allergy faster.

This page will answer the following questions:

What is the milk ladder?

The milk ladder is a method that allows children with milk allergy to reintroduce milk into their diets by following a series of steps involving different forms of dairy. Each step contains a more allergenic forms of milk protein as you go up the ladder, starting with well-baked items like biscuits and muffins and ending with fresh, pasteurised milk or milk formula.

The purpose of the ladder is not necessarily to achieve a full reintroduction of dairy but rather to assess what can be tolerated; some children, for example, may be able to tolerated well-baked milk but not less-cooked forms of milk and will therefore remain on one of the first steps of the ladder, some children may be able to progress all the way through to the final step and start drinking fresh milk, and some may not be able to tolerate any form of milk at all.

The aim is to support a child’s development to full or at least partial tolerance, in order to limit the amount of time that they spend avoiding milk and ensure that they have a nutritious diet.

The first milk ladder was created in 2013 by a team of British experts as a way to reintroduce milk into the diet of children with non-IgE-mediated cow’s milk allergies, like food protein-induced allergic proctocolitis (FPIAP). It was part of the ‘Milk Allergy in Primary Care (MAP)’ guidelines, meant to assist GPs and nurses in recognising mild-to-moderate non-IgE mediated milk allergy in infants and young children. The ladder had 12 steps that focused on common British foods and included commercially available options and homemade recipes for each step.

In 2014, the British Society of Allergy and Clinical Immunology (BSACI) suggested that the milk ladder approach could also be used for children with an IgE-mediated allergy to cow’s milk. The introduction of foods on each step of the ladder could be carried out in a hospital environment if a child had a history of severe reactions, and it could be carried out at home when a child had a history of mild symptoms.

In the years since, the ladder has been widely adopted by healthcare professionals treating children with cow’s milk allergies all around the world. A 2017 survey revealed that 68% used milk ladders for patients with non–IgE-mediated allergies and 60% used a milk ladder approach for IgE-mediated allergies.

That same year, as it became clear that the original UK-based ladder had gone global, an international, simplified version—the iMAP—was produced which shortened the process from 12 to 6 steps and took the focus away from common British foods, putting it on healthier recipes using internationally-available ingredients instead.

Since then, the milk ladder has been recommended by the World Allergy Organization (WAO) as a way to reintroduce milk after an elimination diet and determine tolerance in children who have milder forms of non-IgE mediated allergies, and teams of experts have since produced their own versions for their countries:

• Canada got its own simple, 4-step milk ladder in 2021
• Spain got its own milk ladder in 2023 comprising 4 steps, each split into 2 levels
• Germany got its own 6-step milk ladder in 2023
• India got its own 6-step milk ladder in 2023
• Turkey got its own 4-step milk ladder in 2024

A Mediterranean version of the milk ladder, focussing on healthy eating based on the Mediterranean diet was produced in 2023. It includes 7 steps that avoid using too much sugar, saturated fats (butter) and trans-fats (margarines), using olive oil and avocado oil instead, as well as plenty of vegetables (e.g. carrots, tomatoes and onions), fresh fruit (e.g. banana), dried fruit (e.g. raisins), whole grains (e.g. whole meal flour, oats and brown rice) and non-animal protein sources (e.g. lentils).

Each ladder is slightly dissimilar, with different starting and ending doses of milk protein, different step sizes and, of course, different kinds of food. Some, like the iMAP and Mediterranean ladders, strive to be healthy, and the regional variations focus on being palatable to their target audiences and including ingredients that are locally available.

Although the milk ladder can be compared with milk immunotherapy, the two concepts are not the same.

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How does the milk ladder work?

The milk ladder works by starting with a small amount of milk protein, made less allergenic by extensive processing and progresses with steps that offer foods containing slightly more milk protein in a slightly less processed, more allergenic form, before ending with intact milk proteins.

Heating

The milk ladder capitalises on the fact that the ability to eat foods containing extensively heated milk—aka baked milk—tends to develop earlier than tolerance to fresh milk. This is largely due to the fact that baked milk has less potential to cause allergic reactions than other forms of milk.

Food proteins provoke reactions when IgE antibodies recognise and latch onto certain parts of them—the epitopes. These epitopes come in 2 forms; they can be conformational, and depend on the shape of the protein, or they can be linear/sequential and depend on the sequence of amino acids in the protein. The milk ladder takes advantage of the fact that heat is able to change the shape of milk proteins—to ‘denature’ them. This makes the epitopes on the surface of the milk proteins ‘break up’, which means that milk-specific IgE antibodies can no longer recognise them.

However, heating has no effect on the sequence of amino acids in a protein, so people who are allergic to the linear epitopes in proteins are unlikely to be helped by cooking. People who are allergic to linear epitopes are also likely to have a more severe and persistent form of milk allergy, and are therefore less likely to be helped by the milk ladder.

The milk ladder starts with extensively heated foods (cooked at high temperatures for long periods of time) and continues with foods that are slightly less thoroughly cooked, which results in a succession of foods that contain less-allergenic to more-allergenic forms of milk protein. So, for example, in one study, a third of the participants were found to tolerate rice pudding but still reacted to non-heated milk, even though each food contained 8 g of cow’s milk protein.

Cow’s milk contains a range of different proteins, roughly made up of 80% caseins and 20% whey, and these proteins are affected differently by cooking, with caseins being generally heat stable while whey proteins tend to be more vulnerable to heating. For example, the allergenicity of beta-lactoglobulin, a key whey protein, is reduced by 99% during baking, whereas that of beta-casein is reduced by only 30%. Therefore, people whose IgE antibodies recognise the latter protein will not find muffins as tolerable as those whose IgE antibodies recognise the former.

The food matrix

Another thing that limits a protein’s ability to provoke reactions is the food matrix. The food matrix refers to the physical structure of a food and the way that the protein, fat and carbohydrates molecules inside it interact with each other. The food matrix affects how our bodies handle a food; for example, it impacts a food’s nutritious value as well as its ability to provoke reactions. In the case of a muffin, the egg, milk and wheat interact with each other and with theother ingredients in such a way that there is less of the milk protein available to interact with a person’s immune system.

Italian researchers found that a wheat matrix helped around half of the milk-allergic children involved in their study. However, the interactions between the various type of food molecules are complicated and more work needs to be done before it’s fully understood.

Fermentation

Fermentation is essentially what happens when bacteria chew through large protein chains, breaking them down into smaller peptides and free amino acids. This process can destroy both conformational and linear epitopes, thereby reducing the allergenicity of the proteins in fermented foods, although it does not eliminate it. The amount of destruction achieved—and therefore the reduction in a food’s allergenicity—depends on the species of bacteria used as well as the specific fermentation conditions.

