Allergy: Food- Cow's milk allergy /

The cow's milk ladder

01 In Brief

The milk ladder provides a graduated guide to progressively introduce cow's milk proteins in children with cow milk allergy/ intolerance when it is deemed safe to do so. It starts with well baked milk products then foods are introduced with a gradual increase in the amount and type of cow's milk protein and a decrease in heating or denaturing process.

02 What Do I Need To Know?

In children with diagnosed cow's milk allergy, introduction of milk containing foods should always be done under medical supervision.

Children with mild non IgE mediated symptoms ie colic, reflux, eczema and diarrhoea start to out grow cow milk intolerance earlier and introduction dairy can be considered from about 9-12 months of age. Skin prick or RAST IgE would be expected to be negative or in the low predictive range.

Children with IgE mediated cow's milk allergy out grow their allergy from about 3-5 years of age. There is evidence that exposure to small amounts of baked milk products helps children out grow their allergy sooner. Clinical history, results of skin prick testing or RAST IgE tests will guide your doctor in deciding when a baked milk challenge is safe.


Tolerance of baked milk is a marker of transient IgE-mediated cow’s milk allergy, whereas reactivity to baked milk indicates a more persistent phenotype. The addition of baked milk to the diet of children tolerating such foods appears to accelerate the development of unheated milk tolerance compared with strict avoidance.

Skin prick testing, SPT guides the clinician in deciding when it is safe to do a baked milk challenge. Blood tests to cow's milk protein, RAST are an unreliable predictor for safety.

In general 

< 2 yrs age SPT < 6 mm can consider a challenge. If the SPT is > 6 mm 90% will react

> 2 yrs  age SPT < 8 mm can consider a challenge. If the SPT is > 8 mm 90% will react

How to try the milk-containing food: foods are divided into 5 groups in approximate order of how well tolerated they are.


Modified from Venter et al

Group 1. Manufactured/highly processed foods containing highly cooked cow’s milk Malted milk biscuits Digestive /Garibaldi biscuits (check the labels that they actually have milk), home made muffin mixture, baked at least at 350F for 30 minutes.

Group 2. Cooked homemade food where a small amount of cow’s milk is present Scones, cakes, fruit crumble, scotch pancakes, shepherd’s pie, milk chocolate, cheese-flavoured crisps. (Cooked products using standard margarines containing cow's milk proteins may be tolerated before similar quantities of butter)

Group 3. Dairy products Yoghurt, cheese, butter, fromage frais. Margarines containing cow's milk proteins may be tolerated before similar quantities of butter. May start with baked cheese on pizza, bake at 425F for 13 minutes.

Group 4. Homemade foods containing large amounts of cow’s milk Rice pudding, Yorkshire puddings, pancakes, white sauce. Foods cooked with dried reconstituted milk or sterilised milk may be tolerated earlier than using standard milk.

Group 5. Cow’s milk- sterilised milk may be tolerated earlier Start with 1 tablespoon on cereal. Increase amount of cow’s milk. Some children will tolerate goat's or sheep's milk before cow's milk.


Introduce cow's milk containing foods and then cow's milk into diet over a 1-2 week period.

If no symptoms return within 2 weeks of the mother consuming milk products, then the mother may continue to consume cow's milk and the infant will likely be able to grade up as well.


Include infants who are fully bottle fed or taking formula to complement breastfeeds.

Day 1 30mls of cow’s milk formula into ONE morning bottle only – i.e. 30 mls (1 scoop) cow’s milk + 180 mls (6 scoops) formula. Days 2 – 7 continue to increase the cow’s milk formula IN ONE morning bottle and reduce the Hypoallergenic formula using the following example.

Following Days

Following days   

Volume of boiled   

water( mls)

Cow'smilk formula   

No of scoops 

Hypoallergenic formula   

No of scoops

Day 2 210 2 5
Day 3 210 3 4
Day 4 210 4 3
Day 5 210 5 2
Day 6 210 6 1
Day 7 210 7 0

If no symptoms occur after replacing one bottle with cow’s milk formula, the infant may continue to consume cow's milk formula in all bottles and consume milk containing products. If no symptoms occur within 2 weeks of consuming more than 200 mls cow’s milk formula per day, then the infant does not have cow’s milk allergy or it has resolved.

03 What Others Say

  • Venter et al UK guidelines for manangement of Non IgE mediated cow milk allergy, includes a milk ladder. We recommend that any milk challenge be done under medical supervision and not at home.

How to do a cow milk challenge at home or hospital


04 Clinicians Tools and Resources

  • Journal of Allergy and Clinical Immunology Vol 128, issue 1 Pages 125-131: Kim et al

Dietary baked milk accelerates the resolution of cow's milk allergy in children

  • Ann Allergy Asthma Immunol 2012 November, 109(5): 309- 313: Bartnikas et al

Predicting Food Challenge Outcomes for Baked Milk: Role of Specific IgE  and Skin Prick Testing


The information published here has been reviewed by Flourish Paediatrics and represents the available published literature at the time of review.
The information is not intended to take the place of medical advice.
Please seek advice from a qualified healthcare professional.
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Last updated: 16/11/2013 by Dr Liz Hallam