Some common
questions and
answers

When your baby starts taking an extensively hydrolyzed formula (eHF), you might see changes in their poo pattern as well as the consistency. The consistency and the color may change due to the type of proteins that are used in the eHF, which are designed to be more easily digestible. Some parents suggest that their baby’s poo is a light brown or even greenish color.

It very much depends on the type of reaction your baby has had in the first place. But it has been suggested that it can range from 3 to 5 days in babies who have had an immediate reaction to milk/dairy, to around 1 to 2 weeks in babies who have had a delayed reaction. Some examples of an immediate reaction might be swelling under the skin (also called angioedema), vomiting, or an exacerbation of eczema (within 2 hours of taking the food). Examples of delayed reactions may be eczema, rectal bleeding, and/or digestive symptoms. Note, however that in babies who present with chronic diarrhea, or who have poor growth/growth faltering, it may take 2 to 4 weeks on a milk/dairy free diet before you see a response. And be aware that for some babies it may take longer – some experts report up to 5 weeks in those with colic and even 8 weeks for some forms of eczema.

When your baby starts taking an amino acid-based formula (AAF), you might see changes in their poo pattern, color and poo consistency. Babies on an AAF may pass more formed poo, and the frequency may also vary depending on how long they are on the formula. The color of the poo can vary from yellow to green in babies fed an AAF but can be different between babies.

AAFs require minimal digestion. So if your baby has been experiencing digestive problems, such as persistent diarrhea with bloody in poo or vomiting due to cow's milk allergy, switching to an AAF should see an improvement in these symptoms.

It very much depends on the type of reaction your baby has had in the first place. But it has been suggested that it can range from 3 to 5 days in babies who have had an immediate reaction to milk/dairy, to around 1 to 2 weeks in babies who have had a delayed reaction. Some examples of an immediate reaction might be swelling under the skin (also called angioedema), vomiting, or an exacerbation of eczema (within 2 hours of taking the food). Examples of delayed reactions may be eczema, rectal bleeding, and/or digestive symptoms. Note, however that in babies who present with chronic diarrhea, or who have poor growth/growth faltering, it may take 2 to 4 weeks on a milk/dairy free diet before you see a response. And be aware that for some babies it may take longer – some experts report up to 5 weeks in those with colic and even 8 weeks for some forms of eczema.

What is considered normal?

When it comes to bowel movements "normal" can vary enormously between babies and depends on factors like the age of your baby, if your baby is bottle or breastfed, and if they are taking solids. As babies start eating solid foods, their bowel movements often change both in frequency and consistency. And this can vary depending on the type of foods consumed. The general guidance for what is considered “normal” is as follows:

Frequency:

• Newborn babies have several bowel movements in a day, sometimes even after every feed. But as babies grow, the frequency of their bowel movements often decrease.

Color and consistency:

• Breastfed babies typically have loose, mustard-yellow or seedy poo, which is considered normal. Formula-fed babies may have slightly firmer brown or tan poo, but they should still be soft and easily passed. Poo consistency can vary among babies, and changes in consistency within the normal range is generally not a cause for concern.
• Look out for any noticeable changes in your baby’s poo pattern (frequency and consistency). In the case of diarrhea, keep a record of the number of bowel movements per day along with the poo consistency. Also, it’s good practice to pay attention to your baby’s behavior during bowel movements. Excessive straining, crying, or signs of discomfort might be an indicator of constipation.

Breastmilk is best for your baby. When breastfeeding is not possible your healthcare professional will advise on the most suitable alternative allergy formula (called a hypoallergenic formula) for your baby. When using these formulas there are a few things to consider. Hypoallergenic formulas for babies with allergies can extensively hydrolyzed formulas (eHF) or amino acid-based formulas (AAF). These formulas smell and taste very different to standard infant formula or breastmilk.

Some little ones will transition across to these new formulas easily, however for others the change in taste or smell may put them off, so they may need a little more time.

Here are some tips to ease the transition to the new formula:

• If breastfeeding, and you want to transition your baby to a new formula, try to have someone else feed your baby for the first few feeds
• Waiting until your baby is hungry before trying the new formula
• If your baby has not had an anaphylactic reaction or other immediate severe reaction to cow’s milk/dairy and you are starting a new hypoallergenic formula, you can also gradually change then over (using titration). This is when you mix a small amount, ~25ml (1oz), of their new formula with their current formula or expressed breastmilk, building up until the transition is complete i.e., they are taking 100% hypoallergenic formula. We recommend however that you always discuss this with your baby’s health care professional first.
• If your baby has had an anaphylactic reaction or a severe reaction to milk/dairy then you should stop all forms on milk/dairy and in this case titration of formula is NOT suitable for your baby!
• If foods have been introduced to your baby’s diet, you can mix the formula with the foods before offering it as a drink – this will help them become more familiar with the new taste.
• Your baby may refuse initially as the taste is very different, so we advise you to persevere, since repeated exposure is the most effective way of getting your baby to accept the new feed.

