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The importance of palatability

It is now recognised by clinical guidelines that palatability is an important factor to consider in formula choice, particularly in older infants, when managing Cows’ Milk Allergy (CMA)1-3. This is because often by the time infants are prescribed an extensively hydrolysed formula (EHF) their taste preferences have already developed4. As they are less likely to accept bitter tastes, the chances of rejection are increased5,6, which could impact growth7.

Why palatability is important

The British Society of Allergy and Clinical Immunology (BSACI) Milk Allergy guidelines now recognise that palatability is an important factor to consider in formula choice, particularly in older infants, when managing CMA, including those transitioning from breastfeeding2.

Palatability is important because by the time infants are prescribed an EHF, generally when they are over 5 months of age8, their taste preferences have already developed. This means the ‘window of acceptance’, from birth to 3.5 months, has already closed4. After this, they are less likely to accept bitter tastes, making the chances of rejection high5,6. A recent Allergy UK survey showed nearly two-thirds of infants are diagnosed after four months, highlighting the importance of a more palatable formula9.

BSACI Milk Allergy guidelines now recognise that palatability is an important factor in formula choice when managing CMA2.

EHFs can have an unpleasant taste

EHFs are the first-line choice for most formula-fed infants with CMA1-3. The protein in the EHF is broken down to produce a mixture of short peptides and free amino acids, which are less likely to trigger an allergic reaction10.
Unfortunately, they can taste bitter, which means they are more commonly rejected after the age of 4 months2-4.

96% of healthcare professionals surveyed felt that a more palatable EHF would increase the risk of non-rejection11.

Adequate intake of EHF is important for growth

It is not uncommon for parents to report that their child refuses EHF because of its unpleasant taste6, which may make it hard to achieve recommended daily nutrient intakes. Therefore, poor palatability can lead to rejection, which could impact growth7.

89% of healthcare professionals felt increased EHF compliance could improve the likelihood of achieving the recommended daily nutrient intake11.

Optimal growth is particularly important in the early years when CMA occurs7. Cows’ milk is a rich nutrient source and avoidance, plus increased requirements due to allergic symptoms, can cause poorer growth and nutritional status in infants with CMA12-15. To achieve nutrient requirements, adequate consumption of a hypoallergenic formula, like EHF, is recommended14,15 and should continue up to two years of age where CMA persists1,2,10.

The benefits of superior palatability

Superior palatability of an EHF could benefit the infant, their family, healthcare professionals and the NHS. In fact, healthcare professionals believe that a palatable EHF could increase acceptance, lessen wastage and reduce costs for the NHS11.

 

 

Benefits for an infant:

Superior palatability could reduce the chance of rejection11.
Acceptance of the feed taste may lead to greater consumption and weight gain16,17.

 

 

 

 

 

Benefits for the family:

92% of HCPs surveyed believed that a more palatable EHF resulted in more content families11.
Adequate intake of EHF can minimise negative impact of nutritional concerns18.

 

 

 

 

 

Benefits for HCPs:

Increased palatability may lead to a reduced likelihood of repeat visits11.
Taste acceptance may lead to a decreased need to switch to another formula11.

 

 

 

 

 

Benefits for the NHS:

90% of GPs and dietitians surveyed felt that a more palatable EHF decreased feed wastage and healthcare costs11.

 

 

 

Aptamil Pepti is the UK’s most palatable EHF

The Aptamil Pepti range has been specially designed for the dietary management of CMA. In a recent independent taste panel of 100 dietitians and GPs, Aptamil Pepti was ranked ‘most liked EHF’ on the UK market11*.

What makes it palatable?

Aptamil Pepti is a whey-based EHF. It is widely accepted that the palatability of whey-based EHFs is superior to casein-based EHFs19. It also contains lactose, and studies have shown that lactose containing formulas are more palatable than lactose-free formulas20.

Aptamil Pepti is closer to a standard infant formula in composition

European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines recommend that infants with CMA should be managed with a hypoallergenic formula, which is as close as possible to a standard infant formula composition21.

It is the only EHF to contain prebiotics

Aptamil Pepti contains a unique blend of GOS/FOS which is clinically proven to reduce long-term allergy risk22. Our unique GOS/FOS blend has been shown to help align the intestinal microflora of the baby to that of a breastfed baby23, showing a reduction of potential pathogens in the gut after 6 weeks24.

Aptamil Pepti is tolerated by 97% of infants with proven CMA25.

