Which formulas are best for infants with cow’s milk allergy?

Cow’s milk allergies are a common food allergy in infants and young children. Although anaphylaxis is rare with milk allergies, parents may still struggle to find alternative formulas that can help their child avoid the uncomfortable gastrointestinal symptoms that often come with this allergy.

Nearly 3% of children around the world have immune-mediated allergies to the proteins in cow’s milk, but as many as 17% of parents report symptoms that indicate some level of allergy or intolerance to cow’s milk.¹ Many cases of cow’s milk allergies resolve on their own with age, but this makes the infant feeding stage no less stressful.

Breastfeeding can be a challenge when it comes to cow’s milk allergies, too. Many people who breastfeed encounter situations where they have to supplement with formula at least sometimes, and these infants are particularly at risk of developing cow’s milk allergies. Even those who exclusively breastfeed can encounter problems, as the nursing mother can pass these proteins on through her own milk.

A new study, published in Canadian Family Physician, outlines options for parents in this situation.

“With not many options for formula for babies, especially those found to have cow’s milk allergy, it was important for us to provide an up-to-date and evidence-based summary of options,” said Ran Goldman, MD, a professor of pediatrics at the University of British Columbia in Vancouver, and co-author of the report. “We recognize that a lot of factors need to be considered when choosing an alternative such as symptom severity, patient preference, cost, and efficacy.”

The study isn’t meant to deter families from considering breastfeeding, Goldman said. Rather, an effort to present safe, effective options.

“I truly believe “breast is best” because breastfeeding has so many benefits. I always recommend to mothers in my practice to continue to breastfeed if they can and want to do that,” Goldman said.

Elimination diets are a big part of diagnosing and managing milk allergies in infants, he notes, adding that the same method can work for mothers.

“Elimination of all milk products from the mother’s diet results in significant remission rate of the symptoms in babies,” he said.

A proper diagnosis is also an important first step, as many parents assume their infant’s symptoms are from a milk allergy. However, only a fraction of infants whose parents believe they have a cow’s milk allergy are actually clinically diagnosed.

“I highly recommend consulting the pediatrician in regard to diagnosing cow's milk allergy. Some parents read symptoms like increased gas or fussiness as milk allergy and may be switching formula prematurely,” Goldman said. “Parents who see blood in the stool should see their doctor immediately. Follow up by the primary provider is also important, to ensure that switching the formula actually helped and that they can rule out other conditions that may have been initially thought to be cow’s milk allergy.”

Understanding the benefits of early exposure is important, too, as this has been shown to be effective in a number of food allergies like peanut allergies for years. Decades of research on early exposure² have shown some benefit, but avoidance is still a favorite method when it comes to managing these allergies, Goldman said.

“In general, we know that early exposure results in reduced sensitivity and allergy in children. The best example is the exposure of Israeli babies to a snack called Bamba in early childhood, likely protecting them from any peanut allergy,” he added.

For infants who have true milk allergies or for whom early exposure is not desired or possible, the study offers solutions. Goldman and lead author Sharon Kipfer suggest the following formula options as alternatives to formulas with cow’s milk proteins:

• Partially hydrolyzed cow’s milk formula. Although this type of formula isn’t used to treat cow’s milk allergy because of a 50% chance of cross reactivity, the report notes that extensively hydrolyzed formula that contains no peptides with a molecular weight greater than 5000 Da can be considered hypoallergenic. Only 2% of infants aged younger than 2 years with confirmed cow’s milk allergies had reactions to this type of formula compared to 10% who were given soy-based formula. Bitter taste, high costs, and risks of anaphylaxis are drawbacks to this option, according to the study.
• Hydrolized rice formula. These types of formulas have been a favorite for decades in Europe, but are not readily available everywhere. Rice formula offers infants good growth while somehow modifying its allergenic properties and preventing immune responses. Bitter taste can be a drawback along with limited availability in some areas, according to researchers.
• Soy-based formula. Soy formulas have been debated for use in children with cow’s milk allergies. Although these formulas provide enough nutrition to keep infants on appropriate growth schedule, they tend to have lower weight gain than infants fed with cow’s milk formulas. Even though soy formulas have a 10% risk of allergic reaction, they are favored in many cases for taste, texture, and affordability.
• Amino-acid based formula. These formulas are considered to be hypoallergenic by the American Academy of Pediatrics, and are often used in infants who can’t tolerate other types of formulas. However, these can cost 6 to 8 times more than other high-end formulas, and some infants refuse it because of its taste.

Although hydrolyzed rice formulas appear to have the most wide-ranging applications, Goldman said the decision should ultimately be one made between parents and their infants’ primary care doctor or allergist.

“It is important not to decide in a hurry to switch formula in young children and to avoid changing a new formula after just a few days of trying,” Goldman added. “Pediatricians should work with families around decision-making and support them when symptoms of cow’s milk allergy arise.”

​References

1.Kipfer S, Goldman RD. Formula choices in infants with cow's milk allergy. Can Fam Physician. 2021;67(3):180-182. doi: 10.46747/cfp.6703180

2. Stintzing G, Zetterström R. Cow's milk allergy, incidence and pathogenetic role of early exposure to cow's milk formula. Acta Paediatr Scand. May 1979;68(3):383-7. doi: 10.1111/j.1651-2227.1979.tb05024.x.