The FFF Quick-and-Dirty Guide to Formula Feeding: Recognizing Sensitivity, Intolerance or Allergy to Formula

Those of you who haven’t been following this blog since the beginning may not know this, but my son Fearless Child (FC) has a dairy allergy, which went undiagnosed for the first few months of his life. Having his insides assaulted on a daily basis made him grumpy – so grumpy that he screamed bloody murder for about 20 hours a day. And yet it took us over a month of elimination diets, doctor visits, and late-night consultations with Dr. Google to figure out what was going on. This was partly because FC’s symptoms were slightly atypical, but more so because as new parents, we were utterly confused as to what was “normal” newborn behavior and what necessitated medical intervention.

There’s a good deal of information on dairy intolerance in babies on the Web, but not much specifically geared towards bottle-feeding parents. This is unfortunate, as those of us feeding our kids in this manner actually have a really simple way of figuring out if food issues are at play – and yet so many of us struggle for months, feeling increasingly frustrated and hopeless with our inability to comfort or feed our children adequately.

I always hesitate to offer what might be construed as medical advice, since there’s far too many hacks out there doing just that. So before I continue with this post, let me reiterate: I am not a doctor. I haven’t even played one on t.v. (Does anyone still get that reference? Or does it make me sound old?)  The following information is what I have culled from my own research, talking to pediatricians and pediatric GIs, and from my own experience as the mother of two kids with feeding issues.

Oh, and one more note: I am going to use the terms “intolerance”, “sensitivity”, and “allergy” interchangeably here, even though these three things are entirely different. This is because until you see a physician, you won’t know which of the three you are dealing with. My purpose with this post is to help you realize when something is amiss, and to assist you in navigating a medical system which often ignores the power of parental intuition and knowledge of one’s own child. You’ll have to see an actual MD to get a true diagnosis… and I don’t meant Dr. Google.

 

Behavioral Symptoms of Formula Intolerance or Allergy in Young Babies

Newborns are complicated creatures. Some are calm and sweet (this is the kind of baby everyone else seems to get at least once, but apparently my and my husband’s genetics do not morph in a manner conducive to a docile temperament), others are generally chill except for a bout of colic between weeks 2-8, and others are fussy all.the.time. This last group is the one that we need to worry about. Typically, a calm, contented baby is a well-fed and happy one. This is not to say that food allergies will not strike later in life, once solids are introduced, but a newborn who is sensitive to something in formula will usually express discomfort in a pretty vocal way. Watch out for:

– Extreme fussiness. Colic is defined as crying for a period of 1-3 hours, at least 3 days a week, typically in the evening. A baby who is sensitive to formula will cry constantly, throughout the day. They can sometimes be comforted, but only by extreme measures like continuous movement (we had to bounce FC so vigorously that once, while shopping for a new car, a man came up to us in horror and told us we should stop shaking our baby; a friend’s dairy intolerant breastfed baby was only comfortable while being vibrated in his bouncer – all night long), specific holds (the Harvey Karp /Happiest Baby hold is magical for babies with tummy issues). The difference between a “normal” fussy baby and one with potential allergy or intolerance is that they have 2 settings: sleep and screaming. The fussiness is the default, rather than the exception.

– Trouble sleeping. While many young babies sleep erratically, they usually sleep a lot cumulatively.  A newborn with a formula intolerance will often be too uncomfortable to sleep.

– Trouble eating. This one gets tricky, because other issues can cause trouble with feedings – sensory issues, reflux, dislike of the type of bottle or nipple you are using… but one common symptom in babies experiencing formula intolerance is fussiness around eating. They may pull away from the bottle and scream; or eat only small amounts at a time. Reflux can also be associated with formula intolerance, so spitting up an excessive amount after every feeding (especially if there is curdled formula or blood in the spit up) might signal a problem. Some babies might develop an aversion to eating, associating the formula with pain, and refuse the bottle altogether. Others may “comfort feed” and want to eat constantly (more on this later).

