PEDIATRICS Vol. 122 No. 5 November 2008, pp. 1156 (doi:10.1542/peds.2008-2180)
LETTER TO THE EDITOR |
Caution With Committee Recommendations for Soy Protein–Based Formulas
Bryan R. Fine, MD, MPHDepartment of Hospital Medicine
Sona Sehgal, MD
Department of Gastroenterology,
Children's National Medical Center,
Washington, DC 20010
To the Editor.—
In the May 2008 issue of Pediatrics, Drs Bhatia and Greer and the American Academy of Pediatrics Committee on Nutrition1 made some broad recommendations on the use of soy-based formula. They indicate that breastfeeding remains the "formula" of choice and smartly reinforce that there are only rare indications (galactosemia, congenital lactase deficiency, and vegetarian dieting) when a switch to soy is clearly preferred over cow milk–based formula.
However, we would like to comment on the second summary recommendation, in which it is stated that extensively hydrolyzed protein formulas should be considered in cases of documented cow milk protein allergy.
Cow milk protein allergy is reportedly seen in 2% to 3% of infants. It can have a protean presentation, including bloody stools, infant irritability, and failure to thrive. A "documented" cow milk allergy is rare. More severe cases, which present with anemia and, rarely, life-threatening food protein–induced enterocolitis syndrome, can be supported by endoscopic findings. But generally, the diagnosis is clinical and only suspected, especially in the far-more-prevalent mild cases.
Extensively hydrolyzed infant formulas are not without problems. They are far more expensive than routine milk- and soy-based formulas, they are rarely covered by insurance plans, and they taste worse. Putting an infant on an extensively hydrolyzed (or amino acid) formula risks exposing families to financial challenges and creates obstacles to successful feeding.
We are concerned that the summary recommendations, if followed closely, will further lend support to unnecessary trials of hydrolyzed formulas, often at the expense of breastfeeding. Even if soy protein cross-reactivity with cow milk protein is 10% to 14%, as stated in the American Academy of Pediatrics report, it may be more prudent to try bottle feeding infants with a soy-based formula before switching to hydrolyzed formulas.
In mild cases of suspected milk protein allergy, our opinion is that great effort should be made to (1) continue breastfeeding or (2) use soy-based formulas. Also, if the diagnosis is truly uncertain and improvement is seen with initiation of soy-based or hydrolyzed formula, strong consideration should be given to a retrial of cow milk protein formula after symptoms resolve. We all too frequently see formula switches to extensively hydrolyzed formulas with little consideration for family hardship and infant preferences.
REFERENCE
- Bhatia J, Greer F; American Academy of Pediatrics, Committee on Nutrition. Use of soy protein–based formulas in infant feeding.
Pediatrics. 2008;121
(5):1062
–1068
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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