A hypoallergenic by any other name… will still smell as stinky.

There’s a few definitive things one can say about hypoallergenic formulas:

1) They smell like regurgitated rotten potatoes
2) In order to feed your baby with them for one year, you will need to take out a second mortgage, and
3) They are lifesaving, invaluable substances for kids with food allergies, and many parents are eternally grateful for their existence.

According to this study, though (and please note I have not been able to track down the actual study – it does not appear to be in the current issue of JACI as the articles have implied; maybe it is forthcoming? – I am only going on the media reports, which as we all know are sketchy at best), there is one thing you can’t say about hypoallergenic formulas: that they prevent allergies.

But wait. I forgot! There is one more thing you can say about hypoallergenics: partially hydrolyzed formulas – the kind this study was using – are not technically hypoallergenic. A partially hydrolyzed formula is something like your favorite brand’s  “sensitive” formula. Or Nestle Good Start. These don’t smell as bad as Nutramigen or Alimentum. Nor do they cost as much. Most importantly, they don’t help one bit if your kid is actually suffering from a legit food intolerance or allergy.

Now, as far as I was aware, the evidence was mixed when it came to the actual hypos and allergy prevention. I’ve read some studies that have found a significant (remember, significant only means statistically significant; not necessarily significant in the way you or I might define the term) advantages to using a hydrolyzed protein formula in babies with a high risk of allergies. Others found no difference. But many studies have compared partially hydrolyzed to extensively hydrolyzed, and these have definitely found a difference between the two. This one, done in 2000, found that “the cumulative incidence of confirmed cow’s milk allergy was 1.3% (three of 232) in exclusively breast-fed infants, 0.6% (one of 161) in infants fed extensively hydrolyzed formula (Nutramigen or Profylac), and 4.7%(four of 85) in infants fed partially hydrolyzed formula (Nan HA). Partially hydrolyzed formula was found to be less effective than extensively hydrolyzed formula in preventing cow’s milk allergy, 0.6% vs. 4.7% (p=0.05), but because of the small number of cases the results should be interpreted with caution.”  Another study, published in 2009, showed a significant difference in allergy incidence between those fed partially hydrolyzed versus extensively hydrolyzed.

Okay, so we’re clear that we’re talking apples and oranges here, right? The reporting of this study frustrates me, because most people are probably going to assume that the findings hold true for actual hypoallergenic, extensively hydrolyzed formulas, and this is simply not the case.

My frustration is much higher, though, because of how each and every article reporting these findings had to throw in the requisite breast-is-best message. Even though this study did not compare exclusively breastfed kids to those fed any of the formulas in question (rather, they compared those fed a milk-based, soy, or partially hydrolyzed formula), and we have no way of knowing if breastfeeding would have been any more preventative (or any less) than the so-called “hypoallergenic”.

I want to bring your attention to a Cochrane Review (the “gold standard” of metastudies) which looked at all the good-quality evidence for prevention of allergies by way of childhood nutrition. The review didn’t find much of an advantage to using hypos as a preventative, but it also didn’t find any advantage to breastfeeding in this particular case. Although it’s hard to know, because….

Two trials compared early, short term hydrolysed formula to human milk feeding. 

Sorry to interrupt, but, um… Two. As in a number my son could count to before he could walk.

No significant difference in infant allergy or childhood cow’s milk allergy (CMA) were reported. No eligible trial compared prolonged hydrolysed formula to human milk feeding. Two trials compared early, short term hydrolysed formula to cow’s milk formula feeding. No significant benefits were reported. One large quasi-random study reported a reduction in infant CMA of borderline significance in low risk infants (RR 0.62, 95% CI 0.38, 1.00). 

Interestingly, though, the ‘authors’ conclusion then states, “There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding.” This is a bit oddly phrased to me, because while it is certainly true, it seems a bit misleading. What their review actually found was that there were only a few studies actually comparing these two methods of feeding, and that neither fared particularly well.

Anyway – the takeaway message is that parents who want to prevent allergies in their kids might be wasting their money (and their nasal passages – both my kids had to be on hypos and the smell seriously haunts my dreams) on special hydrolyzed protein formulas. But there’s a few important things that I hope won’t get lost in the media dissemination of this study (gosh, I’m list-heavy tonight, aren’t I?):

1. This study had fudge-all to do with kids who are currently suffering from food allergies. THAT is what these formulas were designed for; the prevention thing was likely just a hopeful scientific extension of a marketing ploy (incidentally, this study was funded by Nestle…) And regardless, for those of us on extensively hydrolyzed formulas (like most with food allergies will be), the type of formula used in this study is not the same as what we are feeding our children.

