What is the best formula for a baby with a milk allergy

Allergic reactions can be immunoglobulin E (IgE)-mediated reactions or non-IgE-mediated reactions. Cow’s milk proteins can cause reactions of either type or both together, which can make them hard to diagnose.

IgE-mediated reactions

IgE-mediated reactions trigger histamine release and happen within two hours of milk being consumed. They include skin reactions such as itching, erythema, urticaria and acute angio-oedema, most commonly of the face. There can be abdominal symptoms such as colicky pain, nausea, vomiting and diarrhoea. Respiratory symptoms can be upper or lower respiratory tract: nasal itching, sneezing, rhinorrhoea, congestion, cough, chest tightness or wheeze.

It is extremely rare for cow’s milk to trigger an anaphylactic reaction.

Antihistamines can be used to treat the symptoms. Allergic reactions may be more severe in people with asthma, particularly if the asthma is poorly controlled[9].

This type of allergy can be diagnosed with a skin prick test or a blood test (specific IgE, previously known as RAST). If this type of allergy is suspected, refer the kid to a paediatrician who will arrange for the test to be done in hospital.

Non-IgE-mediated reactions

Non-IgE-mediated reactions happen hours or days after consuming milk.

Skin reactions such as atopic eczema are common, as well as itching and erythema. Abdominal symptoms include colicky pain (including infantile colic), reflux, blood or mucus in stools, constipation or diarrhoea. There may be lower respiratory tract symptoms such as cough, wheeze, breathlessness or chest tightness.The kid may be pale and tired, and growth may be faltering.

The best way to establish if cow’s milk is causing these symptoms is to exclude it from the diet. There should be an improvement in symptoms within two weeks.


Differential diagnosis

With such a wide range of symptoms that can be caused by CMPA, the differential diagnosis is extensive, and includes other food allergies, non-food allergies such as pollen, animal dander, other gastrointestinal disorders, pancreatic insufficiency such as in cystic fibrosis, and infections — eg urinary tract infection.


Lactose intolerance[20]

Many people confuse lactose intolerance with CMPA.

Lactose intolerance is an inability to digest lactose, due to an inadequate production of the digestive enzyme lactase.

It is generally a condition of older childhood and adulthood. Worldwide it is extremely common, although it is less prevalent in northern European races. It is unusual for babies and young children to be intolerant of lactose, although they do fairly commonly develop a transient lactose intolerance following an episode of gastroenteritis.

People with a lactose intolerance can often consume products such as yoghurt and cheese in which the lactose has been altered and they may be capable to own little amounts of milk without symptoms. They can generally tolerate lactose-free milk.

Clinical Editor’s comments (October 2017)
Dr Hayley Willacy recommends the recently released international Milk Allergy in primary care guideline[1].

The guideline includes updated recommendations on presentation and recognition of cow’s milk allergy (CMA); diagnosis; management of mild-to-moderate confirmed non-IgE-mediated CMA within primary care; suspected severe non-IgE-mediated CMA and referral. A number of additional resources own been developed alongside the guideline to support parents and carers, including an initial factsheet for parents; a home reintroduction protocol to confirm diagnosis; a milk ladder and milk ladder recipes.

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  • Host A, Halken S; Cow's milk allergy: where own we come from and where are we going?

    What is the best formula for a baby with a milk allergy

    Endocr Metab Immune Disord Drug Targets. 2014 Mar14(1):2-8.

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  • Osborn DA, Sinn J; Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. 2006 Oct 18(4):CD003664.

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    Crit Rev Food Sci Nutr. 201656(1):65-9. doi: 10.1080/10408398.2012.713047.

  • Boyle RJ, Ierodiakonou D, Khan T, et al; Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ. 2016 Mar 8352:i974. doi: 10.1136/bmj.i974.

  • Vandenplas Y, Koletzko S, Isolauri E, et al; Guidelines for the diagnosis and management of cow's milk protein allergy in infants. Arch Dis Kid. 2007 Oct92(10):902-8.

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    What is the best formula for a baby with a milk allergy

    Cochrane Database Syst Rev. 2012 Nov 1411:CD009542. doi: 10.1002/14651858.CD009542.pub2.

  • Miraglia Del Giudice M, D'Auria E, Peroni D, et al; Flavor, relative palatability and components of cow's milk hydrolysed formulas and amino acid-based formula. Ital J Pediatr. 2015 Jun 341:42. doi: 10.1186/s13052-015-0141-7.