– Inability to connect or bond. Again, this can signal a far more serious issue, but it should be noted that babies who are in constant pain have a rough time chillaxing enough to focus on their parents or begin engaging in social interactions. I’ve had numerous parents tell me that they had secretly worried their baby “had no soul” or “wasn’t all there” prior to diagnosing and solving a severe allergy or intolerance. If your baby is screaming constantly or is noticeably stiff, writhing, or doesn’t seem to be comforted by touch, see your doctor.

 

Physical Symptoms of Formula-Related Food Intolerance or Allergy

The physical manifestations of a formula intolerance are more straightforward, but they also tend to suggest a more serious problem (i.e., clinical allergy versus sensitivity). In terms of getting a diagnosis, they do make life easier, but they can also be scary when first encountered. These include:

– Weight loss, or extreme weight gain, from comfort feeding.  I’ve heard of more than a few cases where babies who are overeating are misdiagnosed with the excuse that “milk protein intolerance causes failure to thrive”. This is true; many kids will have aversions to formula or breastmilk caused by associations with pain, and refuse to eat; these conditions can also cause malabsorption, so the baby isn’t getting the necessary nutrients to grow. But some babies find the liquid comforting as it goes down (especially those who have reflux associated with the intolerance or allergy), or like the sucking action, and want to eat constantly. The offending food causes more distress, which then creates a need to comfort feed more… and suddenly you’ve got Jabba the Hut, Jr. on your hands. Their girth may cause doctors to dismiss discomfort and symptoms as “overeating”(which can certainly cause a whole list of problems, but my point is that sometimes, the overeating is a symptom, not a cause).

– Blood in the stool – this can appear looking like strawberry jelly (red) or like coffee grinds (black). If you see blood, drop everything and call your pediatrician.

– Mucous in the stool – this is a biggie, because often the blood will be invisible to the naked eye, but mucous is easy to spot. Mucous looks like stringy, gelatinous strands, usually white or clear in color.

– Rashes – these can appear in a variety of forms, and may be hard to differentiate from normal newborn skin issues like diaper rash or infant acne. Sometimes the rashes might look like hives, but they can be atypical. FC would get petechia-type red dots on his cheek, right next to his eye, and down his cheek. (This same reaction continued as he grew into toddlerhood, and was a great way for us to know we’d screwed up and allowed for accidental exposure). Other parents have told me that the rashes congregate near the joints, or as a red ring around the anus. All lovely and comforting things to see on your precious newborn, right?

– Vomiting up blood. Again, this merits a panicked call to the doctor. Stat.

Something you should also know is that milk protein allergies come in two forms: rapid onset (immediate reaction) or delayed onset (reaction within 7-10 days of ingesting milk). This may explain why some babies don’t start reacting to formula until a week or so after birth/switching over from breastfeeding. Rapid onset looks more like a “classic” food allergy – hives, wheezing, bloody diarrhea. The rapid onset form is far more dangerous, as allergies can worsen with every exposure, eventually leading to anaphylaxis, so if you see these sort of symptoms, do not pass go, do not collect $200, just dial your pediatrician.

Which brings me to….

Seeing Your Doctor

There are a lot of fabulous pediatricians out there. There are also some really crappy ones. And in the middle, there are doctors who have seen thousands of neurotic new parents who freak out at the first sign of slight fussiness in their babies, and also a slew of legitimately concerned parents dealing with the untreatable hell that is infant colic. Considering that in the majority of cases the babies they see are either healthy and just waking up to the world (it’s normal for a baby to be impossibly easy and sweet for the first few weeks and then wake up one day with an attitude. Think of it as good practice for the teen years), or are unfortunate victims of colic and just have to wait it out (excuse my tangent for a moment but I cannot for the life of me understand why no one has figured out this colic thing. Seriously? We can clone sheep and we can’t figure out why some babies cry inconsolably for exactly 3 hours at the same time every night??!), it is understandable that some pediatricians have dismissive or patronizing attitudes towards those complaining about fussy babies.

I have seen parents who do overreact to sudden onset of mild spitting up, fussiness, or constipation- it’s hard not to, considering the lack of sleep, the hormones, and the lure of the Internet (Dr. Google is an alarmist). But for the most part, every parent who has emailed me with a laundry list of weird symptoms and a general, foreboding sense that something is “not right” with their newborn, has later followed up to confirm diagnosis of an allergy or intolerance. I’m a big believer in mommy/daddy “gut” when it comes to your baby’s gut.

