The Role of Hydrolysed Rice Formula in the Dietary Management of Infants with Cow’s Milk Allergy: A UK Healthcare Prospective

Summary:

Cow’s milk allergy (CMA) is among the most common food allergies in infancy and often requires careful nutritional management when breastfeeding is not possible or is discontinued. For non-breastfed infants with CMA, both extensively hydrolysed formula (eHF) and hydrolysed rice formula (HRF) are recognized as appropriate first-line nutritional options. UK experts have developed a practical clinical decision framework to support healthcare professionals in identifying situations in which HRF may be a preferred choice. 

HRF contains no cow’s milk protein, making it a valuable option when complete avoidance of residual milk peptides is desired. The framework emphasizes individualized, family-centered decision-making that takes into account clinical presentation as well as caregiver and family factors. Key considerations supporting the selection of HRF include persistent caregiver stress related to ongoing symptoms, symptoms that continue despite multiple feeding changes, cultural or lifestyle preferences, religious dietary considerations, and recommendations from specialist healthcare providers. Additional factors that may influence formula selection include parental preference, proven reactions while breastfeeding coupled with requests for formula feeding, faltering growth, multiple symptoms, concerns about taste acceptance in infants older than 6 months, and interest in microbiome or human milk oligosaccharide (HMO) considerations. 

The framework also highlights the importance of reassessing the diagnosis if symptoms do not improve following elimination of cow’s milk protein and initiation of HRF, as this may indicate that CMA is not the underlying cause of symptoms. Evidence remains limited for certain conditions, including eosinophilic esophagitis (EoE), food protein-induced enterocolitis syndrome (FPIES), and non-food-allergy-related gastrointestinal conditions, requiring individualized clinical judgment. 

Hydrolysed rice formula expands first-line nutritional options for infants with CMA and can support personalized nutritional management aligned with family needs, preferences, and clinical circumstances.

Key Takeaways:

• HRF is recognized as a suitable first-line alternative to extensively hydrolysed formula for non-breastfed infants with cow’s milk allergy.
• Because HRF contains no cow’s milk protein, it may be considered when complete avoidance of residual milk peptides is desired.
• Formula selection should incorporate caregiver burden, cultural practices, religious beliefs, prior feeding experiences, and family preferences alongside clinical assessment.
• Lack of symptom improvement after transition to HRF and elimination of cow’s milk protein should prompt reconsideration of whether CMA is the underlying diagnosis.

Related Questions & Answers

• When might hydrolysed rice formula be preferred over other formula options in infants with cow’s milk allergy?
  Hydrolysed rice formula may be considered when caregivers report persistent stress related to infant symptoms, when symptoms continue despite multiple feeding changes, or when cultural, lifestyle, or religious factors influence formula selection. Specialist recommendation and family preference may also support its use.
• Why is hydrolysed rice formula considered a suitable option for some infants with cow’s milk allergy?
  Hydrolysed rice formula contains no cow’s milk protein and is recognized as a first-line nutritional option for non-breastfed infants with cow’s milk allergy. This characteristic may be particularly valuable when complete avoidance of residual milk peptides is desired.
• What should clinicians do if symptoms persist after an infant starts hydrolysed rice formula?
  If symptoms do not improve after elimination of cow’s milk protein and use of hydrolysed rice formula, clinicians should reconsider whether cow’s milk allergy is the underlying diagnosis and evaluate alternative causes of symptoms.
• Are there clinical situations where evidence supporting HRF remains limited?
  Current evidence is described as limited for eosinophilic esophagitis (EoE), food protein-induced enterocolitis syndrome (FPIES), and gastrointestinal conditions that are not related to food allergy. Clinical judgment is therefore required when considering HRF in these scenarios.

References:

• Makwana N, et al. Nutrients. 2026;18:1225.