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Hi and welcome to the reintroduction of cow's milk protein into your child's diet session.


My name is Helen Mackey and I'm here with Julie wood.


Both of us are dietitians from East Lancashire Hospitals NHS Trust


I'm going to talk you through the session today


So this session is for children who have previously had delayed reactions to cow's milk protein and if your child has had immediate reactions to cow's milk protein and any other food allergies then do speak to your dietitian over the telephone.


In addition to this session today you will be receiving a telephone call and these are things that can be discussed at this time.


So in today's session we're going to talk about a balanced diet and how to meet the nutritional needs for your children


but we're also going to talk about reintroducing cow's milk protein into the diet using a milk ladder


If you have any questions throughout the session do write them down and as I said, you'll be getting a telephone call and can discuss these further with your dietitian.


Between the age of 6 to 12 months, infants are gradually increasing their intake of solid foods

and they start to reduce the amount of breast milk or formula that they're taking.


Every child is different and try your best not to compare


But,  just to give you a rough idea, by the age of one year, we would expect your child to be joining in and eating three nutritious family meals.


In the next slide we're going to talk about what a balanced diet is


So here's an image of the eat well guide. As you can see, it's broken up into a number of different food groups.


The yellow category is starchy food such as bread, rice, potatoes and pasta.


The green group is the fruit and vegetables.


The pink group is the good source of protein such as meat, fish, chicken, eggs, beans and lentils.


The blue group is dairy such as milk, cheese and yogurt but we would also include dairy-free alternatives to this group as well, as long as they've been fortified with calcium.


And then the purple group is a small amount of oil and spread it's really important

that your child gets a range of nutrients and they can do this by having a range

of different food groups within their diet at each meal in similar quantities to those

represented on the eat well guide.


Cow's milk containing products are the main source of calcium within the diet,  so when you're avoiding cow's milk protein it's really important to get enough calcium from other sources. Calcium is needed along with vitamin D for strong bones and teeth.


Until the age of one year, this comes from breast milk or formula.


At the age of one year to three years, your child needs 350 milligrams of calcium. This is equal to around 300ml of cow's milk or a calcium fortified over the counter alternative.


If your child is drinking too much milk, it might impact on their intake of solid foods so it's just important to try and get the right balance.


Around the age of one, if your child is on a formula, your GP will stop this prescription and so it's just slowly transitioning your child onto an over-the-counter fortified calcium-rich alternative. We recommend the ones that have been fortified with iodine as well, including things like the Asda free-from oat milk, the oatly barista and oatly oat milks, and the marks and spencer's coconut milk.


It's worth checking all the ingredients list because products may change and may start to include things like iodine. You can also get good sources of iodine from fish as well such as

cod and haddock.


So let's recap on milk allergy. As we've mentioned in previous sessions, many children with mild to moderate cow's milk protein allergy grow out of their allergy in time. Most of them have grown out of it by the age of two.


Milk and dairy products provide an important source of nutrients in children's diets and we don't want children to avoid these unnecessarily so it's really important to include milk back into the diet at the earliest possible opportunity.


As you may recall, we've discussed in the past that there isn't any test to determine when a child is becoming tolerant to cow's milk protein. Equally, there hasn't been a test to diagnose cow's milk protein allergy. So we've got to go by a process of testing by trial and error at

regular intervals by reintroducing cow's milk protein back into the diet.


It's generally accepted that children with a milk allergies should remain on a milk free diet for at least six months until they're around nine to 12 months of age and then we'll start the milk clutter.


It's good to wait until your child is settled and well in themselves. Start the milk ladder when you are with your child and have a period of time to observe their response.


So for most children, it's completely safe to reintroduce milk protein back into the diet when the child is at home. The only time that we would consider an alternative would be if there'd been any immediate or severe reactions to cow's milk protein products.


I would also recommend to hold off if your child has current severe atopic eczema. If you've got any concerns, you can speak to your dietitian over the telephone.

I'm going to pass you over to Julie to talk about how we go about doing the reintroduction.


So now we're going to talk about how to reintroduce cow’s milk back into the diet using the principle of the milk bladder. It's not perfect, but it's based on clinical experience, it's the best available information and it's widely used across the uk.


You will have received a copy of the milk ladder in the post, along with your appointment.


