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Review
. 2024 Dec 6:5:1516774.
doi: 10.3389/falgy.2024.1516774. eCollection 2024.

Milk ladder: Who? When? How? Where? with the lowest risk of reaction

Betul Buyuktiryaki  1 , Ozge Soyer  2 , Gulbin Bingol  3 , Ceren Can  4 , Hikmet Tekin Nacaroglu  5 , Aysen Bingol  6 , Ebru Arik Yilmaz  7 , Metin Aydogan  8 , Cansin Sackesen  1
Affiliations
Review

Milk ladder: Who? When? How? Where? with the lowest risk of reaction

Betul Buyuktiryaki et al. Front Allergy. .

Erratum in

Abstract

The milk ladder (ML) approach, which is the gradual reintroduction of the milk allergen from the least allergenic forms to the most allergenic forms into the diet of the patients, has been utilized mostly in non-IgE-mediated but in some countries also in IgE-mediated-CMPA due to its possible benefits which include nutrition, quality of life and tolerance induction. Despite increasing interest, so far, there is no guideline on ML; thus, the use of this approach shows discrepancies among healthcare professionals as many factors such as dietary habits, patient history, test results, workload, and facilities of the hospitals, the anxiety of the parents/patients may affect the decision on how, when, where and whom to use ML. Here, we reviewed current data on implementing the ML, suggested a 4-step ML including receipts and amounts, and shared our experience on optimal patient selection, appropriate time and steps for initiating ML, and time intervals between the steps targeting the lowest risk of reaction. We also added the newly developed twice-baked biscotti cake to the ML. We presented the analyses of this product, showing its low allergenicity compared to conventional cake, which provides a safer introduction of milk into the diet.

Keywords: baked milk; cow's milk protein allergy; food allergy; food ladder; immunotherapy; nutrition; tolerance induction; treatment.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Characteristics of an optimal candidate and the appropriate setting for initiating the milk ladder (CM, cow's milk; CMPA, cow's milk protein allergy; CVS, cardiovascular; FPIAP, food protein-induced allergic proctocolitis; FPIES, food protein-induced enterocolitis; GI, gastrointestinal; ML, milk ladder; SPT, skin prick test; sIgE, specific IgE) (created in https://BioRender.com).
Figure 2
Figure 2
Four-step milk ladder. *1A and 3A products are optional based on the clinician's decision (created in https://BioRender.com).
Figure 3
Figure 3
Implementation of milk ladder in clinical practice (created in https://BioRender.com).
Figure 4
Figure 4
The proteomics analysis by LC-qTOF-MS.
Figure 5
Figure 5
ELISA evaluated αs1 casein concentration for milk, cake and biscotti.
Figure 6
Figure 6
Cow's milk amounts in cake.
See this image and copyright information in PMC

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