So, here’s what I would suggest: before you go in for your child’s appointment, write down a list of every symptom you have observed. If you’ve been noticing mucous or blood, collect a stool sample, and show your doctor the craziness that is coming out of your kid’s tush. If your doctor starts talking about colic, explain to him/her that you are well aware of what colic is, and colic does not explain the other symptoms you are noticing (you might also want to mention if your child’s crying doesn’t follow a colic-like pattern – meaning that it is not sustained crying for a specific period of time, but rather constant fussiness throughout the day).

It is also well within your rights to request allergy testing, but here’s the thing: with this sort of testing, only a clinical allergy will show up. If your baby has an intolerance or sensitivity, the testing will probably come back as inconclusive or “normal”. Additionally, there is some controversy on whether allergy testing in young infants is even accurate.

Luckily, there is another, non-invasive way to see if the formula you are using is the problem, which is what I like to call…

The Miracle Cure

I could write a Shakespearean sonnet for hypoallergenic formulas, and I’m sure the folks who like to think I’m paid off by formula companies will find fodder for this conspiracy theory in how often I hawk Alimentum on here. But I just love the stuff. And not just Alimentum. Nutramigen, and Neocate, and whatever comparable product is on the European/Asian markets. The stuff is stinky, expensive….and utterly lifesaving.

If you suspect that your baby has a milk protein sensitivity, and the symptoms are not severe enough to necessitate medical intervention, you might want to consider doing a 48-hour hypoallergenic challenge. This is a 4-step process:

1. Get thee to thy nearest drugstore/grocery store

2. Purchase a commercial hypoallergenic formula (please read my post on types of hypoallergenic formula to ensure that you are choosing a true hypoallergenic and not simply a “sensitive” brand)

3. Serve said formula to thy infant, and observe for the next day or two

4. Thou shalt be singing high praises to the heavens by yonder morning, otherwise the formula probably wasn’t the problem in the first place.

While milk and soy protein allergies are the most prevalent in young infants, there are some kids who are sensitive to corn or other ingredients in formula. And for children with severe milk protein allergy, a commercial hypoallergenic isn’t going to cut it – they will need an amino acid-based formula, which is available by prescription only. But for most babies suffering from mild to moderate sensitivities/intolerances, a hypoallergenic formula is truly a godsend. You should see a marked improvement within 2 days if the problem is food related and not due to some other underlying medical condition (cough*call doctor*cough) or- and I seriously hate to say this – if it’s just colic or fussiness, in which case you really do just need to give it time, and start drinking heavily to get through the next few months. Kidding. (Maybe…)

If you are dealing with colic or normal infant fussiness, the good news is that you can skip the following section, and not have to worry about a childhood without ice cream and birthday cake. But if the formula does make a dramatic difference, you may want to consider….

What the Future Holds

If the hypoallergenic works wonders, you can continue to use the formula and try re-introducing a normal or sensitive formula at about 6 months, once your baby’s system has developed a little more. If symptoms return, then you simply return to the hypoallergenic.

That said, hypos are quite costly, and if your child does have a true milk protein allergy, you might be able to get the formula covered by your insurance. You’ll need to see your pediatrician to get the right paperwork filled out in order to do this.

I’d also suggest that you do ask for a referral to an allergist and/or pediatric GI, just so you will have someone in your corner when you start solids. While most children outgrow a milk protein allergy or intolerance as they become toddlers, some take longer than others. It gets really difficult to figure out a delayed-reaction allergy once they start solids, because the exposure could have been anytime in the week or so prior to the reaction. Also, weaning off formula looks a bit different in a dairy intolerant/allergic child. Sometimes, pediatricians will want you to stay on formula a little longer since it’s harder for kids to get the nutrition they need when they can’t eat or drink dairy products. In other cases, using a milk substitute like soy (unless your child is sensitive to soy as well, which many milk protein intolerant kids are), rice, almond (as long as you’ve seen an allergist and been tested for nut allergies), oat. or hemp, can be a perfectly acceptable option. My kids have both thrived on unsweetened almond milk, which is fortified with so much stuff nowadays that the only thing milk trumps it on is protein content and fat (and we incorporate other foods into their diets that compensates for this).

