by Dr Marie-Therese (Terri) Lovis, General Practitioner
Advice for Formula Feeding Parents
For infants who are being fed a combination of breastmilk and formula, (re)establishing exclusive breastfeeding may resolve symptoms. If this is not effective the mother can exclude dairy from her diet as well. Specialist breastfeeding support may help with the transition.
If the infant continues to be combination fed, if symptoms don’t settle upon switching to dairy free formula, the mother should then move to also exclude dairy from her diet as well.
Which Formula should I prescribe?
First Steps Nutrition Trust has a good summary of independent evidence based information on for the specialised infant milks available. Please follow your local guidance on preferred prescribing of formula. A useful guide from Surrey Prescribing Advisory Database is here.
- It is important to remember that the dairy free formulas available are higher in sugar than standard infant formula, containing maltodextrin or dried glucose syrup, so predispose to dental caries1 and do not contain lactoferrin present in breastmilk which protects teeth. Inform parents that dental hygiene is extremely important and they need to brush teeth after the morning and bedtime feed.
- Soya formulas are not suitable for babies under 6 months2.
- Goat milk formulas are not suitable2 as these usually cause a reaction in babies with CMA as the proteins are almost identical.
Prescribe 2 tins of extensively hydrolysed formula to trial dairy free (or as per local guidelines).
Babies who have a severe IgE-mediated reaction and those who have not tolerated an extensively hydrolysed formula will need an amino acid based formula (as per local guidelines).
Babies who develop CMA whilst being exclusively breastfed and whose parents wish to then combination feed or fully formula feed for other reasons should have an EH formula prescribed as first line unless not tolerated.
Parents may struggle to get the baby to take the new formula (they taste and smell unpleasant compared with breastmilk/milk formula). Unless the baby has had a severe or IgE-mediated reaction, parents may have more success getting the baby to take the new formula if they gradually mix it with reducing quantities of their usual milk so they adapt to the taste.
If introducing formula parents might find it useful to mix expressed breastmilk with the dairy free formula and slowly increase the amount of formula in the bottle compared to breastmilk.
If the infant is refusing the dairy free formula some paediatric dietitians recommend a drop of ethanol free vanilla essence added to the milk, as a very short term option just whilst the baby gets used to it, making it taste and smell more palatable. Note: it is preferable not to allow the baby to become used to sweet tastes and this use falls outside of the product licence.
If the mother plans to reduce or stop breastfeeding it is best to do this gradually to avoid problems including mastitis. Every drop of breastmilk the baby gets is valuable3. If the mother wants to continue breastfeeding even just once a day or at night, her body will adapt and produce this amount. If later on she decides to increase the amount she breastfeeds, her breasts will adapt and milk supply will increase on demand. Signpost to local or national breastfeeding support.
How many tins do I need to prescribe per month for an exclusively formula fed baby with a confirmed diagnosis of CMA?
Refer to local guidance if available, but if not, the following quantities are advised on the Surrey PAD:
- Under 6 months: 13 x 400g tins or 6 x 900g tins (based on 150ml/kg/day) per month
- 6-12 months (will vary depending on solids intake): 7-13 x 400g tins or 3-6 x 900g tins per month
- Over 12 months: 7x 400g tins or 3 x 900g tins per month
When prescribing formula a discussion around responsive formula feeding could occur (see our separate webpage on ‘Infant Milks and Bottle Feeding‘ for further information).
- First Steps Nutrition Trust: Specialised Milks in the UK- Infants 0-6 months old September 2019, scroll down to purple report (see Section 3.12 p102, 108 and Key Points in Section 3.13 p113)
- British Dietetics Association Food Fact Sheet: Suitable Milks for Children with Cows’ Milk Allergy
- World Alliance for Breastfeeding Action (WABA): Protecting, Promoting and Supporting Continued Breastfeeding from 6-24+ Months- Issues, Politics, Policies & Action October 2008