Today I'm sharing a short guide to the milk ladder, based on my own experience and from talking to other CMPA mums online. Our first attempt at the milk ladder was when my daughter was 2, and was unsuccessful. We restarted the milk ladder in May 2017 when my daughter was 3. For a long time, we thought that she was ok with cooked milk. Unfortunately, after a while we discovered that she was getting silent reflux. So we took a break. Now in 2022, aged 8, she can tolerate baked milk, woohoo! Although persuading her to try the next step is a bit more tricky now she is older!
Please note: this post contains general information and does not substitute for healthcare advice. If you are in any doubt about what to do, please speak to a health professional.
What is the milk ladder?
The milk ladder is a step-by-step guide for reintroducing milk to a child's diet if they have been dairy free due to a confirmed allergy. It is suitable for mild to moderate, delayed (non-IgE) cow's milk protein allergy. You can follow the milk ladder if your health professional has advised you it is safe to do this at home.
It is not safe for anyone at risk of anaphylaxis. Children with severe allergies will need repeat allergy testing to find out if they have grown out of their allergies. If tests come back negative for food allergy, your doctor will most likely recommend a food challenge in hospital.
Which milk ladder to follow?
Follow the one your health professional gives you. If in any doubt, follow the 12 step milk ladder as this is the most gradual reintroduction. There are shorter versions available, but they are not suitable for everyone.
When to start
Make sure your child is well when you start - no fevers, colds, rashes or stomach upsets. They should not be taking regular antihistamines as this could mask an allergic reaction. Wait at least 6-12 months from their last allergic reaction to give the best chance of success.
Avoid times when your normal routine is disrupted e.g. starting nursery, potty training or going on holiday. This is partly because stress can make allergic reactions more likely, but also for your own sanity!
When you are first starting, choose a quiet day when you can stay at home and keep an eye on your child. You need to be able to watch them for a signs of reaction. You might like to snuggle on the sofa with a movie or do some special craft activities or baking together.
How long to spend on each step?
This depends on your child. If your child's allergy is very mild you can increase the amount of milk they are eating every three days. You might prefer to spend a week or two on each step. This gives you time to watch for delayed reactions and to see if they react to a build up of cow's milk protein in their bodies.
Try not to make a big deal about each new food you are testing. Keep it low key. It can be confusing for your little one if you make a big fuss about a new food, and then they have a reaction and you have to stop them eating it again. You might prefer not to tell them that they are eating dairy at all until you are confident that they can tolerate it. My little one was well aware of her allergies and when I gave her a new food she would often ask "Am I allowed this?" I would simply tell her, "Yes, you are allowed this biscuit." (or whatever).
How long does it take to complete the milk ladder?
It depends! But it might take longer than you think. In the 12-step ladder, some steps actually have two stages, making 20 stages altogether. If you raced through with no setbacks it could take about two and a half months in total. In reality it will usually take longer because children do get ill, and there will be times when you have other priorities.
Your child might refuse to eat the food the first time you offer it to them, which can also slow things down. It can be helpful to eat dairy-free versions of foods like yogurt, cheese, pancakes, shepherd's pie and so on as part of your normal routine, to make the transition easier. Some children may need to see you eating a new food a few times before they are willing to try it themselves. Don't put pressure on them, just keep offering the food. If they still refuse to eat the food, try an alternative that is at the same step of the ladder. Scroll to the bottom for a free download listing all the alternative foods for each stage!
What if my child has a reaction?
Sometimes it can be difficult to tell if your child has had a reaction or not. If they have very mild symptoms like wind or a slightly upset stomach, carry on for a few days to see whether it settles down. Your child may just need some time to get used to eating cow's milk again. However, you should stop if the symptoms continue or get worse.
If your child has a reaction at the first step, stop altogether and try again in 6-12 months.
If your child has a reaction further up the ladder, go back to the previous step that they were tolerating. Keep giving them foods from this step and all the steps below it regularly (at least 2-3 times a week). Then in 3-6 months time you can try to move up the ladder again.
You might have mixed feelings about starting the milk ladder. It's exciting to think of all the foods they might be able to eat again (or for the first time). But it can also be stressful because of the worry that your child might have a reaction. You may also feel frustrated because it is such a slow process, but don't be tempted to rush ahead. Remember that the milk ladder has been designed to give you the best chance of success by introducing dairy foods gradually.