We recommend that you always discuss this with your baby’s health care professional first. If your baby has not had an anaphylactic or severe reaction to their current formula, then you can mix it with the new formula initially (called titration). Start titrating by mixing a small amount, ~25ml (1oz), of their new formula with their current formula and each day building up until the transition is complete and they are taking 100% of the new formula – it can usually take a few days.

If your baby has had an anaphylactic or severe reaction to their current formula, then you should not titrate! They will be switch to an amino acid formula by the healthcare professional – if you have concerns discuss this with your baby’s healthcare professional.

The time frame for when crying after feeding resolves is very variable between babies, as many factors such as tiredness, gas, over feeding or general discomfort can contribute to crying. If your baby has been diagnosed with infantile colic, secondary to cow’s milk allergy (CMA) then a positive response would be expected within between 2 to 5 weeks using on an extensively hydrolyzed formula (eHF); though some experts have even observed a significant improvement after just 1 week on an eHF, so it varies. If your baby is on an amino acid formula (AAF) then reduction in crying after feeds might be slightly quicker, but it will vary between children. It is recommended therefore, to continue with the new formula even if the crying has not resolved after 1-2 weeks. If you have concerns then you should contact your baby’s healthcare professional to discuss.

Therefore, if your baby has not stopped crying after 1 to 2 weeks this can still be considered normal, and it is important to continue with the formula, as it may take time for all symptoms to resolve. Generally, a 2 to 4 weeks period is expected but as mentioned all babies are different.

Please be reassured also that it is perfectly normal for babies to cry, and therefore it is key to distinguish what is related to allergy and what is normal (hunger, tiredness etc).

The time frame needed to see resolution of skin symptoms depends on the type of allergic reaction your baby has had. If the allergic reaction to cow’s milk/dairy was immediate-type, then resolution of some skin symptoms (e.g., urticarial rashes) can be seen after 3 to 5 days. When the allergic reaction to cow’s milk/dairy was delayed-type, then resolution of skin symptoms (e.g., eczema or atopic dermatitis) can take weeks. In general, in babies with severe eczema (atopic dermatitis) it can take at least 6 weeks before improvements are seen. Experts report that in babies given a whey-based extensively hydrolyzed formula some improvement in atopic eczema was seen after 3 – 5 weeks, with complete resolution of urticarial rashes.

Here is a list of things to look out for to make sure your baby is taking enough formula:

• Weight gain and growth: Consistent weight gain is a positive sign that your baby is receiving enough nutrition. It is important to regularly monitor your baby’s weight and length and compare it with the standard growth charts for age. Your baby’s healthcare professional will support you with this, if needed.
• Wet and dirty nappies: Another way to see if your baby is getting enough formula is by monitoring their nappies. Your baby should have enough wet nappies (around 6-8 per day) and their bowel movements should be of normal consistency (not hard). Your baby’s nappy should be soaked through with clear or pale-yellow urine or feel heavy.
• Feeding frequency: Newborn babies generally feed every 2 to 3 hours and may have around 8 to 12 feeds per day, but every baby is different! As your baby grows, the number of feeds may decrease and the volume taken /feed increase - you can start spacing out their feeds to every 3 - 4 hours/day.
• Volume of feeds: The amount of formula your baby takes per feed can vary depending on your baby's age, weight, and individual needs. In general, newborns start with smaller volumes, around 30 - 60 ml/feed, gradually increasing as they grow. It is suggested that (on average), babies should take about 75ml (2½ ounces) of infant formula for every ½ kg (~1 pound) of body weight/day.

If your baby’s healthcare professional has provided you with a new formula for your baby, then it should help to alleviate their symptoms and improve their condition. Some experts say that hydrolyzed infant formula may be digested faster, helping to improve the symptoms of gastroesophageal reflux. However, if the symptoms do not resolve or get worse, you should always discuss this with the prescribing healthcare professional.

Babies tend to spit up more with thinner milks because they have a lower viscosity (less thick) and can more easily flow back up into the esophagus. However, hydrolyzed infant formulas contain broken down proteins and tend to be digested faster. Specialized thickening agents can be used to thicken the formula your baby has been prescribed but be aware that thickening can also make sucking from the bottle difficult for your baby, so it’s good to talk to the healthcare professional about it.

Please be aware that it is not advisable to add anything to your baby’s feed unless advised by your baby’s healthcare professional.

The improvement or resolution of your baby’s symptoms depends on how the symptoms presented in the first place. Here is a guide on what to expect depending on your baby’s symptoms.

a. – What can I expect to see after the first few days?

The resolution of your baby’s symptoms depends on how the symptoms presented in the first place. If your baby had an immediate-type reaction to cow’s milk/dairy (e.g., angioedema, vomiting, rapid onset of exacerbation of eczema within 2hours of consumption of the food) then you may see some improvement after 3-5 days. But if your baby developed a delayed-type reaction to cow’s milk/dairy (e.g., exacerbation of eczema, rectal bleeding, and/or digestive problems) then it can take longer.

b. – What can I expect to see after the first week?