  • Ludman S, Shah N, Fox AT; Managing cows' milk allergy in children. BMJ. 2013 Sep 16347:f5424. doi: 10.1136/bmj.f5424.

  • Hill DJ, Hosking CS; Food allergy and atopic dermatitis in infancy: an epidemiologic study.

    Pediatr Allergy Immunol. 2004 Oct15(5):421-7.

  • Dupont C, Hol J, Nieuwenhuis EE; An extensively hydrolysed casein-based formula for infants with cows' milk protein allergy: tolerance/hypo-allergenicity and growth catch-up. Br J Nutr. 2015 Apr 14113(7):1102-12. doi: 10.1017/S000711451500015X. Epub 2015 Mar 17.

  • The Milk Ladder; MAP Guideline

  • Bloom KA, Huang FR, Bencharitiwong R, et al; Effect of heat treatment on milk and egg proteins allergenicity. Pediatr Allergy Immunol.

    2014 Dec25(8):740-6. doi: 10.1111/pai.12283. Epub 2014 Dec 18.

  • Leonard SA, Nowak-Wegrzyn AH; Baked Milk and Egg Diets for Milk and Egg Allergy Management. Immunol Allergy Clin North Am. 2016 Feb36(1):147-59. doi: 10.1016/j.iac.2015.08.013.

  • Boyano-Martinez T, Garcia-Ara C, Pedrosa M, et al; Accidental allergic reactions in children allergic to cow's milk proteins. J Allergy Clin Immunol. 2009 Apr123(4):883-8.

    doi: 10.1016/j.jaci.2008.12.1125. Epub 2009 Feb 20.

  • Venter C, Brown T, Meyer R, et al; Better recognition, diagnosis and management of non-IgE-mediated cow's milk allergy in infancy: iMAP-an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. 2017 Aug 237:26. doi: 10.1186/s13601-017-0162-y. eCollection 2017.

  • Vandenplas Y, De Greef E, Devreker T; Treatment of Cow's Milk Protein Allergy. Pediatr Gastroenterol Hepatol Nutr.

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  • Cows milk protein allergy in children; NICE CKS, June 2015 (UK access only)

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Infant formula, baby formula or just formula (American English) or baby milk, infant milk or first milk (British English), is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, generally prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water).

The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines baby formula as «a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a finish or partial substitute for human milk».[1]

Manufacturers state that the composition of baby formula is designed to be roughly based on a human mother’s milk at approximately one to three months postpartum; however, there are significant differences in the nutrient content of these products.[2] The most commonly used baby formulas contain purified cow’s milk whey and casein as a protein source, a mix of vegetable oils as a fat source[note 1], lactose as a carbohydrate source, a vitamin-mineral stir, and other ingredients depending on the manufacturer.[3] In addition, there are baby formulas using soybean as a protein source in put of cow’s milk (mostly in the United States and Grand Britain) and formulas using protein hydrolysed into its component amino acids for infants who are allergic to other proteins.

An upswing in breastfeeding in numerous countries has been accompanied by a deferment in the average age of introduction of baby foods (including cow’s milk), resulting in both increased breastfeeding and increased use of baby formula between the ages of 3- and 12-months.[4][5]

A 2001 World Health Organization (WHO) report found that baby formula prepared in accordance with applicable Codex Alimentarius standards was a safe complementary food and a suitable breast milk substitute. In 2003, the WHO and UNICEF published their Global Strategy for Baby and Young Kid Feeding, which restated that «processed-food products for…young children should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission», and also warned that «lack of breastfeeding—and especially lack of exclusive breastfeeding during the first half-year of life—are significant risk factors for baby and childhood morbidity and mortality».

In specific, the use of baby formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment.[6] A formula-fed kid living in unclean conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child.[7] Rarely, use of powdered baby formula (PIF) has been associated with serious illness, and even death, due to infection with Cronobacter sakazakii and other microorganisms that can be introduced to PIF during its production.

Although C. sakazakii can cause illness in every age groups, infants are believed to be at greatest risk of infection. Between 1958 and 2006, there own been several dozen reported cases of E. sakazakii infection worldwide. The WHO believes that such infections are under-reported.[8]

Infant formula, baby formula or just formula (American English) or baby milk, infant milk or first milk (British English), is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, generally prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water).

