The role of Milk Ladder in cow’s milk allergy

Cow’s milk allergy (CMA) is one of the most frequent causes of food allergy (FA) in children. Dietary avoidance is considered the main treatment for CMA, but it does not promote the development of tolerance. In contrast, milk oral immunotherapy (OIT) and the introduction of baked milk into the diet are two treatment options that may lead to tolerance development. Recently, the “milk ladder” (ML) has emerged as a third therapeutic option. ML can be defined as a gradual home reintroduction of foods containing milk starting from the most easily tolerated forms and progressing to whole cow’s milk. Herein, we assess the impact of different processes on milk protein allergenicity, alongside studies evaluating the efficacy and safety of ML in children with non IgE-mediated and IgE-mediated CMPA. In non-IgE Mediated CMA, excluding FPIES, ML seems to be reasonable since it is not burdened with relevant side effects and is able to promote the early reintroduction of cow’s milk. In IgE mediated CMA, the efficacy of ML seems to be like OIT although it is burdened with similar side effects, even serious as anaphylaxis. If used to perform the first step with baked milk oral challenge seems advisable. The next steps can be done at home. Only children without a clinical history of severe reactions or recurrent wheeziness can be candidates for ML, starting as soon as possible and in any case not in children over 6 years of age.