Fermentation is used to make dairy products like cheese, yoghurt and kefir. It’s not as powerful as heating when it comes to making food proteins less likely to provoke reactions, which is why you can find dairy products on the milk ladder above baked goods and below fresh milk.

In 2018, a Turkish study involving 34 milk-allergic children, 29 of whom had an IgE-mediated allergy, reported that half of the children passed a challenge with yoghurt.

A year later, an Italian study reported that the majority of children with an IgE-mediated allergy to milk could tolerate yoghurt, finding that around two thirds (23 of 34) of their participants were able to tolerate a total dose of 200 g of yogurt. 21 of those children had experienced systemic symptoms to milk in the past. Interestingly, while 10 of the 11 patients who failed the challenge with yoghurt also (unsurprisingly) produced symptoms after a yoghurt ‘rub test’, several of the children who were able to eat yoghurt still developed localised symptoms to it when it was rubbed on their skin.

Some research suggests that yoghurt is most likely to be tolerated by children whose symptoms are predominantly gastrointestinal.

In 2016, Italian doctors gave 40 Spanish children with IgE-mediated milk allergy manifesting as gastrointestinal symptoms oral food challenges with milk. They failed and were offered challenges with yoghurt instead. The parents of 25 children agreed, and all of those children passed their yoghurt challenge. The parents were then asked to include yoghurt into their children’s diets on a daily basis, while the parents of the other 15 children were instructed to ensure that their children avoided all forms of milk in their diets. They were all seen again 6 months later.

All 25 of the first group of children had been able to eat yoghurt without any symptoms or reactions. Their blood levels of IgE antibodies to specific milk allergens—caseins and beta-lactoglobulin—were decreased. This was not the case for the children who had been on a milk-free diet; in fact, their levels of IgE antibodies to both types of milk allergen had increased.

Since beta-lactoglobulin seems to a key factor in the gastrointestinal phenotype of milk allergy, and it’s either absent or present in very low amounts in many types of yoghurt, the Italian doctors suggested that yoghurt might be especially suitable for children with GI symptoms.

This, of course, also applies to children with delayed, non-IgE-mediated forms of milk allergy. Indeed, when a Turkish team challenged a group of children under 2 years old with either IgE or non-IgE-mediated milk allergies with yoghurt, only 1 of the 16 children with IgE-mediated milk allergy tolerated yogurt, whereas 11 out of the 16 children with non-IgE- mediated milk allergy did.

Parmesan (Parmigiano Reggiano) cheese also seems to be tolerated by a majority of milk-allergic children, according to Italian research. Parmigiano Reggiano is a traditional Italian cheese made with a long ageing process that varies between 12 and 36 months. As it ages, enzymes produced by rennet and lactic acid bacteria slowly digest and break down the milk proteins, notably the caseins, which tend to be the most problematic for the milk-allergic. A cheese which has been aged for longer should contain less intact milk protein. Parmigiano Reggiano also undergoes a cooking phase at 55°C before being aged, which may also play a role in reducing its allergenicity.

In one study, 50 milk-allergic children were challenged to Parmesan that had been aged for 3 years, eating a total of 13.3 g (if they got to the end of the challenge), which contains the same amount of milk protein as 200 ml of cow’s milk; 29 (58%) passed. A second study carried out a few years later involving 48 milk-allergic children reported that 78% of them tolerated Parmesan.

Finally, as well as being less allergenic, yoghurt and cheese have beneficial probiotic effects which could promote tolerance to milk by reinforcing the intestinal barrier and activating multiple immune mechanisms.

Significantly less protein content

Butter is also on the milk ladder, just below fresh milk. Butter is made by separating whole milk into cream and buttermilk. The cream, which has a much-reduced milk protein content, is then churned until solid butter granules form. These, in turn, are pressed and kneaded into butter.

Branded butters have a variable milk protein content, but whatever it is, it’s normally not high; in fact, butter was removed from the Canadian milk ladder precisely because of the ‘variable and typically very low cow’s milk protein content across available butter products’.

A Japanese study involving 44 children who reacted to heated milk reported that 38 (86.4%) of them were able to eat 10 g of butter (with a protein content equivalent to 2.9 ml of cow’s milk) without reacting.

It’s complicated

Food ladders are complex; the researchers and dieticians who produce them have to take into account the appropriate dose of food protein required per step and the amount of food needed to reach that dose, so that the foods that are available to make or buy in each step are equivalent to one another. They have to think about how the trigger food protein may react with the other food proteins in the whole food. And they have to consider the temperature and/or for how long the food has been heated, fermented or otherwise processed, and what effect that will have on the trigger food protein.

As such, the various milk ladders out there are not uniform in the amount of protein they offer, and more work needs to be done to standardise them. However, they are currently considered ‘the most promising option’ to manage and treat milk allergy.

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Who is the milk ladder for?

Milk ladders are not suitable for everyone. Researchers have come up with a checklist of factors for doctors to use as a guide when deciding which children are suitable for this type of therapy, namely the four As; Age, active or poorly controlled Asthma, history of Anaphylaxis and Adherence.

Young children…

The milk ladder is recommended for use in young children, preferably younger than 6 years old or younger than 5 years old, if you’re following World Allergy Organization (WAO) guidelines.

This is partly because, the younger a person is, the more ‘plastic’ their immune system is, making it better able to respond to therapy; this has been demonstrated by the results of peanut immunotherapy (the most common and well-studied type of immunotherapy) which is more effective when it is carried out in infants and preschoolers than it is when carried out in older children.

It is also significantly safer, as infants and young children can consume more of their trigger food without reacting and are less likely to have severe reactions involving difficulty breathing, cardiovascular or neurologic symptoms than older children when they do react to their food trigger, as demonstrated by analyses of the results of food challenges. That said, being exposed to a trigger food is still risky for a tiny minority of young children.

… with non-IgE-mediated conditions…

The milk ladder was originally produced for children with non-IgE-mediated gastrointestinal conditions like food protein-induced proctocolitis (FPIAP) and food protein-induced enteropathy (FPE).

This is partly because, compared to IgE-mediated allergy, studies have shown that tolerance develops at earlier ages in allergies like FPIAP.

More importantly, the symptoms associated with these conditions are not life-threatening. They include:

• Diarrhoea
• Bloody and/or mucousy stools
• Vomiting
• Constipation
• Stomach pain
• Refusal to eat
• Fussiness and irritability
• Poor sleep
• ‘Failure to thrive’ (failure to show proper growth for their age group)

… with a ‘mild form’ of milk allergy…

Children who are considered suitable for home introductions of their trigger food(s) are those whose previous reactions have been mild.