The importance of lactose for development

Lactose is the primary carbohydrate in breastmilk, providing benefits for the gut microbiotia26. The Codex Alimentarius Commission, part of both the Food and Agriculture Organisation of the United Nations and the World Health Organisation, has published guidance on standards for infant formula and formulas for special medical purposes for infants. It recommends that lactose and glucose polymers should be the preferred carbohydrates in formula based on cows’ milk protein and hydrolysed protein – and that sucrose, unless needed and the addition of fructose as an ingredient should be avoided27.
Lactose also plays an important role in infant development, helping to stimulate the absorption and retention of calcium, which is key for bone mineralisation28.

Lisa Waddell, Bsc Nutr (Hons), RD, PhD, MBDA, Specialist Community Paediatric Allergy Dietitian, Nottingham CityCare Partnership; Food Allergy Nottingham Service (FANS)

“Lactose enhances calcium absorption and improves the palatability of infant formula. Lactose may support growth of commensal bacteria which in turn may influence gut integrity, inflammation and allergic disease. Given these potential benefits, it is recommended to consider including lactose in the diet of those needing to restrict cows’ milk, to a level tolerated by the individual”29.

  1. Venter C, et al. Clin Transl Allergy 2013;3(1):23.
  2. Luyt D, et al. Clin Exp Allergy 2014;44(5):642-72.
  3. Walsh J, et al. Br J Gen Pract 2014;64(618):48-49.
  4. Mennella JA, et al. Am J Clin Nutr 2011;93(5):1019-24.
  5. Mennella JA, Castor SM. Clin Nutr 2012;31(6):1022-5.
  6. Vandenplas Y, et al. Eur J Pediatr 2014;173(9):1209-16.
  7. Meyer R, et al. Clin Transl Allergy 2014;4(1):31.
  8. Sladkevicius E, et al. J Med Econ 2010;13(1):119-28.
  9. Allergy UK survey of CMA awareness among 3278 parents of children diagnosed with CMA. 2017. Data on file.
  10. Fiocchi A, et al. World Allergy Organ J 2010;3(4):57-161.
  11. Campden BRI conducted a blind taste test using a home usage design with a sample of 100 Dietitians and General Practitioners from 16.11.2016 to 09.12.2016. Participants rank ordered the extensively hydrolysed formula (eHF) milk samples (Danone Aptamil Pepti, Abbott Similac Alimentum, Nestle SMA Althera and Mead Johnson Nutramigen LGG) in terms of overall liking and answered a series of attitudinal questions in relation to the impact of eHFs’ palatability on infants with CMA and their families. The results from the ranking showed that the Danone Aptamil Pepti sample was liked significantly more than all the other three samples tested.
  12. Christie L, et al. J Am Diet Assoc 2002;102(11):1648-51.
  13. Maslin K, et al. Clin Transl Allergy 2016;6:20.
  14. Flammarion S, et al. Pediatr Allergy Immunol 2011;22(2):161-5.
  15. Meyer R, et al. J Hum Nutr Diet 2014;27(3):227-35.
  16. Vandenplas V et al. J Pediatr Gastroenterol Nutr 1993;17:92-96.
  17. Menella JA et al. Pediatrics 2011;127:110-118.
  18. Mikkelsen A et al. Pediatr Allergy Immunol 2015;26(5):409-15.
  19. Venter C. Cows’ milk protein allergy and other food hypersensitivities in infants. [Online]. 2010. Available at: https://www.jfhc.co.uk/cows_milk_protein_allergy_and_other_food_hypersensitivities_in_infants_20679. aspx [Accessed March 2017].
  20. Miraglia Del Giudice M et al. Ital J Pediatr 2015;41:42.
  21. Høst A et al.. Arch Dis Child. 1999;81(1):80-4
  22. Arslanoglu S et al. J Biol Regul Homeost Agents. 2012;26:49-59.
  23. Moro G et al. J Pediatr Gastroenterol Nutr. 2002;34:291-5
  24. Knol J et al. J Pediatr Gastroenterol Nutr. 2003;3:566
  25. Giampietro PG et al. Pediatr Allergy Immunol. 2001;12:83-86.
  26. Francavilla R et al. Pediatr Allergy Immunol 2012 Aug;23(5):420-7
  27. Codex Alimentarius. Standard for infant formula and formulas for special medical purposes intended for infants CODEX STAN 72 – 1981. Available from: www.fao.org/input/download/standards/288/CXS_072e_2015.pdf [Accessed September 2017].
  28. Heyman MB. Pediatrics 2006;118:1279-86.
  29. Waddell L. What do we know about lactose? Complete Nutrition. 2016; 15(6):73-78.

† BSACI Milk Allergy guidelines and the Milk Allergy in Primary Care guidelines.

* A home usage test assessment was carried out between 16/11/16 and 9/12/16 on 4 products for CMA from birth; Aptamil Pepti, SMA Althera, Similac Alimentum, Nutramigen LGG, and included 100 UK healthcare professionals.