Milk Ladder FAQ’s For Parents of CMPA Babies

Milk ladder FAQ’s for parents of babies and toddlers with cow’s milk protein allergy. Essential reading if you’re looking to start the milk ladder challenge.

Everything You Need to Know About the Milk Ladder Challenge

My youngest daughter, known as Elfin here on the blog, was born with a dairy allergy. It made life very difficult for a really long time, but things did get a little easier when she passed the milk ladder.

Please note the important update at the end of this post.

In this post I’m going to explain everything you need to know to see you through the dairy ladder challenge yourself.

It goes against everything we instinctively feel we should be doing to protect our little ones.

As ever, this information is based on my own experiences and if you have any concerns I recommend reaching out to your GP or other health care professionals for support.

Most young children eventually outgrow a dairy allergy and, if a good candidate, at some stage (more on when later), your child may be ready to test whether they’ve reached that milestone.

This is important because dairy foods are an important source of calcium and unnecessarily cutting an entire food group out of a child’s diet is obviously not ideal.

It’s Normal to Have Mixed Feelings About Starting the Milk Ladder

After being so meticulously careful for so very long, I remember all too well how scary it felt to be offering Elfin foods which would potentially make her ill. It goes against everything we instinctively feel we should be doing to protect our little ones. 

It’s natural to want to resist this, however bear in mind that all being well, it’s a really positive step. 

The milk ladder is used in the process of establishing whether your child’s allergy remains and, critically, to what extent.

Once your child has passed a stage on the milk ladder, that’s one more food you can reintroduce to their diet. And the end goal, of course, is to return to eating normally without the need for dairy products to be eliminated. 

Imagine no more careful planning and meticulous product label checking; no more stresses when your child is in somebody else’s care; no more slip ups and reactions and desperately trying to figure out what’s gone wrong and where the mistake occurred.

Imagine the improved quality of life for your whole family.

Milk Ladder FAQ’s

You likely have a lot of questions before commencing what is undoubtedly a huge and worrying step. Being armed with lots of information is the best way to prepare for the journey up the milk ladder.

In our case, we were fortunate that we passed the milk ladder first try. We’re proof that it’s entirely possible. So with the above in mind, hopefully the following information will help you to feel ready and confident to get started.

What is the Milk Ladder?

It’s entirely possible for your child to have an allergic reaction to some foods that have milk in the ingredients list, but to tolerate others.

The milk ladder is used in the process of establishing whether your child’s common food allergy remains and, critically, to what extent.

Cows milk protein allergy, as the name suggest, is an allergy to a protein found in cow’s milk. This essentially means the immune system is not functioning correctly, resulting in an overactive immune response (hypersensitivity) to a substance, reacting to the allergen as though it were harmful.

But, when it comes to foods with dairy listed on food labels, all is not equal.

Foods processed in different ways will contain varying amounts of the allergen since heating changes the structure of the proteins, causing the problematic protein to denature.

What this essentially means is that it’s entirely possible for your child to have an allergic reaction to some foods that have milk in the ingredients list, but a development of tolerance to others.

The milk ladder is designed so that the lowest rung is a food which has been processed in such a way (through baking/heating) that its milk content is less allergenic than the foods at the top of the ladder.

The milk ladder is approached starting at the first stage, and carefully climbing up at predetermined intervals, challenging foods with a higher uncooked allergen content, until you reach a plain glass of fresh milk.

There are two different milk ladders, the 12 step and the iMAP, which I’ll explain more about later. 

A Note on Milk Protein and Denaturation Through Heating

A vital piece of information about cow’s milk protein allergy that is commonly overlooked is the fact that there are actually two offending proteins:

• Whey protein
• Casein

Caution should continue to be exercised.

It’s possible to be allergic to one or both of these proteins, and they respond differently to heat treatment: whey is easily denatured by heat, while casein is highly resistant. Read more here.

What does all this mean?

It suggests that tolerating baked or heated foods containing dairy might indicate an allergy to whey protein as opposed to casein – and not that the allergy has diminished.

In other words, caution should continue to be exercised.

Who is the Dairy Ladder For / Is the Milk Ladder Right For My Child?

This depends on several things, and there are some really important factors to consider before deciding to challenge milk, including medical history.

You must be confident that your child is not going to have a severe or potentially life-threatening reaction before attempting the milk ladder, and to that end you should think carefully about the following questions before proceeding:

1. Have you confirmed CMPA in your child?

If you’ve not yet confirmed CMPA then this would be the first step. The milk ladder is specifically designed for the reintroduction of dairy into the diet of a child with confirmed CMPA.

