Most babies with a mild milk allergy will at some point be recommended to do a home milk challenge to see if they have outgrown their milk allergy. Your dietitian will advise if this is safe for you to this type of challenge at home. This is usually recommended for babies with a non-IgE type milk allergy.

Babies with mild IgE milk allergy may also be advised to do home milk challenge, but this is usually a much more cautious approach - and ALWAYS under careful supervision. A hospital challenge may be recommended in IgE milk allergy, especially if the allergy is moderate to severe. An allergy team should be involved in your babies care if they have this type of milk allergy.

So what is a milk challenge or a milk ladder?

A milk ladder is a structured approach designed to help reintroduce milk proteins in a safe and controlled way.

Starting the milk ladder

Before you start you need to make sure your child is well (although this may in itself feel like a challenge). Use this checklist before you start:

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

When to start the milk ladder?

For non-IgE allergies

According to iMAP (International Milk Allergy in Primary Care), the milk ladder can be started six months after diagnosis or when the child is around 9-12 months old

For IgE-mediated allergies

If your child has an IgE allergy, you must have guidance from an allergy specialist team before starting
Some children may start as early as 6 months, but this ALWAYS depends on individual risk factors

What are the different types of milk ladder?

There are several versions of the milk ladder out there, a simple google search will show you lots of results. The main ones used in the UK are:

iMAP 6-Step Ladder – the most widely used in the UK
iMAP 12-Step Ladder – a slower, more gradual approach
BSACI 4-Step Ladder – used in some UK allergy clinics - although I feel this jumps massively at step 3! Which is not suitable for many babies and young children with more sensitive food allergy
Indian and Mediterranean Ladders – these versions have been adapted for different cultural diets

This guide is based on the 6-step iMAP milk ladder, pictured below.

the milk ladder, dairy reintroduction plan

If your child has been recommended to start the 6-step iMAP milk ladder, ready my guide to step 1 here.

What are the steps of the milk ladder?

A typical milk challenge or ladder progresses from baked milk → cooked milk → pure milk because heat alters milk proteins, making them less allergenic

The 6-step iMAP milk ladder has the following steps:

A small amount of milk or milk powder extensively heated milk in a wheat matrix (e.g. biscuits, cake)
Milk baked in a recipe (e.g. muffins, scones)
Milk in a flour matrix cooked for less time OR milk used in a baked recipe (e.g. pancakes; or a shepherds pie/pasta bake)
Cheese
Yoghurt
Cow’s milk itself

Recipes vs commercial foods

Many ladders consist of recipes for the first few steps and rely on parents cooking or baking foods containing milk. Check out the biscuit recipe for step 1 of the milk ladder here.

How much to give on each step?

This depends on the child and their previous reactions:

For mild IgE reactions in the past, you might start with a crumb
For non-IgE allergies, you may start with half a normal baby portion and gradually increase

Always get personalised guidance from your dietitian about what is safe for a home challenge. Check out my complete guide to step one of the milk ladder here.

How long should we stay on each step?

This varies from child to child:

If they are tolerating a full portion at one step and they have had a full portion, you can consider moving on

There is no need to rush: gradual exposure is key- and part of the goal of the ladder is to PROMOTE TOLERANCE but exposing to small amounts of low-allergen milk - not simply to PASS the ladder

Some children may need weeks or months at one step before progressing upwards!

What to watch for

Every child is different. Some common signs of a reaction might include:

Skin symptoms: hives, rashes, redness, swelling
Tummy symptoms: vomiting, diarrhoea, bloating
Respiratory symptoms: cough, wheeze, sneezing (less common in step one)

Stop the ladder and contact your dietitian, doctor or allergy team if you see any signs you’re concerned about

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) or moderate-severe (e.g. vomiting, hives, breathing issues)?

If there is 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!

Breastfeeding and the milk ladder, if I am breastfeeding, can I do the milk ladder?

🤱 For breastfeeding babies with milk allergy, I usually recommend to go straight to baby first when it comes to doing a milk challenge, as babies are usually 9-10 months or older when they start a milk challenge and so are capable of eating a wide range of foods

I find this way around it avoids any uncertainty - as you know how much milk protein your baby is having and how much they can tolerate. That way it is also clearer if your baby reacts to a particular food - we can take it out and put it back in again more easily

With breastmilk it can take hours (and in some cases days) for milk proteins to leave breastmilk

Once baby tolerates milk in their diet, mum can reintroduce dairy into hers

That said, some babies do not like the foods we suggest to offer as part of a milk challenge (although I’ve got lots of tips if this sounds like your baby!)

There are also some benefits to giving your baby milk via your breastmilk- it is diluted- only a very small proportion of your milk contains intact milk proteins- so this may feel more reassuring to you if you are nervous about introducing milk to your baby

What I would suggest is wait for your little one to be symptom free and then add some dairy back into your diet and see if baby has a reaction. If they do, stop and take it back out again and wait for symptoms to settle before giving any milk to your baby or starting a milk ladder

Where to go next? If your child has been recommended to start the 6-step iMAP milk ladder, ready my guide to step 1 here.

What is a milk ladder challenge?