The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines baby formula as «a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a finish or partial substitute for human milk».[1]

Manufacturers state that the composition of baby formula is designed to be roughly based on a human mother’s milk at approximately one to three months postpartum; however, there are significant differences in the nutrient content of these products.[2] The most commonly used baby formulas contain purified cow’s milk whey and casein as a protein source, a mix of vegetable oils as a fat source[note 1], lactose as a carbohydrate source, a vitamin-mineral stir, and other ingredients depending on the manufacturer.[3] In addition, there are baby formulas using soybean as a protein source in put of cow’s milk (mostly in the United States and Grand Britain) and formulas using protein hydrolysed into its component amino acids for infants who are allergic to other proteins.

An upswing in breastfeeding in numerous countries has been accompanied by a deferment in the average age of introduction of baby foods (including cow’s milk), resulting in both increased breastfeeding and increased use of baby formula between the ages of 3- and 12-months.[4][5]

A 2001 World Health Organization (WHO) report found that baby formula prepared in accordance with applicable Codex Alimentarius standards was a safe complementary food and a suitable breast milk substitute. In 2003, the WHO and UNICEF published their Global Strategy for Baby and Young Kid Feeding, which restated that «processed-food products for…young children should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission», and also warned that «lack of breastfeeding—and especially lack of exclusive breastfeeding during the first half-year of life—are significant risk factors for baby and childhood morbidity and mortality».

In specific, the use of baby formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment.[6] A formula-fed kid living in unclean conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child.[7] Rarely, use of powdered baby formula (PIF) has been associated with serious illness, and even death, due to infection with Cronobacter sakazakii and other microorganisms that can be introduced to PIF during its production.

Although C. sakazakii can cause illness in every age groups, infants are believed to be at greatest risk of infection. Between 1958 and 2006, there own been several dozen reported cases of E. sakazakii infection worldwide. The WHO believes that such infections are under-reported.[8]


Uses, risks and controversies

Further information: Baby food safety

The use and marketing of baby formula has come under scrutiny. Breastfeeding, including exclusive breastfeeding for the first 6 months of life, is widely advocated as «ideal» for babies and infants, both by health authorities[6][9] — and accordingly in ethical advertising of baby formula manufacturers.[10]

Despite the recommendation that babies be exclusively breastfed for the first 6 months, less than 40% of infants under this age are exclusively breastfed worldwide.[11] The overwhelming majority of American babies are not exclusively breastfed for this period – in 2005 under 12% of babies were breastfed exclusively for the first 6 months,[9] with over 60% of babies of 2 months of age being fed formula,[12] and approximately one in four breastfed infants having baby formula feeding within two days of birth.[13]

Some studies own shown that use of formula can vary according to the parents’ socio-economic status, ethnicity or other characteristics.

For example, according to a research conducted in Vancouver, Canada, 82.9% of mothers breastfeed their babies at birth, but the number differed between Caucasians (91.6%) and non-Caucasians (56.8%), with the difference essentially attributed to marital status, education and family income.[14] In the United States, mothers of lower socio-economic status own been found less likely to breastfeed, although this may be partly related to adverse effects of government nutrition supplementation programs that provide subsidies for baby formula.[15]

The use of hydrolysed cow milk baby formula versus standard milk baby formula does not appear to change the risk of allergies or autoimmune diseases.[16]

Use of baby formula

Main article: Breastfeeding contraindications

In some cases, breastfeeding is medically contraindicated.

These include:

  • Mother’s health: The mom is infected with HIV or has athletic tuberculosis.[17] She is extremely ill or has had certain kinds of breast surgery, which may own removed or disconnected every milk-producing parts of the breast. She is taking any helpful of drug that could harm the baby, including both prescription drugs such as cytotoxic chemotherapy for cancer treatments as well as illicit drugs.[17]
    1. Societal structure: Breastfeeding may be forbidden at the mother’s occupation, school, put of worship or in other public places, or the mom may feel that breastfeeding in these places or around other people is immodest, unsanitary, or inappropriate.[32]
    2. Baby is unable to breastfeed: The kid has a birth defect or inborn error of metabolism such as galactosemia that makes breastfeeding hard or impossible.[25]
    3. Baby is considered at risk for malnutrition: In certain circumstances infants may be at risk for malnutrition, such as due to iron deficiency, vitamin deficiencies (e.g.

