Cow's milk protein allergy (CMPA) is probably one of the most common conditions we see in clinical practice as paediatric dietitians and usually presents in the first year of life, with the prevalence suggested being to around 2 – 3%.
It is important to distinguish between different types of allergies, I have written a detailed blog on this here.
Before we start, it is important to highlight who the milk ladder is NOT suitable for:
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Little ones with immediate CMPA (IgE mediated allergies)
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Severe forms of delayed CMPA such as FPIES (food protein include enterocolitis syndrome) or eosinophilic gastrointestinal food allergies.
If you are not sure if your little one falls into any of these categories, please double check with your HCP
So, let’s skip to the part where your little one has been diagnosed with a delayed CMPA, you have been avoiding cow's milk protein (as recommended by your little one’s doctor or dietitian) but now ready to start reintroduction…it's time to start the milk ladder!
Of course, any introduction of an allergenic food, especially one your little one has reacted to previously, is super scary but the milk ladder has been designed to gradually introduction of milk protein in terms of allergenicity profile, quantity and in a structured, easy to follow manner.
The first step of the milk ladder involves the introduction of baked milk, this is because flour used in baking, mixes with the milk to form a food matrix, which reduces the risk of an allergic reaction. Also, when milk is baked at high temperatures, the protein structure is altered, making the body less able to “recognise” it as a milk protein, reducing the risk of a reaction. Studies show that around 75% of children with milk allergy can tolerate baked milk without issue!
There are lots of milk ladders around if you do a quick google search but the one we usually use in the UK is the iMAP ladder, this has been carefully designed by a group of allergy experts to ensure it is safe, age appropriate and the correct doses of milk protein are used! It is an exciting time in the milk ladder world, as lots of work is being done to look at the recipes, the steps and how it might be able to be used in different ways or for different types of allergies.
The current milk ladder involves 6 steps. As mentioned above, starting with the least allergenic forms of milk in the baked form, increasing to the very last step of fresh pasteurised cow's milk.
Step 1: Cookie / biscuit
Step 2: Muffin
Step 3: Pancake
Step 4: Cheese
Step 5: Yoghurt
Step 6: Fresh pasteurised cow's milk
Each step has been calculated to ensure there is enough cow's milk protein present, so unfortunately, it's not as easy as finding any old biscuit with milk in and trying it out. There are specific recipes for step 1, 2 and 3. There are also specific measurements of cheese, yoghurt and milk at each step, so always check these as you move up
From a practical perspective, I would recommend starting with a ¼ to ½ of the starting dose and building up as per the recommended plan on the milk ladder. As the ladder is used for introduction in delayed CMPA, I would suggest leaving at least 24 - 48 hours between each dose increase, as it might take this long for a reaction to occur (but fingers crossed it doesn’t). Below is an example of how you might introduce the baked milk in the form of a biscuit:
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Day 1: ¼ baked milk biscuit
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Day 2: Nil introduction
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Day 3: If tolerated without issue, increase to ½ biscuit
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Day 4: Nil introduction
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Day 5: If tolerated without issue, increase to1 biscuit
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Day 6: Nil introduction
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Day 7: If tolerated without issue, increase to 2 biscuits
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Day 8: Nil introduction
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Day 9: If tolerated without issue, increase to 3 biscuits
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Day 10: Nil introduction
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Day 11: If tolerated without issue…. Yay, progress to the next step of the milk ladder once that top portion has been given 3 times and tolerated without issue
Of course, this is just a guide, some little ones will progress much faster and increase the dose daily or some may take much longer. So, go at the pace that feels comfortable for you, you might just do the introduction at the weekend when you are not at work and your little one is not at nursery, which is totally fine. There is no recommended timeframe that your little one should stay at each step, so if your friends little one is flying through and your little one is a bit slower, that is totally fine.
Unfortunately, because reactions for delayed CMPA can be nonspecific, so for example a flare in eczema, a loose poop or disturbed sleep. It can be tricky to unpick if the milk introduction has caused this or its just one of those pesky childhood symptoms. In these cases, I would suggest returning to the previously tolerated step of the milk ladder, keep there for a week or so, then try again with the higher dose. If the symptoms or suspected reaction occurs again, this is more convincing it is driven by the milk introduction. You might have to repeat a step 2 – 3 times to be sure that milk is an issue at this level or not. This does not mean you have to stop the milk ladder altogether, just go back to that previous tolerated step and hold it there for 4 – 8 weeks before trying the next step again. Having a little bit of the protein in, even just ¼ of a biscuit is amazing and helpful for your little one to gain tolerance to the milk protein overtime.
Before you start the milk ladder, it is important to ensure the following things:
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Your little one is well, so no coughs. Colds, teething, etc. This also applies as you move up the portions or doses
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If they have eczema, that it is well managed. So, you have a plan which creams, lotions and potions to use if they have a flare
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Be aware of their normal baseline. So little ones do have random poor sleep or a change in poops, knowing what is “normal” for your little one before starting, helps unpick a reaction, if they occur
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Avoid starting if you have a lot going on at that time, so starting nursery, or going on holiday or moving house. These things are overwhelming as it is, let alone if you're adding the milk ladder into the mix!
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If your little one is starting other medication or medical treatment around the same time, you may want to delay a little bit
Some of my top tips for the milk ladder:
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There is no agreed starting time of the milk ladder, usually its 6 months after the diagnosis of delayed CMPA, which is usually around 9 – 12 months. If it’s a little bit later than this, please don’t worry, there is still plenty of time to get going
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Depending on your little one's age, they may struggle with some of the lower steps of the ladder from a texture perspective. You can be creative in how you offer this!
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Grind up the portion and mix into their porridge, plant yoghurt or fave fruit puree
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Soak in their usual milk
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Spread with chai jam or fruit puree of choice
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You can batch cook and freeze these recipes (hooray – nobody wants to be making a single biscuit at a time)
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Offer the milk containing food early in the day, this gives you a good window to monitor for symptoms.
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Keep relaxed (even if you are stressed about the introduction), little ones are very attuned to parental stress
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Do the introductions at home or under your care and just keep all nursery meals or childminder meals milk free until you finish the ladder.
It can be daunting starting these introductions, but there is fantastic support around, this might be your NHS dietitian, access to charities such as Allergy UK, or I can help in clinic if you want some more 1:1 support.
Remember if your little one reacts to milk, even at the bottom of the ladder, you or they have not “failed” they are just not there yet. For most children, especially with delayed CMPA they have gained tolerance by school age, so keep trying and like I said above, even that teeny tiny bit is amazing!
Of course, if they have any signs of an immediate reaction stop the food and seek medical attention.