Milk proteins and three ways to manage cow's milk allergy
What it found
In children with IgE-mediated cow's milk protein allergy, strict avoidance, the milk ladder and oral immunotherapy all showed some success in building tolerance, but the studies varied widely and no trial has compared the three directly.
What they found
Studies in people
Avoidance and natural tolerance
Avoiding cow's milk protects against allergic reactions until natural tolerance develops. One analysis found 56% of children formerly diagnosed with cow's milk allergy became tolerant at one year of age and 77% at two years.
Alternative formulas
In one study, 41 of 52 children (78.8%) taking an amino acid-based formula for a mean of 11.4 months achieved tolerance to cow's milk. Another study found that a formula with a probiotic led to more children developing tolerance than the formula alone.
The milk ladder
Studies of baked milk introduction found that 54% to 88.1% of children (mean 62.5%) became tolerant to unheated milk, compared with 0% to 66.7% (mean 21.42%) of those who strictly avoided milk. In one study, 43% of patients had a mild to moderate reaction during the milk ladder, but no anaphylaxis needing adrenaline.
Oral immunotherapy
Success rates for oral immunotherapy varied across studies, with some reporting that 71.4% to 91.3% of children reached a target dose of 200 mL of cow's milk. Adverse reactions were common, and a small number of patients needed adrenaline.
Early introduction in infants
In one study, 97% of infants under 12 months reached a target of 150 mL of milk with a home-based protocol. In another, 98.5% and 98.1% of infants in two groups completed treatment successfully.
Other findings
Comparing the strategies
The authors say it is not possible to objectively compare the effectiveness of the three strategies because there are no clinical trials directly comparing them. They note that the milk ladder can be done at home, while oral immunotherapy requires at least three oral food challenges.
What the authors conclude
“Though the milk ladder and early introduction to milk using oral immunotherapy may provide methods of introduction to milk for CMPA, further studies should prospectively compare the effectiveness and safety of these treatments for IgE-mediated CMPA compared to the natural acquisition of tolerance to milk.”
Also in their conclusions
- They conclude that the milk ladder and early introduction using oral immunotherapy may provide methods of introduction to milk for children with IgE-mediated cow's milk protein allergy.
- They advise that further studies should prospectively compare the effectiveness and safety of these treatments compared to the natural acquisition of tolerance to milk.
How it was done
Rates of resolution of cow's milk protein allergy are slowing down, so the authors wanted to look at other ways to promote tolerance to cow's milk in children.
They combined and appraised published studies on three management methods for IgE-mediated cow's milk protein allergy: strict avoidance, the milk ladder, and oral immunotherapy. They also looked at early introduction using oral immunotherapy in infants.
What it can’t tell you
- The studies included in this review used different rules, doses and lengths of treatment, so their results cannot be directly compared.
- It is not clear whether the milk ladder or oral immunotherapy actively change the allergy or simply introduce milk while the child is naturally outgrowing it.
- The review cannot show whether one strategy is safer or more effective than another because no trial has compared them head to head.
Who paid
- Funding
- Funded by National Dairy Council and Dairy Research Ireland (from the PubMed record).
- Conflicts
- The authors declare no conflict of interest.
- Authors work at
- University College Cork, Ireland; Cork University Hospital, Ireland
The paper
- Title
- 'Early Introduction' of Cow's Milk for Children with IgE-Mediated Cow's Milk Protein Allergy: A Review of Current and Emerging Approaches for CMPA Management
- Type
- ReviewThe authors read earlier studies and describe what they found. It isn’t a new study.
- Evidence
- Studies in people
- Summarised from
- Full text
- Licence
- CC BY. Words in quotation marks are the authors’; the rest is our summary.
- Cite
- Cronin C, Ramesh Y, De Pieri C, Velasco R, Trujillo J (2023). 'Early Introduction' of Cow's Milk for Children with IgE-Mediated Cow's Milk Protein Allergy: A Review of Current and Emerging Approaches for CMPA Management. Nutrients. doi:10.3390/nu15061397Free full textPubMed 36986127DOI
Summary written 26 Sep 2026. Check it against the paper before it changes what you eat. How we summarise papers · Report an error