2. Speaking of Nestle, this study also looked at one particular formula, made by everyone’s favorite company of ill repute. Formulas do vary, contrary to what you may have heard.  Nutramigen and Alimentum, the two most popular commercial hypoallergenics in the States, are nearly identical – and yet any GI will tell you that many kids who can’t tolerate Enfamil’s option will do better on the Similac version. There are tiny, incremental differences in these two similar formula – I think soy products are more heavily used in one, and corn in another, or something like that (I’m sure one of you FFF’s knows about this and can fill us in). These tiny differences might matter if we’re talking about allergens/immunoresponse to allergens.

3. Just in case this gets used as anti-formula ammunition, let’s be clear: this study does not say that hypoallergenics make allergies worse than breastfeeding. All it says is that this particular type of hypoallergenic does not help prevent allergies.

Now if you will excuse me, I must go wash the scent of regurgitated potatoes out of my hair.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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13 thoughts on “A hypoallergenic by any other name… will still smell as stinky.

  1. Offhand, the only specific examples I can think of aren't very illustrative: the laetrile and chelation (for atherosclerosis) reviews are the stand-outs for me, but they're examples of inappropriate fence-sitting rather than bias. Kimball Atwood over at Science Based Medicine addresses one of the outstanding issues with Cochrane reviews here (continued here). Basically, he discusses how Cochrane reviews rely heavily on clinical data and overlook basic science (for example: a meta-analysis of homeopathy studies might tell you that homeopathy doesn't work better than placebo, but basic physics tells you that you don't have to bother demonstrating that, because the premise of homeopathy is implausible).

    But in general, I think my issue with Cochrane reviews is that they are perceived as more comprehensive and more rigorously vetted than regular meta-analyses when they are not. So it's not so much that they are less reliable than one-off systematic reviews as it is that they have the same shortcomings (cherry-picking by authors with angles, etc) but those shortcomings are more often overlooked due to the cache of the “brand”.

  2. Not that I don't love the analysis of good science and takedown of shoddy journalism that I find on this blog, but I wish people would stop referring to Cochrane reviews as “gold standard”. They're not. They're just popular. In fact, the idea of Cochrane reviews being somehow more thorough, rigorous or reliable than independent meta-analysis (the opposite is often true) is yet another example of the media's failure to represent science accurately.

  3. My daughter is allergic to cherries, nectarines, peaches and apricots yet she CAN have almond milk. Makes no sense to me either. I think it has something to do with relations; like they are cousins or something.

  4. Thanks for interpreting that article, that was really interesting. I honestly had no idea that parents were using hypoallergenic formula because of fear of allergies, I can't imagine paying that kind of money unless my child was clearly displaying allergic reactions to other formulas!

    It does seem like formula companies are out to promote “sensitive” formulas and parents buy into it because they are advertised as being for fussiness and gas and what baby doesn't have that? I would be interested to learn if there are any benefits of using partially hydrolyzed proteins or whey proteins, etc. I remember reading on Bottle Babies that in the UK 0-6 month formula is made with whey protein and second stage formula with casien. Here in the US only Good Start is made with 100% whey and the others have casien. If whey is truly better then why isn't it more widely available? Why don't we know that? The other thing about the partially hydrolyzed formulas is they are low or no lactose which means they have corn syrup solids as sweeteners. I'm sick of hearing from ignorant people about how formula contains HFCS same as soda (it's NOT the same), but I'll admit I tried to steer away from formula with corn syrup solids, although I have no idea if it's actually detrimental. I would love to see more independent research on how to make a better formula rather than the same old breast vs. bottle crap.

  5. This too. It would be way more helpful to improve the quality formula versus than just telling women to EBF when they already know they can't or for whatever reason won't EBF. There is an organic brand called Baby's Only, I believe they only use brown rice syrup and no corn products. I used it when DD was over 9 months old. It was a pretty good formula.

  6. What is interesting is that my daughter is clearly allergic to milk, but is able to tolerate the “sensitive” version of Similac. We were ready to take out that second mortgage and put our baby on the hypoallergenic stuff, but as it turned out, it was unnecessary. Whole milk, on the other hand, was a disaster. I have dealt with severe food allergies my whole life, so I know how to do an elimination diet, keep a food diary, space out new foods so we can tract reactions, etc. So that combined with the ped's take on the situation confirmed the allergy for us. We figure she's allergic to some milk proteins but not all.

