About non-IgE cow’s milk protein allergy

0 to 6 months

• Your baby should be settled and free from symptoms on a cow’s milk free diet (either through change to maternal diet if required during breastfeeding or through a change in your baby’s formula).
• If symptoms don’t improve or you have any concerns regarding your baby’s feeding please contact our team for further advice.
• Babies from birth to 1 year of age who are being breastfed should be given a daily supplement containing 8.5 to 10 micrograms of vitamin D. Babies who are formula fed (and are having more than 500ml formula per day) do not require vitamin supplementation. If you are breastfeeding (and following a dairy free diet) you may need to start taking a calcium supplement as your body’s requirement is much higher during breastfeeding.

6 months+

Weaning

• When your baby shows signs of readiness to wean (for further guidance on weaning), your child should be weaned onto a completely milk-free diet. Weaning should not be started before 17 weeks unless advised by a health professional.
• Please refer to our ‘milk free weaning’ section for support with weaning
• After 6 months of age your child can be introduced to other common food allergens, each food allergen should be introduced very gradually, one food at a time to allow you to see clearly if your child reacts to the food allergen (for further guidance weaning food allergies)
• After 6 months your child can be introduced to fortified dairy-free alternative products (for example, soya, oat, coconut, pea, nut based products). Rice milk is not suitable for children under 4.5 years old. Please see our ‘milk free weaning’ section for further advice on choosing the right product for your child.
• If you are using shop bought products, you will need to check the food label each time to ensure that it is completely free from milk products. By law, if the product contains milk it has to be clearly labelled (in bold, italics, underlined or highlighted).Your infant should be started on a vitamin A, C and D supplement if their formula intake is less than 500ml or if they are breastfed and over 6 months old.

9 to 12 months

Milk reintroduction

• Most children will outgrow their milk allergy. Introducing milk back into their diet needs to be slow, to get their body used to tolerating it.
• If your child is between 9 to 12 months and has been free from milk and symptoms for 6 months, they are ready to be reintroduced to milk using ‘the milk ladder’. Please see our ‘Milk ladder’ including guidance notes and recipes to support with this.

12 months+

• By 12 months old your baby should be eating a varied diet with foods from all food groups included in their diet.
• Your GP will stop prescribing the specialist formula, and instead your child can be given a fortified dairy-free milk alternative (for example, oat, soya, pea, coconut, nut milk, see milk free weaning guide for further information).
• Your child should continue to have a daily vitamin A, C and D supplement until they are 5 years old

When should I start weaning?

We should aim to start weaning around 6 months old, when child is showing signs of readiness (please see how to start weaning your baby). Weaning should not be started before 17 weeks unless advised by a health professional.

For general weaning advice, including types of foods and textures to offer at each stage as well as guidance on finger foods and baby-led weaning please see what to feed your baby from around 6 months.

All children under 5 taking less than 17floz or 500mls formula every day should be given a daily multivitamin. You can get these with healthy start vouchers or buying these in a pharmacy or supermarket. Continue to provide your child with a daily multivitamin to their 5^th birthday.

How to wean my infant on a milk-free diet?

Your infant needs to be weaned on a completely milk-free diet and continue with this until advised otherwise by a health professional or until they are old enough to begin milk-reintroduction via the milk ladder (9 to 12 months old). Weaning an infant who has CMPA should be the same as weaning an infant without a milk allergy, except that you must not give any foods that contain cow’s milk. The types of foods and textures offered at each stage is the same for all infants.

A cow’s milk free diet means avoiding the proteins in cow’s milk, which are called whey and casein. It is recommended to avoid all mammalian milks if your child has a CMPA as the protein structure is similar, therefore goat and sheep milks are not suitable alternatives.

Reading food labels

• Your infant needs to avoid any food which has milk listed in the ingredient list. Milk is a common food allergen, so it must be clearly labelled in bold, italics, underlined or highlighted on all food packaging. Remember ingredients of foods can change over time, so please check the food label every time the food product is given.
• You do not need to avoid foods that say they ‘may contain milk’, if milk is not a listed ingredient on the packaging.

