What is the best formula for infants with spitting up and lactose intolerance?

Best Formula for Infants with Spitting Up and Lactose Intolerance

For infants with both spitting up and lactose intolerance, extensively hydrolyzed protein formulas are the best option as they address both protein sensitivity and are lactose-free.

Understanding the Dual Problem

When an infant presents with both spitting up (regurgitation) and lactose intolerance, we need to address two distinct but potentially related issues:

1. Lactose intolerance: Inability to digest lactose sugar in milk
2. Spitting up: Could be related to gastroesophageal reflux or food protein sensitivity

Assessment Algorithm

Before selecting a formula, confirm both conditions:

• For lactose intolerance: Look for symptoms after lactose ingestion including gas, bloating, diarrhea with watery/loose stools
• For spitting up: Evaluate frequency, volume, and associated symptoms (discomfort, weight concerns)

Formula Selection Hierarchy

First-Line Option:

• Extensively hydrolyzed casein formula (EHF-C)
  • These formulas contain pre-digested proteins that are less allergenic
  • They are lactose-free, addressing the lactose intolerance
  • They have been shown to reduce symptoms in infants with both protein sensitivity and digestive issues 1

Second-Line Options:

1. Amino acid-based formula (AAF)

   • Consider if symptoms persist on extensively hydrolyzed formula
   • These are the only completely non-allergenic formulas 1
   • More expensive but may be necessary for 10-20% of infants with severe symptoms

2. Soy formula (for infants >6 months)

   • Lactose-free but carries 20-40% risk of cross-reactivity in US infants with cow's milk protein sensitivity 1
   • Should be introduced under physician supervision if considering this option

Administration Tips

• Monitor growth (weight and height/length) regularly to ensure adequate nutrition 1
• When transitioning to a new formula:
  • Introduce gradually over 2-3 days
  • Monitor stool consistency and frequency
  • Watch for improvement in spitting up episodes

Important Considerations

• Commercial anti-regurgitant formulas containing processed rice, corn, or potato starch may help with spitting up but don't address lactose intolerance 2
• Formula composition affects stool characteristics - parents should be informed that extensively hydrolyzed formulas may produce more watery stools, which is normal 3
• Avoid goat and sheep milk as alternatives due to high protein homology with cow's milk 1

Common Pitfalls to Avoid

1. Using partially hydrolyzed formulas - these may not be sufficiently broken down for infants with true protein sensitivity
2. Switching formulas too frequently - allow 1-2 weeks to evaluate effectiveness unless severe symptoms persist
3. Overlooking the need for calcium supplementation if dairy is eliminated long-term 4
4. Assuming all spitting up is formula-related - positioning after feeds and feeding volume/frequency adjustments should also be addressed

When to Reassess

• If symptoms persist despite appropriate formula selection, consider:
  • Formal evaluation for food protein-induced enterocolitis syndrome (FPIES) 1
  • Assessment for other causes of regurgitation (anatomical issues, etc.)
  • Evaluation for failure to thrive if weight gain is inadequate

Most infants with cow's milk protein sensitivity will develop tolerance by age 3, with many tolerating it by age 1 1. Regular reassessment for reintroduction should be performed under physician supervision.