Use of Hypoallergenic Infant Formulas

The AAP Committee on Nutrition and Section on Allergy and Immunology clinical report, published in Pediatrics in January 2008, reviewed the impact of various foods in infancy that may precipitate allergic disease. The report found:

The documented benefits of nutritional intervention that may prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy (ie, infants with at least 1 first-degree relative [parent or sibling] with allergic disease). Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation. There is evidence that breastfeeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy and wheezing in early childhood. In studies of infants at high risk of atopy and who are not exclusively breastfed for 4 to 6 months, there is modest evidence that the onset of atopic disease may be delayed or prevented by the use of hydrolyzed formulas compared with formula made with intact cow milk protein, particularly for atopic dermatitis. Comparative studies of the various hydrolyzed formulas also indicate that not all formulas have the same protective benefit. There is also little evidence that delaying the timing of the introduction of complementary foods beyond 4 to 6 months of age prevents the occurrence of atopic disease. At present, there are insufficient data to document a protective effect of any dietary intervention beyond 4 to 6 months of age for the development of atopic disease.”1

Elsewhere, it has been reported that 2 to 5 percent of infants manifest a food allergy in the first 1 to 3 months of life, which typically resolves by 1 year of age.2Guidelines for use of protein hydrolysate or amino acid-based infant formulas for allergic indications are proposed below. These recommendations result from a literature and experience review by Drs. Bancroft and Chilmonczyk on July 13, 2009.

Proposal:

Most, but not all, infants whose diet is restricted to extensively hydrolyzed- or amino acid-based formulas are assigned these restrictions in response to allergic conditions. For those children, we recommend the following approach:

Patient < 1 year of age
Anextensively hydrolyzed formulais indicated for:

  • severe eczema
  • bloody stools due to allergic enterocolitis
  • anaphylaxis triggered by exposure to cow’s milk or soy proteins
  • elevated IgE RAST test to cow’s milk and soy
  • consultative recommendation of an allergist or pediatric gastroenterologist
  • asthma in the first year of life

Anamino acid-based formulais indicated for:

  • preexisting diagnosis of Eosinophilic Esophagitis or Eosinophilic Enteropathy
  • biopsy-confirmed Eosinophilic Esophagitis or Eosinophilic Enteropathy
  • documented anaphylaxis (pending consultation with allergist)
  • consultative recommendation of an allergist or pediatric gastroenterologist

WIC will provide the first month ofelemental formula, but MaineCare Prior Authorization forcontinued elemental formulaprescription by a primary care provider must be accompanied by a consultation with a pediatric gastroenterologist or pediatric allergist as appropriate to the condition (consultation may initially be by telephone). Special formula requirements for the above indications, begun in the first year of life may be continued by the primary care provider up to 1 year of age. Continuation of a special formula beyond 1 year of age, for the above indications, requires reconsultation with a pediatric allergist or pediatric gastroenterologist.

Patient ? 1 year of age
Consultation with an allergist or pediatric gastroenterologist is required to initiate either an extensively hydrolyzed formula or amino acid-based formula after 1 year of age.

Any child assigned to an extensively hydrolyzed or amino acid-based formula beyond 1 year of age should have reconsultation with an allergist or pediatric gastroenterologist every 12-18 months as a requirement for continuation of the formula.

Definitions

Atopic disease:Clinical disease characterized by atopy; typically refers to atopic dermatitis, asthma, allergic rhinitis, and food allergy. This report will be limited to the discussion of conditions for which substantial information is available in the medical literature.

Atopic dermatitis (eczema):A pruritic, chronic inflammatory skin disease that commonly presents during early childhood and is often associated with a personal or family history of other atopic diseases.

Asthma:An allergic-mediated response in the bronchial airways that is verified by the variation in lung function (measured by spirometry) either spontaneously or after bronchodilating drugs.

Cow milk allergy:An immunologically mediated hypersensitivity reaction to cow milk, including IgE mediated and/or nonIgE-mediated allergic reactions.

Food allergy:An immunologically mediated hypersensitivity reaction to any food, including IgE-mediated and/or nonIgE-mediated allergic reactions.

References

The AAP Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics. 2008:Vol 121, No1:183-191.

AAP Committee on Nutrition. Lactose Intolerance in Infants, Children and Adolescents. Pediatrics. 2006:Vol 118. No 3:1279-1286.

[back to top]