What is the milk ladder?

The milk ladder is a step-by-step approach to reintroducing cow’s milk into the diet. It is used with children with non-IgE (delayed) Cow’s milk Allergy (CMA) as most of these children will outgrow their milk allergy.

 We know that the more cooked/processed milk protein is, the less allergenic it tends to be. This is because heating cow’s milk proteins to a high temperature causes them to break apart so the body’s immune system does not recognise them. The milk ladder makes use of this concept and gradually introduces foods with increasing amounts of milk protein; providing a stepwise approach towards being able to fully tolerate milk and dairy products.

The milk ladder MUST NOT be used if your child has presented with symptoms suggestive of IgE mediated (immediate) milk allergy and/or has had a positive blood or skin test (Specific IgE or Skin Prick Test) to cow’s milk.

 With IgE milk allergy, any re-introduction advice will need to be guided by the specialist allergy team or paediatrician. If you are unsure on the type of allergy that your child has, PLEASE ENSURE THAT YOU SEEK GUIDANCE FROM YOUR HEALTH CARE PROFESSIONAL.

When Should I start the milk ladder?

•  We generally advise commencing the milk ladder at around 12 months of age or at least six months after cow’s milk has been excluded from your child’s diet (whichever is soonest)
• Do not start the milk ladder if your child is unwell, actively teething or has had an immunisation in the last few days
• Ensure any eczema or bowel/tummy symptoms are settled

What step should I start on?

•  Most children will start on Step 1 (highly cooked/processed milk protein)
• If your child can already tolerate some foods containing milk, start on the step which is closest to those foods (rather than starting at the bottom of the ladder)
• Start each step early in the day, rather than in the evening. This will ensure that you can closely monitor tolerance.

How much should I give & how long should I stay on each step?

• For each new step, we generally recommend starting with a quarter of a portion and gradually building up to half; three-quarters and finally a full portion that is suitable for your child’s age
• For some children who have presented with severe symptoms, a smaller portion (for example a ‘pea size’ amount) may be a more appropriate starting point
• The duration of each step on the milk ladder can vary widely, and there isn’t a one-size-fits-all answer
• We generally recommend staying on each step for at least three days (as a minimum)
• Once a new milk containing food is tolerated, try to regularly include that food in the diet, while continuing to progress through the ladde

What do I if my child doesn’t tolerate a step on the ladder?

• If your child is having symptoms, stop giving the food on that step and re-try again one to two months later
• During this time, it is important to continue to offer tolerated foods from steps lower down the milk ladder.

I am not sure if my child is having a reaction. What should I do?

•  Sometimes it can be difficult to determine if your child is reacting to the milk protein or if their symptoms are related to something else; particularly if symptoms are quite mild e.g. a slight change in bowel habit, or a little more wind
• If you are unsure, it’s advisable to wait a day or two and then re-try the same food. If it is a reaction to the milk protein, then the same reaction will happen again
• If symptoms are very mild; you may wish to persevere, as these types of symptoms often settle down after a few days.

If my child has multiple allergies, can I manage multiple non-IgE ladders alongside each other?

 Some children will have allergies to other foods such as soya or egg as well as to cow’s milk protein. If you have been advised to commence ladders for multiple allergens it’s important to note that two different food allergens should not be introduced or increased at the same time.

Ladders can however be managed alongside each other; as long as you only make changes to one at a time. For example, if your child is tolerating step 2 of the milk ladder, you could ‘park’ it there if you are struggling to get beyond this point.  Whilst you continue to give your child the cow’s milk protein that he/she has tolerated up to step 2, you can then work on a relevant step of a different ladder.

The table below shows a stepwise summary of the milk ladder.

Please note that steps 1-3 are designed to be carried out with specific recipes (see iMAP recipes: FINAL_Milk_Ladder_Recipes-Dec-2025.pdf to allow for a controlled, gradual exposure to milk protein.

Each of the iMAP recipes has an egg and wheat-free option (they are all soya free) to make the ladder suitable for children with multiple food allergies who may need them.

In acknowledgement that some families may not have the facilities or time to bake, we have also provided examples of some shop-bought alternatives.

If using shop brought products, it’s important to note that the specific amount of milk protein in different products cannot be guaranteed and that there will be variability between different products. If your child is particularly sensitive to milk protein, it would be advisable to use the iMAP recipes where possible.