If you haven’t confirmed CMPA then you’ll want to do that first, before moving forward with the milk ladder. If you need support with this, I have another post dedicated to how to confirm CMPA and why blood tests or a skin prick test are generally not the answer.

A milk allergy via breastmilk is uncommon and suggests your child may have a severe allergy.

2. Does your child have non-IgE mediated CMPA?

You should never attempt the milk ladder challenge at home without medical guidance / supervision for an IgE mediated dairy allergy.

If you’re unsure of the difference between IgE CMPA and non-IgE cow’s milk allergy, head over to my post about confirming CMPA to find out more. 

3. Is your child at least 9 months old?

The milk ladder is designed for babies 9 months+ and ideally over 12 months, who have confirmed mild to moderate CMPA.

4. Is your child breastfed?

If your child is breastfed and you have confirmed CMPA then presumably they’ve never been directly exposed to dairy. A milk allergy via breastmilk is uncommon and suggests your child may have a severe allergy.

If you answer no to any of the above questions then it is not safe for you to attempt the milk ladder without medical supervision.

Note: in case of a reaction, be sure to have antihistamines on standby for when you start the milk ladder.

What Help Can I Get With the Dairy Ladder Challenge?

If answering the above questions discourages you from attempting the milk ladder challenge alone but it’s something you wish to explore further, then I highly recommend speaking to a qualified and trusted dietitian or allergy specialist for medical advice.

From my own experiences I understand that it can be very difficult to access this help but, if you discuss your thoughts and concerns with your GP or health visitor, they should arrange a referral for you.

Around half of children will have outgrown their allergy by 9-12 months of age.

When Should We Start the Milk Ladder Challenge?

If you’ve established that your child is a good candidate to attempt the milk ladder challenge at home, then there are still a couple of other considerations before you begin.

Babies who have reacted through breastmilk are more sensitive to the allergen than those who’ve reacted directly.

Although formal guidance says babies can start the milk ladder from 9-12 months, I recommend waiting until a year as by this time, around half of children will have outgrown their allergy. 60-75% will outgrow the allergy by two, and 85-90% by three years old.

As well as age, other considerations include whether your child has had a known reaction within in the last 6 months, and whether they are generally well.

So, a quick recap for when you should be thinking about starting the milk ladder challenge at home:

• When your child is at least 9 months old and ideally over a year,
• They have non-IgE mediated CMPA,
• They’ve had no known reactions to dairy in the last six months,
• They are generally well,
• They’re formula fed.

Remember that babies who have reacted through breastmilk are more sensitive to the allergen than those who’ve reacted directly, and caution should be exercised.

If you have any concerns please speak with your GP, health visitor, or dietitian before starting the milk ladder.

Which Milk Ladder Should We Use?

As I mentioned earlier, there are two official milk ladders (though you may find more variations if you search online): 

• The 12 step MAP milk ladder
• The iMAP milk ladder

If your child has had severe reactions, it is not recommended to use the condensed iMAP ladder.

12 Step MAP Milk Ladder

This is the original milk ladder created to wean dairy-allergic children back onto milk products and foods containing dairy. 

6 Step iMAP Milk Ladder

This is a newer version of the 12 step MAP milk ladder which has been condensed to only six steps.

Note that if your child has had reactions severe enough to leave you anxious about beginning the milk ladder challenge, then it is not recommended to use the condensed iMAP ladder. Personally I’d prefer to use a longer ladder to reduce the risk of a serious reaction.

What Alternatives Can I Use If I Don’t Like the Milk Ladder Options?

If you wish to vary the items offered to your child at each stage, this document provides a list of recipes for each stage of the 12 step MAP milk ladder, which can be used to prepare foods at home.

This is ideal for creating recipes with reduced sugar or if you know your child has multiple coexisting allergies.

There’s another accompanying recipe document, which you can find here, to be used in conjunction with the condensed 6 step iMAP ladder, reflecting the adjusted stages on this ladder.

This NHS milk ladder is recommended because, though it has only 7 stages, they’re each broken down into smaller steps. This is ideal for anybody who’s very anxious about how their child is going to react.

If you’re already confident that your child can tolerate a milk biscuit, you can start at the upper end of the stage one steps, moving more quickly onto the following stage, where you can exercise caution and take the smaller steps laid out for stage two.

