Breastfeeding is the recommended feeding method for infants diagnosed with Cow's Milk Allergy (CMA) from birth until two years of age. Breastmilk is a unique source of nutrition for infants. It adapts to meet the infant’s changing requirements and provides prebiotics, probiotics, and non-nutritive factors such as antibodies for the growing infant.
In cases where breastmilk isn’t available, infants with CMA should be prescribed a hypoallergenic formula1.
Certain types of formula are not appropriate in CMA management, including1:
- standard infant formula (including anti-regurgitation, lactose-free, organic, newborn and their follow-on formulas)
- goat or sheep milk-based infant formula, other mammal milk and formula
- Partially hydrolysed formula
- A2 formula
Goat and other mammalian infant formulas are not recommended for infants with CMA due to the risk of cross-reactivity with cow's milk proteins1.
What are the suitable alternatives or substitutes to cow's milk for infants with Cow's Milk Allergy?
When a CMA infant cannot be fully breast fed, a hypoallergenic formula is required1, of which there are two types available in Ireland.
One is known as an extensively hydrolysed formula (EHF). In EHF, cow's milk proteins are broken down into smaller fragments so that the body does not recognise them as an allergen.
The second is an amino acid formula (AAF). Here the formula is made up of individual amino acids and can be used for the treatment of severe CMA.
In most cases an EHF formula should be recommended as the first choice2, 3.
However, if an infant with CMA suffers from severe symptoms such as significant atopic dermatitis, faltering growth or their symptoms do not improve on EHF, healthcare professionals can prescribe an AAF as an alternative1. If they’ve had anaphylaxis to cow’s milk, they should also be prescribed an amino acid formula.
For parents who prefer a plant-based formula, soy infant formula can be used as a second choice for the management of CMA but only from six months of age. However, some infants who are allergic to cow's milk protein may also react to soy1.
For this reason, parents should always consult with their paediatric dietitian before introducing soy formula to their infant.
Infant formula for Cow’s Milk Allergy
It’s best to advise parents that EHF and AA formulas may have a different taste and smell compared to breastmilk and standard formulas.
However, most infants do not acquire the ability to perceive taste and smell until around 12-14 weeks of age.
If an infant with CMA initially rejects the change to the new formula, healthcare professionals can recommend introducing it gradually into the infant’s current cow’s milk formula feeds over a few days.
It’s also helpful to advise parents that the consistency and colour of the infant’s stools may change (becoming greener for some babies) when switching to EHF or AA formula but reassure them that this is normal.
Tips for transitioning to a hypoallergenic formula
Below is one example of how parents can transition from standard cow's milk formula to an EHF formula, when this is safe to do so.
In severe CMA with anaphylaxis, or when clinically indicated, an immediate switch to the prescribed hypoallergenic formula should be made without delay1.
| Day | Total volume in bottle | Formula |
| One | 90 ml | Start with 30ml EHF and add 60 ml cow’s milk formula |
| Two | 90 ml | Increase to 60 ml EHF, reduce to 30ml cow’s milk formula |
| Three | 90 ml | Increase to 90 ml EHF and stop cow’s milk-based formula |
Closely monitor the infant’s response to the new formula and provide ongoing support to parents as needed. By following these recommendations, the transition to an EHF or AA formula can be made smoother.
Other types of hypoallergenic formulas
Partially hydrolysed formula
Parents may ask about using partially hydrolysed formulas (pHF) for infants with CMA. However, these formulas are not recommended for CMA infants as the molecular weight of the peptides in pHF is still too large4 and can cause an allergic reaction in CMA babies.
Therefore, pHF is not suitable for the dietary management of CMA and should not be used as a substitute for breastmilk, EHF, or AA formula.
Formula with added prebiotics, probiotics and synbiotics
Some hypoallergenic formulas may have added prebiotics, probiotics and synbiotics to help support a balanced gut microbiota in food-allergic infants.
Formulas that contain a probiotic will need to be prepared with water that is boiled and then cooled to room temperature, as per the instructions on the tin.
Hypoallergenic formula with lactose as an ingredient
It is worth noting that some hypoallergenic infant formulas may contain lactose which is known to naturally enhance the flavour. Lactose is a key primary carbohydrate present in breastmilk and has been shown to have a prebiotic effect, help shape the microbiota6-8 and facilitate calcium absorption 9.
EHFs containing purified lactose have also been found to be safe and effective in the treatment of CMA10-11.
It is, therefore, recommended to work with a paediatric dietitian to help determine the most appropriate formula for infants with CMA and receive expert advice and support.
- Luyt D et al. BSACI guideline for the diagnosis and management of cow's milk allergy. Clin Exp Allergy 2014;44(5): 642–72.
- Venter C, 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; 7:26. DOI.1186/s13601-017-0162-y
- The GP Infant Feeding Network. Milk Allergy in Primary Care (MAP) Guideline 2019. Healthcare Professional Factsheet. [internet] [cited 2023 March 14] Available from: https://gpifn.files.wordpress.com/2019/10/imap-additional_tool_for_hcps-5rm_-tb_original.pdf
- D'Auria E, et al. Hydrolysed Formulas in the Management of Cow's Milk Allergy: New Insights, Pitfalls and Tips. Nutrients. 2021;13(8):2762. doi: 10.3390/nu13082762. PMID: 34444922; PMCID: PMC8401609.
- FSA. Warning against using rice milk for infants and young children. [internet] [cited 2023 March 14] Available from: https://www.fsai.ie/news_centre/press_releases/rice_milk_warning_10032022.html
- Romero-Velarde E, et al. The Importance of Lactose in the Human Diet: Outcomes of a Mexican Consensus Meeting. Nutrients. 2019;11(11):2737. doi: 10.3390/nu11112737. PMID: 31718111; PMCID: PMC6893676.
- Szilagyi A. Lactose-a potential prebiotic. Aliment. Pharmacol. Ther. 2002;16:1591–1602. doi: 10.1046/j.1365-2036.2002.01321.x.
- Szilagyi A. Redefining lactose as a conditional prebiotic. Can. J. Gastroenterol. 2004;18:163–167. doi: 10.1155/2004/350732.
- Abrams SA, et al. Calcium and zinc absorption from lactose-containing and lactose-free infant formulas. Am. J. Clin. Nutr. 2002;76:442–446. doi: 10.1093/ajcn/76.2.442.
- Niggemann B, et al. Safety and efficacy of a new extensively hydrolyzed formula for infants with cow’s milk protein allergy. Pediatr Allergy Immunol 2008;19:348–54.
- S. Koletzko et al. Diagnostic Approach and Management of Cow’s-Milk Protein Allergy in Infants and Children: ESPGHAN GI Committee Practical Guidelines. JPGN Volume 55, Number 2, August 2012
%20No%20shadow?ts=1772620279583&dpr=off)
You may also be interested in
Nutricia offers access to a wide range of support services and resources including:
- • Our free Sampling Service to order product samples and have them sent to your patients' homes.
- • A range of CPD accredited e-learning programmes.
- • Order free paper copies of our support tools for yourself or to use with your patients.
- • Sign up to receiving marketing communications and be the first to know about our free educational events & webinars, the latest scientific research and product updates.
Help us provide information most relevant to you
Please ensure your role and areas of interest are up to date.
Also on this website
About Nutricia
Follow us on LinkedIn
Follow us on Twitter
- Nutricia Ireland Limited is a company registered in the Republic of Ireland with company number 106997. VAT Number IE4800652P
- © 2024 Nutricia. All rights reserved