MANAGING cow’s milk protein allergy (CMPA) requires avoiding cow’s milk proteins while ensuring infants receive adequate nutrition. Specialised infant formulas are integral to treatment, including extensively hydrolysed formulas (eHF), amino acid formulas, hydrolysed rice formulas (HRF), and, in certain cases, soy-based formulas. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2023 guidelines reinforce eHF as the first-choice formula but recognise HRF as an effective alternative.
HRF offers unique advantages, such as accommodating cultural, religious, and economic preferences. By providing families with a broader range of treatment options, HRF promotes patient-centred care, fostering satisfaction and adherence. Concerns surrounding HRF, including protein quality and arsenic content, have largely been addressed by recent studies, showing comparable growth outcomes to eHF. Furthermore, HRF has demonstrated good tolerability in infants with CMPA.
Acquiring tolerance to cow’s milk proteins is a significant milestone in CMPA management. Although limited data exist, some studies suggest that HRF may support earlier tolerance acquisition compared to eHF. However, further research is required to confirm these findings. The evidence highlights the need for randomised trials to compare HRF and eHF more comprehensively, focusing on growth, safety, and tolerance outcomes.
One study compared infants fed HRF and eHF, finding normal growth and similar anthropometric measures over a 12-month period. Tolerance was acquired by more than half the infants before the age of two, comparable to previous findings indicating tolerance development by ages three to four in 80% of children. Importantly, the safety analysis showed low arsenic exposure, well below recommended thresholds, reinforcing HRF’s suitability.
In conclusion, HRF is an effective alternative to eHF for managing CMPA, with benefits in accommodating diverse needs while ensuring safety and nutritional adequacy. While more robust data is needed to assess its role in tolerance acquisition, current evidence supports its use as a viable option for families navigating CMPA.
Katie Wright, EMJ
Reference
Lemoine A et al. Growth, safety and tolerance in infants fed rice protein hydrolysate formula: the GRITO randomised controlled trial. Nutrients. 2024;17(1):162.
