The milk ladder is a structured way to reintroduce milk products back into your baby’s diet. The Simple Guide on how to do the Milk Ladder: 2023 will make sure you know just how to do it!
Cows milk protein allergy is one of the most common food allergies in young children – affecting 2-3% worldwide.
You might have been given a copy of the iMAP milk ladder like the one above, and that was it, no explanation, no advice on the next step, you were just told to start with your baby when they’re ‘around’ 12 months old.
If this is you and you want to find out more then keep reading, you are definitely in the right place!
Remember this is only advised to be used with babies with non IgE mediated reaction (delayed). This will have been diagnosed via a food challenge. This advice is not for babies with IgE-mediated allergies (immediate reaction to dairy foods) that have been diagnosed via a blood or skin prick test. You should speak with your health professional for more support if this is the case.
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What is the milk ladder?
As an Expert Milk Allergy Dietitian I advise parents that the milk ladder is a specific way to reintroduce cows’ milk protein back into your baby’s diet after they have been following a milk-free diet for a period of time. The ladder is usually started around 6 months after your baby was diagnosed with cow’s milk protein allergy and is done by introducing small amounts of milk-contained foods in a stepped approach.
What age should you start?
Usually anytime from 10-18 months of age. This will depend on when the diagnosis was made as it is recommended to follow a strict milk-free diet for 6 months after diagnosis.
Only start if your baby is well
This can be a little tricky as your baby will likely be teething (red cheeks, runny poop) or have a snotty nose or cold as their immune system is developing. These symptoms are normal for a young baby but can make it difficult to know when to start the reintroduction.
If symptoms are mild, and not due to milk protein, then you can start the ladder. If you find your baby is struggling with these symptoms then it is a good idea to wait until they are well as you won’t be able to tell if symptoms are due to food allergy or other illness.
Don’t start the ladder if your baby has;
- A high temperature/fever
- Very loose stools – tummy bug
- Recently been prescribed medication such as antibiotics
- A rash or flare-up of eczema
- A chest infection or bronchiolitis
- Taken antihistamines in the last 5 days
Use your mummy intuition and start when you feel that your baby is symptom free and well.
What if you are breastfeeding
I’m going to give you an overview of the pros and cons.
Introducing dairy with your baby
- You know how much milk protein your baby can tolerate
- You know when you last gave your baby food with milk proteins. No confusion if it was something you ate and the milk content of your breast milk.
- If allergic reactions occur you can stop the food immediately and go back to the last step that your baby could tolerate.
- You have to wait until your baby has been on a cow’s milk protein-free diet for 6 months. This can be tricky if your baby has their diagnosis at an older age.
- It can be difficult to get a younger baby to eat the whole portions of foods recommended on the ladder. Or you may not want to give them the food yet, such as a malted milk biscuit.
Introducing dairy when breastfeeding.
- Your baby will likely receive less milk protein via your breastmilk than if they were to eat the food themselves. (It is felt that the volume of milk protein in breastmilk is 10,000 times less than if your baby was to have milk themselves). This can be helpful if you are a little nervous about starting reintroduction.
- Your baby might be able to tolerate dairy products through your breastmilk which means you don’t have to avoid milk-containing food anymore
- It might be easier to start through your milk before 9-10 months if your baby has been milk free for 6 months.
- You don’t always know what it was that you ate that your baby reacted to, especially if the allergic reaction is delayed. We don’t know quite yet how quickly or slowly milk protein moves through your breastmilk – research is continuing on this one.
So what’s my advice
I’d say to start with your baby before you reintroduce milk back into your diet. I think this is the easiest way to see your baby’s tolerance level of cow’s milk protein and stops any confusion. But, honestly, the choice is up to you. I would always say to monitor each step and my;
MILK LADDER DAILY PLANNER WILL HELP TO PROGRESS, ENTER YOUR DETAILS BELOW
The 6-step or 12-step ladder?
I advise the 6 step. Although I’m not a huge fan of the foods recommended and the recipes are a little boring.
Just a little hint, I’m currently developing a milk reintroduction course (keep watching)
You can find a copy at the 6 step milk ladder at top of the page and also through the link below
Breaking it down a little:
- Step 1 – The first step is biscuit. In a biscuit, the milk powder is baked and can be found lower down the ingredients list on the food label. The most common biscuit used is a malted milk.
- Step 2 – Cake, another milk contained food but milk should be lower down the ingredients list
- Step 3 – Pancake, again with cow’s milk contained in the ingredients.
You may also see the words whey protein or whey powder, which are other names for cow’s milk protein.
As you move up the ladder you get to steps 4, 5 & 6. These include hard cheese, yoghurt/fromage frais, and fresh cow’s milk.
The higher you go up the ladder the more allergenic the food becomes.
Allergenic means how much the food is likely to cause an allergic reaction
The lower steps of the ladder contain baked milk protein.
The Science bit! When milk is baked and flour is added this makes the food products less allergenic. As you go up the milk ladder there is a gradual increase in the amount of milk protein and at the higher end of the ladder, the protein is exposed to less heat and in a purer form.