You’ll get very good at reading labels, and creative with recipes, and become a master at surreptitiously pulling vegan cupcakes out of your diaper bag at birthday parties so your kid won’t feel left out. You’ll probably do “challenges” with your kid every so often to see if his or her body has decided to make friends (or at least frenemies) with dairy, and when that day comes, you may even get to see a face like this:

Fearless Child’s first time eating cake & ice cream at a friend’s birthday. And yes, I cried.
Until then, remember- you are the expert on your child. You are also your child’s best advocate. Formula can be changed at any time, so there is no reason to suffer stoically if you suspect an intolerance or allergy to the one you are using now.
Great Links/Sources
http://kidshealth.org/parent/medical/allergies/milk_allergy.html
http://www.allergy.org.au/patients/food-allergy/cows-milk-dairy-allergy
http://foodallergies.about.com/od/dairy/a/babymilkallergy.htm
http://adc.bmj.com/content/92/10/902.full.pdf
http://www.kidswithfoodallergies.org/resourcespre.php?id=140&
http://www.medscape.org/viewarticle/563463

FFF Friday: “My wife had the courage to put her son’s welfare above ideological stubbornness.”

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They are also not political statements – this is an arena for people to share their thoughts, and I   hope we can all give them the space to do so.

This is only the second father-written FFF Friday post I’ve ever received, which is a real shame. Obviously, mothers are the ones who deal with most of the breastfeeding-related emotional and physical trauma, but dads are affected as well. It’s the fathers (and non-birthing, female partners, of course – as a side note, I wish we’d hear from more same-sex couples as well as heterosexual fathers) who have to sit on the sidelines feeling conflicted about how best to offer support. Except for the male breastfeeding advocates and physicians, there is a real lack of testosterone in this discourse…and wouldn’t it be interesting to hear what fathers really think, when they aren’t being lumped into categories like “breastfeeding friendly” and “pushing bottle-feeding”? I have a feeling that for most of our partners, these decisions and actions are based less on parenting theories and societal expectations of perfection, and more on ensuring the immediate happiness and survival of the people they love the most.

So, to FFF Brian – thank you for being an incredible father, incredible writer, and incredible resource for the readers of this blog. I hope this great post will inspire other men to contribute…because I, for one, want to hear what you have to say.

Happy Friday, fearless ones.

