Advice on milk re-introduction at home

For children who have had a previous mild reaction to milk, it is appropriate to try re-introduction of well-cooked (baked) milk products at home. Most children with a milk allergy grow out of it in early life. As the allergy resolves, many children will start to tolerate well-cooked milk products first, followed by lightly cooked milk, and finally, uncooked milk.

The speed with which milk allergy resolves can vary greatly between individuals, and therefore the timing and appropriateness of reintroduction should be individually assessed. Children who have had only mild symptoms (only skin rashes or swelling) on significant exposure (such as a mouthful of milk) with no on-going asthma are suitable for baked milk products like malted milk biscuits, to be introduced at home.

This stepwise guide can also be used for non-IgE mediated milk allergy.

Important information about the re-introduction plan

• Firstly, ensure your child is well, and any eczema or hayfever is well controlled.
• The first stage is ‘home reintroduction of baked milk’. Your child must complete this stage with no reaction, before moving onto the next stages.
• You can stay at each stage for longer than stated in this plan but do not move to the next stage more quickly than stated. Do not skip any stages.
• Try to give the dose every day or on most days. If you miss several days (e.g. your child is unwell) give a smaller dose when you restart.
• Do not increase to a higher dose if your child is unwell.
• Ensure you have an up to date allergy action plan and your emergency treatment to hand (for IgE mediated milk allergy)
• If your child begins to show symptoms such as a rash, eczema flare, tummy ache, vomiting, diarrhoea/loose stool, throat tingling, reduce the dose to a lower level that has previously been tolerated. Contact your doctor or dietician if necessary.

Stage 1: Home milk reintroduction of baked milk

You can either buy a supermarket brand of malted milk biscuit or make your own (recipe provided below). Please ensure any shop-bought biscuit contains ‘milk powder’ and not ‘whey powder’ as an ingredient.

Week one

Small crumb of biscuit containing milk to be eaten every day - malted milk biscuit

Week two

Large crumb of biscuit to be eaten (two days)

1/16 biscuit to be eaten (two days)

1/8 biscuit to be eaten (three days)

Week three

¼ biscuit to be eaten daily

Week four

½ biscuit to be eaten daily

Week five

One whole biscuit to be eaten daily

*Milk biscuit recipe for stage 1 (makes 5 biscuits)

• One tablespoon of flour (gluten-free if necessary)
• One teaspoon of coco powder (optional)
• One and a half teaspoons of sugar or two teaspoons of fruit puree
• One teaspoon of dairy-free margarine
• One teaspoon of milk

Preheat oven to 200 degrees C (180 C for fan ovens). In a small bowl, cream the margarine and sugar together, add the milk and then flour and cocoa (if using). This will make stiff dough: if it is too dry add a small amount of water. Make 5 small equal size balls and place on baking tray covered with greased baking paper. Cook for 12 - 15 minutes or until completely cooked.

Only move onto stage 2 once your child is tolerating 1 biscuit daily with no reaction. Discuss this with your doctor or dietitian if you are unsure.

Stage 2: Other baked milk products

Once your child is tolerating a whole biscuit, you can begin to offer other foods that contain milk and are mixed with flour and cooked at high temperatures:

• Other biscuits (no cream filling or icing)
• Cakes (no icing or filling)
• Ready-made Yorkshire puddings
• Trifle sponges/ice cream wafers/pastry cases
• Scotch pancakes
• Waffles/muffins/shortbread
• Breaded fish/chicken
• Bread containing milk or butter as an ingredient
• Naan bread

You can also try butter, and recipes that contain butter or margarine.

Remember:

• For each new food tried, try a small amount first and increase the amount slowly.
• If a particular food causes symptoms, leave it out or try a smaller quantity
• If symptoms are frequent with stage 2, stick to stage 1 (one biscuit per day) for two to three months and then try stage two again.

Stage 3: Products containing cooked cheese or heated milk

These foods contain considerably more milk protein, which can vary greatly between products. Only begin to try foods from this stage if your child is regularly eating foods freely from stage 2 without symptoms, or your dietician has advised you to do so.

Foods to try include:

• Crisps or snacks with cheese flavouring
• Custard, custard tart
• Pizza, cheese or white sauce
• Soup made with milk (cream soups)
• Rice pudding
• Dishes that contain heated milk such as cottage/shepherds/fish pie with a mash potato topping, lasagne or other oven baked pasta dishes
• Homemade batters, for example pancakes, Yorkshire pudding
• Chocolate and chocolate covered items like chocolate/chocolate chip biscuits
• Fermented desserts e.g. yoghurt, fromage frais

Remember:

• Give small amounts initially such as one lick of yoghurt or one strand of cooked cheese and build up on the quantity.
• Each food is different so do not assume if you are eating one product, all will be tolerated. Start each new food in small quantities first.
• If symptoms occur on small traces of these products, stay on stage two for another two to three months.
• It is much better to have a daily ‘dose’ of a milk-containing food and build up the quantity every week rather than give it only once or twice per week in larger quantities.

Stage 4: Uncooked milk products

These foods should only be tried if your child is regularly eating foods from stage 3.

Foods to try include:

• Uncooked cheese
• Uncooked non-yoghurt desserts like cheesecake, mousse, ice cream, cream cakes
• Fresh cow’s milk, milk shakes

Remember:

• Start with small doses e.g. teaspoon ice cream, small piece of cheese.
• If trying fresh cow’s milk, start by trying one teaspoon on breakfast cereal and increase every couple of days.
• If your child dislikes the taste of milk, try it in hot chocolate, milkshake or mixed with the child’s usual milk substitute.
• If symptoms occur, refer to your allergy emergency treatment plan and continue to only allow foods from stage three, but retry in two to three months until full tolerance is achieved. If severe symptoms occur obtain advice before moving back up to stage four.