Dairy Re-introduction plan – Milk Ladder

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Important advice for health professionals: This Patient Information sheet is for use with babies/children with non IgE mediated cow’s milk allergy only (eg symptoms of “colic”, unsettledness, reflux, blood in stools, diarrhoea). Patients with an IgE mediated cow’s milk protein allergy should be referred to the Paediatric Day Care Unit for a review of their allergy status.

Many babies/children with a cow’s milk protein allergy will grow out of this reaction between the ages of one and three years. Your Dietitian or doctor will decide when you should try to reintroduce cow’s milk into your child’s diet. This can be done using a step by step process, often called the ‘Milk Ladder’. Although most children will outgrow their cow’s milk allergy, there is still a small possibility that your child will react to fresh cow’s milk or foods containing cow’s milk. We therefore recommend that you:

Only start the Milk Ladder when your child is well. If they have eczema, a rash, upset tummy, cough, wheeze, spots or have just had a chest infection or bronchiolitis, wait until they are completely better.
Don’t start the Milk Ladder when you are very busy or have an important appointment to go to. It is better to start in the morning or lunchtime, rather than in the evening, so you can monitor tolerance during the day.
The Milk Ladder starts with food which is highly processed. Ensure that these foods are being tolerated before moving to the next step.
You may find your child can only tolerate foods where the milk is processed. For example, they may be okay when they eat biscuits and cakes containing milk, but get symptoms when you give them fresh cow’s milk. If this happens, talk to your doctor or dietitian about it at your next appointment.

Start at Week 1, at the bottom of the ladder:

Steps	Food	How much should I give each day?	By day 7*
Week 6	Fresh milk from the carton	Start with 50ml as a drink or added to cereal and increase the amount daily until your child is drinking up to 200ml by day 7	200ml fresh milk
Week 5	Fresh milk that has been boiled in a saucepan for 2 minutes. Allow to cool to room temperature.	Start with 50ml as a drink or added to cereal and increase the amount daily until your child is consuming up to 200ml by day 7	200ml boiled fresh milk
Week 4	Any flavour yoghurt, fromage frais or ice cream	Start with one small teaspoon and increase daily until they are eating up to 1 scoop of ice cream or a small pot of yoghurt/fromage frais by day 7	1 scoop of ice cream or small pot of yoghurt/ fromage frais
Week 3	Hard cheese or milk pudding eg. cheese on toast, cheese on crackers, rice pudding, custard	Start with a very thin slice of cheese (the size of a 2p coin) or with one teaspoon of rice pudding/custard. Increase the amount daily until your child is eating up to 25g cheese (the size of a matchbox) or 125ml rice pudding/custard by day 7	25g cheese or 125ml rice pudding/ custard
Week 2	Meal containing milk or cheese eg. lasagne, pizza, shepherd’s/fish pie, mashed potatoes, cheese omelette	Start with 2 of your child’s normal bite sizes on day 1 and increase daily until they are eating a normal portion size for your child by day 7	Your child’s normal portion size
Week 1	Malted milk biscuit or sponge cake that contains milk as an ingredient	Start with only a small corner of the biscuit or piece of cake and increase the amount given daily until a whole biscuit or piece of cake is eaten by day 7	1 malted milk biscuit or piece of cake

*Do not proceed to the next step of the ladder even if your child has eaten the required amount before day 7. Simply repeat this same amount on the remaining days before moving to the next step.