The Simple Guide on how to do the Milk Ladder: 2024

By Hannah Whittaker RD, PGDip | Jul 26, 2023

Updated on 1/7/2024

The milk ladder is a structured way to reintroduce milk protein back into your baby’s diet. The Simple Guide on how to do the Milk Ladder: 2024 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 received a copy of the iMAP milk ladder, without any explanation or advice on the next step. You were simply told to start with your baby when they are ‘around’ 12 months old. Or, you may be a bit confused in what do.

If this is you and you want to find out more then keep reading!

The milk ladder is generally advised for babies with non-IgE-mediated reactions (delayed), diagnosed via a milk challenge. In babies with IgE-mediated allergies (immediate reaction to dairy foods), diagnosed via a blood or skin prick test it may be advised. You should speak with your health professional for more support if this is the case. There is some new evidence, and I am supporting babies with IgE allergies to milk protein in special circumstances.

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. This is usually after they have been following a milk-free diet for 6 months.

This mik ladder involves introducing small amounts of milk-containing foods in a stepped approach. As you go up the ladder the amount of milk protein increases in the foods given.

What age should you start?

Usually anytime from 10-18 months of age. This will depend on when your baby was diagnosed with milk allergy. It is usually 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 sometimes as your baby may be teething (red cheeks, runny poop) or as their immune system is developing they can pick up colds quite easily. These symptoms can be normal for a young baby but can make it difficult to know when to start the reintroduction. How will you know the symptoms are due to milk protein.

If cold or teething symptoms are mild then you can likely 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 their symptoms are due to food allergy or other illness.

Definitely don’t start the ladder if your baby has;

  • A high temperature/fever
  • Very loose stools – tummy bug
  • Recently 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. 

Milk Ladder

What if you are breastfeeding

I’m going to give you an overview of the pros and cons and whether you or your baby should do the milk ladder.

Introducing dairy to your baby.

Pros

  • You know how much milk protein your baby is having and can tolerate
  • You know when you last gave your baby food with milk protein contained. There is no confusion if it was something you ate and whether it was due to the milk protein in your breastmilk.
  • If symptoms occur you can stop the food immediately and go back to the last step that your baby could tolerate. 

Cons

  • 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 iMAP Milk ladder. Or you may not want to give them the food yet, such as a biscuit.

Introducing dairy when breastfeeding.

Pros

  • Your baby will likely receive less milk protein via your breastmilk than if they were to eat the food themselves. It is believed that the volume of milk protein in breastmilk is 10,000 times less than if your baby were to have milk directly. 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. This 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.

Cons

  • 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

If you have been on a milk free diet for 6 months and your baby is symptom free you could try to reintroduce dairy into your diet and see if your baby again has symptoms. If your little one doesn’t then you can be free to have dairy in your diet.

If your baby has a reaction to milk protein through your breastmilk then I would say to wait 2-4 weeks before then starting the milk ladder with you baby. Always monitor each step and my;

MILK LADDER DAILY PLANNER WILL HELP TO PROGRESS, ENTER YOUR DETAILS BELOW

    The 6-step or 12-step ladder?

    At the moment the 6 step milk ladder is used widely in the UK.

    You can find a copy at the 6 step milk ladder at top of the page and also through the link below

    IMAP MILK LADDER

    Just a little secret, I’m currently developing a milk reintroduction course and you can keep updated by downloading this blog or my milk ladder planner.

    Breaking the current 6 step ladder 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 again 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 in the ingredients list, 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 lower steps of the ladder contain baked milk protein.

    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 Science bit! When milk is baked and flour is added, the food products become less allergenic. As you go up the milk ladder, the amount of milk protein gradually increases. At the higher end of the ladder, the protein is exposed to less heat and is 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 planner gives you a day-by-day guide on how to progress with milk reintroduction.

      I have put together two different versions.

      1. Reintroduction is completed each day
      2. 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 a reaction. You should then stop at pancake, keep biscuits and cake in their diet on a regular basis (it doesn’t have to be everyday), and after 2-4 weeks re challenge at Step 3.

      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?

      Common delayed milk allergy symptoms are;

      • Vomiting
      • Loose stools – mucous may be present
      • Constipation
      • Tummy upset
      • Red, itchy rash
      • Sounding chesty
      • Coughing
      • Snotty/congested

      If your child starts with their original symptoms then you should stop on the step that they are able to tolerate. Give 2-4 weeks and then restart on last step tolerated.

      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. Your health care professional should guide you 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 cows 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.

      12-18 months

      Your baby is fine to continue with their prescribed infant formula up until around 18 months. After 18 months, I’d advise you to move them to a plant based milk alternative 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 concerns about their growth and they are having a well-balanced weaning diet. 

      Plant based milk for toddlers

      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 little longer. It may be that illness is affecting your babies progress as you can’t always tell if the symptoms are due to milk allergy reaction.

      Remember if you baby can tolerate a certain level of milk protein contained foods to keep them in their diet during this time.

      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. 

      All the answers on this blog are based on evidence and frequently asked questions. If you have your own questions, you can contact me here

      Hannah x

      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 after a milk allergy diagnosis and elimination.

      Hannah Whittaker Dietitian Bump2baby Nutrition
      Expert Pregnancy & Paediatric Dietitian at  | info@bump2babynutrition.com | Website

      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.

      Credentials

      Registered Dietitian
      First Class Degree in Nutrition

      Experience

      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

       

       

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