Milk Ladder Process: Growing-up with CMPA

If the child has had an immediate-type CMPA (IgE or mixed) then the OFC would be performed in a supervised clinical setting. While a child who has had a non-IgE-mediated allergic reaction to cow’s milk/dairy can usually start (supervised) reintroductions at home.

HCPs will decide, along with the parents/child, when the reintroduction process can start. In those that have a home supervised challenge it is usually done using a step-by-step process, commonly called the ‘Milk Ladder’ (MAP) or international Milk Ladder (iMAP) (Venter et al., 2013;Venter et al., 2017).

  • Only start the Milk Ladder when the child is well.
  • Don’t start the Milk Ladder if the parent/caregiver is going through a busy period at work or at home.
  • Encourage the parent/caregiver to start in the morning or lunchtime, rather than in the evening, so that they can monitor the child throughout the day.
  • The Milk Ladder starts with foods that are highly processed. Ensure that these foods are tolerated before moving to the next step on the ladder. The length of time on each step will vary depending on the individual child it can vary from one day to seven days.
  • Some children will tolerate the more processed foods (earlier steps of the ladder), for example, biscuits and cakes containing milk, but may develop symptoms when given yoghurt or cheese (later steps of the ladder). If this happens, it is best not to proceed with further steps but to encourage that the child continues to consume all foods that have been tolerated up to that point. The symptom-causing foods can be tried again later.
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Food challenges should always be supervised by an allergy specialist HCP.