The FFF
***
My wife has been the recipient of more unsolicited advice than anyone I know.  When she was pregnant, she had a violent case of hyperemesis gravidarum.  Friends, family and strangers would tell her that she should try ginger, lemons, and other natural remedies to cure an illness that hospitalized her for dehydration multiple times.  She explored every possible holistic avenue to avoid having to take Zofran and other drugs to help her manage her symptoms.  When given the choice between letting our son die or trying some modern medicine, the choice was a no-brainer.  Had we lived just a few decades ago, she would have been written off as not just a physical failure but an emotional failure because doctors believed that hyperemesis was caused by a mother’s unwillingness to have a child.
As we prepared for childbirth, my wife and I did private HypnoBirthing classes, breastfeeding workshops, and hired a Doula.  We ended up changing our hospital to one that was more receptive to natural childbirth methods.  We had high hopes that the birth would be a totally natural process – just like the many HypnoBirths we saw during our classes.  Once again, our plans were thrown out the window.  My wife’s water broke before contractions had begun.  Because the water had broken, the nurses and midwife were concerned about infection if labor didn’t progress adequately.  So, my wife went on Pitocin while using only hypnosis as a pain-reliever.  My wife endured over 10 hours of Pitocin-enhanced contractions before the staff recommended that she have an epidural so they could avoid a C-section.  I don’t know how she made it for 10 hours on Pitocin without any pain medicine – I have never seen anyone in so much pain.
Somehow she did it, without having to do a C-section.  Our son was born healthy and happy; his weight gain of almost eight pounds was not coincidentally more than my wife had gained during her pregnancy.  When our son was born, we both hoped that we could finally have the natural experience that everyone told us was, without a doubt, the best thing for a baby – breastfeeding.  Once again, conventional wisdom failed us.  Our son was not keeping his food down at all – we kept him upright for an hour after feedings to avoid acid reflux, which basically meant that we did not sleep for the first month of his life.  Our pediatrician suggested we see an allergist to have our son tested for food allergies. 
It turned out that our son was allergic to peanuts, pecans, sunflower seeds, cow milk, gluten, oats, soybeans, mangos, strawberries, tomatoes, paprika, eggplant, peppers, mustard, ginger, dill, cinnamon, and corn.  Having been told from everyone that “breast is best”, my wife resolved to do an elimination diet.  We went to the store and my wife prepared herself for several months of eating nothing but lamb and brown rice.  One problem though – she was only producing a couple of ounces of milk a day, not anywhere close to nourish our son.
Having exhausted all other options, we gave our son an exclusive diet of Simliac Alimentum Ready-To-Feed.  It was the only formula that did not have anything to which he was allergic.  It has cost a small fortune, but it was worth it.  Our son ate well, and his mood improved tremendously.  Today, he is a thriving, delightful eight month old.  Had we lived fifty years ago, he would likely have died from malnutrition.  I am glad that my wife had the courage to put her son’s welfare above ideological stubbornness.
Our experience reminds me of a joke I heard the other day.  There was a man stuck on an island as the river rose. A rescue team threw him a rope and he refused to grab it because “God Saves”. The river rose and the rescue team sent a boat to him and he refused to get in because “God Saves”. The river rose and he climbed the flag pole and a helicopter came by to pick him up and he refused to get in because “God Saves”. He finally drowned and when he stood before God, he was miffed. “Why didn’t you save me?” he screamed out. God looked down and said “I sent you a rope, a boat and a helicopter. What more do you want?”
When my wife was pregnant, God sent us Zofran. When she gave birth, He sent us Pitocin and an epidural.  When our son couldn’t feed, He sent us Alimentum.  
***

Why put off until tomorrow what you can do today? Send your FFF Friday submission over ASAP to formulafeeders@gmail.com. (This is coming from the queen of procrastination, but whatever…) 

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.

Hyping hydrolysates: All about hypoallergenic formulas

I want to admit my bias towards hydolysates up front:  I think they are magical. My son has been on hypoallergenic formula since he was about 3 months old, and the difference between FC on breastmilk/regular formula/soy formula and the hypoallergenic formula we ultimately switched him to was astounding. It was like the kid had received a spontaneous lobotomy. He was miserable for the first 10 weeks of his life, with terrible skin rashes, gas, stomach issues, and a personality that can best be described as the Grinch meets Chairman Mao; within 24 hours of switching him to hypoallergenic formula, he could have starred as the “after”  in a Harvey Karp instructional video. FC was truly the happiest baby on the block, thanks to Alimentum.

Still, I was concerned about the long-term safety of such a space-age, highly processed formula. The stuff smelled like regurgitated potatoes. (Although for some reason, FC loved it; up until a month ago, we still used a scoop of the stuff to flavor his hemp milk because he so adores the taste. But then again, he likes kiwi as well, and hates chocolate. I’m blaming FH’s taste genes.) And the whole “pre-digested” thing kind of skeeved me out. So, I did a little research, and the following is what I’ve found. Needless to say, I am by no means a doctor or have any background in science; this is just what I’ve gleaned from a layman’s perspective (with the slight advantage of a journalism background that focused on health issues), so take it all with a grain of salt. Or a grain of pre-digested protein. Your choice.

First, a definition: What are hydrolysates?

Basically, in kids who are allergic or sensitive to milk protein, the lower the molecular weight of a protein, the better. Casein hydrolysates like Similac Alimentum or Enfamil Nutramigen contain tiny, broken-down versions of milk protein, making it easier for milk-sensitive babies to digest. There’s another level of hypoallergenic-ness (yes, I made up that word, sue me) which you find in amino-acid based formula (Neocate); for some babies, even the infinitesimal amount of milk product in the hydrolysates is problematic. Since Neocate is only available by prescription, and the majority of kids with food sensitivities have success with the over-the-counter hydrolysates, we’re going to focus on these.


What are the nutritional differences?