      vitamin D which may be less present in breast milk than needed at high latitudes where there is less sun exposure), or inadequate nutrition during transition to solid foods.[26] Risks can often be mitigated with improved diet and education of mothers and caregivers, including availability of macro and micronutrients. For example, in Canada, marketed baby formulas are fortified with vitamin D, but Health Canada also recommends breastfed infants get additional vitamin D in the form of a supplement.[27]

    4. Food allergies: The mom eats foods that may provoke an allergic reaction in the infant.[citation needed]
    5. Personal preferences, beliefs, and experiences: The mom may dislike breast-feeding or ponder it is inconvenient.[28] In addition, breastfeeding can be hard for victims of rape or sexual abuse; for example, it may be a trigger for posttraumatic stress disorder.[29][30] Numerous families bottle feed to increase the father’s role in parenting his child.[31]
    6. Absence of the mother: The kid is adopted, orphaned, abandoned, or in the sole custody of a man or male same-sex couple.

      The mom is separated from her kid by being in prison or a mental hospital. The mom has left the kid in the care of another person for an extended period of time, such as while traveling or working abroad.

    7. Lack of training and education: The mom lacks education and training from medical providers or community members.[citation needed][35]
    8. Financial pressures:Maternity leave is unpaid, insufficient, or lacking. The mother’s employment interferes with breastfeeding.[32] Mothers who breastfeed may experience a loss of earning power.[33]
    9. One of the main global risks posed by breast milk specifically is the transmission of HIV and other infectious diseases.

      Breastfeeding by an HIV-infected mom poses a 5–20% chance of transmitting HIV to the baby.[18][19][20] However, if a mom has HIV, she is more likely to transmit it to her kid during the pregnancy or birth than during breastfeeding.

      What is the best formula for a baby with a milk allergy

      A 2012 study conducted by researchers from the University of North Carolina School of Medicine showed reduced HIV-1 transmission in humanized mice, due to components in the breast milk.[21]Cytomegalovirus infection poses potentially dangerous consequences for pre-term babies.[19][22] Other risks include mother’s infection with HTLV-1 or HTLV-2 (viruses that could cause T-cell leukemia in the baby),[19][20]herpes simplex when lesions are present on the breasts,[20] and chickenpox in the newborn when the disease manifested in the mom within a few days of birth.[20] In some cases these risks can be mitigated by using heat-treated milk and nursing for a briefer time (e.g.

      6 months, rather than 18–24 months), and can be avoided by using an uninfected woman’s milk, as via a wet-nurse or milk bank, or by using baby formula and/or treated milk.[23]

    10. In balancing the risks, such as cases where the mom is infected with HIV, a decision to use baby formula versus exclusive breastfeeding may be made based on alternatives that satisfy the “AFASS” (Acceptable, Feasible, Affordable, Sustainable and Safe) principles.[23][24]
    11. Social pressures: Family members, such as mother’s husband or boyfriend, or friends or other members of society may urge the use of baby formula.

      For example, they may believe that breastfeeding will decrease the mother’s energy, health, or attractiveness.[citation needed][34]

    12. Lactation insufficiency: The mom is unable to produce sufficient milk. In studies that do not account for lactation failure with obvious causes (such as use of formula and/or breast pumps), this affects around 2 to 5% of women.[36] Alternatively, despite a healthy supply, the lady or her family may incorrectly believe that her breast milk is of low quality or in low supply.

      These women may select baby formula either exclusively or as a supplement to breastfeeding.[citation needed]

  • Baby is unable to breastfeed: The kid has a birth defect or inborn error of metabolism such as galactosemia that makes breastfeeding hard or impossible.[25]
  • Baby is considered at risk for malnutrition: In certain circumstances infants may be at risk for malnutrition, such as due to iron deficiency, vitamin deficiencies (e.g. vitamin D which may be less present in breast milk than needed at high latitudes where there is less sun exposure), or inadequate nutrition during transition to solid foods.[26] Risks can often be mitigated with improved diet and education of mothers and caregivers, including availability of macro and micronutrients.

