Pediatric Nutrition in Practice

Food Intolerance and Allergy 201

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the first-line treatment for infants with cow’s
milk allergy. Infants with ongoing symptoms
while on an extensively hydrolyzed formula, and
those with a history of cow’s milk anaphylaxis,
require an amino acid-based formula [15 , 17].
The role of soy formulas in the treatment of young
infants with cow’s milk allergy is controversial.
Concomitant soy allergy occurs in about 15% of
infants with IgE-mediated cow’s milk allergy
[18]. Because of the risk of soy allergy and con-
cerns regarding the phytoestrogen and phytate
content of soy formulas, the European Society for
Pediatric Gastroenterology, Hepatology and Nu-
trition has advised against using soy formulas
with infants with cow’s milk allergy under 6
months of age [15 , 19]. However, for older infants,
soy is a suitable treatment option for cow’s milk
allergy, provided tolerance to soy has been estab-
lished [19].

Conclusions

• Hypoallergenic formulas (extensively hydro-
  lyzed formulas or amino acid-based formulas)
  are used in the treatment of cow’s milk allergy
  in formula-fed infants. Soy formulas are also
  suitable for infants over 6 months of age with-
  out concomitant soy allergy


• In breastfed infants with food-allergic mani-
  festations, a maternal elimination diet may
  control symptoms in the infant. Prolonged
  maternal elimination diets should be super-
  vised by a dietician


• Lactose intolerance is the most common food
  intolerance and is treated with a low-lactose
  diet. Causes of secondary lactose intolerance,
  such as celiac disease, should be considered in
  the differential diagnosis

Ta b l e 4. Formulas used in the treatment of infants with food allergies or intolerances

Type of formula Features and indications

Partially hydrolyzed cow’s
milk-based formula

Contains relatively large cow’s milk protein fragments/peptides

Not suitable for treatment of cow’s milk allergy

May have a role in allergy prevention in high-risk infants in the first 6 months of life

Extensively hydrolyzed cow’s
milk-based formula
(whey-predominant
or casein-predominant)

Treatment of choice for formula-fed infants with cow’s milk allergy

Contains small cow’s milk peptides

Residual allergenicity due to trace amounts of cow’s milk proteins

Infants with previous cow’s milk anaphylaxis require introduction of extensively

hydrolyzed formula under medical observation

Not tolerated by approximately 10–20% of infants with cow’s milk allergy

Amino acid-based formula Synthetic formula containing mixture of free amino acids
Nutritionally complete formula
Treatment of choice for infants with intolerance to extensively hydrolyzed formula,
multiple food allergy of infancy or history of cow’s milk anaphylaxis

Soy formula Generally not considered first-line treatment formula for infants with cow’s milk allergy
under 6 months of age
Has a role in the treatment of cow’s milk allergy in older infants who are tolerant to
soy protein
Treatment of lactose malabsorption or galactosemia

Lactose-free cow’s
milk-based formula

Contains intact cow’s milk protein (same as in standard cow’s milk-based formula)

Useful for infants with transient lactose intolerance (e.g. after acute gastroenteritis)

Not suitable for infants with secondary lactose malabsorption due to cow’s milk protein-

induced enteropathy

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 195–202
DOI: 10.1159/000360340