Early Formula Introduction and Risk of Cow’s Milk Allergy

The following information is taken from the July 22, 2019 newsletter from “IABLE”, the Institute for the Advancement of Breastfeeding and Lactation Education, regarding the research article “Formula supplementation remains a risk for cow’s milk allergy in breastfed infants” from Pediatric Allergy Immunology July 11, 2019.

hand scooping baby formula from a can with baby bottle sitting in the background

What is the relationship between formula supplementation and cow’s milk allergy?

In 1935, Bret Ratner MD published an article on the treatment of milk allergy in the Journal of the American Medical Association. One of a few recommendations to prevent milk allergy was to avoid isolated feedings of raw cow’s milk to the breastfed infant during the newborn period. His reasoning was that during the newborn period, there is increased gut wall permeability, allowing increased passage of proteins into the newborn’s blood stream. This allows for early sensitization to the cow’s milk protein, such that when infants are introduced to cow’s milk protein later during infancy, they have a higher risk of cow’s milk allergy.

A study was done in Ireland on 55 children diagnosed with cow’s milk allergy by an allergist. The study showed that breastfed infants who were given formula in the first 24 hours were 7 times more likely to have cow’s milk allergy than those who were exclusively breastfed in the first 24 hours. Their conclusion was that breastfed babies are still being put at significantly increased risk of Cow’s Milk Protein Allergy by receiving supplemental formula in the first 24 hours of life, despite the major predictors of supplementation being subjective and remediable in other ways. Mothers and health care providers should be better educated on the benefits of exclusive breastfeeding and resourced adequately to avoid unnecessary formula supplementation to reduce risk of development of Cow’s Milk Protein Allergy. 

IABLE Comment by Anne Eglash MD, IBCLC, FABM

The results of this study were consistent with previous research showing that breastfed infants receiving small amounts of formula within 24 hours of life are much more likely to develop cow’s milk allergy later in life as compared to infants who have a much greater exposure to formula early in life, such as infants who are exclusively formula fed. In this study, the breastfed infants exposed to a small amount of formula in the first 24 hours were 16 times more likely to develop cow’s milk allergy as compared to exclusively formula fed infants. Formula fed infants had the same rate of cow’s milk allergy as exclusively (unsupplemented) breastfed infants. Authors have hypothesized that exclusively formula fed infants develop a tolerance to formula over time because of repeated exposure.This research has been flying under the radar, and we need to bring it into focus. The take home message for clinical practice is that there seems to be enough evidence to recommend that infants needing supplementation in the first 24 hours receive either donor human milk or a hydrolyzed or elemental formula in order to avoid the risk of cow’s milk allergy. 

Comment by Diane Erdmann RN BSN IBCLC

Many newborns in the hospital are supplemented with formula for a variety of reasons. Some medical reasons include hypoglycemia (low blood sugar) and a weight loss of over 10% of their birth weight. Ideally, donor breastmilk should be used if mom is unable to nurse or pump enough to provide the breastmilk needed. Most of the hospitals in Omaha do provide donor milk for some of these situations. If donor milk is not available, formulas such as Alimentum or Nutramigen, would be better options than cow’s milk based formulas. Other newborns are given formula because baby is fussy or has been sent back to the nursery so mom can get more rest. If moms are educated on the importance of having fewer visitors in the hospital and to sleep when baby sleeps, then she has a better possibility of getting more rest and being able to nurse her baby. Moms also need to be informed of comfort measures such as skin to skin, swaddling and letting baby suck on her finger to comfort baby instead of using pacifiers or sending baby to the nursery. The more baby nurses in the hospital, the more colostrum is removed from mom’s breasts and the sooner her mature milk comes in so baby is more satisfied at the breast. The more mom is with baby and rooms in with baby, the better she will get to know her baby and understand feeding cues and what baby is communicating to her to help avoid the use of formula. 

If you have any questions, please contact Diane Erdmann by email or calling (402) 707-1696.