Introduction Introducing baked milk into the diet of children with cow’s milk protein allergy (CMPA) has been shown to potentially accelerate the development of tolerance to non-heated milk. However, there is no standardised milk ladder (ML) protocol, and different scientific societies across countries recommend varying versions. This study aims to assess the effectiveness and safety of the four-step ML (4-ML) compared with the six-step ML (6-ML) in children with IgE-mediated CMPA. Methods and analysis We will perform an open-label randomised trial with two parallel arms in two departments of the same academic hospital. A total of 92 children with IgE-mediated CMPA will be allocated in a 1:1 ratio to introduce cow’s milk into their diet according to either 4-ML or 6-ML with a 4-week break period between subsequent steps. Oral food challenge (OFC) with tested products at each subsequent step of the ML will be conducted in hospital settings. The primary outcome will be the percentage of children with tolerance to non-heated cow’s milk proteins defined as no allergic reaction to raw cow’s milk (120–240 mL depending on the age of the patient) during the last OFC; measured at the end of the 12-week observation period for the 4-ML and 20-week observation period for the 6-ML. Secondary outcomes will include the percentage of children with a negative OFC to each ML step; the percentage of children with anaphylaxis (both those who were treated and those who were not treated with epinephrine); the percentage of children with exacerbation of atopic dermatitis; growth; compliance; and quality of life of the caregivers and parents’ anxiety about adverse events during their child’s OFC. Ethics and dissemination The bioethics committee of the Medical University of Warsaw, Poland, approved this protocol (KB/107/2024). The findings will be published in a peer-reviewed journal and submitted to relevant conferences no later than 1 year after data collection. Trial registration number NCT06664918.

Background/Objectives: This study aimed to evaluate diet diversity and feeding practices in toddlers with food allergy (FA) compared to healthy peers. Methods: This cross-sectional survey was conducted in Polish nurseries and included children aged 13–36 months with and without FA. Parents completed a questionnaire assessing feeding practices, anthropometric measurements, diet diversity using the Food Frequency Questionnaire, and feeding difficulties using the Montreal Children’s Hospital Feeding Scale. Results: Data from 388 children (predominantly from Warsaw and from families with high socioeconomic status) were analyzed. Among them, 61 (16%) had FA confirmed by a physician (however, an oral food challenge was performed only in one-third of cases). The proportion of underweight children (≤third percentile) was similar between the FA and non-FA groups (3.4 vs. 0.9%, respectively). Compared with the non-FA group, children with FA had significantly lower median overall diet diversity, food group diversity (≥nine food groups), food item diversity, and mean food allergen diversity. We found no difference in the proportion of children with feeding difficulties between the FA and non-FA groups (median = 18% vs. 13.5%). Although a lower proportion of children with FA had introduced cow’s milk, hen’s egg, tree nuts, nuts, and sesame compared with the non-FA group, only a minority had confirmed allergies to nuts, peanuts, and sesame. Most children with cow’s milk and hen’s egg allergy reintroduced baked milk (48.9%) and egg (40%). Conclusions: Children aged 13–36 months with FA are at risk of reduced overall diet diversity and over-restriction of potentially allergenic foods.

Background/Objectives: This study aimed to evaluate diet diversity and feeding practices in toddlers with food allergy (FA) compared to healthy peers. Methods: This cross-sectional survey was conducted in Polish nurseries and included children aged 13-36 months with and without FA. Parents completed a questionnaire assessing feeding practices, anthropometric measurements, diet diversity using the Food Frequency Questionnaire and feeding difficulties using the Montreal Children’s Hospital Feeding Scale. Results: Data from 388 children (predominantly from Warsaw and from families with good socioeconomic status) were analyzed. Among them, 61 had FA confirmed by a physician (however an oral food challenge was performed only in one-third of cases). The proportion of children with underweight (≤3 percentile) was similar between the FA and non-FA groups (3.4 versus 0.9%, respectively). Compared with the non-FA group children with FA had significantly lower median overall diet diversity, food group diversity (≥ 9 food groups), food item diversity, and mean food allergen diversity. The WHO Minimum Dietary Diversity and fruit/vegetable diversity were similar in both groups. We found no difference in the proportion of children with feeding difficulties between the FA and non-FA groups (median = 18 versus 13.5%). Although a lower proportion of children with FA had introduced cow’s milk, hen’s egg, tree nuts, nuts and sesame compared with the non-FA group, only a minority had confirmed allergies to nuts, peanuts and sesame. Conclusions: Children aged 13-36 months with FA are at risk of reduced overall diet diversity and over-restriction of potentially allergenic foods.

Cow’s milk protein allergy (CMPA) is one of the most common food allergies in early childhood. Although a strict elimination diet effectively prevents allergic symptoms, it does not promote the development of tolerance to cow’s milk proteins (CMPs). The milk ladder is a stepwise approach to the reintroduction of CMPs, starting with extensively heated forms and gradually progressing to unheated cow’s milk, according to the individual tolerance levels. The rationale for this approach lies in the reduced allergenicity of heated forms, mainly due to the food matrix effect. The milk ladder was originally developed to gradually expand the diet in children with non-IgE-mediated CMPA. However, recent evidence suggests that it can also be applied in IgE-mediated CMPA to accelerate tolerance development. In children with high-risk IgE-mediated CMPA, this approach may be more challenging. Even minor recipe modifications, particularly those affecting composition or heating conditions, can alter the allergenicity of heated foods. Moreover, barriers to reintroducing food allergens, including parental anxiety or the child’s food aversion, may be more pronounced in this group. Although for high-risk patients, reintroduction is usually performed in hospital settings, increasing evidence indicates that, in selected cases, it may also be safely conducted at home. Several emerging strategies, including early low-dose exposure and oral immunotherapy, show promise in further enhancing tolerance development. Despite these challenges, early reintroduction of CMPs appears to play a crucial role in modulating the immune response and promoting tolerance. This review provides the summary of evidence and practical insights into the implementation of the milk ladder in children with IgE-mediated CMPA.