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.

I’m so pleased to have Specialist Paediatric Allergy Dietitian Lydia Collins-Hussey (AKA The Milk Allergy Dietitian) contributing her top tips to this post. Lydia is an award winning, UK registered dietitian with over 10 year’s experience. She sits on the  British Dietetic Association (BDA) Food Allergy Specialist Group Committee.

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
  • 5 top tips from a dietitian when starting the milk ladder

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.

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. In some circumstances it may be used under strict guidance from an allergy team. 

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.

5 top tips from a dietitian when starting the milk ladder

by Lydia Collins-Hussey

The reintroduction of milk can feel daunting for most families, especially in those early days where it may have been difficult to even obtain a diagnosis of CMPA. The thought of now introducing milk may fill you with worry that symptoms could return. 

The Milk Allergy Dietitian

My name is Lydia Collins-Hussey and I am a specialist paediatric allergy dietitian. Here are my top tips to support you with the ladder. But before we begin, let me cover the basics…

The milk ladder is a gradual step-by-step guide to introducing milk back into your child’s diet. It is intended for non IgE mediated milk allergy (delayed milk allergy). However, more recently it is also being used in IgE mediated allergy (immediate milk allergy) under strict guidance from an allergy team. 

The ladder starts with baked milk (biscuit). This is more likely to be tolerated compared to fresh milk because the milk protein is heated and mixed in a wheat matrix. As you increase up the ladder the milk protein becomes less baked or processed until fresh milk is reached.  

Lydia’s Top Tips

1. Seek advice

Make sure you are being supported by a health care professional that works in the field of allergy. I know this is easier said than done in the current NHS climate and waiting times. However, the milk ladder is only a guide and should be tailored to each individual. 

You may need to start at a much slower pace depending on previous symptoms. Or, you may go quicker as your little one has had accidental exposure to steps higher on the ladder and tolerated.  

Not only is it important to seek advice initially, but to also communicate with your healthcare professional or team regularly. They can provide ongoing guidance, support and more importantly adjustments to your plan (surprisingly this happens more than you think). 

2. Getting started 

The one thing you need to ensure before starting… is that you feel 100% confident in what to do and what the ladder involves. If you’re not sure, reach out to your dietitian. 

You will see from a simple google search that there is an array of different ladders which can make it confusing which one to choose. The 6 step is more commonly known and most up to date. But, you will find that different allergy teams adapt ladders and have their own versions too. 

Before getting started, ensure your child is well, with no tummy symptoms and any eczema under control.

3. It’s not a race 

Try not to compare to others that are on the ladder. Sure, there are some little ones that fly up. But for the majority it can take a lot longer, with research showing the average time to complete is around 15 months.  

Delays in the ladder are common whether its due to illness, second guessing if it’s a reaction or not, or simply because you are starting with much smaller amounts (yes, there are cases where we start with a crumb). Remember slow progress is still progress. 

4. Be patient

Your little one may not be progressing as you expected but please don’t rush the process. Usually, non IgE mediated allergy is outgrown quicker than IgE mediated with the majority by school age. 

If your child is over 5, please don’t be disheartened as there is research that children go on to outgrow in later childhood too. Tolerating baked milk is a good sign that your little one will then go onto outgrow their milk allergy.  

5. Take a step back 

If it’s all getting too much, take a deep breath and pause. There is no harm pausing with where you are on the ladder and keeping in foods you know are being tolerated. 

Reach out to your dietitian. That’s what they are there for, to support and provide you with guidance. 

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

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