Hydrolysed Formulas in the Management of Cow’s Milk Allergy: New Insights, Pitfalls and Tips

Abstract

An allergy to cow’s milk requires the avoidance of cow’s milk proteins and, in some infants, the use of a hypoallergenic formula. This review aims to summarize the current evidence concerning different types of hydrolysed formulas (HF), and recommendations for the treatment of IgE- and non-IgE-mediated cow’s milk allergy and functional gastrointestinal disorders in infancy, for which some dietary intervention and HF may be of benefit to both immune and motor mechanisms. Current guidelines recommend cow’s milk protein (i.e., whey or casein) extensively hydrolysed formula (eHF) as the first choice for cow’s milk allergy treatment, and amino acid formulas for more severe cases or those with reactions to eHF. Rice hydrolysed formulas (rHF) have also become available in recent years. Both eHF and rHF are well tolerated by the majority of children allergic to cow’s milk, with no concerns regarding body growth or adverse effects. Some hydrolysates may have a pro-active effect in modulating the immune system due to the presence of small peptides and additional components, like biotics. Despite encouraging results on tolerance acquisition, evidence is still not conclusive, thus hampering our ability to draw firm conclusions. In clinical practice, the choice of hypoallergenic formula should be based on the infant’s age, the severity, frequency and persistence of symptoms, immune phenotype, growth pattern, formula cost, and in vivo proof of tolerance and efficacy.

Clinical Effect of Standardized Dietary Avoidance Therapy on Children with Milk Protein Allergy and Its Effect on Intestinal Flora

“…The standardized dietary avoidance therapy has the same mechanism as the establishment of oral immune tolerance, and both are treated with a deeply hydrolyzed formula powder or an amino acid formula powder. It can induce immune tolerance in children, that is, inhibit the proliferation and activation of B lymphocytes, reduce the secretion of immunoglobulin IgE, and reduce the inhibitory effect, increased secretion of plasma immunoglobulin IgA, immunoglobulin IgG1, and immunoglobulin IgG4, thereby reducing allergic symptoms [ 24 , 25 ]. In addition, the extensively hydrolyzed formula (eHF) is to hydrolyze casein, whey, and lactoglobulin into molecular weights without changing their nutritional value by hydrolyzing casein, whey, and lactoglobulin by related enzymes.…”

Cows’ Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

“…When human milk is not available or it is insufficient, extensively hydrolysed CM formula, rice hydrolysate or amino acid formula are recommended for the management of CMA [ 143 ]. Hypoallergenic formulas may vary for protein source and content, method and degree of hydrolysis and additional components, which affect tolerance and efficacy [ 143 , 162 ]. In formula-fed infants with food-allergic motility disorders, the use of extensively hydrolysed formulas has been shown to be effective [ 162 ].…”

“…Hypoallergenic formulas may vary for protein source and content, method and degree of hydrolysis and additional components, which affect tolerance and efficacy [ 143 , 162 ]. In formula-fed infants with food-allergic motility disorders, the use of extensively hydrolysed formulas has been shown to be effective [ 162 ]. Amino acid-based formula can be used if symptoms persist on extensively hydrolysed cow’s milk protein-based formula or if GI symptoms are associated with malabsorption and faltering growth [ 163 ].…”

“…Rice hydrolysate formula is also a suitable alternative to CM-based hydrolysed formulas. Other plant-based milk alternatives are not nutritionally complete, and they are contraindicated as cows’ milk substitutes in infants [ 143 , 162 ].…”

“…The direct effect of hydrolysed proteins on gastrointestinal motility has been considered. A number of studies indicated that source protein (casein vs. whey) and degree of hydrolysis (intact protein vs. partial or extensively hydrolysed protein) may influence gastric emptying time [ 162 , 169 ]. Conversely, very limited data have been published on the effect of different proteins on intestinal motility.…”