So the milk ladder is based on the three following principles:


The small amounts of milk protein will be tolerated before larger amounts


Heating cow’s milk protein will change the shape of the protein structure, therefore makes it less likely to cause an allergic reaction


When you mix cow's milk protein with other food components such as fat and carbohydrates

and they're eating this all together that this will reduce the likelihood olf an allergic reaction as opposed to milk as an ingredient on its own.


So now is the time to have a look at the milk ladder that you were sent in the post. It will look very similar to the one on the right hand side of the screen.


The one on the left hand side of the screen was the old milk ladder that was previously used. So if you did google milk ladder, a similar one may appear, but we now use the one on the right hand side, which is much faster. But it's still also a gradual process. As you can see, at the bottom of the milk bladder are things that contain well-baked sources of cow's milk, for example biscuits and cookies.


Some of these items do contain quite a lot of sugar, therefore we also recommend using things like bread, bread sticks or crisps that will also contain cow's milk and you're just looking at the ingredients list and ensuring that the product now contains cow's milk as an ingredient, preferably the fourth or fifth ingredients down the list.


Steps number two and three on the milk ladder are things like muffins and shop-bought pancakes which, again, contain small amounts of cow's milk. But as the ladder gets higher,

it does contain slightly more cow's milk and will be heated to a lesser degree at this point.


We talk about trying firstly with heated butter in, for example mashed potatoes or scrambled eggs, before moving on to heated cheese.


Next is yogurt, and right at the top of the ladder is Cow's milk and we would advise that the cow's milk is heated first for example, in porridge before allowing your child to have cold

cow’s milk.


It's really important at this point to also mention that once you try a product on the milk ladder, you should leave at least two days in between before trying again to ensure that your child is not having a delayed reaction.


When you are trying a new product, you may want to try with, for example, a quarter,

then a half, then three quarters and then a full amount. This can be used at each step

of the ladder.


What happens if your child's symptoms return at any stage of the milk ladder?


So, don't go any higher up the milk ladder,  just stop where you are.


Continue to regularly include all the previously tolerated items on the milk ladder and for example, if your child reacts at heated butter, continue to have the pancakes, muffins, cookies and biscuits. Stay there for approximately two months before trying again to move up the milk ladder.


Some challenges along the way. Children obviously do get unsettled and have some symptoms around this age anyway. It could be due to illness, teething.


Have they just had their one-year immunisations?


Have you just gone back to work, therefore they're being looked after by a child minder or a grandparent?


So sometimes they might have some symptoms, don't always assume that it's due to introduction of new foods, for example cow's milk.


It might be due to something else and that's why they may be showing signs of some unsettledness.


So the big thing is just not to always assume that it's down to cow's milk.


So we obviously do get asked what if my child was to have a serious reaction? and thankfully these are very rare and unlikely, but obviously we do have to talk about it.


If your child does develop any breathing difficulties, a hoarse voice, they become faint or lose consciousness, then always seek immediate medical attention and do not continue with the milk ladder. But, like we said, this is very rare and very unlikely.


So now is just a little bit of an example so obviously let you have a chance to read through it.  Adam is very unsettled with lots of wind. He strained every time he opened his bowles and he also had some eczema.


All improved when dairy was removed from his diet.


Adam's getting older now, he's 10 months old. He's been dairy free since he was four months.  


Mum has started the milk ladder and he's absolutely fine with biscuits with milk in, muffins, pancakes and butter. A few days after eating a quarter portion of cheese, he starts to get loose stools, but he has just started nursery and he's picked up a bug.


So, what might you do?


Hopefully you're thinking that his loose stools are due to cow's milk, or could it be due to him

starting nursery? Therefore you would stay exactly where you are on the milk ladder.

Still giving him the biscuits, muffins and pancakes and butter and stay there for maybe a couple of months and then move on again with cheese.


So what does the future look like?


Remember to stay positive, and to continue with the milk bladder and every couple of months remember the benefits of reintroducing cow's milk and dairy back into your child's diet. Don't worry or don't overthink things too much if you're having any problems with the milk bladder.


It's really normal, and remember that you've avoided cow's milk for the last year, therefore it is normal to have some small symptoms and this will hopefully get better as time goes on.


Over the next slide is some websites with useful information with regards to portion sizes which hopefully you'll find really useful.


Like I mentioned before, you will get a telephone call by one of the dietitians, so we can answer any of your questions that you might have.


We will likely discharge you from our dietetic care and we will only offer you any further

appointments if you felt they were needed. But this can be discussed at your telephone call.


Thank you very much for listening to today's session and we look forward to hearing from you soon.


Thank you