It is disappointing if they have a reaction at any stage but hopefully it just means they need a bit more time to grow out of their allergy. Focus on the progress you have made, even if it is just to learn more about how they react! We failed our last attempt to move up the milk ladder. Surprisingly, it still felt positive, because my daughter's reaction was so much milder than I had feared. This has taken away a lot of my anxiety about cross contamination and accidental exposure.
Don't rush it, take your time, and good luck!
It's quite common to get 'stuck' on a particular step of the milk ladder for various reasons. Sometimes a child reacts to the next step up the ladder. When this happens, you have to go back to the previous step and stay there for a while until you are ready to try again. Or you may have other things going on like teething, illness, potty training, or starting nursery that mean it's not a good time to move up the ladder right now.
In this situation your child might, quite understandably, get fed up of having to eat the exact same thing every single day. So I've put together this cheat sheet to help you! It will show you all the alternative options (for some stages, there are lots!) to help give you some choices.
It might also come in handy if you have a fussy eater who doesn't want to eat the food suggested in the milk ladder.
Have you started the milk ladder with your child? How are you finding it? Leave a comment below!
Hi, my son has a dairy intolerance and we’ve been given a milk ladder to use at home. He’s now one years old and I was advised to start now. I was wondering if you know if I can start eating dairy myself while we reintroduce or if it would interfere? I still breastfeed him you see and so I have been dairy free since we had his intolerance confirmed.
Hi there, I would follow along one step behind your son on the milk ladder. For example, once you know he can tolerate biscuits with milk in, then you can start eating biscuits. That way, if he does have a reaction to anything, your milk is still safe for him. Good luck!
This is long past helpful for you I imagine, but maybe this will help others.
My doctor actually had us start with me directly.
My doctor had us started with 30 mls/day of milk and waited a week and then increased it little by little every day after that until I could have as much as I wanted, and after that was settled and good we started my little one with bisquits.
I've heard of this approach and I'm glad it worked for you! One advantage of doing it this way is you get dairy back into your own diet much quicker. However personally I would be concerned that you don't really know for sure how much milk protein is passing through to your little one and when, which can make it harder to track reactions. In addition, if your little one doesn't react well, you would need to pump and dump until the milk protein is out of your system again, and have some expressed milk stored as backup (or dairy free formula). If you're already dairy free then this would only need to be for about 24 hours, but you'd still need to be prepared.
On the other hand, I've heard other breastfeeding mums advised to stay one step behind their child on the milk ladder, so that their breastmilk is never above their child's level of tolerance.
For other mums who are reading this, this would be a great question to ask your health professionals before starting the milk ladder.
Hi, thanks for your useful post. My first daughter had a dairy allergy (among others) but grew out of it completely by 10 months when we did the milk ladder. My second daughter also has dairy allergy, and We’ve both been dairy free since shortly after her birth until now, she’s nearly 8 months - However, last week I accidentally ate chicken that had been cooked with butter. She has had terrible nappies for the last 4 days. Does this mean I can’t start the milk ladder for at least 6 months? I was hoping that we could make progress up the ladder soon and hoping the slip up hasn’t set us back ? thank you x
Hi Katie, I'd count that as a milk ladder fail and give it a few months before trying again. As for the exact time to wait before trying again, your dietitian or doctor should be able to advise you. I know of people being told to wait anywhere between 3 months and 12 months. I know it's frustrating but waiting will give your little one the best chance of success next time you try.
Hi, I’m just starting the milk ladder with my 3 yr old. What milk is used to bake muffins? Full fat/semi/skimmed? Thanks ?
Hi Liz, as far as I’m aware, it doesn’t matter which milk you use for the milk ladder recipes. However, generally speaking full fat milk is usually recommended for children under 5. Good luck!
We are just working our way through the milk ladder.
Any tips on how much milk and if you used butter for the shepherds pie stage?