Note: one of the options at stage two of the above NHS milk ladder is flavourings that contain milk, with crisps as a suggestion; this is a mistake.

It has come to light that these crisps often add flavourings after baking. Because the flavouring is not baked during the cooking process, the allergen is not denatured. This means the crisps actually come much higher up the milk ladder and therefore this option should not be used.

Should the Milk Ladder Challenge Be Direct or Through Breastmilk?

This is a tricky one that only you (along with your dietitian/other health professional if applicable) can determine. There are pros and cons to both options, so I’ll give you the necessary information to help you make an informed decision:

If your child is at risk of an extreme reaction then you should not be attempting the milk ladder at home/without professional guidance.

The Argument For Challenging Through Breastmilk

If you do the challenge via your breast milk, there’s less allergen exposure to your child, causing a less serious reaction if there is going to be one. However, the pay off is that your milk will now contain the allergen until it leaves your system.

The Argument For Challenging Directly

If you choose to do an oral food challenge directly, the allergen exposure will be greater, resulting in a more severe allergic reaction if there’s going to be one; however, any reaction will be quickly evident, and your milk remains clear of allergens so you’re able to stop exposure immediately.

Plus, challenging directly means you know exactly when and how much allergen your baby has been exposed to, whereas through breastmilk you can only use your best guess as to when the allergen reaches your baby.

Essentially, it boils down to risk vs benefit. And as we’ve already established, if your child is at risk of an extreme reaction then you should not be attempting the milk ladder at home/without professional guidance.

How Much Of Each Food Should I Give?

Never feel pressured to do anything you’re not comfortable with when it comes to your child’s health and safety.

This is dependent upon your child’s history. IgE allergic children should be exposed to far less than non-IgE.

If your child’s reactions are less extreme and non-IgE, if you already know they’re able to tolerate a small amount of milk and you’re not too anxious, then it’s fine to follow the guidelines in the documents I’ve linked to or even start with a whole biscuit.

If, on the other hand, you’re very apprehensive then there’s no problem with starting with a just a crumb and building up. 

Never feel pressured to do anything you’re not comfortable with when it comes to your child’s health and safety. And, as ever, if you’re unsure then please seek support from a dietitian.

What If My Child Has a Reaction?

If your child has a mild to moderate reaction, stop. Administer antihistamines and carefully observe your child for the next few hours. 

If your child has difficulty breathing or any other severe reaction this is a medical emergency.

If in doubt call 999.

How Do I Know If It’s Okay to Move On to the Next Stage of the Ladder?

This is one of the most frustrating parts of the process I’m afraid! 

If you see a reaction, then you obviously need to stop. The difficulty is in determining what is a potential reaction.

There are many symptoms of milk allergy, including dermatological (milk rash), gastrointestinal, general fussiness and more… which kind of sounds like a standard baby in may cases doesn’t it?! And when you consider that your infant might display one or all of those, then you begin to appreciate the task ahead of you:

If your baby has picked up a cold or is teething, then a symptom which might otherwise be considered a reaction, can become unclear. Which is it? How can you be certain?

Remember that reactions typically occur within 72 hours of exposure to the allergen.

Well, unfortunately, you can’t. In this case you may well find yourself having to stop and restart the challenges.

This is one of the reasons that it’s vital to start when your baby is generally well, so that you get a clearer picture of any symptoms and whether or not they’re likely to be reactions. 

It’s also a good idea to begin at a time of year that your child is unlikely to be aggravated by seasonal allergens such as pollen; it’s important that your child is not taking antihistamines during challenges because they will give a skewed picture of your child’s tolerance levels.

Remember that reactions typically occur within 72 hours of exposure to the allergen.

In addition to the above, you also need to be aware of build up reactions (see the next point).

How Long Should We Wait Before Moving Onto the Next Stage of the Ladder?

This is both simple and yet different for everyone.

Prolonged exposure to the allergen, over several days or weeks, can cause what’s known as a build up reaction.

It’s fine to move on once you’re confident that your child is able to tolerate the allergen they’re being exposed to without any adverse reaction.

Since it can take up to 72 hours for a child to exhibit non-IgE reactions, you should wait a minimum of three days in case of delayed reactions. 

Personally I was comfortable waiting a week or two to rule out a reaction before moving on to the next step of the ladder. 

