1. What Milk? Jo Caines Paediatric Specialist Dietitian

2. Breastfeeding 1 st choice - continuation of breastfeeding 1 st choice - continuation of breastfeeding ? Mother may require exclusion diet if child has severe eczema or gastrointestinal symptoms ? Mother may require exclusion diet if child has severe eczema or gastrointestinal symptoms Most evidence with maternal exclusion diets is for cow’s milk and egg Most evidence with maternal exclusion diets is for cow’s milk and egg ? Calcium supplementation for mother if excluding cow’s milk ? Calcium supplementation for mother if excluding cow’s milk

3. Degree of Hydrolysis

4. Extensively Hydrolysed Casein Formula (EHC-F) Nutramigen 1 (£8.20/400g) Well tolerated in younger infants Unpalatable Nutramigen 2 > 6 months Tastes better and has increased calcium Pregestimil (£8.91/400g) Similar formula containing increased level Similar formula containing increased level of medium chain triglycerides useful in fat malabsorption

5. Extensively Hydrolysed Whey Formula Pepti (£17.10/900g) Pepti (£17.10/900g) More palatable than extensively hydrolysed casein formulas Contains lactose Larger peptides - ? Less well tolerated Useful in children who refuse EHC-F Pepti Junior (£9.42/400g) Pepti Junior (£9.42/400g) Contains MCT’s Does not contain lactose More expensive than Pepti

6. Amino Acid Formulas Neocate LCP and Nutramigen AA Neocate LCP and Nutramigen AA Suitable for children with: - multiple food allergies - multiple food allergies - children with food allergy and GI symptoms/faltering growth - failure of extensively hydrolysed formula Expensive (Neocate £22.02/400g, NutramigenAA £21.22/400g) Unpalatable but very effective

7. Amino Acid Formulas Neocate Advance (£35.50/15x50g) Neocate Advance (£35.50/15x50g)  >1 year  1kcal ml  Need large volumes to be nutritionally complete but can be used as a sole source of nutrition  Neocate Active (£49.12/14x63g)  > 1year  1kcal/ml  Increased iron and calcium to meet requirements in 600mls  Designed as a supplement to diet

8. Soya Formulas Safety concerns regarding effect of phytoestrogens (COT 2003) Safety concerns regarding effect of phytoestrogens (COT 2003) Cross reactivity with cow’s milk protein Cross reactivity with cow’s milk protein - Non IgEUp to 60% - IgE17-47% More palatable More palatable SMA Wysoy (£7.58/860g) / Cow & Gate Infasoy (£7.44/900g) / Heinz Soya Nurture Formula SMA Wysoy (£7.58/860g) / Cow & Gate Infasoy (£7.44/900g) / Heinz Soya Nurture Formula BDA Paediatric Group (2004) BDA Paediatric Group (2004) - Avoid < 6/12 as a precautionary measure - Vegans, Galactosaemia, CMPA refusing eHF

9. Partially Hydrolysed Formulas Not suitable for cow’s milk protein allergy treatment Not suitable for cow’s milk protein allergy treatment More peptides with high molecular weight More peptides with high molecular weight Antigen content reduced to avoid primary sensitisation Antigen content reduced to avoid primary sensitisation Example: NAN HA (£4.29/400g) Example: NAN HA (£4.29/400g)