The original study that established that around three quarters of people with milk allergies can tolerate baked milk demonstrated key differences between those who could and those who could not tolerate it—namely, that those who could not tolerate baked milk were more likely to need adrenaline during their challenges (in fact, none of those who tolerated baked milk needed it), suggesting that those with a more severe form of allergy were less likely to be able to eat baked milk without experiencing symptoms.

Similarly, more recent research has also demonstrated that milk-allergic patients who fail their challenges to baked milk are less likely to experience skin symptoms and more likely to develop respiratory symptoms like wheeze and shortness of breath.

Suitable candidates will also have corroborating lab tests showing small skin prick test responses and lower levels of milk-specific IgE antibodies in the blood and, according to some guidelines, should not have had a reaction to milk in the previous 6 months. If a child did start off with relatively large skin or blood test results, these should have significantly decreased in the previous months.

They will not react to traces of milk in a food but will have a higher reaction threshold, meaning that they should be able to eat a small amount of baked milk without reacting.

Currently, the milk ladder is not considered suitable for children with FPIES. Although, some studies indicate that many children with FPIES over the age of 1 can tolerate baked milk and that some also tolerate fermented milk, more research needs to be done before treating these children with a milk ladder becomes common practice.

This is because a) FPIES symptoms are often more severe than those of other non-IgE-mediated allergies to milk, b) FPIES is less likely to resolve than other non-IgE-mediate allergies, and c) people with FPIES are sometimes also sensitised to their trigger food; i.e. they produce IgE antibodies which can provoke the more dangerous, immediate symptoms of allergy.

People with eosinophilic oesophagitis (EoE) are also often sensitised to milk and the milk ladder is also currently not considered suitable for children with eosinophilic oesophagitis (EoE); people with this type of allergy are still advised to avoid baked milk.

… whose coexisting diseases are under control…

Children who are considered suitable for home introduction with the milk ladder either have no coexisting conditions—namely asthma or eczema—or, if they do, those conditions are under control.

Out of control asthma or eczema has been linked with a greater likelihood of having more severe reactions to food. A recent review of near-fatal and fatal reactions to milk during ‘dietary advancement therapy’ (i.e. diets using a ladder-like approach) noted that all of the people who had those reactions were asthmatic, and many either had poor control over their condition or were suffering from an exacerbation at the time of the reaction.

If the conditions are initially uncontrolled but are eventually brought under control, the child’s suitability for home reintroduction to milk will be re-evaluated.

… and with motivated families who are able to follow the procedure

Parents whose children are following a milk ladder need to be able understand the doctor or dietician so that when the details, benefits and risks of the protocol are explained to them, they understand what the milk ladder is supposed to accomplish what they need to do to make it work.

This includes being able to commit to feeding their child the required doses of milk(-containing food) on a daily basis. Parents need to be able to make or buy the required food for the step they are currently on and they need to have the time to measure the right portion and feed it to their child, at least 3 to 5 times a week

Parents need to know not to administer the dose if potential cofactors are involved; for example, not if their child is ill, or has taken medication, or has just exercised or had a hot bath.

Parents need to be able to recognise the symptoms of an allergic reaction and to be able to deal with it, which includes being prepared to use an adrenaline autoinjector. Children who have a delayed allergy may have an accompanying IgE sensitisation to milk proteins and parents of those children must learn about the symptoms of early and delayed type allergic reactions so that they can recognise both types if necessary.

Parents also have to be able to keep their child’s asthma or eczema under control and know to stop the dosing if it gets out of control.

Parents need to know when to access healthcare support—i.e. when to ask their doctor or dietician for help—and they should also be able to access emergency services in the unlikely event that their children require them which requires not living in a remote location. And they must be able to keep their medical appointments.

All of these things—including the risks and benefits that are applicable in your child ‘s specific case, so you can make an informed choice about whether you want to go ahead with this therapy in the first place!—should be discussed with you before your child undertakes home reintroduction. If you don’t understand something, you should never be afraid to ask for clarification!

The unexceptional exception to the rules: IgE-mediated allergy

There are (almost) always exceptions to rules, and nowhere is this more evident than in the application of the milk ladder, at least when it comes to its primary audience; although the original milk ladder was conceived with children with non-IgE-mediated conditions in mind, it is regularly used to treat children with IgE-mediated milk allergy.

Indeed, the Canadian food ladders (for milk and egg) were specifically developed for use in preschool-aged children with a history of mild IgE-mediated reactions to those foods, based on the ‘evidence that the vast majority of egg- and milk-allergic children are able to tolerate extensively heated forms of these allergens.’

The only slight modification that’s suggested in the case of a child with IgE-mediated allergy, at least according to World Allergy Organization (WAO) guidelines, is that they should be a bit younger than their counterparts with a non-IgE-mediated allergy when they get started, i.e. under 3 years old. (And even that advice is often not followed.)

Even the rule that the milk ladder should only be applied to children with mild symptoms has been relaxed; some clinics treat young children who have experienced anaphylaxis.

To be clear, anaphylaxis is very rarely life-threatening, especially in young children. When allergy specialists refer to anaphylaxis, they are not necessarily talking about the kind of reaction that most people think of when they hear the term ‘anaphylaxis’.

An infant or young child experiencing anaphylaxis is most likely to be suffering from relatively mild symptoms which are affecting 2 organ symptoms, for example generalised hives (skin) and stomach pain (digestive), or coughing (respiratory) and a swollen face (skin).

According to a 2024 study from Ireland, children with a history of anaphylactic symptoms can be treated quite successfully with milk ladders. Researchers examined the medical records of 171 children who had followed the milk ladder, most of whom were between 6 to 11 months old and 36 of whom had had symptoms of anaphylaxis at diagnosis. 28 (77.8%) of the children with anaphylaxis at diagnosis completed the ladder, compared with 120 (88.9%) of the children with milder initial reactions to milk.

Both the children who had experienced anaphylaxis and those who had not completed the ladder at around the same rate (they took an average of 21 months vs 18 months, respectively), and they also experienced allergic symptoms while on the milk ladder at around the same rate (50% vs 41%, respectively). Most of those reactions were skin-related (swelling, hives, eczema) with some children experiencing GI symptoms (vomiting and stomach pain). 3 of the children experienced anaphylaxis during the treatment period, all of which resulted from accidental exposure to milk rather than from milk ladder foods.

