The basics of the iMAP milk ladder

Want to find out more about how to reintroduce dairy using the iMAP milk ladder? Here I am sharing all the basics you need to know, including links to the official iMAP ladder and accompanying guidance.

Read on to find out:

• What is the milk ladder? 
• Who developed the iMAP milk ladder?
• How many steps does the iMAP ladder have?
• What about the 12 step iMAP milk ladder?
• Who is the ladder recommended for?
• What about if my child has immediate or particularly severe delayed reactions?
• Recipes to accompany steps 1 to 3

What is the milk ladder? 

The milk ladder is a structured way to attempt to reintroduce milk into the diet after a period of avoidance. It progresses through different forms of dairy to assess what can be tolerated. It starts off with well baked milk (for example in a biscuit). The end goal is to be able to drink fresh milk or dairy based formula. 

This explanation from Allergy UK is helpful in explaining how it works:

“The milk ladder starts with well cooked (baked) milk products because this is the form of milk least likely to cause an allergic reaction. The presence of flour is also important in binding with the baked milk and making it less allergenic. When milk is heated or ‘baked’, the protein is changed into a less allergenic form and so your baby/infant can tolerate this form first. If your baby shows no allergic reaction, then lightly cooked milk products (less baked) or heated milk products without flour are given until finally uncooked fresh milk can be tried when recommended.” 

The purpose is not purely to achieve a full reintroduction of dairy. Working up through the steps of the ladder in a controlled way allows tolerance to be assessed. If a certain step is tolerated, the idea is that it can then be maintained in the diet – even if steps higher up the ladder are not yet tolerated. 

Who developed the iMAP milk ladder?

The iMAP milk ladder is one of the supporting documents accompanying the international Milk Allergy in Primary Care (iMAP/MAP) Guideline. The guideline was most recently updated in 2019. It was developed by a team of clinical experts, with patient involvement.

The guidelines and accompanying documents are hosted on the GP Infant Feeding Network website. They state that “GPIFN and the MAP team have shared goals of promoting appropriate management of infants with suspected milk allergy, avoiding over diagnosis or delayed diagnosis, encouraging breastfeeding and improving the quality of life for families and infants.”

I talk about this more in the basics of CMPA, but if you’re struggling with getting the right support from your GP then I really recommend getting familiar with these guidelines. You can even share them with your GP if necessary.  In fact, the introduction to the guideline suggests this: “GPs have to be aware of so many topics, please feel able to share this website, including the MAP 2019 update with your GP if you feel it could help them to help you.”

How many steps does the iMAP ladder have?

The current iMAP ladder has 6 steps. It starts with cookies or biscuits containing baked milk. It then moves on to muffins, pancakes, cheese, yogurt and finally pasteurised milk or infant formula. 

The ladder suggests amounts to be given at each stage, but this can be adjusted by your healthcare professional if necessary. In terms of how long to spend on each stage, the guidance states “The time spent on each Step will vary from one child to another depending on their individual expression of milk allergy. This should also be discussed and agreed with you.” 

Each individual situation is different and there may be very good reasons for deviating from the 6 step ladder; the iMAP guidance states “your HCP may adjust the number of Steps to suit your child best”. You may also find that some healthcare professionals have their own versions of the ladder based on the same principles.

If you’re unclear as to why a particular approach is being recommended for your child, you can use the information here to inform a conversation with your healthcare professional.

What about the 12 step iMAP milk ladder?

You may well have seen references to a 12 step ladder. This was the ladder accompanying the original MAP guidelines, which has since been replaced by the streamlined 6 step ladder. The 12 step ladder may still be suggested if there’s reason for a more gradual reintroduction. Again, if you’re unsure you can use the information in this post to ask why the 12 step ladder has been suggested instead of the 6 step approach.

Who is the ladder recommended for?

The iMAP guidance states that it is “to be used only in children with Mild to Moderate Non-IgE Cow’s Milk Allergy under the supervision of a healthcare professional”. 

Non-IgE is otherwise known as delayed onset Cow’s Milk Protein Allergy. Symptoms can occur between 2 and 72 hours after consuming the allergen. This type of delayed allergy used to be referred to as an intolerance, but this term is no longer used. It is now clear that it is an allergy affecting the immune system.

The other type of Cow’s Milk Protein Allergy is IgE, or immediate onset. With IgE reactions, symptoms typically appear immediately after consuming the allergen, or within two hours. There’s generally a clear link between what’s been eaten and the subsequent reaction. The milk ladder is not usually recommended for children with an IgE allergy.

You can read more about Non-IgE and IgE reactions, including common symptoms, in this basics of CMPA post.

What about if my child has immediate or particularly severe delayed reactions?

Children with IgE allergies are often offered a hospital based milk trial. Doing a milk trial in hospital allows exact monitoring of portions, as well as a swift response to any reactions. Your child’s allergy team will consider factors such as results from recent skin prick and blood tests when deciding if this is an appropriate approach.

Recipes to accompany steps 1 to 3

There is a booklet of recipes that iMAP have created to accompany the first three stages of the ladder. Following these recipes and making the food yourself allows for more control over how much dairy is included in each portion. 

Download the recipes here

All the recipes are free from egg and soya. Very helpful if your child is allergic to either of these; you don’t need to fuss around making your own amendments! For each recipe there are also gluten free adaptations.

And finally… good luck!

I know from personal experience that the milk ladder is a daunting thing to get started with. If you have any other questions then pop them in the comments and I’ll do my best to answer them, or send you in the direction of the right info x x