Sarah Merson reviews the conditions that could cause your baby to need a special formula - and what is available.

Millions of pounds are invested each year by the dairy industry to ensure that dairy products represent a major portion of our diet. But, how often do we stop to think where our milk comes from and what or who, it is really meant for?

For many, cow’s milk and cow’s milk products are a valuable food source, providing a great many nutrients, including proteins, essential fatty acids, vitamins and minerals. But a growing number of babies, children and adults react to it. And, if we consider that cow’s milk is actually intended for baby calves not humans, surely it should not come as a surprise that many of us cannot tolerate it?

Reactive Symptoms
Symptoms can include everything from diarrhoea and/or constipation, bloating and flatulence to conditions such as halitosis, migraine and colic in babies. They are believed to be caused by a reaction to the proteins casein, beta-lactoglobulin and alpha-lactalbumin, the major allergens found in milk (cow’s milk protein allergy or CMA) or to the lactose sugar in milk (lactose intolerance).

Lactose Intolerance
Lactose intolerance does not involve the immune system and is common although frequently undiagnosed. Reactions may take days to develop, and normal amounts of milk are usually required to trigger a reaction. Skin and laboratory tests are no help as far as diagnosis goes. The only way to make a firm diagnosis is by demonstrating improvement on avoidance of milk, followed by ‘challenge tests’ in which, symptoms can be shown to recur on the ingestion of milk.

Various studies have shown that infants can recover spontaneously from lactose intolerance: 50% in a year, 75% in two years and 90% in three years. This tendency of lactose intolerance to spontaneous recovery has greatly reinforced scepticism among the medical professions regarding the diagnosis. As a result lactose as the possible cause of a problem is often dismissed. Accurate diagnosis requires a high index of suspicion, asking the right questions and, above all, time to listen. A family and infant feeding history are most important at all ages.

Cow’s Milk Protein Allergy
CMA is an IgE mediated allergy, which is uncommon, although increasing numbers are suffering problems in infancy. According to a study from the Department of Paediatrics, Wilhelmina Children's Hospital in The Netherlands, around 3% of all new-borns will suffer from CMA within the first year of life. And, whilst up to 60% of children, will outgrow the allergy by the age of four and 80% by the age of six, there is still a significant percentage of adult milk allergy sufferers.

Moreover, it’s possible for adults to develop a milk allergy with no childhood history of allergies. Reactions are generally sudden and dramatic and can be triggered by very small amounts of milk.

Management of CMA involves avoidance of milk proteins, and includes either breast milk for babies or hypoallergenic formulae based on hydrolysed protein for both babies and adults.

Total Food Intolerance
Total food intolerance (TFI) is a rare and largely unrecognised condition in which most or all normal foods cause an adverse reaction.

In children, TFI may be associated with an eosinophilic gastrointestinal disorder (EGID).

In adults, TFI appears to develop in patients whose health is already compromised by some other illness, such as MS, ME/CFS, multiple chemical sensitivity or Candida. Whilst the onset of TFI in children can be rapid, adult patients typically experience a creeping progression of symptoms over time and, as ever more foods start to cause reactions, finding anything safe to eat can become difficult or even impossible.

Management of this disorder relies on special medical feeds and alternative methods of feeding and expertise in treating TFI is inevitably extremely limited.

Breast is best...
With the recent revival in breast-feeding, few can be left in doubt that breast really is best when it comes to preventing or managing lactose intolerance or CMA, especially in the case of babies born of an atopic parent.

An infant with an atopic genetic inheritance, if brought into contact with any ‘foreign’ protein (not just milk but any food) before it is ready, may become sensitised to that food (or food protein) so that it will continue to react adversely to it in the future. This is why it is so vitally important that new born babies from atopic families should, whenever possible, be breast fed.

Expert bodies such as the European Academy of Allergology and Clinical Immunology observe that, for infants with a family history of atopy (at least one first degree relative), breastfeeding and avoidance of solid food and cow's milk for at least four to six months is the most effective preventative regimen.

...but not foolproof
We should be aware though that, even when a baby is breast fed, it does not guarantee that they will not develop a milk intolerance or allergy. Indeed, according to the paediatric specialists at the Wilhelmina Children's Hospital up to 1.5% of breast-fed infants will develop CMA. In these cases, the mother should also follow a strict cows milk-free diet.

