Table 2.

Reintroduction of cow's milk proteins following a period of therapeutic elimination diet

	Milk ladder	Liquid milk
IgE mediated CMA
Setting	•Usually under physician supervision in a medical setting •Selected cases might be considered for home reintroduction •younger than 3 years •without previous history of anaphylaxis or wheezingfrom any causes •skin prick test whealdiameter less than 8 mm for cow's milk	•Usually under physician supervision in a medical setting •At the physician discretion, home introduction might be considered for children who are known to tolerate milk in baked products and had mild symptoms to large amounts of liquid milk in the past
Pros	•Up to 70% of children who react to liquid milk, tolerate milk in a form of a baked product •High chance of success •Minimizes unnecessary milk elimination when access to food challenges is limited	•Straightforward •Short period •Easy to find products
Cons	•Prolonged process, more labour intense •Some forms of baked foods may not be appropriate for young infants •Children who react to baked milk tend to have more severe symptoms and higher risk of anaphylaxis	•More allergenic form of milk might induce uncomfortable symptoms •Children with feeding difficulties might refuse to try a new food in a medical setting under time constraint
Non-IgE mediated CMA: FPIAP, FPE
Setting	•Usually done at home •Helpful when caregiver apprehensive/worried about reintroduction	•Can be done at home as symptoms are usually delayed, e/g., appear after few days •Typically lower GI tract involved: bloody stool, diarrhoea, discomfort
Pros	•Starting from less allergenic forms of foods at lower doses •Milder symptoms	•Straightforward •Short period •Easy to find products
Cons	•Prolonged process •More labour intense •Some forms of baked foods may not be appropriate for infants and young children	•More allergenic form of milk might induce uncomfortable symptoms
• Non-IgE mediated CMA: FPIES
Setting	•Typically under physician supervision in a medical setting •Those with mild symptoms to large amounts of liquid milk might be considered for a very gradual home introduction	•Typically under physician supervision in a medical setting
Pros	•Some children with milk-FPIES might tolerate baked milk •More gradual, starting from lower doses of baked milk •Home setting usually more comfortable for infants and young children, more likely to try a new food in a familiar environment and unlimited time •Might induce milder symptoms from lower GI tract compared to violent vomiting in acute FPIES	•Clear indication of tolerance/reactivity •Short process (1 day) •Easy to find foods
Cons	•Unclear what % of FPIES patients is tolerant to baked milk •If tolerate baked milk, will need another trial for liquid milk •Risk of FPIES symptoms at home •Unclear if symptoms to baked milk would be milder than to liquid milk •Prolonged process, labor intense on the part of a caregiver •Some forms of baked foods may not be appropriate/well accepted by infants and young children •If introduction stopped for mild, non-specific GI symptoms, it may result in unnecessary prolonged elimination of milk from diet	•Larger dose might induce more violent vomiting •Usually intravenous access is required and can be difficult to secure •Child may refuse to eat the new food in an unfamiliar setting and under time constraint

Legend: GI, gastrointestinal; FPIAP, food protein-induced allergic proctocolitis syndrome; FPE, food protein-induced enteropathy; FPIES, food protein-induced enterocolitis syndrome.