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When is the milk ladder introduced?

Milk ladders have been used for children of all ages; one study has reported that the Canadian milk and egg ladders have been used for children aged between 7 months and 15 years old, with around two thirds of the children already tolerating some form of baked milk (often in the form of muffin) when they were started on the milk ladder. However, the older a child is, the less likely they are to benefit from food allergen ladders and the more likely they are to have serious reactions.

The optimal time to implement the milk ladder is around the age of 1. This is because infants often start to outgrow their milk allergy around this age, and this natural decline in their clinical sensitivity to milk protein is generally seen as a ‘window of opportunity’ to reintroduce milk into their diet, a) to help speed up the resolution of the allergy, and b) to avoid a prolonged and unnecessary exclusion diet which can sometimes lead to serious reactions.

However, the best time for you to reintroduce your child to milk will depend on when they were diagnosed and what type of allergy they have. The usual recommendations for children with a diagnosed milk allergy are to follow a strict milk-free diet for at least 6 months or up to the age of 9–12 months, whichever is reached first, before tests are carried out to see whether they can tolerate small amounts of baked milk and reintroduction is considered.

A doctor will typically make the decision based on a child’s history of symptoms—they should preferably have not had any reactions for at least a month—and their lab test results. Indicators such as the size of the skin test response and the levels of IgE antibodies in the blood can be used to see whether or not a child will probably be able to tolerate baked goods and are suitable candidates for the milk ladder.

Research suggests that the level of milk-specific IgE antibodies in the blood is more important than the size of the skin test response when it comes to guesstimating how far a child will progress up the ladder and whether or not they will complete all the steps.

When children have had moderate to severe reactions to milk in the past, the doctor will probably wait for an indication that they are starting to outgrow their allergy before recommending that they use the milk ladder. This is typically done by giving children skin prick or blood tests at regular intervals (e.g. every 6 months) to see whether the responses are getting smaller.

However, lab tests are not infallible. A high level of milk‐specific IgE antibodies cannot definitely predict who can tolerate baked milk and will eventually be able to tolerate fresh milk. Therefore, some experts suggest that all patients allergic to milk should be offered baked milk challenges, irrespective of their lab test results, because the chances are that they would pass and could therefore benefit from ‘the huge benefits of baked milk introduction’.

The doctor may propose an oral challenge to a bit of muffin or even a drop of milk to determine your child’s allergic status; if they do, you may want to take them up on their offer. Doctors only suggest challenges when they are as sure as they can be that a child will not have a (serious) reaction, and food challenges are often associated with an improvement in the mental health of both the allergic child (when they are old enough to understand what it going on) and the parents, because they take away the anxiety of not knowing what a reaction is going to be like and what to do if one happens.

When it comes to challenges in the context of the milk ladder in particular, a study by a team of Irish doctors reported that a single challenge with a tiny amount of whole milk at the time of diagnosis was associated with a more successful introduction of milk in the child’s diet.

After diagnosing 37 infants with milk allergy, a doctor gave them a quick challenge with a drop of milk—equivalent to the amount of milk protein (0.5 mg), which is thought to provoke a visible reaction in around 5% of the milk allergic—and told their parents how to introduce them to the 12-step MAP milk ladder. The parents of another 20 infants simply got the standard treatment; a diagnosis of milk allergy for their child followed by instructions on how to introduce them to the 12-step milk ladder.

6 months later, 27/37 (73%) of the children in the first group were on step 6 or above of the milk ladder, whereas only 10/20 (50%) of the second group were at the same level. 11/37 (30%) in the first group were even fully tolerant, versus 2/20 (10%) of the second group. One year after the initial diagnosis, 24/37 (65%) of the group of infants who’d had the initial challenge to a drop of milk had completed the ladder compared to just 7/20 (35%) of the other group.

The doctors put this result down to the initial milk challenge carried out in the presence of the infants’ mothers, which they thought had given the parents the confidence they needed to initiate and progress through the milk ladder. Their assumption was supported by assessments made of the mothers’ mental state during the study, which showed that the mothers of the infants who had received the challenges felt much less anxious than those who had not seen their infants handle a drop of milk. And, to be clear, a few of the infants did react; 4 of the infants had mild reactions which resolved without medication within a half hour. And all of those infants were drinking whole milk a year later.

The decision to reintroduce a food allergen in a child’s diet is always taken together with the child’s parent or caregiver. When a milk ladder is being considered, the doctor will work with the parents to identify the appropriate step to start on.

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How should I use the ladder?

If your child has a diagnosed milk allergy, you should get support from a healthcare professional in the form of advice and written instructions on how to use the ladder, as well as appropriate medication with which to treat reactions that don’t resolve by themselves. If you are following the procedure under medical guidance, someone should be in regular contact with you and you should be able to get in touch with them with any questions that you may have.

Starting the process

Most children will start on step 1 of the ladder. However, some children may already be eating some forms of processed milk in their diet, such as small portions of baked milk in muffin or pancake, or small amounts of cheese on pizza, in which case they can start at the step corresponding to the foods they can tolerate.

The ladder is a guide and not an absolute prescription and, in some cases, the doctor/dietician will propose something slightly different; for example, if your child has had moderate to severe reactions to milk in the past, you may be advised to start the ladder with smaller quantities than suggested, such as a few crumbs or a small piece of biscuit, or half a biscuit, instead of a whole biscuit.

When children who are at risk of being allergic to milk (e.g. because their parents are atopic) have not yet had any milk in their diet, or if a child has an IgE-mediated allergy and a history of moderate to severe reactions, the initial taste of a milk-containing product will probably take place under medical supervision. If the food is tolerated, you can take your child home and continue feeding them the agreed amount of milk protein for that step of the ladder.

Many of the milk ladder studies that have been published have required medical supervision for at least some of the upgrading steps; i.e. when going from, for example, extensively baked biscuits to muffins and from muffins to pancakes. In clinical practice, a supervised initial feeding may also be required for the first few steps of the ladder. It entirely depends on how your child reacts to milk.

The initial introduction of milk-containing food at home is likely to be suggested when children are known to tolerate baked milk and/or have had only mild symptoms in the past to relatively large amounts of milk (i.e. have high thresholds). In such cases, the introduction of new foods for each step of the ladder will also be done at home.

The first feeding of a new food (or a larger amount of the same food) at any level of the milk ladder must always be done when your child is feeling well and is free of symptoms associated with their milk allergy, and their asthma and/or eczema is under control.