Milk alternative products

• From 6 months old your infant can have milk-free alternative products such as cheese, yoghurt or milk. Including these products as part of your infant’s diet will mean that they don’t have to miss out on eating certain meals or snacks as you can use their milk-free alternative.
• Recommended options include soya, oat, coconut, pea, and nut based products. You should avoid rice-milk as this is not suitable for children under 4.5 years old due to its arsenic content.
• You can use milk-alternatives on your infant’s breakfast cereal or porridge and in cooking from 6 months old. but it should not be used as their main drinking milk until over 12 months old.
• You will find milk free alternative products in most common supermarkets and most supermarkets have their own range of dairy-free products, which can often be a cheaper alternative to branded products.
• Milk-alternative products vary in terms of their nutritional content – please choose carefully using the top tips below.

Top tips for choosing a milk-free alternative

• Choose a product that is fortified with calcium (ideally 120mg or 100ml) and ideally has added iodine, vitamin D and vitamin B12.
• Check the energy and protein content of the milk alternative, ideally choose one that contains more than 50kcal per 100ml and 2 to 3g protein per 100ml. If your child is underweight, choose an option that has the highest calorie content.
• Choose unsweetened versions as your child does not need added sugars in their diet.
• Avoid organic versions as these do not have the added vitamins and minerals that your child needs.
• Avoid choosing products with added salt

Can I give my child other common food allergens during weaning?

For infants with CMPA, the guidance is no different to infants without CMPA in that we would encourage common food allergens to be introduced at around 6 months old. For some infants at high risk of food allergy, earlier introduction of certain food allergens may be helpful, but this should not be started unless advised to by a health professional.

When introducing allergens into your infant’s weaning diet, each allergen should be introduced one at a time starting with a very small portion of the food to make sure they don’t react, before increasing portion size. For further information on food allergies.

Soya around 50% of children with CMPA react to soya in the same way as they did to milk as their protein structure is similar. If you think your child is reacting to soya in the same way as they did to milk, please exclude soya from your child’s diet as well as milk at this stage. Soya is not recommended to be given until 6 months old.

Who and when?

Infants and children

• Breastfed infants are recommended to have a daily vitamin D supplement from birth of 8.5 to 10mcg/day.
• A daily infant multivitamin containing vitamin A, C and D is recommended for infants over 6 months who are breastfed and for formula fed infants once their daily intake is less than 500ml per day. This is recommended to continue until your child is 5 years old.
• If you receive income support, you are able to receive healthy start vitamin drops from your local baby clinic or health visitor. Otherwise, you can buy children’s vitamins from your local pharmacy, supermarket or order online.

Whilst breastfeeding:

• Whilst breastfeeding, it is recommended to take a daily vitamin D supplement of 10mcg per day
• If you are unable to meet the daily calcium requirements whilst breastfeeding (1250mg/day) through diet alone (for example, drinking 1 litre calcium fortified dairy-free milk per day), it is recommended to consider taking a daily calcium supplement.

Most children with delayed CMPA can tolerate cow’s milk again as they get older. Approximately 50% of children grow out of their milk allergy by 12 months old, with around 85 to 90% growing out of their milk allergy by 3 years old.

Once your child is between the age of 9 to 12 months and has had at least 6 months free from any milk and any associated symptoms, we will support with gradual introduction of milk back into their diet. This is completed in a structured way using a ‘milk ladder’. You will receive further guidance on this when your child is between 9 to 12 months old

Who can use this guide?

This guide is for children with non-IgE (delayed) cow’s milk protein allergy, who have been advised to reintroduce dairy products back into their diet by a dietitian.

When should we start?

We recommend starting the milk ladder between 9 to 12 months old, once your child has been milk-free for at least 6 months, with symptoms well controlled. Please make sure your child is well at the time of starting.

Why should I use the milk ladder?

Most children will outgrow their milk allergy. Introducing milk back into their diet needs to be slow, to get their body used to tolerating it. The first step includes milk in a very well baked form (cooking at a high temperature breaks down the milk proteins so it is less likely to cause a reaction). We then move up the ladder, introducing less well-cooked dairy products. Using the milk ladder provides a structured plan to introduce milk, which makes it easier to notice if and when any symptoms occur.