    For example, in Canada, marketed baby formulas are fortified with vitamin D, but Health Canada also recommends breastfed infants get additional vitamin D in the form of a supplement.[27]

  • Personal preferences, beliefs, and experiences: The mom may dislike breast-feeding or ponder it is inconvenient.[28] In addition, breastfeeding can be hard for victims of rape or sexual abuse; for example, it may be a trigger for posttraumatic stress disorder.[29][30] Numerous families bottle feed to increase the father’s role in parenting his child.[31]
  • Absence of the mother: The kid is adopted, orphaned, abandoned, or in the sole custody of a man or male same-sex couple.

    The mom is separated from her kid by being in prison or a mental hospital. The mom has left the kid in the care of another person for an extended period of time, such as while traveling or working abroad.

  • Food allergies: The mom eats foods that may provoke an allergic reaction in the infant.[citation needed]
  • Financial pressures:Maternity leave is unpaid, insufficient, or lacking. The mother’s employment interferes with breastfeeding.[32] Mothers who breastfeed may experience a loss of earning power.[33]
  • Societal structure: Breastfeeding may be forbidden at the mother’s occupation, school, put of worship or in other public places, or the mom may feel that breastfeeding in these places or around other people is immodest, unsanitary, or inappropriate.[32]
  • Social pressures: Family members, such as mother’s husband or boyfriend, or friends or other members of society may urge the use of baby formula.

    For example, they may believe that breastfeeding will decrease the mother’s energy, health, or attractiveness.[citation needed][34]

  • Lack of training and education: The mom lacks education and training from medical providers or community members.[citation needed][35]
  • Lactation insufficiency: The mom is unable to produce sufficient milk. In studies that do not account for lactation failure with obvious causes (such as use of formula and/or breast pumps), this affects around 2 to 5% of women.[36] Alternatively, despite a healthy supply, the lady or her family may incorrectly believe that her breast milk is of low quality or in low supply.

    These women may select baby formula either exclusively or as a supplement to breastfeeding.[citation needed]

  • Fear of exposure to environmental contaminants: Certain environmental pollutants, such as polychlorinated biphenyls, can bioaccumulate in the food chain and may be found in humans including mothers’ breast milk.[37]
    1. Research on risks from chemical pollution is generally inconclusive in terms of outweighing the benefits of breastfeeding.[39][40] Studies supported by the WHO and others own found that neurological benefits of breast milk remain, regardless of dioxin exposure.[40][41]
    2. However studies own shown that the greatest risk period for adverse effects from environmental exposures is prenatally.[37] Other studies own further found that the levels of most persistent organohalogen compounds in human milk decreased significantly over the past three decades and equally did their exposure through breastfeeding.[38]
    3. In developing countries, environmental contaminants associated with increased health risks from use of baby formula, particularly diarrhea due to unclean water and lack of sterile conditions – both prerequisites to the safe use of formula – often outweigh any risks from breastfeeding.
  • Lack of other sources of breast milk:
    1. Lack of wet nurses:Wet nursing is illegal and stigmatized in some countries, and may not be available.[42] It may also be socially unsupported, expensive, or health screening of wet nurses may not be available.

      The mom, her doctor,[43] or family may not know that wet nursing is possible, or may believe that nursing by a relative or paid wet-nurse is unhygienic.

    2. Lack of milk banks:Human-milk banks may not be available, as few exist, and numerous countries cannot provide the necessary screening for diseases and refrigeration.

    Health risks

    Use of baby formula has been cited for numerous increased health risks. Studies own found infants in developed countries who consume formula are at increased risk for acute otitis media, gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity,[44] type 1 and 2 diabetes, sudden baby death syndrome (SIDS), eczema and necrotizing enterocolitis when compared to infants who are breastfed.[45][46][47][48] Some studies own found an association between baby formula and lower cognitive development, including iron supplementation in baby formula being linked to lowered I.Q.

    and other neurodevelopmental delays;[49][50] however other studies own found no correlation.[45]

    Melamine contamination

    Main article: 2008 Chinese milk scandal

    In 2008, a case of melamine poisoning of baby formula was discovered in China, where milk was deliberately adulterated with the chemical, leading to the death of six babies, and illnesses in more than 300,000 infants, including cases of acute kidney failure. Large quantities of melamine were added to watered-down milk to give it the appearance of having adequate protein levels. Some of those responsible for the poisoning were sentenced to death.[51]

    In November 2008, traces of melamine were reported to own been found by the U.S.