Hi Mel, we have had a conversation on Instagram about this now, but for anyone who has the same question, the milk ladder recipes are online here: http://ifan.ie/wp-content/uploads/2015/10/MAP-Milk-Ladder-Additional-Recipes-Oct-2015.pdf
Good luck with the milk ladder, hope it goes well for you x
Hi, thanks for this great information. I struggle though, to give these unhealthy foods full of additives and sugar to my 14 month old. Do you have a suggestion for dairy introduction with foods that aren't so unhealthy? I would never, for example, give my little one biscuits or chocolate, Thanks for any advice.
Hi Christine, this is a common concern! There are some savoury recipes for the milk ladder at this website: https://www.allergyuk.org/assets/000/001/767/iMAP-Recipes_%28Final%29_original.pdf?1524663093
Hello. Thanks for this useful post. I am breastfeeding my 7 month old who had suspected CMPA and is currently dairy and soy free. I wondered whether I could do the milk ladder rather than him as he’s always reacted to my breastmilk if I have any of those so I’m thinking that would be a better and less stressful way to do it. Thanks!
Hi Jen, this is a great question!
Every woman is different and there's no way of knowing how much milk/soya protein actually goes through into your milk and when. So it's not a great way to trial the milk ladder. For example, if you eat a malted milk biscuit and he is ok, that doesn't necessarily mean it's ok for him to eat a malted milk biscuit. And if he has a reaction to the milk protein through your milk, you'll have to wait for it to get out of your system before you can feed him again, which might take 24 hours (https://www.myallergykitchen.com/2018/11/13/breastfeeding-food-allergies/).
I know it's nerve-wracking to give your little one milk or soya for the first time, we've been there! But it's best if you stay one step behind your little one on the milk/soya ladder. That way if he does have a reaction at any point, your milk will still be ok for him.
I'm confused as the first biscuit recipe has butter as well as milk powder? In the other recipe sheet it has dairy free spread
Hi Nicola, I'm not sure exactly which recipes you are referring to. There are a few different versions of the milk ladder recipes, it doesn't really matter which one you use. Butter only has a very small amount of milk protein so won't make too much difference to the recipe. Just pick the one you feel most comfortable using.
Hi, my daughter and I are wanting to start the milk ladder with my 2 year old grandson. He also has many other allergies which include gluten intolerance and intolerance to rice and potato. So we are stuck about what to give him for step 1 of the milk ladder. We have read that it must be a shop bought biscuit containing milk. Malted milk biscuits contain wheat flour. Any suggestions will be gratefully received.
Hi Sue, there are some milk ladder recipes here, including wheat free https://www.allergyuk.org/assets/000/001/767/iMAP-Recipes_%28Final%29_original.pdf?1524663093
If these recipes are not suitable for your grandson, I would suggest that your daughter seeks further advice from his dietitian. They should be able to provide personalised guidance as to how to reintroduce different foods safely. She can ask her son's GP or paediatrician for a referral if this hasn't already been done.
john wick 2
thank you or thanks you
my daughter was only diagnosed about 5 years ago, I have no professional help, her consultant discharged her from his clinic 3 years ago and said its self care, as she is developing is perfect, we only ever had 1 meeting with the dietrion and all i got was a booklet on foods jot to give her, she is soon be turn 13 and I am not sure when is the best time to start the ladder, she wants to but my concern is I have been very very strick with her diet over the years as she has other food intolerances that she is sensitive to i am worried that I will go to fast or to slow with reintroduction dairy to her diet
Hi Sam, thanks for your message. I would ask your GP refer your daughter back to the dietitian for advice about the milk ladder. You should only use the milk ladder if you have been advised to reintroduce milk at home by a health professional - it's not suitable for everyone. Plus if she has other food intolerances as well, it makes things a bit more complicated for you, and you might need more support in adapting the recipes/foods to suit her needs.
I’m having a really tough time finding malted milk biscuits or something similar that is made with whey powder etc. Does anyone have a specific brand/name? I’m looking to purchase not make my own.
Hi Demi, you need malted milk biscuits made with milk powder NOT whey powder if you are following the 12-step ladder. I'm not sure where you are in the world but here in the UK most supermarkets sell malted milk biscuits that contain milk powder so it's usually pretty easy to find 🙂
If I want to make my own biscuits etc, what milk powder do I buy in the UK? I know to not use whey powder but what exactly am I buying? Any brands or links would be really appreciated. Thank you
Hi Emily, you can buy milk powder from any supermarket. I would recommend you speak to a dietitian if you need further advice.
