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Infant Formula - Part Two

Bridget Young, PhD, CLC and Parul Bhatia, MD
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Infant formula expert Bridget Young discusses the ins and out of different types of infant formulas, highlighting sources of macronutrients, and indications for use of standard and non-standard formulas.

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David F. -

I thank Bridget for her participation on this episode, but I was left questioning her recommendation to use partially hydrolyzed formulas as a starting formula. In my review of the literature, I found that hydrolyzed formulas have a mixed record in multiple systematic reviews in treating things like colic, but I have not been able to find any evidence to support her recommendation specifically in the setting of initiating formula. Partially hydrolyzed formulas are a bit more expensive than regular infant formulas and I believe this is also a side effect worth weighing.

Solomon B., MD -

David- I reached out to Bridget, and here was her response (I hope you find it useful!) :
"David raises a very nice question (and very respectfully - Thank you David!). I try to be really clear when I am quoting organizational recommendations vs my own opinion. It's definitely just my opinion that partially hydrolyzed formulas are a good starter for newborns (under 3 months), but I don't hold to that like doctrine. Every baby is different and individual characteristics will impact their "tolerance" of larger proteins. For example, if formula is used to supplement a mostly breast milk diet, I find babies tolerate intact proteins really well from birth. I agree the point about cost is critical and needs to be considered (if a family can afford it, or if a family is on WIC, they will have at most 1 partially hydrolyzed option that may or may not be a good fit.)
Research wise - yes partially hydrolyzed formulas as a starter is not a consensus. It depends on who you ask. I'll provide a bunch of references below on both sides. Taken all together I personally interpret the "controversy" to be that some research studies show benefit to partially hydrolyzed mostly (for eczema in particular), while others show that the benefit may not be there. So basically - it may be super helpful, it may not be, but it's not harmful. David's right that the data for other outcomes like colic are hardly convincing. The AAP does suggest using partially hydrolyzed if infant is at risk for atopic disease (which is a huge proportion of kiddos; Greer 2008).
So, we have to take the literature and have it inform how we council patients on an individual basis, taking into account their unique medical history. So, for me, that usually involves using a partially hydrolyzed formula in the newborn phase, particularly if there is history of allergic disease.
As I said, patient's individual characteristics and family situation obviously impact any recommendation I make. I don't think there is a single "best formula" out there. It will be different for each baby depending on their biology. That's my opinion anyway, and how I have tried to incorporate research insights into my clinical practice. Always happy to chat more. I really love nerding out on this stuff.
Warm regards,

Von Berg et al. Preventive effect of hydrolyzed infant formulas persists until age 6 years: Long-term results from the German Infant Nutritional Intervention Study (GINI) Study. J Allergy Clin Immunol. 2008; 121: 1442-1447.
Von Berg et al. Allergies in high-risk school children after early intervention with cow's milk protein hydrolysates: 10-year results from the German Infant Nutritional Intervention (GINI) Study. J Allergy Clin Immunol. 2013; 131: 1565-1573.
Vandenplas et al. Should Partial Hydrolysates Be Used as Starter Infant Formula? A Working Group Consensus. JPGN. 2016; 62 (1): 22-35.
Szajewska H, Horvath A. A partially hydrolyzed 100% whey formula and the risk of eczema and an allergy: an updated meta-analysis. World Allergy Organization Journal. 2017; 10:27-38.
Part. Hyd. whey safe and effective at preventing atop derm. in general population (not just those at risk). Sauser J, Nutten S, deGroot N, Pecquet S, Simon D, Simon H, Spergel J, Koletzko S, Blanchard C. Partially Hydrolyzed Whey Infant Formula: Literature Review on Effects on Growth and the Risk of Developing Atopic Dermatitis in Infants from the General Population. Int Arch Allergy Immunol. 2018. DOI: 10.1159/000489861.
The big Meta-analysis that was contrary to Cochrane and FDA health claim: Boyle et al. Hydrolysed formula and risk of allergic or autoimmune disease: systematic review and meta-analysis. BMJ 2016; 352: i974.
Part. hyd. Effecteicve treatment of atopic dermatitis: Jin et al. Partially hydrolyzed cow’s milk formula has a therapeutic effect on the infants with mild to moderate atopic dermatitis: a randomized, double-blind study. Pediatric Allergy and Immunology 2011; 22:688.
Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and
children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and
hydrolyzed formulas. Pediatrics. 2008;121:183–191 "

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For Whom the Bell's Tolls Full episode audio for MD edition 206:52 min - 97 MB - M4AHippo Peds RAP August 2018 Written Summary 404 KB - PDF