    Food and Drug istration in baby formula sold in the United States made by the three main American firms[52][53] — Abbott Laboratories, Nestlé and Mead Johnson — responsible for 90–99% of the baby formula market in that country.[15][52] The levels were much less than those reported in China, where levels of melamine contamination had reached as much as 2,500 parts per million, about 10,000 times higher than the recorded US levels. The safety data sheet for melamine (CAS registry number 108-78-1; C3-H6-N6) recorded the acute oral toxicity (median lethal dose) at 3161 mg/kg for a rat.

    Health Canada conducted a separate test and also detected traces of melamine in baby formula available in Canada. The melamine levels were well under Health Canada’s safety limits,[54] although concerns remain about the safety of manufactured food for infants and monitoring of potentially dangerous substances.[51]

    Other health controversies

    1. In Canada, New Zealand and elsewhere, public concerns own been raised over the continued sale and marketing of soy-based formulae potentially containing high levels of phytoestrogens,[59][60] linked to abnormal kid development[61] including damage to babies’ thyroid glands.
    2. In 1985, Syntex Corporation was ordered to pay $27 million in compensation for the deaths of two American infants who suffered brain damage after drinking the company’s baby formula, called Neo-mull-soy.[55] Formulas produced by Syntex had previously been subject to a major recall as they were found to own insufficient chloride to support normal baby growth and development.[56]
    3. In 2003, baby formula manufactured by the German company Humana and sold in Israel under the brand Remedia caused severe vitamin deficiencies in babies.

      Babies who consumed the formula were hospitalized with cardiac and neurological symptoms. Three of them died, and at least twenty others were left with severe disabilities. An investigation revealed that the formula contained a much lower quantity of Thiamine than is needed for healthy baby development because of a manufacturing error. Humana’s chief food technologist received a 30-month prison sentence for negligent manslaughter in February 2013 over the case.[57]

    4. In 2010, Abbott Laboratories issued a voluntary recall of about five million Similac brand powder baby formulas that were sold in the United States, Guam, Puerto Rico and some Caribbean countries.

      The recall was issued after the presence of a ‘small common beetle’ was detected in the product.[58]

    5. In December 2011 Wal-Mart recalled a quantity of baby formula after a baby died in Missouri. «We extend our deepest condolences to this baby boy’s family as they attempt to come to grips with their loss,» said Dianna Gee, a Wal-Mart spokeswoman. «As soon as we heard what happened, we immediately reached out to the manufacturer of the formula and to the Department of Health and Senior Services to provide any information we may own to assist with the investigation.» Wal-Mart said it pulled a batch of Enfamil from its stores nationwide that matched the size and lot number ZP1k7G of the formula that may own sickened the baby in Missouri, Gee said.

      The baby formula was purchased from a Wal-Mart in Lebanon, Missouri. After the purchase, a 10-day-old baby died from a rare bacterial infection, CNN affiliate KYTV reported. Authorities ran tests to determine if the death came from the formula, the water to make the formula or any other factor, said Mead Johnson Nutrition, the company that makes Enfamil. «We are highly confident in the safety and quality of our products – and the rigorous testing we put them through,» said Chris Perille, a Mead Johnson Nutrition spokesman.[Source CNN]


    Management [10]

    Alternative milks

    Soya formulas own been prescribed in the past for CMPA but soya is also a common allergen, so this is no longer routinely advised.

    About 10-15% of children allergic to cow’s milk will also react to soya. Soya milk also contains isoflavones which own a feeble oestrogenic activity.

    Other milks, such as pea, oat or coconut, may be used after the age of 2 years, depending on the child’s nutritional status and any other allergies they may own. A brand fortified with calcium should be used if available. Rice milk is not recommended for children aged under 4.5 years.

    If the symptoms of CMPA persist into older childhood or beyond then patients need to continue to avoid milk and milk products.

    The proteins in goat’s milk and other mammal milks which may be available are almost identical to those found in cow’s milk, so those are not suitable substitutes. It is significant to maintain an adequate calcium intake. Children who are avoiding cow’s milk for allergy reasons should be referred to a paediatric dietician for specialist advice.

    Allergen avoidance

    The management of CMPA generally consists of avoidance of the allergen. If CMPA is the cause of the symptoms then they should resolve within two weeks of stopping cow’s milk.