Progressing up the ladder

The first steps of most milk ladders include homemade recipes because this allows you to control exactly how much milk protein is present in the food. It’s difficult to know how much milk a shop-bought alternative contains, as this can differ per brand and brands can also change their recipes. However, by the time your child can handle the steps with the homemade foods—step 3, in the iMAP’s case—it’s safe to start using commercial foods instead, which is handy if your child is getting bored with eating the same thing every day.

There is no consensus on how long a child should spend on each step of the ladder before going on to the next one. Each step can be conducted over any length of time, it completely depends on how your child is progressing. Some children can get through a step in a week, others may take several weeks to do so.

The British Society for Allergy and Clinical Immunology (BSACI) recommends starting with a small crumb of commercial malt biscuit, building up to 1 biscuit per day in weekly increments and completing in the first step in 5 weeks. The next steps may last between 4 to 6 months.

The experts behind the Canadian milk ladder recommend starting the first step with a grain- or pea-sized amount of food which should be eaten every day. The dose should be gradually increased until it reaches an age-appropriate serving, and your child should keep eating that amount for 1 to 3 months before advancing to the next step. They note that any kind of progress, even if it’s very slow, is good, as simply feeding your child baked goods from the first step of the ladder on a regular basis has been shown to promote tolerance.

Some doctors have carried out trials in which they recommend that a child start with a dose of milk protein determined by the symptoms experienced during a food challenge, to be eaten at least 3 to 5 days a week and, after tolerating that amount for 2 to 3 months without symptoms, doubling the dose and eating that for 3 to 5 days a week until it’s been tolerated for 2 to 3 months, and continuing in that vein until the maximum amount of milk protein for that step has been reached. Then it’s time to advance to the next step.

Some doctors simply propose waiting until your child can eat an age-appropriate amount of each food allocated to the step of the ladder that you’re on for at least 3 days a week without reacting before moving on to the next one.

One study has compared a very slow escalation (staying on one step for 12 months) with a faster escalation (staying on one step for 6 months). 136 children aged between 4 and 10 years old with a suspected IgE-mediated allergy to cow’s milk were given challenges to baked milk. Then, the doctors tested two consecutive steps of the milk ladder on the same day to determine which foods the children could tolerate; first they tried muffin and then, 2 to 3 hours later, if the children tolerated the muffin, they were given some pizza. 2 weeks later, those who passed the test to pizza were tested with rice pudding and fresh milk on the same day.

A total of 85 children who could tolerate at least a muffin were split into 2 groups and sent home with the instruction to keep eating the last food that they had tolerated, and either to return in 6 months to repeat the challenge that they had failed or to return after 12 months for the same reason. Each time the challenge to one food was passed, the next, more allergenic food was introduced.

At 36 months, the status of each group of children was evaluated; there was no significant difference in the progression of children who had proceeded to the next step after 6 months and those who had done so after 12 months; the children who had reached the last step of the ladder (41 of them, 48.2%) had taken an average of 18 months to do so. There was also no significant difference in the average time that those children had taken before being able to tolerate drinking whole milk, whether they had initially been able to tolerate muffin, pizza or rice pudding.

Ultimately, the length of time that your child will spend on each step basically depends on 3 things:

1. Why the ladder is being used in the first place:

• If it’s being used to determine whether or not your child can tolerate the foods on the milk ladder, the time spent on each step will be relatively short
• If it’s being used to induce tolerance, the time spent on each step will be longer

2. What type of allergy your child has:

• If your child has a low-risk form of milk allergy with a history of mild reactions, the interval between each step will be relatively short, perhaps between 1 week to 1 month, whatever time it takes to make sure that they can tolerate each food in that step without reacting before moving on
• If your child has a high-risk form of milk allergy with a history of moderate to severe reactions, a schedule which involves starting with small doses of each food and building up to an age-appropriate serving is safer, and therefore intervals between steps will be longer
• If your child has a low-risk form of non-IgE-mediated allergy to milk, the time that it takes for them to develop a reaction to their trigger food—which can be as long as up to 2 weeks after eating it in some cases of FPIAP—has to be taken into account, and the time interval between steps will be longer

3. Whether cofactors like exercise or illness get in the way:

If your child has a tendency to suffer from infections or a tendency to run around a lot, this can lower their tolerance to their food trigger, in which case they may suffer from symptoms that will require you to lower the dose and build up the amount of protein that they eat during each step of the ladder more slowly. Some families also experience problems in building up the dose because, for example, they have busy schedules and cannot always take the time that’s needed to make and measure out the next food on the ladder, or they can’t get their hands on the right ingredients.

The important thing to remember is that, if your child is able to incorporate any kind of processed milk into their diet on a regular basis, you are already helping them on their way, either to tolerance or the ability to weather accidental exposures.

If your child can tolerate the food(s) allocated to a certain step of the ladder, they should keep eating it while also trying the food allocated to the next step.

When your child develops symptoms

Symptoms are most likely to occur when your child transitions from extensively-baked to less heated products, like from muffin to pancake.

The procedure for dealing with symptoms generally involves either going back to eating previously tolerated foods or, if symptoms happen when your child was eating more of a certain food—e.g. if you were increasing the amount of biscuit from half a biscuit to a whole biscuit—going back to the amount that they tolerated.

The experts behind the Canadian milk ladder advise that, if your child develops symptoms to a new food on the ladder, they should go back to eating the food(s) that they do tolerate for at least 1 month before ‘cautiously attempting to advance on the ladder.’

The experts behind the original MAP ladder for non-IgE-mediated allergies recommend giving your child the foods or amounts that they do tolerate for another 4 to 6 months before trying the new food or the larger amount again.

They also point out that tolerance to milk-containing foods relates only to the foods that are included in the milk ladder. So, if your child reacts to milk chocolate, they should still be fine with foods that are heated more and/or contain less milk protein, such as biscuits, cakes, pancakes and baked milk dishes, but should continue to avoid chocolate, yoghurt, cheese and milk.

If your child developed symptoms to a food that they previously tolerated, check for the presence of cofactors; were they feeling unwell when they ate their dose of milk-containing food? Had they been exercising? Had they just taken a hot bath? Have they been sleeping badly? If any of these apply, only give them the food that provoked reactions when that cofactor no longer applies; e.g. when they feel better, not around exercise, etc.

If they are unwell but are several steps up the ladder by then, try giving them less allergenic foods; e.g. if they react to cheese on a pizza, try giving them pancake, muffin or biscuit. It’s important that they keep eating some form of milk-containing food on a regular basis, if at all possible.

If you’re not sure what caused the symptoms or whether they are even connected to the food itself—for example, they might be teething—get in touch with your supervising doctor/dietician for advice, if you have one.