Hydrolysed formulae – what are they, who uses them, and what are their roles?
Hydrolysed formulae contain cow’s milk in which the milk proteins and lactose have been broken down and are easier to digest. Formulae can be either ‘partially’ or ‘extensively’ hydrolysed.

Partial hydrolysates
Partial hydrolysates are characterised by a larger proportion of long chains (peptides). They are considered more palatable than extensively hydrolysed formulas. However, they are intended for prophylactic use - to reduce the risk of cow’s milk allergy in formula fed babies where there is a family history of allergy. Partially hydrolysed formulas are not suitable for treatment of cow’s milk allergy/intolerance as there have been many reports of adverse reactions to these products.

Extensive hydrolysates
The extensively hydrolysed proteins are predominantly made up of free amino acids and short peptides. Casein and whey from cow’s milk are the most commonly used sources of protein for hydrolysates because of their high nutritional quality and their amino acid composition. Whey hydrolysates are preferred since they taste significantly better. In addition, they are regarded by many as being closer to breast milk, which contains more whey versus casein protein.

Both the European Society for Paediatric Allergy and Clinical Immunology (ESPACI) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) stress that ‘only extensively hydrolysed formulae should be used in IgE mediated CMA owing to their proven safety and hypo-allergenicity. Partially hydrolysed formulae should be avoided in infants having CMA due to the unacceptable frequency of adverse, at times even severe, reactions associated with their ingestion’.

Elemental feeds – what are they, who uses them, and what are their roles?
Some babies, or even adults, who are highly sensitive or have suffered an anaphylactic reaction to milk, may still not be able to tolerate hydrolysed or soya-based milk formulae. Indeed, some, are allergic not only to cow’s milk, but a number of foods, including soya, and to these ends, an elemental diet may be necessary.

Elemental feeds are primarily designed to be free from the substance in food that provokes allergic and intolerance reactions. At present elemental formulae are used only in rare cases where all other elimination diets have failed to resolve symptoms, but the suspicion of an allergic aetiology causing illness remains high. Elemental feeds contain proteins that are broken down entirely into amino acids, and mixed with macro and micronutrients, vitamins, minerals and calories.

Semi-elemental feeds
Semi-elemental (oligomeric) feeds contain a hydrolysed, peptide form of protein, which is not as fully refined as the individual amino acids used in elemental (monomeric) feeds. The protein in semi-elemental feeds however, is sufficiently modified to prevent the body from recognising it and reacting adversely to it and is often very successful.

Hydrolysed Formulae

• Pregestimil® LIPIL®
  (part of the Enfamil family of formulas) by Mead Johnson Nutritionals.
  A hypoallergenic formula with medium chain triglyceride (MCT) oil, specially designed for babies with fat malabsorption.
• Nutramigen2® LIPIL®
  (part of the Enfamil family of formulas) by Mead Johnson Nutritionals.
  Cows milk protein hydrolysed into 3 short chain amino acids.
• NEXT STEP® Prosebee® LIPIL® (part of the Enfamil family) - by Mead Johnson Nutritionals.
  Soya-based, cow’s milk free formula specially formulated for toddlers 9-24 months.
• Enfamil® ProSobee® LIPIL® by Mead Johnson Nutritionals.
  A soya-based, cow’s milk free formula that does not contain lactose.
  
  More info on all Enfamil products at www.enfamil.com/products/formulas
  
  
• Karicare De-Lact - Nutricia
  Lactose-free, casein-based formula.
  
• Karicare Soya formula - Nutricia
  Soya-based, contains no lactose and is an option for older children.
  
• Karicare SensiKare HA
  (recommended for bottle-fed infants with first degree family history of allergy such as a parent or sibling) - Nutricia
  Made from partially hydrolysed 100% whey protein.
  
  
• Pepti-Junior - Nutricia
  A hydrolysed protein formula with proteins broken down to peptides.
  
