Expert Consensus on Hydrolyzed Rice Formula for Cow's Milk Allergy in Infants
A concept paper published in Nutrients reports a new expert consensus on the use of hydrolyzed rice formula (HRF) for infants with cow's milk allergy (CMA). The paper presents a decision tree developed during two UK expert meetings in 2025 to help clinicians identify situations where HRF may be an appropriate choice.
Background
Cow's milk allergy is described as common in infancy, typically resolving by 3-5 years of age. For non-breastfed infants with CMA, first-line options include extensively hydrolyzed cow's milk-based formulas (eHFs) or hydrolyzed rice formulas (HRFs). Amino acid formulas (AAFs) are normally reserved for severe presentations when symptoms persist despite eHF or HRF use.
A New Decision Framework
According to the paper, five primary factors may influence the selection of HRF:
- Persistence of symptoms despite multiple formula changes
- Parental requests influenced by lifestyle or faith considerations
- Specialist recommendations
- Potential sensitivity to traces of cow's milk protein beta-lactoglobulin
- Faltering growth when eHF intolerance is suspected
The tool aims to help clinicians choose appropriate specialist formulas rather than guide diagnosis or treatment.
Secondary Considerations
The framework also notes several secondary considerations, including:
- Presence of multiple symptoms across organ systems
- Parental preferences shaped by previous CMA management experience
- Infant acceptance issues, particularly after six months of age
- Potential microbiome-related benefits (though long-term impact remains under investigation)
When HRF May Not Be Appropriate
The authors clarify that HRF may not be the right choice in certain situations, such as:
- When both eHF and HRF fail to relieve symptoms and restore adequate nutrition
- When symptoms don't improve on HRF with proper cow's milk exclusion
- For children with severe presentations like eosinophilic esophagitis
- For children with gut conditions not due to food allergies
Context and Limitations
The authors state the decision tree is not intended to replace current or future published official guidelines on CMA. HRF has been used in Europe for over 20 years without reported adverse effects on infant health. International organizations recommend HRF or eHF for CMA, anaphylaxis, and food protein-induced enterocolitis syndrome, though guidance varies.
The paper discloses industry funding and potential conflicts of interest among contributors. The authors note that further high-quality research is needed to strengthen the evidence base, particularly since current recommendations are informed by expert consensus.
Future research should explore HRF's impact on growth, immunity, and the gut microbiome, according to the authors.