The decision on whether to postpone introducing a new food or trying a larger amount of a new food should also depend on how severe the reactions are and why they are happening. Mild symptoms like localised hives or flushing, coughing, sneezing or a runny nose should not impede progress too much; you may consider, for example, trying a smaller portion of the food on the same step. For more severe reactions, going back a step for a few weeks is warranted. If you are trying the milk ladder under the supervision of a healthcare professional, always report symptoms (write them down if you think you will forget them before your next contact with the doctor) and never be afraid to ask for advice on what steps to take and how long to wait before trying to advance up the ladder again.

In the case of non-IgE-mediated allergies, recognising the symptoms of a reaction may be more difficult because they can easily be confused with other signs that are common during feeding time in infancy (like spit up or a reluctance to eat something), and it’s even more difficult when you’re dealing with an infant who’s not able to tell you what they’re experiencing. When symptoms are ambiguous, experts recommend repeating the last step again—i.e. trying the same food or amount of food—when the symptoms have resolved rather than unnecessarily delaying the introduction process because of teething problems or a runny nose caused by a cold.

In the study run by the experts referenced above, around half of the parents whose children ended up completing the ladder had to try more than once to see whether their child was able to tolerate a certain milk-containing food because of their confusing symptoms, and parents whose children were only partially tolerant or still allergic made even more attempts at reintroduction before figuring out their child’s allergic status. (But no serious reactions were reported during the study.)

Always get in touch with your doctor if you are unsure how to proceed.

After completing the ladder process

When children outgrow their allergies, they must include the food that they have become tolerant to in their diets on a regular basis, otherwise there’s a risk that the allergy will return. So, if your child tolerates milk in any form, whether it’s just muffins or less heated forms of milk, be sure to include it in their diet at least once or twice a week.

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How effective has the milk ladder been for other children?

IgE-mediated allergy

Research on the milk ladder suggests that it helps the majority of the children who are considered suitable candidates by doctors.

A 2019 review of the medical records of 86 children attending a British clinic who underwent home-based milk reintroduction reported that, by the end of a follow-up period of around 2 years, only eight children were not tolerating almost all dairy products; a 91% (partial) tolerance success rate.

The milk ladder was entirely implemented at home, but doctors ensured safety by carefully selecting children who did not have severe allergies; although all of the children had an IgE-mediated milk allergy, they did not have a history of severe (respiratory or cardiovascular) reactions and did not react to trace amounts of milk. They were also very young; children started their baked milk reintroduction around the age of 13 months (with a range of 8 to 33 months).

Parents were also instructed to use great caution and to start each new stage of the ladder with very low doses of food. The first stage was started off especially carefully; a small crumb of malted biscuit per day for a week—before building up to the full dose (a whole biscuit) over a 5-week period. Each subsequent stage was expect to last around 4 to 6 months, with the speed being determined by the child’s symptoms and general health.

Although the first stage was quite strict, the following stages were designed to be more flexible; instead of focusing on measuring the amount of milk protein in each food, the process focused on starting with very small amounts of each new food and increasing the dose only when it didn’t provoke any symptoms. Allergic symptoms were reported by parents during less than half (43%) of the scheduled doctor’s appointments, 4 in 5 of which were from the milk ladder, but no child experienced severe anaphylaxis.

A 2018 review of the medical records of 187 milk-allergic children attending an American clinic who had had an oral food challenge with cake or muffin before been instructed to introduce baked milk into their diets reported a 73% (partial) tolerance success rate after a follow-up period of around 4 years; 43% had progressed to direct milk, 20% could eat more allergenic forms than muffin and 10% continued to eat baked goods, while 28% strictly avoided all forms of milk. (1% were just ghosts in the rounding-off machine).

At this clinic, the initial introduction to baked milk was done under medical supervision and the parents of children who passed were sent home with instructions on how to start introducing their children with the milk ladder, making sure that they ate milk-containing products at least 3 to 5 times per week for 2 to 3 months before advancing to the next step. Parents of some of the children who failed the challenge were also instructed to introduce their children to baked milk, but starting with a lower dose that was determined according to the symptoms they had during the challenge.

Although the authors found that being relatively young and having a relatively low level of milk-specific antibodies in their blood gave children a better chance of success with the milk ladder, they noted ‘tremendous individual variability’ within the group. Several children who passed the baked milk challenge were never able to successfully introduce it into their diets, while others who had very high blood levels of IgE antibodies to milk or had to be treated with adrenaline during their challenge were eventually able to tolerate fresh milk.

Of the 99 children who passed the challenge with baked milk 54 were eventually able to tolerate unheated milk, 17 baked cheese and 9 cooked/baked milk, with 19 ending up having to avoid milk in their diet. Of the 88 who failed their challenge and were asked to introduce baked milk into their diets starting with smaller doses, 26 were eventually able to tolerate fresh milk, 9 baked cheese and 20 cooked/baked milk, with 33 having to adopt a milk-free diet.

Research has also shown that successful advancement up the milk ladder is accompanied by positive immunological changes, with Irish research reporting that progress on the milk ladder was significantly associated with a decreased skin test response, and American research reporting that levels of IgE antibodies to whole cow’s milk as well as casein and beta-lactoglobulin milk proteins also decreases, while levels of IgG4-antibodies to casein—typically associated with acquired tolerance—increased.

Finally, the American study also included a ‘comparison arm’ of children who met the same criteria as those who had undertaken the milk ladder but, for various reasons, had continued to avoid milk but returned to the clinic for testing every year. None of those children became tolerant to baked or fresh milk, suggesting that the milk ladder does help children to outgrow their milk allergy.

A 2024 Japanese study that aimed to compare the performance and safety of the milk ladder with that of oral immunotherapy (OIT) with fresh milk in milk-allergic infants concluded that both types of treatment were as safe and effective and each other. The researchers examined the medical records of 89 children under the age of 2 who attended one allergy clinic where they underwent food-based therapy for their allergy.

In total, 51 children underwent OIT and 38 children with treated with a milk ladder approach. 18 children in both groups (35% and 47%, respectively) achieved tolerance to fresh milk. 32 (63%) children of the children undergoing OIT experienced symptoms, as did 21 (55%) of those following the milk ladder, with more children undergoing OIT suffering from respiratory symptoms. One child on the milk ladder experienced anaphylaxis and required adrenaline, but this happened when they deviated from the milk ladder protocol and were given yoghurt instead of cake which they did not like.

