Alternative milk formulary (Formularies)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Guidelines:

Nutritional prescribing advice for suspected non-IgE mediated CMPA

Primary care:

  • Prescribe a one-off prescription while awaiting diagnosis

    • Eg, Aptamil Pepti 1 (contains lactose)

    • Infants presenting with severe gastrointestinal symptoms: prescribe Nutramigen 1 with LGG instead

    • Arize (Hydrolysed Rice Formula) or Neocate LCP should ONLY be used if symptoms are severe (see guidelines)

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Dietitian will then:

  • Assess growth

  • Advise if repeat script is required

  • Provide milk free weaning advice before 6 months

  • Initiate milk reintroduction advice at around 12-month review

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Primary care:

  • If Dietitian has advised: prescribe as a repeat prescription with a stop date of the child’s first birthday.

  • Approximately 10 tins will be required per 4 weeks.

  • Further prescriptions, after 12 months of age, are at dietetic request ONLY.

Dental health

Hydrolysed formula and soya-based formulas contain alternative sugars, which can cause tooth decay. Once the deciduous teeth start to erupt, they should be brushed twice daily with a small, soft toothbrush and a smear of fluoride toothpaste

Alternative milks formulary

Extensively hydrolysed formulas (EHF)

  • Place in therapy: FIRST LINE

Birth onwards

Lactose free

Nutramigen LGG 1: 420g
(Mead Johnson)

Contains lactose

Aptamil Pepti 1: 400g, 800g (Nutricia Early Life Nutrition)

Aptamil Pepti Syneo: 400g, 800g (Nutricia Early Life Nutrition)

SMA Althera: 400g
(Nestle Health Science)

Over 6 months of age

Lactose free

Nutramigen LGG 2: 400g
(Mead Johnson)

Contains lactose

Aptamil Pepti 2: 800g
(Nutricia Early Life Nutrition)

NB: Nutramigen LGG 1 and 2 contain the probiotic Lactobicillus GG and therefore should NOT be fed to premature infants (until they have reached their estimated date of delivery) or infants who might have immune problems.

Alternative protein formulas

  • Place in therapy: SECOND LINE where there is intolerance to EHF

Birth onwards

Lactose free

Similac Arize infant formula 400g
(Abbott)

Amino Acid Formulas (AAFs)

Place in therapy:

  • THIRD LINE where there is intolerance to Alternative protein formula

  • FIRST LINE: ONLY for infants with:

    • Reaction to breast milk

    • Severe reaction and/or growth failure, alongside symptoms of milk allergy.

Birth onwards

Lactose free

Neocate LCP: 400g
(Nutricia SHS)

Neocate Syneo: 400g
(Nutricia SHS)

Nutramigen Puramino: 400g
(Mead Johnson)

SMA Alfamino: 400g
(Nestle Health Science)

Elecare *400g:
(Abbott Nutrition)

Gastrointestinal symptoms associated with CMPA can cause secondary lactose intolerance. To reduce the risk of misdiagnosis during the exclusion and challenge process, an alternative formula, which is also lactose free should be prescribed in those infants presenting with gastrointestinal symptoms.

Lactose containing formula can be used for the treatment of cows' milk allergy, following confirmation of diagnosis or if there is poor palatability of initially prescribed formula.

Soya and other formula and milk substitutes

Soya formula (SMA Wysoy) & Lactose free formula (SMA LF/Aptamil LF):

  • Do NOT prescribe for CMPA. 

  • These can be purchased from pharmacies and supermarkets.

Soya infant formula

is NOT on the Highland Formulary and should NOT be prescribed.

It is available for purchase from retail outlets, therefore, if soya formula is required, it does NOT require prescription.

Soya infant formula should NOT be used first line in the diagnosis and treatment of cows' milk protein allergy as, dependent on presenting symptoms, there may be up to a 50% chance that infants will also react to soya formula.

Soya formula should NOT be used in infants under 6 months but can be used in infants over 6 months if EHF are not accepted due to poor palatability. 

  • Soya formula should NOT be used routinely in infants aged 0 to 6 months as it contains phytoestrogens that could pose a risk to long term reproductive health.  A recent systematic review and meta-analysis found no significant effect on reproduction function, however, currently recommendations remain unchanged in that it is not suitable for under 6 months of age except for:

    • Vegan mothers who do not exclusively breastfeed, may choose to use soya infant formula

    • Under the advice of special paediatric services eg for galactosaemia

    • Infants who are at nutritional risk as refusing alternative formula.

Other formula and milk substitutes

Goat or other mammalian milk formulas are NOT suitable for the treatment of Non-IgE CMPA as protein structures are similar to cow’s milk and there is a high risk of cross reaction.

Supermarket soya, oat or nut milks are not nutritionally complete and should NOT be used as a milk substitute for infants under 12 months.  In most cases, following dietetic review, they can be used as the main drink after 12 months.

Commercial rice milk should NOT be used in children under 4.5 years due to unacceptable levels of naturally occurring arsenic, relative to body weight.

Editorial Information

Last reviewed: 30/04/2026

Author(s): Dietetics.

Version: 1.2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): J Chapple, Lead Dietitian, Argyll & Bute, J Johnson, Paediatric Dietetic Lead, Highland Council.

Document Id: AF014