How do I use the ladder?

The milk ladder has 6 steps to introduce milk back into your child’s diet. At each step, start with a very small portion of that specific food. If tolerated, gradually increase amount given with the aim being to giving a full portion of the food before moving to the next step. For example:

• For step 1 to 4: We would recommend starting with a quarter portion > half portion > three quarter portion > full portion
• For step 5 to 6: We would recommend introducing a small amount of yoghurt or milk into your child’s dairy free alternative product, for example, 1 spoonful and 1oz (approximately 30ml) and then gradually increase the amount every few days, until your child manages a full portion.

We would recommend giving each portion of the food at least three times to make sure it is tolerated before moving up, for example, quarter biscuit to be given 3 times, before increasing to half biscuit.

If you are worried about starting the milk ladder, you could start with an even smaller portion size. The total portion size of each food is for guidance only, smaller children may not manage the full amount.

How long will it take to complete the ladder?

All children are individual and will work their way up the milk ladder at different rates. It is important to support your child to go at a pace that is manageable for them and doesn’t cause symptoms to flare up.

What if my child reacts?

A reaction would mean that your child develops similar symptoms to what they had when they previously had dairy in their diet. If your child reacts, firstly make sure that the symptoms are not related to something else, for example, tummy bug, teething, virus. You can do this by removing milk for 2 weeks or until symptoms settle and then try again. If your child reacts to the first portion size in step 1, return to a milk-free diet for 3 months before trying again. If your child reacts further up on the ladder, please go back to the step tolerated and continue to offer this food 2 to 3 times weekly for 2 to 3 months, before trying again. Please avoid stopping the milk ladder completely if your child is tolerating some of the foods on the milk ladder, as regular exposure is helpful to progress.

Can I use other foods?

Shop bought alternatives can be used, but it is harder to control how much milk protein is in each portion (with the recipes we know exactly how much milk protein is in each food). Please do always check the ingredients as things do change and please check for other allergens if your child needs to avoid any others.

Should I tell nursery and school to do the milk ladder?

Keep your child on a milk-free diet whilst at school and nursery and just try the reintroduction at home. This will help you to keep control of portion sizes and note any reactions your child has.

At each of the following steps, cookie, muffin, pancake, cheese and yoghurt:

It may be advisable in some cases to start with a quarter or half of that particular food and then over a few days to gradually build up to a whole portion, Please ask your healthcare professional for guidance on this.

The lower steps are designed to be used with home made recipes. this is to ensure that each step has the appropriate milk intake. the recipes will be provided by your healthcare professional.

Should you wish to consider locally available store-bought alternatives, seek the advice of your healthcare professional.

Step 1

Cookie or biscuit

Amount: 1 and build up to 3 (see recipe).

Step 1 shop bought option: malted milk biscuit, Aldi shortcake biscuit, Tesco or Sainsbury’s digestive, Belvita breakfast biscuit, ‘baby’ biscotti (Heinz or Kiddilicious apple or banana flavour or Aldi Mamia apple flavour).

Step 2

Muffin

Amount: half and build up to 1 (see recipe)

Step 2 shop bought option: Plain cupcake (no buttercream or chocolate), milk roll bread, plain naan, for example, pataks and plain brioche.

Step 3

Pancake

Amount: Half and build up to 1 (see Recipe)

Step 3 shop bought option: Buttermilk or scotch pancake, frozen Yorkshire puddings

STEP 4

Cheese

Amount: 15g (half fl oz) (hard cheese, for example, cheddar or parmesan). Once your child tolerates cheese, you can introduce 15g baked cheese on a pizza or baked on other food as well.

Step 5

Yoghurt

Amount: 125mls (4.5 fl oz)

Once your child tolerates yoghurt, butter, spread, chocolate buttons, fromage frais, petit filous (be careful of the sugar content), you can introduce softer cheese like cream cheese and camembert and brie- remember to use pasteurised soft cheese for children.