However, the milk ladder did have one advantage over OIT; it allowed more children to eat processed foods like bread, cookies, ham, chocolate and butter on a regular basis.

Non-IgE-mediated allergy

Only one study investigates the effectiveness of the milk ladder in children with mild, non-IgE-mediated allergy to cow’s milk–the milk ladder’s original target audience. It was carried out in 2021 by a team of British doctors who used a ladder approach to establish a home introduction protocol for a range of allergens (milk, egg, wheat and soy) for a group of 114 children aged between 1 month of 16 years old, most of whom were toddlers.

After an elimination diet of around 4 to 8 weeks, the children were given a shortened protocol to follow in order to try and introduce the trigger foods into their diets in about 2 weeks, although this sometimes took longer because of ongoing symptoms or general health problems.

92 of the children were allergic to milk although, at the time of the home introduction, about a third were able to tolerate some form of processed milk. By the end of the study, 42 (46%) of the children were considered fully tolerant (they could drinkan age-appropriate amount of fresh milk), 33 (36%) were partially tolerant (they tolerated a baked, fermented or highly-processed form of milk in their diet) and 17 (18%) were still allergic, having not managed the first step of the ladder. Those who achieved full tolerance reached it around the age of 17 months (although their ages ranged from 9 to 27 months old), those who achieved partial tolerance did so around the age of 25 months (their ages ranged from 16 to 35 months old) and those who were considered still allergic were categorised as such around the age of 36 months (between 24 and 47 months old).

The authors of the study also note that, although over 98% of the children showed overall symptom improvement, not all of the children were left symptom-free; in particular, there were lingering gastrointestinal symptoms, notably gas and stomach pain with back arching, and some of the children still showed food aversion.

Children who can tolerate baked milk are more likely to progress up the ladder and to outgrow their milk allergy

Most of the milk ladder studies involve children whose tolerance to baked milk was confirmed before starting milk reintroduction. This is worth noting as some experts suggest that children who tolerate baked milk could have a less severe phenotype of milk allergy, with one team of researchers calculating that, in their study, children initially tolerant to baked milk were 28 times more likely to become tolerant to unheated milk than those who reacted to baked milk.

A 2023 review calculated that around 2 in 3 (62.5%) of the children who took part in studies examining baked milk as a treatment for milk allergy outgrew their allergy, whereas only around 1 in 5 (21.42%) of those reacted to baked milk and were instructed to keep to a milk-free diet were eventually able to tolerate unheated milk.

Supporting the idea that children with a milder form of milk allergy are more likely to outgrow it is research from the US that found that children who had received treatment during their challenge were less likely to advance to higher steps of the milk ladder than those who did not; 71% of the children who needed adrenaline and 58% of those who received any form of treatment were avoiding milk by the end of the study period. They calculated that those who had required any form of treatment during their challenge were 2.5 times more likely to end up following a milk-free diet than those who had not required treatment. (That said, it could also be that seeing their child experience a reaction made parents more nervous about proceeding with the ladder, as has been demonstrated in egg ladder research).

Finally, another American study reported that when some of the children who managed to achieved full tolerance were asked to avoid milk in their diets for a month and were then re-challenged to unheated milk, they all passed. This result stands in stark contrast with children who undergo oral immunotherapy treatment, who typically have a more severe form of food allergy and who often fail this kind of test. Additionally, of the children in the study who reacted to a baked muffin during their challenge, only 1 in 5 were able to tolerate muffins by the end of the 3-year study period, and none were able to tolerate unheated milk.

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What are the risks associated with the milk ladder?

Food ladders entail offering a child their trigger food, so they inevitably come with inherent risk, notably for children with IgE-mediated allergy. Even when children who undertake the milk ladder only have a history of mild reactions, having a history of mild reactions doesn’t mean that your future reactions will be mild, so the risk of anaphylaxis remains. Other factors—that is, cofactors or poorly controlled asthma or eczema—can lower a child’s tolerance or put them at risk of experiencing worse reactions.

There have been some serious reactions reported among children undergoing dietary therapy with baked milk, including one death in a child with severe milk allergy who was not tolerant to baked milk but had been advised to try a non-standard protocol by her allergist. This tragic event remains unexplained; asthma may have been a contributing factor, or other cofactors may have been involved.

Importantly, this happened to a child who normally would not have been considered a good candidate for the milk ladder. Severe reactions as a result of milk ladder treatment are almost unheard of and much more likely to happen to children undergoing oral immunotherapy who are unlikely to outgrow their allergy naturally.

Additionally, although a person undergoing some kind of food immunotherapy is more likely to have a reaction to their food trigger, the vast majority of those reactions are mild; importantly, a fatal reaction is just as likely to happen to someone practising strict avoidance.

You can minimise the risk of reactions in your child by taking the following precautions.

If you have a child who has been diagnosed with milk allergy, consult a doctor before beginning on the milk ladder, if at all possible. A doctor can give you guidance and, most importantly, rescue medication including an adrenaline autoinjector (or two), if necessary. Doctors can also (order or) carry out tests to see whether or not your child is ready to get started with the milk ladder and, if yes, on which step.

Follow the guidance carefully. If you’re making the food that your child will eat, measure out the ingredients carefully to make sure that the right amount of milk goes in it. Use the correct baking times and temperatures and don’t add any extras to the food; for example, don’t add chocolate or icing to a muffin, because they will add to the amount of milk in the food, and be careful with ‘wet’ ingredients like fruit, because they will make it more difficult to ensure that the middle of the muffin is baked properly. Some mild symptoms have been reported after children have eaten ladder food which has been undercooked. And don’t buy biscuits with a cream or chocolate filling.

Be careful with processed foods because recipes for similar products can differ widely in the quantity of milk protein used per portion as well as the type of milk protein used (e.g. whole milk protein or whey powder), as well as the length of time and temperature at which they are cooked. When trying a new brand, try a smaller amount of it first. That said, according to experts, people who can tolerate baked milk or egg should be able to eat dry goods containing milk or egg ‘if listed as the third ingredient or lower’.

The food matrix matters, and so do the various ingredients you put in it. When a recipe calls for wheat flour, try to use wheat flour and not a replacement; research has found that using alternatives like rice flour makes the baked goods more allergenic for people with milk and egg allergies. That said, one study has reported that wheat-free biscuits seem to be just as good, so if your child has a wheat allergy, a gluten-free option could still work, but perhaps you should try giving a smaller amount to your child first.

It’s not just wheat that you have to take into account. Fat, for example, can make allergenic protein less available to cause reactions. Researchers have noticed that children who are challenged to peanuts react to smaller doses when the peanut protein comes in a food that contains less fat. So a recipe with less fat in it may produce reactions when the same food item is otherwise tolerated by your child.