The resolution of your baby’s symptoms depends on how the symptoms presented in the first place. If your baby had an immediate-type reaction to cow’s milk/dairy (e.g., angioedema, vomiting, rapid onset of exacerbation of eczema within 2 hours of consumption of the food) then you may see some improvement after 3-5 days. But if your baby developed a delayed-type reaction to cow’s milk/dairy (e.g., exacerbation of eczema, rectal bleeding, and/or digestive problems) then it can take longer than a week.

c. – What can I expect to see after 2 weeks?

The resolution of your baby’s symptoms depends on how the symptoms presented in the first place. For the majority of allergic symptoms, you should resolution after 2 weeks. However, if your baby presented with digestive symptoms (e.g., chronic diarrhea and or has poor growth) it can take up to 4 weeks on a hypoallergenic formula and dairy free diet. It may even take longer for some delayed-type digestive allergies like eosinophilic esophagitis (EoE) or allergic colic (around 5 weeks). And if your baby has had severe atopic dermatitis, dairy elimination may take up to 6 weeks before an improvement is seen. In fact, some guidelines recommend a 6-to-8-week trial of an extensively hydrolyzed or amino acid-based formula when under 6 months of age with moderate or severe atopic eczema.

No. The improvement or resolution of your baby’s symptoms may take a few weeks depending on how their symptoms presented in the first place. The guidelines often recommend waiting for 2 to 4 weeks after removal of the allergen. (see Q14 for more details).

If you are not seeing an improvement in your baby’s symptoms within the specified time (given by your baby’s healthcare professional (HCP), then it may be that your baby needs a new treatment plan. However, you should always discuss this with the prescribing HCP as it may take longer than anticipated, depending on your baby’s initial presentation of symptoms, volume consumed etc.

Your baby’s healthcare professional (HCP) may advise that your baby tries a different low allergen formula. There can be several reasons why the removal of milk/dairy from their diet does not work. For example, if your baby does not like the taste and therefore does not consume enough of the formula. So, it is important to discuss the situation with the HCP and agree on a plan of action together.

If the symptoms have not resolved fully on the eHF after the specified time period (given by your baby’s healthcare professional (HCP) then the HCP may recommend that your baby tries another formula, which might be an AAF. This will very much depend on the symptoms your baby presented with and the situation they are in on review.

You should always wait until your baby has been seen by their healthcare professional (HCP). And what happens next will depend on several factors including your baby’s age, initial symptoms, current food intake (diet) as well as their growth and development. Your baby’s HCP will usually advise that your baby continues on the formula for a specified period of time. During or after this time, a review or follow-up appointment will be arranged to look at your baby’s allergic status (initial and current symptoms), food intake as well as their growth and development. Once all symptoms have resolved and your baby is growing well, your baby’s HCP will discuss what you should do next. Until then you should continue to follow their instructions.

This will depend on your baby’s initial presentation of symptoms and the follow-up reviews by the healthcare professionals (HCP). However, most babies outgrow their allergy (around 80%) to milk/dairy by the age of three to five years. Your baby’s HCP will commonly re-test the milk/dairy allergy around 1 year of age to see if your baby has outgrown his/her allergy (depending on how your baby responds they may be able to take milk/dairy foods in their diet again).

This very much depends on how the symptoms presented in the first place. But it is known that around 80% of children will outgrow their allergy to cow’s milk/dairy by the age of three to five years. However, this depends on many different factors, including what symptoms your baby presented with, if your baby’s reaction was immediate and severe (e.g., anaphylaxis) following the consumption of milk/dairy or if it was delayed (taking some days or longer to show up). If your baby had an immediate severe reaction e.g., an anaphylactic reaction, then it usually takes longer for them to outgrow their allergy, and in this case, they will be tested (often called challenged) in the hospital setting by the healthcare professional (HCP). The exact timing is very difficult to predict, but in some (severe) cases it can last as long as 5 to 10 years. If however your baby had a delayed reaction, for example with digestive symptoms (also called non-IgE-mediated CMPA), then outgrowth will occur much earlier; in some cases within 1 year - and in this case they will be tested (challenged) in your home.

During the home challenge the HCP will probably use the milk ladder to introduce the allergen (cow’s milk/dairy) in a stepwise manner. They will advise you on when the time is most appropriate for your baby to be challenged. Also, the time it takes for your baby to progress up the rungs of the ladder i.e., tolerating more forms of dairy/milk, will depend on how they respond to each new food introduced.

Sometimes babies have accidental challenges when they consumed an allergenic food by accident. How they react will indicate if they remain allergic or not. If this should happen, it’s a good idea to gather some information for the HCP e.g., the type of food eaten, if there was a reaction, details of the reaction, how long it took to see the reaction, the time of day, who was present etc., providing this important to your HCP will help them guide the most appropriate actions and the next steps.