I like the idea of thinking that “the milk ladder has branches” as that way we think of something organic like a tree with branches, with different food-sensitive families working out which factors may matter most to a food sensitive person or their child when they want to test milk for tolerance, rather than a series of steps that follow one from another. Where there are any concerns about a serious reaction discuss your plan with your dietitian or doctor.
Testing milk tolerance is complex but manageable. It is a very good example of all the diet detective ideas applied to one food. As a dietitian looking after food sensitive people for over 40 years I have met people with widely different dairy tolerance.
Following are short notes on the different factors that may make a big difference. More detail and stories of patients are available on each idea in the Best Guess Food Guide, in Tolerating Troublesome Foods.
Tolerance is improved the more the milk is hydrolysed
Once milk is completely hydrolysed into individual amino acids in elemental infant formulas it can be tolerated even in milk allergic infants. Infants can then test milks that are extensively hydrolysed such as Alfare or Pepti Junior where the protein chains are short. The next step is to test milk where the protein chains have been partly hydrolysed, as has been done in the Easy to Digest hypoallergenic (HA) formulas.
How much the milk is changed by pasteurisation, UHT change or cooking –
Cooking changes the structure of the milk molecule as bonds that hold the long chain are broken.
There are people who know they tolerate a cappuccino coffee but not cold milk to drink. They show us that cooked milk may be better tolerated. Of course milk in baked goods is also well cooked. Milk is better tolerated if families heat milk in the microwave or on the stove until it is hot and fluffy and use it to make a drink, or put it in the refrigerator overnight so it can be used cold on cereal, or as a drink.
How strong is your allergy to dairy
As with any food allergy discuss testing for tolerance with your doctor or dietitian. It is important to remember that allergy tests are a starting point, and that tolerance in infants improves greatly as age increases. So you can gradually test all the ideas mentioned here, particularly including what you know about milk tolerance, and fussiness, in your family, using the Family Sensitivity History.
Is milk or cheese better tolerated?
Another way to test dairy tolerance is to test mild cheddar first. This way you are minimising the whey part of milk. This may mean you are reacting to the whey part but tolerate the casein part remaining in cheese. The cheese avoiders are probably reacting to the amines which can be higher in stronger cheeses.
Freshness and stale smells
Freshness and amount of time since the milk was opened matter. Milk is best put back in the refrigerator immediately after some is used at meals so changes that happen with staling are minimised. One professional woman found that she could only use milk if it had not been opened for more than 24 hours.
The type of milk or cheese
A2 milk has a different form of protein so is better tolerated by some. All the other factors mentioned in this section on milk also apply to A2 milk. Goat milk is a slightly different protein so is also better tolerated by some, and the other factors still also apply to its tolerance.
Powdered milk is milk that has been dried. I trained as a dietitian over 50 years ago when Sunshine powdered milk was tried when infants seemed to be ‘unsettled’ on breast milk, or fresh milk. At that time the milk was heated to dry it and so the changes from cooking were some benefit to some milk sensitive babies. Nowadays we can say that where a baby is ‘unsettled’ on breast milk the mother can investigate her own diet.
Use the idea that the more concerned you are about milk tolerance the smaller is the amount you begin trials with. Even when testing hydrolysed formulas in babies begin with small drips diluted in the tolerated formula. Testing one bite of a bread loaf that has some milk in it may be a big step for some.
Build up effect over days
Years ago I met many mothers whose babies were admitted to hospital and given a milk challenge with no worsening of symptoms. But when they went home and continued the milk their baby’s symptoms returned after five or six days. Now that delayed allergy is recognised this does not happen as much.
Temperature of milk
Milk is sometimes better tolerated if it is very cold. Many adults who were given warm milk in a post war program to increase protein intake felt really nauseated. I have met children who enjoy milk only when they put a few ice blocks in their breakfast cereal with the milk, and adults who say it is better tolerated if chilled.
Whether the dairy is liquid milk or solid as in cooked custard, or junket, or as cheese.
Some people report that after they drink milk their throat feels “furry” or mucous, but they tolerate milk when it is in cold thick custard, as cheese or as junket.
If you have been diagnosed as lactose intolerant it is necessary to use lactose free products. Your doctor may advise you whether to expect your lactose intolerance to be temporary or permanent. Either way it may be wise to be carefully lactose free for three months. This gives the gut wall time to recover and the enzyme that is used to digest lactose, lactase, time to be produced again, even if in small amounts.
Intolerance to dairy fat only is unusual but it does occur. A nurse had a very restless and unhappy toddler. She changed the brand of milks to see if it affected tolerance with no improvement. She tried skim milk and the toddler’ symptoms decreased markedly. This is unusual but it does happen.
For more information on each of these ideas, and 300 other foods, see book Tolerating Troublesome Foods by Joan Breakey https://foodintolerancepro.com/tolerating-troublesome-foods/ or https://www.amazon.com.au/Tolerating-Troublesome-Foods-Investigating-intolerance-ebook/dp/B00I7DS87O