    If the kid is formula-fed, they can be given extensively hydrolysed milk formula such as Nutramigen®, Aptamil Pepti® or Pepti Junior®.

    These are based on cow’s milk but the proteins are broken below into smaller peptides that are less likely to trigger an allergic reaction.

    Babies who own CMPA may own their growth and development impaired by the disorder; however, hydrolysed formula is shown to provide balanced nutrition and to restore normal growth and development[12, 13].

    If the symptoms persist on hydrolysed formula but a suspicion of CMPA remains, then attempt an amino acid formula. These include Nutramigen AA® and Neocate LCP®. Hydrolysed milks are cheaper and are also generally better tolerated, although the flavour and tolerability varies[14].

    If the kid is breast-fed and the mom wishes to continue breast-feeding, she must eliminate milk and milk products from her diet.

    This will include checking ingredients for anything derived from milk, such as casein, whey and lactose. The mom should make certain she is still getting adequate calcium in her diet. It is recommended that she be offered calcium and vitamin D tablets; however, calcium can also come from tinned fish, pulses, almonds, kale, oranges and soya products such as soya milk and tofu[8].

    Babies who are being weaned, and older children with persisting CMPA, will need to follow a cow’s milk-free diet as above. Parents must be advised about how to check the ingredients of processed foods for milk-derived constituents.

    Children should be referred to a paediatric dietician for advice about maintaining a balanced diet while excluding allergens.

    Challenge test

    The prognosis of CMPA is excellent with a remission rate of approximately 45-50% at 1 year, 60-75% at 2 years and 85-90% at 3 years[15].Children can own a challenge test every 6-12 months to see if they are capable to tolerate milk. It may take several days for the reaction to show, particularly for non-IgE allergy.

    The challenge test can be carried out in stages, according to the ‘Milk Ladder’[16]. This is a hierarchy of milk-containing foods, beginning with those least likely to cause a reaction and gradually moving towards being capable to drink a glass of milk.

    In baked form, such as muffins, cakes or malted milk biscuits, cow’s milk is less allergenic and may be tolerated sooner than unbaked milk. There is some evidence that including cooked milk in the diet may hasten the resolution of allergy to non-cooked milk[17, 18].

    If the kid has had IgE type reactions, particularly if they own been severe, then a challenge test should be carried out under shut supervision.

    New treatments

    Immunotherapy, in which children are given a gradually increasing dose of milk over a period of several months, is one option which has been tried for children with persisting severe allergy.

    The results own been extremely promising, although a Cochrane review concluded that further studies of higher quality were necessary before it can be recommended without reservation[19].


    Epidemiology[2, 3]

    CMPA affects about 7% of formula-fed babies but only about 0.5% of exclusively breast-fed babies, who also tend to own milder reactions. Exclusive breast-feeding may also protect babies from developing an allergy to cow’s milk protein after they are weaned[4].

    There are a number of diverse proteins in cows milk: there are five protein components in each of the casein and whey fractions of milk.

    A kid can be allergic to one or more components within either group.

    CMPA is more likely in children who own other atopic conditions such as asthma, eczema or hay fever, or if shut family members own those conditions. The presence of atopic eczema is a predictor for sensitisation to common food allergens. The earlier the eczema starts and the more severe it is, the higher the risk of food allergy[5].

    If there are other food allergies, it is more likely that CMPA will persist into later childhood.

    Some work has been done looking at the development of food allergies and whether this can be prevented by feeding infants at risk with hydrolysed formula.

    What is the best formula for a baby with a milk allergy

    However, the results own so far not been clear[6, 7].


    Preparation and content

    Variations

    Infant formulas come in powder, liquid concentrate, and ready-to-feed forms. They are designed to be prepared by the parent or caregiver in little batches and fed to the baby, generally with either a cup or a baby bottle.[6]

    Infant formulas come in a variety of types:

    1. Protein hydrolysate formulas contain protein that’s been broken below into smaller sizes than are those in cow’s milk and soy-based formulas. Protein hydrolysate formulas are meant for babies who don’t tolerate cow’s milk or soy-based formulas.
    2. Cow’s milk formula is the most commonly used type.

      The milk has been altered to resemble breast milk.