  More info on Nutricia products at www.nutriciababy.co.nz
  
  
• NAN H.A.1 - Nestlé
  Partially hydrolysed infant follow-on formula. (0-6 months)
• NAN H.A.2 - Nestlé
  Partially hydrolysed infant follow-on formula. (6 months onwards)
  www.nestle.co.uk
  
  
• Similac® Alimentum® Hypoallergenic Formula - Similac
  Hydrolysed milk protein formula.
• Similac® Lactose Free Formula - Similac
  Similac Lactose Free is milk-based but contains no lactose.
  More info on all Similac products at www.similac.com
  
  
• Pepdite (+ Pepdite 1+, MCT Pepdite, MCT Pepdite 1+) - SHS International
  Powdered infant formula containing low molecular weight peptides (non-milk derived), essential amino acids, etc
  www.shsweb.co.uk/giall
  
  Elemental feeds
  
  
• Prejomin - Milupa
  Semi-elemental infant feed, often successful with adult patients.
  
  
• Neocate (+ Neocate Advance, recommended for children over 1 year) - SHS International
  Proteins have been broken down entirely into essential and non-essential amino acids and mixed with vitamins and minerals.
  
  
• Emsogen - SHS International
  Powdered elemental feed with protein broken down into amino acids, also high concentration of MCT’s.
  
  
• Elemental 028 (Elemental 028 Extra + Elemental 028 Extra Liquid) - SHS International
  Special hospital supply, powdered elemental feed for children and adults.
  
  More info at www.shsweb.co.uk
  
  
• Elecare - Ross Nutritional Products
  Nutritionally complete, amino acid-based, fully-elemental formula. Comes in both ‘unflavoured’ and ‘vanilla’.
  More info at www.ross.com
  
  Soya Formulae
  
  
• Wysoy - SMA Nutrition
  Dairy free, based on natural soya.
  
  
• Farley’s Soya Formula - Heinz
  Soya-based product, containing no animal products.
  
  

What about Goat’s Milk?

Although many people who are sensitive to cow’s milk, opt for soya milk as the first alternative, around 30% of cow’s milk intolerant/allergic babies also react to soya milk. In this case, either a hydrolysed formula or a goat’s milk formula may be more agreeable.

Although goat’s milk is also animal milk with a number of cross reactivities with cow’s milk it is widely reported, anecdotally, to be far better tolerated than cow’s milk, although, to date, there has been a dearth of robust scientific studies to support these reports. However, recent research suggests that:

• Goat’s milk contains very low levels of alpha-sl-casein resulting in smaller, softer and more easily digested curds when acidified in the infant stomach.
• Goat’s milk naturally contains nucleotides, which recent studies suggest may be able to modulate the immune system and suppress response to food allergens.
• Regular consumption of goat’s milk has been shown to reduce gut leakiness, inflammation and villi damage. It may also enhance the gastrointestinal barrier function, reducing the opportunity for food allergens to pass intact into the blood stream.
• In terms of nutrition (a concern of some health professionals) a study reported in the Journal of Paediatric Child Health (November 2005) concluded that ‘adequate growth is sustained over the first half of infancy when goat milk formula is the predominant source of nutrition...’

‘Nanny’ - infant nutrition

These goat’s milk products are based on the milk of free-range, pasture-fed New Zealand goats, raised without the use of stimulants, hormones, or growth enhancing drugs.

But, although Nanny is accepted in New Zealand on prescription, it still has not been accepted in the EU. ‘We do have an expert panel meeting in New Zealand, in January though, and we’re anticipating a positive response’, says Vitacare Director, Clare McGee.

More information on Nanny on 0800 328 5826
www.vitacare.co.uk

References:
1. Kuo-Inn Y et al (2000). Effect of a new infant formula containing nucleotides on vaccine response and morbidity of infants. Abstract presented at the World Congress of Pediatric Gastroenterology, Hepatology and Nutrition.
2. Pickering LK et al (1998). Modulation of the immune system by human milk and infant formula containing nucleotides. Pediatrics, 101:242-249.
3. Martinez-Augustin O et al (1997). Dietary nucleotides might influence the humoral immune response against cow’s milk proteins in preterm neonates. Biology of the Neonate, 71:215-223.

First published in 2007

Click here for more articles on the management of cow's milk allergy

Click here for more articles on infant and child health

Back to top