How to do the milk ladder
Download my MILK LADDER DAILY PLANNER BELOW based on the 6 step milk ladder
This gives you a day-by-day plan on how to progress.
I have put together two different versions.
- Reintroduction is completed each day
- Reintroduction is completed every few days.
You can have a little break between the steps if you like, just keep the other foods that your baby can tolerate in their diet whilst having this break before you re challenge.
How long do you stay on each step?
Each step of the ladder is different and each baby is different when it comes to dairy allergy. I would always say to be guided by your baby and their symptoms.
If your baby has a reaction on a certain step, stop where they can tolerate the food given. You need to then leave 2-4 weeks for symptoms to settle (as this is generally how long the body takes to recover from allergic reactions), and then return to the previous step and re-challenge. To give you an example;
Your baby may tolerate – Step 1 – biscuits (malted milk biscuit), and Step 2 – cake, but when given Step 3 – pancakes they start to have mild reactions. Stop at pancake, keep biscuits and cake in their diet on a regular basis, and after 2-4 weeks re challenge at Step 3 – pancake, to see if they again have allergic symptoms.
Remember: You don’t have to go back to the bottom of the ladder. You may want to seek further advice from your healthcare provider if your baby has a severe reaction.
How do I know if my baby’s symptoms are due to the reintroduction of milk?
- Loose stools – mucous may be present
- Tummy upset
- Raised red, itchy rash
- Sounding chesty
If your child starts with their original symptoms then you should stop on the step that they are able to tolerate.
Mild to moderate vs severe cow milk allergy – does it matter?
If your baby has a mild-moderate cow’s milk allergy then you may find that as you introduce dairy products into their diet they will progress a little quicker up the milk ladder. This may be due to them being less sensitive to cow’s milk protein but this is not always the case.
If your baby has a moderate–severe delayed reaction then you may want to go a little slower, starting off with smaller portions (crumbs) on each step. You should be guided by your health care professional on whether it is appropriate to start introducing dairy.
Use my milk allergy food diary to help you with tracking progress with the milk ladder.
Should my baby stay on their hypoallergenic formula when they’re reintroducing cow’s milk protein?
This is all dependent on their age.
Under 12 months
Yes, they should continue on their formula. If your baby gets to 12 months and can’t tolerate fresh milk to drink then you can start to introduce a fortified plant-based alternative. See my blog post on plant based milk for toddlers for more support.
Your baby is fine to continue with their infant formula up until around 18 months. After 18 months, I’d advise you to move them to milk alternatives if they still can’t tolerate fresh cow’s milk to drink.
Your baby is also fine to switch to fortified plant milk at 12 months old as long as there are no worries about their growth and they are having a well-balanced weaning diet.
Does my baby need a multivitamin if they take hypoallergenic formula?
If your baby is having less than 500mls (16oz) of hypoallergenic formula then yes they will need a multivitamin containing Vitamins A, C & D (10mcg). If they are having more than this then they don’t need a multivitamin as their formula is providing all that they need.
My baby isn’t tolerating any foods, what can I do?
Firstly don’t worry, everyone goes at their own pace and not all babies will move up the milk ladder in the same way.
If you find that allergy symptoms are always present on a certain step when introducing a new food and you have tried 3 times on that same step then take a break.
As I mentioned above, if an allergic reaction occurs take 2-4 weeks, however, if you can’t get past a certain step then instead take a 3-4 month break and then again retrial at the step that your baby wasn’t able to tolerate.
Remember to make sure that during this time that you keep all the cow’s milk contained foods in your child’s diet that they can tolerate.
How long does it take to complete the milk ladder?
This is individual and every baby is different. Some babies don’t have any reactions and others take a little longer to tolerate fresh milk. When following the milk ladder there is a good chance that most children will grow out of their cow’s milk allergy between 12 months of age to 3 years. The stats show that 80% of babies grow out of their milk allergy between 3-5 years
Try not to worry as your baby is going at their own pace. Remember that if they are having a balanced diet and moving through the weaning process alongside their formula, breastmilk, or fortified plant-based milk then there are likely no concerns with nutritional balance or growth.
Remember that if your baby has a severe allergic reaction you must seek medical advice immediately.
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All of the answers on this blog have come from evidence base and questions I get asked frequently, however if you have your own questions then you can contact me here.
Bump2baby nutrition LTD accepts no responsibility for any adverse reactions that occur from following the milk ladder. The milk ladder should not be completed without the support of a registered dietitian. If your baby is showing signs of anaphylaxis, please seek medical attention immediately.
The milk ladder should not be completed until 6 months post-weaning and 6 months post diagnosis of a milk allergy.
Hannah is an Expert Registered Dietitian specialising in Vegan Family Nutrition and Cows Milk Protein Allergy.
She is a respected figure in the field of nutrition and a captivating speaker and sought after media spokesperson being featured in esteemed publications including the Sunday Times, Independent and Huffington Post.
- Registered Dietitian
- First Class Degree in Nutrition
- Over 15 years experience working in the field of nutrition
- Respected Media Spokesperson both in the UK & USA; quoted online, TV and in local and international news
- Writer & Researcher, supporting the BDA and PEN Nutrition