    3. Soy protein based formulas are frequently used for infants allergic to cow’s milk or lactose. Soy-based formulas can also be useful if the parent wants to exclude animal proteins from the child’s diet.
    4. Specialized formulas are also available for premature infants and those with specific medical conditions.[62]

    Manufacturers and health officials advise it is extremely significant to measure powders or concentrates accurately to achieve the intended final product concentration; otherwise, the kid will be malnourished. It is advisable that every equipment that comes into contact with the baby formula be cleaned and sterilized before each use.

    What is the best formula for a baby with a milk allergy

    Proper refrigeration is essential for any baby formula which is prepared in advance.

    In developing countries, formula is frequently prepared improperly, resulting in high baby mortality due to malnutrition and diseases such as diarrhea and pneumonia. This is due to lack of clean water, lack of sterile conditions, lack of refrigeration, illiteracy (so written instructions cannot be followed), poverty (diluting formula so that it lasts longer), and lack of education of mothers by formula distributors. These problems and resulting disease and death are a key factor in opposition to the marketing and distribution of baby formula in developing countries by numerous public health agencies and NGOs (discussed in more detail at Nestlé boycott and International Code of Marketing of Breast-milk Substitutes).

    What is the best formula for a baby with a milk allergy

    Nutritional content

    Besides breast milk, baby formula is the only other milk product which the medical community considers nutritionally acceptable for infants under the age of one year (as opposed to cow’s milk, goat’s milk, or follow-on formula). Supplementing with solid food in addition to breast milk or formula begins during weaning, and most babies start supplementing about the time their first teeth appear, generally around the age of six months.

    Although cow’s milk is the basis of almost every baby formula, plain cow’s milk is unsuited for infants because of its high casein content and low whey content, and untreated cow’s milk is not recommended before the age of 12 months.

    The baby intestine is not properly equipped to digest non-human milk, and this may often result in diarrhea, intestinal bleeding and malnutrition.[63] To reduce the negative effect on the infant’s digestive system, cow’s milk used for formula undergoes processing to be made into baby formula. This includes steps to make protein more easily digestible and alter the whey-to-casein protein balance to one closer to human milk, the addition of several essential ingredients (often called «fortification», see below), the partial or entire replacement of dairy fat with fats of vegetable or marine origin, etc.

    The nutrient content of baby formula for sale in the United States is regulated by the Food and Drug istration (FDA) based on recommendations by the American Academy of Pediatrics Committee on Nutrition. The following must be included in every formulas produced in the U.S.:[64]

  • Protein
  • Fat
  • Linoleic acid
  • Vitamins: A, C, D, E, K, thiamin (B1), riboflavin (B2), B6, B12
  • Niacin
  • Folic acid
  • Pantothenic acid
  • Calcium
  • Minerals: magnesium, iron, zinc, manganese, copper
  • Phosphorus
  • Iodine
  • Sodium chloride
  • Potassium chloride
  • Carbohydrates
    1. Carbohydrates are an significant source of energy for growing infants, as they account for 35 to 42% of their daily energy intake.

      In most cow’s milk-based formulas, lactose is the main source of carbohydrates present, but lactose is not present in cow’s milk-based lactose-free formulas nor specialized non-milk protein formulas or hydrolyzed protein formulas for infants with milk protein sensitivity. Lactose is also not present in soy-based formulas. Therefore, those formulas without lactose will use other sources of carbohydrates, such as sucrose and glucose, dextrins, and natural and modified starches. Lactose is not only a excellent source of energy, it also aids in the absorption of the minerals magnesium, calcium, zinc and iron.[65]

  • Nucleotides
    1. Nucleotides are compounds found naturally in human breast milk.

      They are involved in critical metabolic processes, such as energy metabolism and enzymatic reactions. Also, as the building blocks of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA), they are essential for normal body functions. Compared to human breast milk, cow’s milk has lower levels of the nucleotides uridine, inosine, and cytidine. Therefore, several companies that produce baby formula own added nucleotides to their baby formulas.[65]

    Other commonly used ingredients:

    1. Emulsifiers and stabilizers: Ingredients added to prevent the separation of the oil from the water (and its soluble components) in the baby formula.

      Some commonly used emulsifiers include monoglycerides, diglycerides, and gums.[64]

    2. Diluents: Skim milk is commonly used as the primary diluent in milk-based liquid formula to provide the bulk of the volume. In contrast, purified water is the most commonly used diluent in milk-free formulations.[64]


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