How to Reintroduce Dairy to Children Using a Milk Ladder
Should you reintroduce dairy into your preschooler's diet?
When you found out your child had a food allergy to milk, you were probably told to avoid all dairy and substitute with non-dairy ingredients. But now that they're a little older, it may be time to start reintroducing dairy using a tool to help make the process a little less daunting - the milk ladder!
A milk ladder helps ease a child back into drinking cow's milk and other dairy products by starting with small amounts of milk products in certain forms and gradually increasing them. Milk ladders should never be used without first consulting with your pediatrician. A milk ladder can then help ensure that a child tolerates dairy well and has a positive experience with reintroduction.
Keep reading to find out how to reintroduce dairy using the four steps of the milk ladder.
Milk Allergy vs. Intolerance
Cow's milk is one of the most common food allergies in young children.
There are two types of milk allergies – those that involve the immune system (IgE mediated) and those that do not involve the immune system (non-IgE mediated).
Most IgE-mediated reactions happen quickly, within about 2 hours, and can be severe reactions that affect the respiratory system. Non-IgE-mediated reactions usually occur from 2 to 72 hours after consuming dairy. These reactions may upset tiny tummies with GI issues but aren't life-threatening.
Lactose intolerance is an example of milk intolerance. This happens when a child doesn't produce enough lactase, an enzyme, to digest milk sugar fully. So kids with a milk intolerance will have gas, bloating, diarrhea, or even constipation.
Many children grow out of an allergy to dairy milk by the time they begin elementary school. However, the allergy persists into adulthood for about 6% of children.
What is a Milk Ladder?
The milk ladder is a process used to reintroduce milk to preschool-aged kids in a stepwise gradual introduction of dairy that can be done at home. The ladder works as a food hierarchy, starting with the least allergenic milk-containing food options and moving up to those more likely to cause a reaction.
It’s similar to Oral immunotherapy (OIT). The difference is that OIT is a standardized method known in the U.S. The milk ladder was popularized in the UK and is used in Europe and Canada. The milk ladder was designed for kids who have non-IgE-mediated milk allergies.
The UK National Health Service developed a tool called the international MAP, or iMAP, which is the basis of the food ladders that are gaining in popularity. The iMAP guidelines were developed to help doctors diagnose and manage milk allergies and help determine if a child has outgrown an allergy.
While the milk ladder may help children with mild to moderate (delayed) non-IgE-mediated allergies to cow’s milk protein, a recent UK study suggested that a home-based reintroduction of cow's milk may help children with IgE-mediated allergies who only have GI reactions to milk.
In any case, for children with severe allergies to milk who are at risk of anaphylaxis, further and/or repeat testing may need to happen first through an allergist, before dairy reintroduction can be considered.
What are the 4 Stages of Reintroducing Dairy using a Milk Ladder?
There are different ladders with different numbers of steps available. The Canadian option involves four steps in the milk ladder. Any milk ladder must always be done under a doctor or allergist’s supervision. So, before beginning step 1 of reintroducing dairy to your preschooler’s diet, always be sure to consult your child’s pediatrician first. And be sure to start with a healthy, happy kid so you don’t confuse a virus or other issue with a reaction.
Step 1
Start with baked milk, found in baked goods with heated milk. These include cupcakes, muffins, and cookies.
Step 2
In step 2, you would offer foods that contain cooked milk like waffles, pancakes, or crepes.
Step 3
Once kiddos reach the third step, you can offer cooked cheese or boiled milk. Pizza is an example of a food with cooked cheese.
Step 4
If your little one reaches this step, they are ready for milk, yogurt, cheese, and ice cream.
Guidelines for Introducing Milk using the Food Ladder
The Canadian milk ladder’s guidelines for parents to follow at home are:
Start with a grain or pea size amount of food. If your little one tolerates the food, offer the food daily. Then gradually increase the serving size daily over a few weeks until an age-appropriate portion size is achieved.
Offer an age-appropriate portion size daily for 1-3 months in each step before moving to the next step.
If your child has an allergic reaction, return to the previous level for one month before attempting to advance to the next stage on the ladder.
Should Kids with an IgE-Meditated Milk Allergy use a Milk Ladder?
Oral immunotherapy (OIT) may be a better option for children over 5 to 6 years old who haven’t outgrown their milk allergy.
OIT is a standardized method that desensitizes kids to IgE-mediated food allergies, especially milk, egg, and peanut. The goal of OIT is to build a young child's tolerance to an allergen by gradually increasing their tolerance.
Once a level of exposure is established, your child would continue to consume a small amount of the allergen frequently to maintain desensitization. Some little ones who undergo OIT develop full tolerance, but many do not.
However, most children who don't have asthma or severe allergic reactions will most likely grow out of a dairy allergy.
Why do Dairy Ladders Start with Baked Milk?
According to the National Institute of Allergy and Infectious Diseases (NIAID), incorporating baked milk products in a milk-allergic person's diet speeds up the process of tolerance.
Some children with CMA can tolerate milk baked into cookies, biscuits, and muffins. Some of the proteins transform when milk is baked, changing how the protein "looks" to the immune system.
One 2019 study looked at how children with IgE-mediated CMA responded to a "structured gradual exposure protocol" (milk ladder approach). First, the children were exposed to baked milk, other foods containing heat-treated milk, then cooked cheese such as pizza, and regular pasteurized milk over 12-18 months. And the children who followed this protocol were better able to tolerate regular milk than kids who avoided all milk-containing foods.
Do note that every child is different and this method won't work for all kids. For example, in another study, 25% of children with CMA had reactions to the baked milk and couldn't continue with the study.
Another study found that tolerance of baked milk items doesn't necessarily mean the child will have long-term tolerance to milk.
Milk Ladder Precautions
It's critical to consult your child's allergist or doctor before adding baked milk to their diet because there are risks involved.
Introducing baked milk may not help resolve CMA or can even be dangerous if your child shows any of the following:
Large wheel size on skin prick tests
Blood test results that indicate antibodies to a wide range of milk proteins
The presence of other allergies, asthma, eczema, or atopic diseases
Previous severe reactions to milk, including anaphylaxis
You should only start the first step (introducing baked milk) when:
No other allergies or eczema are flaring up
Your child has stopped taking antihistamines or other medications that could interfere with a reaction
You’ve discussed the reintroduction of dairy with a health professional
Final Thoughts
The milk ladder is helpful for kids who may have outgrown their milk allergy.
But if adding baked milk to your child's diet isn't possible now, avoiding milk is the best treatment for food allergies. There are many different types of milk allergies, each requiring a different avoidance. For some children, this means not eating anything that contains milk, while others may be able to eat baked goods or drink lactose-free milk.
Don’t cut out whole food groups unless you have to.
Your kiddo should have as many nutritious foods as they can safely tolerate, so they don't miss out on key nutrients. As both a parent and a pediatric dietitian who works in the food allergy space, I understand that the uncertainty of an allergic reaction may be scary. That's why I encourage parents to work with a pediatrician and allergist when reintroducing milk to their child's diet.
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