Step one of the milk ladder: What you need to know to get started…
Ok, so you’re ready to start the milk ladder! In this post I’m going to answer all your questions on step 1 of the milk ladder!
Starting step one of the milk ladder can feel like a huge deal, and parents have usually had quite a journey before getting here! But it’s also a really exciting to think that your little one might be starting to tolerate milk again soon – even if just in tiny amounts.
What is step one on the milk ladder?
Step one usually involves introducing baked milk in a flour matrix – specifically, foods where milk has been cooked at a high temperature for a long time,-like in a biscuit, rusk or a savoury muffin.
Why is baked milk on step 1 of the milk ladder? This is because the heating process changes the protein structure in milk, making it less likely to trigger an allergic reaction in some children.
What are the options for step 1 of the milk ladder?
The options available to you depend on which milk ladder you are using and whether your little one has IgE or non-IgE milk allergy. If your little one has a mild-moderate non-IgE then you may use the 6-step iMAP milk ladder.
This guide is based on the 6-step iMAP milk ladder for mild-moderate non-IgE milk allergy reactions.
Options for step 1 iMAP 6-step ladder:
Malted milk biscuits (shop bought) not my personal fave as they are high in sugar and the brands have differing amounts of skimmed milk powder in them, thus the target amount can be tricky to determine
Shop bought baby rusks, again amounts can vary, but these are preferable from a sugar perspective
Homemade iMAP milk ladder cookie recipe is preferable as no added sugar and amount of milk is controlled, however, requires baking (who has the time hey?!). Check out the iMAP biscuit recipe here
Get a copy of my guide to shop bought alternatives and homemade recipes for step 1 of the milk ladder here- coming soon- message me if you are interested :)
These are low-risk starting points for many children on the ladder – but only if advised by your allergy team or dietitian that it is safe to do a home milk challenge using the 6-step iMAP milk ladder first
Why is baked milk first?
Milk proteins like casein and whey are the parts that typically cause allergic reactions. But when they’re baked their structure changes. Some babies and toddlers who react to fresh milk (like in yoghurt or cheese) may tolerate baked milk just fine. This is why it’s used at the beginning of reintroduction – to test for gradual tolerance
Checklist before you start
Make sure:
Your child should be well – no illness, teething, belly bugs or other issues
No vaccines due
No new medications that might have side-effects
Eczema should be under control
You should feel confident in what a milk ladder and what to do at each step
Top tips
Start small – a crumb or small bite at first! This will reduce the chance of an allergic reaction happening 👍🏽
Offer food during the day and avoid offering food close to bedtime- or when it’s dark- so you can see your babies skin!
Stay with your child after offering the food. Observe closely for at least 2 hours. Watch for any delayed reactions - occurring up to 72 hours after initial exposure
If no symptoms occur, slowly increase the amount offered over 3–5 days (go slower if you suspect your baby is more sensitive to milk)
What to watch for
Every child is different. Some common signs of a non-IgE milk allergy reaction might include:
Non-IgE milk allergy symptoms
Skin symptoms: rashes, worsening eczema
Gut symptoms: constipation, belly pain, reflux, vomiting, diarrhoea, bloating
Sometimes mucus in poo, other times we see some specks of blood in poo
Mild-IgE type allergy symptoms include:
Skin: Hives, skin redness, worsening eczema
Respiratory symptoms: itchy throat, sneezing
Gut symptoms: vomiting, diarrhoea
Moderate to severe IgE allergy symptoms include: any of the above listed symptoms, plus facial swelling, wheezing and other respiratory symptoms, and anaphylaxis
>> Do not perform a home milk challenge if your little one has a history of any of these IgE type milk allergy symptoms
Stop the ladder and contact your dietitian, doctor or allergy team if you see any signs you’re concerned about
iMAP recipe: guidance on how to start the milk ladder step one
Start with one biscuit on day 1, then 2 on day 2, then 3 on day 3. Then wait 72 hours before progressing up to the next step (see option 1 below)
Or, you can start more cautiously and start with a crumb, or 1/4 of a biscuit, and take longer to build up (see option 2 below)
Here are two example building up protocols:
Option 1: Day 1: 1 biscuit, Day 2: 2 biscuits, Day 3: 3 biscuits
Option 2 (cautious approach): Day 1-3 a small crumb, Day 4: 1/4, Day 5: 1/2, Day 6: 1 - now you can follow the standard step-by-step plan on the previous page (increasing from 1-3 biscuits)
If a baby has reacted on step 1 before, I would use option 2 next time
What if my child reacts?
First, ask yourself:
Could this be teething, illness, or a medication reaction?
Are symptoms mild (e.g. a bit of tummy upset, reflux, change in poo, unsettled behaviour, sleep issues)
If baby has a mild reaction:
If baby has a mild reaction at step 1-3 → We usually advise to wait around 2-3 months before retrying
If only a tiny amount caused a reaction (e.g. a crumb) → We might advise you to wait even longer than this- 5-6 months before retrying again
However, there is no blanket rule and it really depends on the individual get individual guidance from your dietitian if unsure!
Download the iMAP recipes here.
Need help navigating the milk ladder?
Book a 1:1 session with me for expert guidance on managing milk allergy reintroduction! Check out my clinic or book now and we can be chatting as early as tomorrow :)