Comparing nutritional labels, there doesn’t seem to be much difference between your average milk-based formula and a casein hydrolysate one. But a 2003 study in the American Journal of Clinical Nutrition did find that “the iron status of infants fed (casein hydrolysate formula) was lower than that of all other groups. The amounts of amino acids provided by hydrolysate formulas appear excessive compared with regular formula, which is reflected by high serum urea nitrogen… and high plasma amino acid concentrations.” The study authors suggest, in their conclusion, that a “reduced and more balanced amino acid content of hydrolysate formulas may be beneficial.” I’m not sure if the formula companies have changed the recipe since 2003, but I will look into it and get back to you.

The International Society of Infant Food Manufacturers has a good run down of the nutritional issues surrounding hydrolysates, but I’m well aware that there’s a bias against the formula organizations, so do with this what you will. They claim that “on the whole, available data suggest that there is no evidence that feeding (hydrolysate formula) impairs the growth and biochemical parameters of term infants. There is also no evidence of differences between infants fed (hydrolysates) and an adapted cow’s milk formula and/or human milk on growth parameters and biochemical parameters, except on indices of protein metabolism.”

What’s the deal on allergies?

A 2008 clinical report from the AAP suggested that hydrolysates may actually have a preventative effect against allergies:

The documented benefits of nutritional intervention that may prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy (ie, infants with at least 1 first-degree relative [parent or sibling] with allergic disease). Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation. There is evidence that breastfeeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood. In studies of infants at high risk of atopy and who are not exclusively breastfed for 4 to 6 months, there is modest evidence that the onset of atopic disease may be delayed or prevented by the use of hydrolyzed formulas compared with formula made with intact cow milk protein, particularly for atopic dermatitis.

It’s not clear in this synopsis, but reading through the entire study, it seems that both breastfeeding and use of hydrolysate formulas confer equal benefits in this particular case. Obviously, if you have a history of allergies and are able to breastfeed, it’s a no-brainer – why feed your kid expensive and atrociously smelly formula? But for those of us whose kids are unable to tolerate breastmilk due to severe allergies, or who cannot breastfeed for any other reason, but have a family history of allergies, the hydrolysates might be worth the cash.

The skinny on soy: Are soy formulas safe?

Let me preface this post by saying that I am a huge fan of the soybean. Having been a vegetarian (and occasional vegan) for the past 20 years, soy products and I have obviously become BFF.

So when we were trying to figure out my son’s eating issues, I was hoping that soy formula would be the golden ticket. Unfortunately, it turned out that he was allergic to both dairy and soy, and we ended up on hypollergenic formula (Similac Alimemtum). But this had nothing to do with my feelings about soy. Just so we are clear. I still love you, my sweet soybean!

Soy has been in the news a lot lately. Once the golden child of women’s health (it was said to prevent numerous cancers, heart disease, and help alleviate problems associated with menopause), like so many things that have once been exalted for health reasons, the establishment has turned on poor old soy. Now it is being blamed for all sorts of ills, including decreasing metabolism, enlarging thyroids, and killing testicular cells. Yummy.

What does this mean for babies on soy formula? One would think that any problems associated with soy would be exacerbated in its use as an infant formula, since, well, babies are small, and things affect them more strongly than bigger humans (how’s that for a scientific explanation?). In 2008, The AAP came out with a report called “Use of Soy Protein-Based Formulas in Infant Feeding,” which updated it’s 1998 review of soy formulas. Basically, it says the following:

1. Soy formulas have no advantage over cow milk-based formulas.

2. For pre-term infants, soy formulas are not recommended.

3. Soybeans are high in phytoestrogens (estrogen-like compounds found in plant products), but there is no “conclusive evidence” from any study showing that that “eating soy causes problems to human development, reproduction or endocrine function.” (WebMD)

3. If you are vegetarian and do not feel comfortable with milk products (well, actually, the correct term would be “vegan” as vegetarians are fine with dairy products, but hey, semantics…it’s not like the AAP has dieticians on staff or anything….) or your child is lactose intolerant, soy is a safe choice; otherwise stick to milk-based formulas.