In the same vein, doctors have reported that some of their young patients react to certain brands of ice cream, even if they can tolerate other brands, possibly because the brands contain different amounts of fat or concentrated whey solids.

Proceed with caution. Stick to the foods allowed on the step of the ladder you’re on. If your child has reacted to foods on previous steps, take each step slowly and introduce them to smaller amounts before building up to the whole portion. The authors of one study reported that children experienced symptoms quite frequently when they ate ‘too much’ of a food item.

What research says about the safety of the milk ladder

The milk ladder has been shown to be quite safe, whether a child is introduced to it under the guidance of their GP or an allergy specialist at a clinic.

Although children who climb the milk ladder will almost invariably experience symptoms at some point, often when trying a new food on the next step, most ladder-related symptoms are mild and successfully managed by parents at home without the need for professional medical care.

The most common symptoms reported by parents tend to be isolated skin symptoms, mild gastrointestinal symptoms (stomach pain, diarrhoea and vomiting), and mild respiratory symptoms (coughing, itchy eyes and runny noses), with symptoms becoming milder and less frequent as treatment continues. Doctors supervising home reintroduction to milk also report skin and gastrointestinal symptoms as the most common ones.

Very (very) few children have been reported to experience from anaphylaxis as a direct result of eating milk ladder food, and the few children who do have anaphylaxis during the treatment period are most likely to experience it as a result of:

• accidental exposure to milk (generally in non-ladder food)
• escalation to a new food on a higher step of the ladder (notably in children who fail a full challenge to baked milk and therefore probably have a ‘moderate to severe form’ of milk allergy)
• trying larger amounts of a more allergenic form of milk protein (notably baked cheese on pizza)
• exercise after eating

Although symptoms occur relatively frequently when children follow the milk ladder, as well as being mild, they are not unexpected, which makes them less stressful than reactions that occur after accidental exposure. In the vast majority of cases, symptoms do not prevent progress with the milk ladder. Most do not require anything stronger than an antihistamine, if that, and parents can generally deal with them by reducing the dose of milk protein for a while before continuing again.

However, some children do have symptoms that cause their parents to discontinue treatment—an American study that followed 187 children who had been instructed to introduce some baked milk into their diets reported that 52 children ended up avoiding milk completely. The parents of 29 of the children blamed the symptoms that their children had suffered as they tried to progress up the milk ladder as the main reason for stopping.

Otherwise, regardless of the severity of the initial reactions to milk, most children are able to use the milk ladder with at least partial success, and the most common reason for dropping out of a study tends to be scheduling conflicts (and, in many of those cases, parents continue to use the milk ladder without medical oversight).

A retrospective review examined the medical records of 171 milk-allergic children seen at an Irish hospital and allergy clinic, with cases ranging from children who had had anaphylactic reactions to children who were already tolerant to baked milk. It reported that 73 (42.7%) had experienced allergic reactions to milk while on the milk ladder, and 32 (18.7%) had experienced symptoms because of accidental exposure to milk above their current stage on the ladder. Most of the reactions manifested as skin symptoms (hives and/or swelling).

3 children had anaphylactic reactions. All of those cases were due to accidental exposure to milk above their current stage on the ladder, and not because of ladder foods. Allergic reactions to ladder foods occurred at a similar rate in the children who managed to complete the ladder and those who did not; 41.9% vs 47.8%. Similarly, allergic reactions due to accidental exposure to milk occurred at a similar rate in the children who managed to complete the ladder and those who did not; 17.6% vs. 26.1%.

The only study carried out in children with mild, non-IgE-mediated allergy to cow’s milk reported ‘no serious adverse events’.

The only adverse reaction of note reported by a couple of American studies is the development of eosinophilic oesophagitis (EoE). This was reported in an early study in which 65 children tried incorporating baked milk products into their diet in an attempt to reach tolerance to unheated milk; during the study period, 2 of the children developed EoE. However, among a group of 60 children who continued to avoid milk, 5 developed EoE.

In a more recent study involving 187 children following a milk ladder, 6 developed EoE. The authors also suspected that some of the 13 children who stopped treatment because of GI symptoms may have also developed EoE, but no formal diagnosis was made.

Ultimately, no dietary management strategy for milk (or any other food) allergy will be ‘risk free’; parents and doctors must weight up the potential risks of following the milk ladder against the potential benefits.

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What are the benefits of the milk ladder?

There are several advantages to following a milk ladder.

A milk ladder allows your child to eat a more varied and nutritious diet. Food allergies, especially milk allergy, are associated with nutritional deficiencies and reduced growth in young children. Even if your child can only tolerate muffins, they will be able to get some milk protein in their diet, which may improve their growth.

Being able to eat some milk protein also has another important benefit; helping to avoid the potentially severe, even fatal, reactions that can happen when a trigger food is reintroduced after along elimination diet undertaken by someone with a previously mild (or asymptomatic) form of allergy.

Of all the possible food allergies, milk allergy is reported to be the most burdensome, in terms of food-related anxiety, planning time, food and healthcare costs, and social limitations. The ability to eat at least some milk improves the quality of life of both children and parents, because it reduces the fear of accidental exposure and because being able to tolerate milk protein in some form also means that dietary restrictions can be loosened at school and when children go to friends’ and relatives houses, which improves their social lives. It also makes it somewhat easier to do the grocery shopping.

Children who are on milk exclusion diets also tend to experience more feeding difficulties, so being able to liberalise your child’s diet may help to prevent them from becoming fussy eaters.

Incorporating baked milk into a young child’s diet on a regular basis may even help them to outgrow their allergy faster. This theory was first tested in 2011 by a team of experts in America who carried out a study involving 65 milk-allergic but muffin-tolerant children who were instructed to incorporate baked milk products into their diets on a daily basis. Every 6 months or so, they were offered challenges to pizza. If they passed it, they incorporated in into their diets and were later offered challenges to unheated milk.

5 years later, 41 (59%) of the children were able to tolerate unheated milk. Among a group of ‘controls’, 60 children who were never challenged to baked milk and got ‘standard’ care (i.e. were told to avoid milk), only 13 (22%) were able to tolerate unheated milk. The experts calculated that the children who incorporated baked milk into their diets were 16 times more likely to become tolerant to unheated milk, and that eating baked goods ‘appears to accelerate the development of unheated milk tolerance compared with strict avoidance.’

Since then, some studies have produced results that support this idea but some experts are not convinced. The debate continues.

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