Milk ladder as a therapeutic option for cow’s milk allergy: Proposal for a step-by-step plan for cow’s milk introduction in cow’s milk allergy

In regard to cow’s milk allergy, the current option of avoiding can be expanded by (re-)introducing milk using a milk ladder. So-called “food ladders” are internationally well known and utilized for both non-IgE-mediated and IgE-mediated cow’s milk allergy. Stepping up the stairs from highly processed baked goods with milk via cooked milk products to pasteurized fresh milk reflects the status of acquired tolerance of each level. The allergenicity of milk depends on processing and amount. By implementing the milk ladder, it can enhance the clinical process of tolerance development, lead to meeting nutrient requirements quickly, and involve parents actively in the therapeutical process. The milk ladder, for the first time being published and adapted for Germany, describes a structured framework that might be adapted individually regarding the time period on a certain level or other variations such as preparation/amount of milk products. From a safety perspective, healthcare professionals should pay great attention to patient selection and education prior to implementing the milk ladder. Detailed advice as well as recipes and a graphical presentation can be found in the supplemental material.