Introducing Cow's Milk To Babies

Is it necessary to use a ladder approach for introduction? There has been an increasing trend of parents using a version of the dairy ladder when introducing their bub to dairy for the first time…but is this approach really needed? Or does it just add more mental load and stress for parents at what is already an overwhelming busy stage of life?

Lactose intolerance

The theory is that a baby's digestive system is not mature, and like them, it is still developing. For this reason, some forms of dairy aren't well tolerated by bub, specifically dairy products high in lactose. Most people have heard of lactose intolerance, right? So far this theory doesn't seem wildly impossible. There is a huge BUT coming though…

BUT as breastmilk in 5-7.5% lactose (the main carbohydrate/sugar in cow's milk too) true lactose intolerance is diagnosed very early in a baby's life. It is incredibly rare that a baby is born without any of the enzyme needed to break down lactose (this enzyme is called lactase). These babies have faltering growth and poor weight gain from birth, as well as severe diarrhoea. Lactose intolerance is more common in older children and young adults and can happen when the naturally occurring lactase enzyme starts to decline. This is very uncommon in children younger than 5 years of age, so it isn't a reason to have to introduce the dairy ladder in steps. So once again it looks like we have more unnecessary food rule spreading like wildfire over social media thanks to accounts sharing non-evidence-based information with the world.

Also, cow's milk also has LESS lactose in it than human breast milk.

How about a dairy allergy though?

A cow's milk protein allergy (CMPA) is different to a lactose allergy or intolerance. This is an allergy to the protein found in the milk. Dairy is a top 9 allergen and one of the most common infant allergies in Australia and New Zealand, So, it makes sense that parents want to be cautious about introducing dairy and doing it in a way that is safest for their little one. However, only about 2% of infants have a diagnosed cow's milk allergy, which means most families will not have to worry about managing a dairy allergy.

But what should you be looking for when it comes to dairy allergy?

Signs of CMPA:

Firstly, there are two different types of allergic reaction when it comes to CMPA.

There is your immediate reaction:

This is also known as IgE-mediated allergy and it has a rapid onset and usually occurs within 15 minutes but up to 2 after having dairy.

With a mild to moderate reaction, you may see:

• swelling of lips, face, eyes
• hives or welts on the skin
• stomach pain
• vomiting
• diarrhoea

With a severe reaction (anaphylaxis) you may see:

• noisy breathing or wheezing
• change in their voice or their cry and or difficulty vocalising
• swelling or tightness in throat or tongue
• young children may be pale and floppy

Then there is your delayed reaction:

Also called a non-IgE mediated allergy, this usually occurs two or more hours after having dairy and can even present days afterwards. This type of reaction is often really tricky to diagnose because it has symptoms that also overlap with your average baby fussiness. Signs of a delayed reaction include:

• Gut pain
• Vomiting
• Diarrhea (this may contain mucous or even blood)
• Constipation
• Colic like symptoms
• Eczema
• asthma, wheezing, coughing
• Poor growth and weight gain in some cases

Unlike immediate allergic reactions, there is no test (like a skin prick test) for delayed allergies. A strict elimination diet with monitored reintroduction is the only way to diagnose these types of allergies and this is finally where the dairy ladder does come in.

The dairy ladder is a diagnostic tool to confirm and then rechallenge a diagnosed dairy allergy. It has many steps and can take weeks to properly complete. It should only be used under the supervision of a qualified healthcare professional including a paediatrician or allergist and you should also work with a specialised paediatric dietitian. Although the ladder itself seems simple enough, if you aren't successful in progressing up the ladder knowing when to retry and how to address any nutritional gaps in the meantime for your little one is really important too. This is where a dietitian comes in. Only a dietitian, not a nutritionist, is qualified to work with allergy management. All properly qualified nutritionists will be the first to advise that consulting on allergies is outside their scope of practice.

So, the take home-if you are introducing dairy for the first time you do not need to use any version of the dairy ladder! The advice to do so once again, makes starting solids more complicated than it needs to be for your family.