Why so long? Because while your child may not react to exposure to dairy on a single occasion, you may find that prolonged exposure to the allergen, over several days or weeks, can cause what’s known as a build up reaction.

Keeping a Food Diary During the Milk Ladder Challenge

Because of the possible timescales involved as well as the variety of ways a reaction can be exhibited, I highly recommend recording your / your baby’s diet and observe carefully, noting down any potential allergic symptoms.

I’ve created an allergy food diary specifically for this purpose, with space for both your and your baby’s diet, as well as a symptom tracker and pages to plot the various symptoms you notice. The idea with the diary is that it should hopefully make it easier to see patterns and figure out if what you’re seeing is a reaction.

It’s also helpful if you suspect multiple allergies, to track and record other possible allergens affecting your child so that you can confirm other allergies too. Note this would not be alongside the milk ladder challenge, and should be done at a separate time so that you can carefully monitor how various potential allergens present in your child.

The diary includes a list of common food allergies in the front, and is available as a free downloadable PDF from our resources library.

What Happens When We Pass a Step on the Milk Ladder?

Once you’ve confidently passed a step then as mentioned above, you can move on to the next stage of the milk ladder, using the advice above or according to your dietitian’s guidance if relevant in your situation. 

Ensure you keep the tolerated level of milk in the diet including lower stages.

In the meantime guidelines state that you should continue to give your child the food that they’ve tolerated on a regular basis. This is because continual exposure to allergens has been shown to help reduce sensitivity. 

If you have concerns regarding the regular inclusion of biscuits, cakes and muffins in your child’s diet, trust me – you are not alone! I was horrified when I learned all of this, but thankfully this is where the recipes I linked to earlier are really useful. You can adapt them to your preferences, substituting sugar for alternatives such as banana.

Personally I did not start offering Elfin these specific items every week once we’d passed that stage of the milk ladder. The important thing is to ensure you keep the tolerated level of milk in the diet including the previous step and all lower stages; how you choose to do that is up to you.

What If My Child Fails a Step on the Milk Ladder?

If at any point during the milk ladder challenge you are confident you see a reaction, you must stop immediately.

This is why it’s so important to start the ladder when your child is generally well.

If you’re unsure due to a teething or illness, you will ideally continue for a day or two to be sure.

At this point it may be tempting to stop and restart when your child is well, however this is not recommended because you should be waiting six months after a reaction before attempting the same step. This is why it’s so important to start the ladder when your child is generally well.

If you’ve moved beyond the first step and fail a higher stage then you can drop back to the last stage you’ve passed, continuing to give the foods tolerated at all lower levels.

I would recommend remaining at this stage for six months before re-attempting the next stage.

What If I Don’t Want to Do the Milk Ladder Challenge?

There are some schools of thought that eliminating dairy and not reintroducing will hinder your child’s progress when it comes to overcoming their allergy.

As far as I’m concerned it’s not that simple – your child’s overall health and your family’s wellbeing are also a priority.

The milk ladder should not be attempted at the expense of the family’s wellbeing.

There is no point putting yourself through intense stress and anxiety in order to attempt the milk ladder.

Your child may well pick up on those negative feelings and you may then be at greater risk of food aversions forming during the process.

While it may be beneficial to your child’s tolerance of dairy to reintroduce the allergen (when the time is right), not doing so will not prevent them from outgrowing the allergy. And the milk ladder should not be attempted at the expense of the family’s wellbeing.

Go at your own pace; don’t feel rushed; follow your gut.

Tips For Starting the Milk Ladder Challenge

Finally, a few points to remember before proceeding:

1. Be sure your child is generally well.
2. Ensure you have antihistamines readily available.
3. I recommend a notebook or food diary for recording diet and symptoms.
4. Go at your own pace; don’t feel rushed; follow your gut.

For further support and advice check out my other posts about CMPA.

Best of luck!

Important Update

Some time after what we believed was a successful journey up the ladder, I discovered to my regret that symptoms can change, and therefore go unrecognised. Our daughter was under a specialist for chronic constipation who assured me dairy was not the issue, and when you’re paying to see a medical professional, you listen to them.

It eventually became apparent through our own gut feelings and exploration that while the undeniable dermatological symptoms (extreme facial rash) was not going to reappear, our daughter continued not to tolerate dairy well. Her gastrointestinal symptoms still remain at four years old and we have once again gone dairy free, for quite some time now.

All advice here remains true and accurate, but please be aware that your child’s symptoms may change over time.