Thank you so much for such a useful article! My daughter is 14 months old and we started the milk ladder a couple of weeks ago. Because she has all of her meals at nursery 4 days a week, we have been doing step 1 with her 3 days a week for a couple of weeks and were about to move to step 2 when unfortunately we noticed a rash/spots on her cheeks! Do we stop altogether? Can we go back to half a biscuit, which she seemed to tolerate, rather than a whole biscuit?
Please speak to a health professional for advice.
My little boy is 14 months and we have just got to step 11 sterilised milk - he hasn’t had any reactions so far - do you have any suggestion /preference on what brand to use ? Dietitian said could just stay on soya milk but I would like to try cows milk
Congrats on getting to step 11! Please follow your dietitian's advice regarding the milk ladder. Step 11 is UHT milk (longlife) - this could be normal cow's milk or made up packs of formula. In the shops, these are kept on a shelf and not in a refrigerator. Hope this helps.
Hi I am doing the 12 step milk ladder with my grandson and am currently on step one. Looking at step 2 I don’t understand why it is telling me to give digestive biscuits as I don’t see any ingredients in there that’s an issue, and I feel garibaldi are a bit too hard for him. Any suggestions what I could use here.
I am doing the 12 step milk ladder and am currently on the first step, I am a bit confused by the second step of the digestive or garibaldi as the digestive doesn’t have anything in it milk based but I feel a garbaldi is too hard for him to eat as he is only 10months any suggestions as to what else I could use for this step.
Hi Joanne, this is a great question! Since the milk ladder was written, some brands have changed their recipe to make them vegan friendly - which means no milk. However, some supermarket own brands of digestives do still contain milk. If you shop around you should still be able to find some.
Hi Zoe thanks for your reply I don’t think it will matter now anyway it looks as though he has failed step one 😢he is only 4 days in on a quarter of a malted milk a day, he has had foul smelling mucousy nappies wind and very squirmy. Does this mean we have to stop now dietian have us the milk ladder and told us he would review him in 4 months x
Sorry to hear that Joanne, just remember 10 months is still very young so there's plenty of time. The dietitian will be able to tell you when to try again.
Hey! My little one has been bloated, fussy, & having difficulty sleeping for a couple days now. Is this considered a fail? Thanks!
It could be! Is there anything else going on for your little one right now? Teething? Cold? Growth/developmental spurt? Any other new or unusual foods eaten?
If they are not in distress you could try continuing for a day or two and see if it settles down. Otherwise I would stop at the step you are on and try again in a few months' time (your health professional should be able to provide further advice on how long to wait as every child is different).
Hey my daughter is allergic to milk, soya, eggs. I reintroducing eggs to her but she faild. Can I reintroducing milk ladder to her?
Hi, you should check with a medical professional about whether to try the milk ladder with your child. If you have been told it is ok to try reintroducing milk at home then yes, go ahead - even if she still reacts to egg she may be ok with milk.
What is kind of reaction to the cow’s milk is considered allergic reaction when following the ladder?
My son’s allergist said as long as he doesn’t have diarrhoea then that ladder of food is tolerated.
However, I have reservation. I found my son’s eczema prone skin will get worse when he consumes dairy products. But other than that, he doesn’t have any other obvious symptoms.
Can you advise? Thanks
Hi Sally, there is a detailed list of allergy symptoms in this blog post (written by a paediatric dietitian) https://www.myallergykitchen.com/introduction-to-cows-milk-protein-allergy/
Your doctor may advise that it is better to treat the eczema and keep dairy in your child's diet, than to avoid dairy completely. However, there are many people who do avoid dairy to control their eczema.
My son is 2.5 years old and we managed to get to step 3 and then stopped as he was having reactions. I'm concerned he isn't getting enough calcium as he doesnt like the taste of any plant based milks. Would you suggest he take a supplement?
Hi Vicki, you can find out more about calcium requirements here: https://www.bda.uk.com/resource/calcium.html
If you would like to give your child a calcium supplement you can buy them from pharmacies, supermarkets and online. There are a few child-friendly options to choose from.
For personalised advice please speak to a health professional.