    Allergies are not the exact science that people make them out to be. When you just look at the issue of cross-reactivity (not cross-contamination, a wholly other–but important–issue), it's enough to make you cross-eyed. If you're allergic to tree nuts, are you allergic to almond too? And why are so many almond-allergic people not allergic to fruits like nectarines, cherries, plums, or peaches? Coconuts are technically a palm but are considered a nut because some people cross-react–why? And what about cashews, which, like almonds and coconuts, aren't even technically a nut, yet are considered one of the top tree nut allergens? What about the difference between birch pollen OAS and an allergy to, say, apricots? And why do some people (like me) with ragweed allergies also react terribly to bananas, but can practically inhale cucumber and zuchini with no problems?

    Even milk allergies can be separated into whey and casein allergies for some people. And even that level of subtlety seems to be beyond the grasp of some of the reporters out there. So I'm deeply suspicious of any article that makes blanket statements about food allergies in general, much less articles that talk about breastfeeding as if it was even studied in the first place.

    What I come back to each time is if breastfeeding is supposedly so great for allergies, how come a) BFing resources like kellymom are lousy with information about elimination diets for moms of children with food allergies and b) as breastfeeding rates have increased, food allergy rates have jumped, and a lot. Correlation vs. causation, anyone?

  7. I'm confused by this because on the Good Start website Corn Malodextrin is listed as an ingredient of both their regular and gentle formulas. Whereas my daughter drinks Similac Advance and the word corn does not appear on the ingredients list at all. The carbohydrate appears to come solely from lactose.

  8. Trish, excellent point! I should have clarified that even the most broken down proteins won't help if what you're allergic to isn't the milk proteins. 😉 And that is really helpful information about Good Start. FWIW, my pediatrician recommended GS to us when Fearlette was born – she said it fared really well in studies about weight gain and allergies and was a lot cheaper than our go-to Alimentum. Unfortunately Fearlette couldn't tolerate it, but she's a mess, and even Alimentum doesn't offer a magic cure for her like it did for her bro. Goes to show that no 2 kids are alike, and there is no one-size-fits-all solution. Thanks so much for sharing – you are always an awesome source of info.

  9. This explains a lot! I have had many moms tell me that they tried so many formula brands out there and nothing worked and the one really big surprise they found on which formula worked for their baby was the Nestle Gerber Good start, but no one ever mentioned the “no corn” products. That makes so much sense now. Good information Trish! I have some ready-to-feed bottles of this brand ready and now I feel even better that I bought this brand. -Michelle K

  10. Not for nothing, but milk isn't the only thing a kid can be allergic to.

    Robbie was allergic to corn, which is the source of carbs in damn near everything EXCEPT Nestle/Gerber Good Start. (and pretty much everything else under the sun, but that's another topic.)

    We tried nutramigen, nutramigen AA,(no help) and alimentum (Robbie flat refused to eat it. Have you ever seen a 4 pound baby spit with purpose? I have!) and even Elecare (which is supposedly “impossible” to be allergic to.)
    I most definitely agree they all smell horrid, though. I think the alimentum was the worst. Though to be fair, they said the unflavored elecare is so disgusting, they actually have a vanilla flavored that the docs recommended because babies won't eat the regular stuff. So it smelled like regurgitated potatoes but with a vanilla overtone.
    (I feel like I need to add that we tried all of those after also trying various “regular” formulas and soy, too.)
    Fortunately we were only using it to supplement my breastmilk so eventually we gave up (relying on my plain skim breastmilk alone), but then when he stopped eating altogether, we had to try again. that's when we *finally* figured out the corn thing, tried Good Starts and Walla! Success.

  11. Gah. You are right. When I read the article and posted on FB I didn't catch the whole bit of comparing regular to partially hypoallergenic formula. That actually makes more sense about why they are calling it “preventative” since I know several parents who have opted for some kind of 'sensitive' formula. Apart from all the flaws you and others have pointed out about this study, what I really hate is that sleazy research like this from Nestle reinforces the argument that formula companies are just out to brainwash us for the money. Which in the case feels kinda true…

  12. It's e-published ahead of print. I've managed to get to it via Athens login, but unfortunately it's in a format that's impossible to send to someone else easily. (I mention that purely hypothetically, you understand, because naturally I would never do anything to violate copyright laws and so the point is entirely moot.) Anyway, the abstract is at http://www.ncbi.nlm.nih.gov/pubmed/21696814 .

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