Step 6

Pasteurised milk and suitable infant formula

Amount: Start with 100ml (3.5 fl oz) of pasteurised milk and infant formula and mix this with current milk replacement. Build up to 200 ml (7 fl oz). If this is tolerated switch all current milk replacements (bottle and in breakfast cereals) to pasteurised milk or suitable infant formula. Discuss what is an appropriate amount of milk and milk products with your healthcare professional. UHT and sterilised milk will be tolerated as well.

Step 1: Baked milk powder, Biscuit

(makes 8 to 10 biscuits)

Sweet biscuit

Ingredients:

• 125g plain flour (if using wheat-free flour, add 3g Xanthan Gum)
• 50g cold dairy free spread
• 1 teaspoon skimmed milk powder
• 2 tablespoons grated apple, pear, mashed banana
• 1 to 2 drops vanilla essence

Instructions:

1. Mix the flour and milk powder
2. Rub in the cold dairy free spread
3. Mix in the fruit (you may need to add a little bit more if the mixture is too dry) and vanilla essence
4. Roll out and cut in to 8 to 10 biscuits (dough can be easier to handle if chilled for 30 minutes before rolling out)
5. Bake in the oven at 180^oC or 350^oF for 10 to 15 minutes

Savoury biscuit

Ingredients:

• 125g plain flour (if using wheat-free flour, add 3g Xanthan gum)
• 50g cold dairy free spread<
• 1 teaspoon skimmed milk powder
• 40g grated dairy free cheese
• 2 tablespoons of cold water

Instructions:

1. Mix the flour and milk powder
2. Rub in the cold dairy free spread
3. Mix in the grated dairy free cheese. Add water (if mixture is too dry, you can add more)
4. Roll out and cut in to 8 to 10 biscuits (dough can be easier to handle if chilled for 30 minutes before rolling out)
5. Bake in the oven at 180^oC or 350^oF for 10 to 15 minutes

Step 2: Baked milk, Muffin

(makes 6 muffins)

Sweet muffin

Ingredients:

• 250g self-raising flour (if using wheat-free flour, add 3g Xanthan gum)
• 250ml whole milk
• 110g grated and mashed fruit: Apple, pear, banana
• 50ml sunflower oil
• 25g sugar
• 1 to 2 drops vanilla essence
• A pinch of salt

Instruction:

1. Mix the flour and salt together
2. Mix oil and milk together then add to the dry ingredients
3. Add in chopped fruit and vanilla essence and mix through
4. Divide mixture between 6 muffin cases
5. Bake in the oven at 180^oC or 350^oF for 15-20 minutes

Ideas to try: Add 50g fresh or frozen blueberries, raspberries, sultanas or add 2 tablespoon cocoa powder to dry ingredients for a tasty chocolate muffin.

Savoury muffin

Ingredients:

• 250g self-raising flour (if using wheat-free flour, add 3g Xanthan gum)
• 250ml whole milk
• 60g grated dairy free cheese
• 50ml sunflower oil
• A pinch of salt

Instruction:

1. Mix the flour and salt
2. Mix oil and milk together then add to the dry ingredients (whisk oil and milk for lighter muffins)
3. Add grated dairy free cheese and mix through
4. Divide mixture between 6 muffin cases
5. Bake in the oven at 180^oC or 350^oF for 15 to 20 minutes

Ideas to try: Add chopped spinach, grated carrot, sweetcorn for some extra colour and fibre

Step 3: Pancakes

(makes 6 pancakes)
Ingredients:

• 125g plain flour (wheat or wheat-free)
• 250ml whole milk
• 50ml water
• 30ml sunflower oil
• 10g baking powder
• A pinch of salt

Instructions:

1. Add flour to a large mixing bowl
2. Mix together wet ingredients, then gradually mix into flour to create a smooth pancake mixture
3. Add to a hot pan with oil and cook until golden brown
4. Serve with toppings of your choice, for example, lemon, berries, dairy free yoghurt

Step 3 Alternative

If your child does not like pancake texture, you can try baked mashed potato as an alternative option for this stage.

Boil 1 small potato until soft. Mash with 42ml whole milk and some dairy free spread. Add to baking dish, cover with foil and bake in the oven for 40 minutes.

• Weaning
• Milk allergy
• Cow’s milk free diet