4. For kids with food allergies, hypoallergenic formulas are a better bet; many kids who are sensitive to cow’s milk protein are also sensitive to soy. There is no evidence that soy formula confers any protection against the development of allergies over regular formula. (Note: there actually was a recent AAP paper stating that there is possibly an advantage to hydrolysate formulas like Alimentum in this respect; that’s fodder for another post though, so we won’t go into it here.)
 

Now that we’ve seen what the AAP has to say, let’s look at this from a real-world perspective. Telling a parent that there are “no conclusive studies” on something and then warning him/her to stay away from it isn’t very comforting to that parent. No one wants to be responsible for his/her kid growing breasts at age 8 (especially if that kid is a boy). Why would they warn parents away from soy formula if it were safe?

Here’s one possible answer: the AAP likes to cover it’s bases. These are the same folks who told us to treat peanuts as arsenic for the first few years of a kid’s life; now they are sheepishly (and quietly) admitting that perhaps this policy had a contradictory effect (more kids getting peanut allergies rather than less). Take their statements with a grain of salt – like your mom, they mean well, but can be a little over-dramatic. The truth is that there have simply not been enough studies on the long-term effects of soy formula. I know this won’t put anyone’s mind at ease, but let’s look at it another way – science is discovering new advantages and disadvantages to everything in our world every freaking day. Soy formula has been used for the past 100 years, and while there could obviously be a study that comes out tomorrow saying that it causes all sorts of evils, there could just as easily be a study that proves that potatoes cause cancer. You just never know. All you can do is make an informed decision and weight the pros and cons, and overall, soy formula seems to be a relatively safe choice.

I turned to Dr. Greene, my new favorite pop pediatrician, for some insight. In 2001, he posted the following:

Babies who drink soy formula receive significant amounts of estrogen-like compounds (phytoestrogens) in the form of soy isoflavones. This happens at a developmental time when permanent effects are theoretically possible. Some have speculated that soy formula might be responsible for early puberty in girls or infertility in boys.  The August 15, 2001 issue of The Journal of the American Medical Association (JAMA) contains the results of a study of 811 adults, some of who drank soy formula as children and others who drank milk-based formulas. No statistically significant differences were observed between the groups in either women or men. They followed more than 30 different measures of general health or reproductive health. Breast milk is clearly the ideal food for babies, but this study is quite reassuring that soy formulas are a safe alternative. This is good news for babies who do not tolerate cow’s milk formulas well.

Granted, this was nine years ago; the AAP statement came out seven years later. But reading the AAP statement, it doesn’t seem like much has changed, does it?

What I think has changed is the perception of soy in general. The issue with soy is that it is in practically everything. Read any label in your kitchen cupboard – I guarantee you’ll see some terms like soy protein isolate, soy lecithin, soy isoflavens. Even if nary a cube of tofu should ever pass your lips, you’ll still be consuming a fair amount of soy in your lifetime. The problems we are seeing now that are associated with soy are most likely from an overabundance of it in our diets – a real conundrum for vegetarians like me. Once I started looking into it, I realized I was eating soy cheese, soy yogurt, soy milk, tofu, and a myriad of veggie-friendly products all made from soy. Rather than freaking out completely, I opted to switch to almond milk, coconut milk yogurt, and decided to eat dairy cheese or no cheese at all. I still eat tofu and veggie meat (made with soy) nearly every day, but at least it’s not the main ingedient in everything I eat. Moderation, people, moderation.

Back to the babies… If your child can’t tolerate dairy, you basically have two choices in formula – soy or hypoallergenic. It comes down to preference – for those who don’t like the idea of processed, chemical food, then soy formula will probably be a better bet. You can get it in organic variants, and at least you can prononce the majority of the ingredients. The hydrolysate formulas tend to fare better in studies, but they are completely manufactured, not available organic, and extremely cost prohibitive. Plus, a lot of kids won’t drink them, because they taste like crap. Weight the pros and cons and realize that no matter what, you’ll be able to switch them off the stuff in a few short months. (At which point, if you are concerned about an overabundance of soy, I would recommend weaning to regular milk, or a substitute other than soy, like rice, oat or hemp).

Take away message? Go for the soy if it works for your family – my hubbie was raised on the stuff and he doesn’t have boobs. I promise.

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